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NC50842 | Death of a 14-week-old boy from serious non-accidental injuries in July 2016. Elias lived with his mother, sibling and three half siblings at the time of his death. Mother married Father 2 under Islamic law but he had another family. The eldest child had a diagnosis of Autism and Elias was born with a hand deformity. Family known to Children's Social Care and Police for domestic abuse with Father 1 and allegations that mother was mistreating the children. Elias taken to hospital by ambulance after mother found him unconscious. Mother and Father 2 were arrested for grievous bodily harm and siblings taken into local authority care. Mother of Bangladeshi origin. Methodology: a systems based approach to meet learning and improvement requirements of statutory guidance. Findings: failure of the systems and processes designed to safeguard children with inaccurate recording; the interface between Child in Need and Team Around the Child did not work well; system around midwifery care was disjointed with lack of communication between midwifery teams and midwives and GPs; insufficient focus of emotional impact of Elias and Child A's diagnoses on their parents. Recommendations: health services should review documentation and assessment tools and include household composition and functioning of the household; to seek assurance from health and partner agencies of emotional impact of having a child born with any abnormality/disability features within consultations with recognition of any risks to the child; all GPs to be notified of the pregnancy of all women registered in their care; to seek assurance that the application of thresholds is now consistent.
| Title: Serious case review: overview report: Child ‘Elias’: DOB: 31.03.16: DOD: 06.07.16. LSCB: Tower Hamlets Safeguarding Children Board Author: Nicki Walker-Hall Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. FINAL Tower Hamlets Safeguarding Children Board Serious Case Review Overview Report Child ‘Elias’ DOB: 31.03.16 DOD: 06.07.16 Independent Reviewer and Report Author Nicki Walker-Hall MSc, MA, RSCN, RGN Published: 28 February 2019 1 TABLE OF CONTENT ERROR! BOOKMARK NOT DEFINED. 1 INTRODUCTION 2 1.1 Initiation of Serious Case Review ........................................................................................................................................ 2 1.2 Methodology................................................................................................................................................................................... 2 1.3 Agencies involved......................................................................................................................................................................... 4 1.4 Structure of the report .............................................................................................................................................................. 4 2 CONTEXT 5 2.1 Family composition ..................................................................................................................................................................... 5 2.2 Symbrachydactyly ........................................................................................................................................................................ 6 2.3 Autism ................................................................................................................................................................................................. 6 2.4 Background ...................................................................................................................................................................................... 6 3 OUTLINE OF THE CIRCUMSTANCES RESULTING IN THE REVIEW 8 3.1 Key Events......................................................................................................................................................................................... 8 3.2 Evaluation of practice falling outside of the key focus points ........................................................................ 11 4 ANALYSIS OF THE KEY ISSUES, FINDINGS AND RECOMMENDATIONS 12 5 CONCLUSIONS 26 6. APPENDIX 1 – GLOSSARY OF TERMS & ABBREVIATIONS 28 2 1 INTRODUCTION 1.1 Initiation of Serious Case Review 1.1.1 This serious case review was initiated following the death of Elias. An ambulance had attended the family home at the request of mother who reported Elias unconscious; on arrival Elias was in cardiac arrest, he was noted to have serious injuries. Elias was transported to hospital, accompanied by mother, where he was placed on life support. Ambulance staff had also noted scratches on Child D’s back (a sibling) and raised concerns. Mother and father 2 were arrested for grievous bodily harm; the four older children within the family were taken into Police Protection and later Local Authority care. 1.1.2 A decision was made by the Serious Case Review sub-group, supported by the chair of Tower Hamlets Local Safeguarding Children Board, that the known facts in relation to this case met the statutory requirement, in accordance with Working Together to Safeguard Children 20151: Abuse or neglect of a child is known or suspected and a child dies; or a child is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child 1.1.3 The Department for Education and the National Serious Case Review Panel were informed. 1.2 Methodology 1.2.1 The review adopted a systems based approach, which aimed to meet the learning and improvement requirements of statutory guidance. The review sought to understand: precisely who did what, through development of agency chronologies and review of relevant documentation the underlying reasons that led individuals and organisations to act as they did, through conversations with practitioners involved in the case. Where practitioners were no longer in post, managers of the services provided organisational and service context 1.2.2 The review was managed by a panel consisting of senior managers of the involved agencies, working with an experienced lead reviewer Nicki Walker-Hall from a health background and the independent chair of the panel Keith Ibbetson from a social care background. 1.2.3 The review looks in depth at the period from June 2014 until the death of Elias in July 2016. 1 Working Together to Safeguard Children, 2015 Chapter 4 3 1.2.4 The report is concise in nature reflecting the way such reports are currently written and concentrates on the findings and recommendations. In order to protect the surviving children within the family, information deemed not relevant to the findings and recommendations has been removed. The report takes account of changes that have been made to systems and processes as a result of internal audits and external inspections. Where issues identified in the report are being addressed through alternative local action plans, no additional recommendation has been made and it is for the LSCB to ensure that any such action has been taken and has been effective. Key focus points 1.2.5 The Serious Case Review panel decided upon the key focus points for the review and highlighted the following lines of enquiry for consideration: How effective was the identification of need and risk during the mother’s pregnancy with Elias? How effective are local arrangements for identifying need and risk during pregnancy more widely? How effective was the response of social care, police and health colleagues, to the reported physical abuse of Elias’s half-sibling in February 2015? Was this reflective of normal practice? What factors shaped the response? What was the coordinated Team Around the Child (TAC) approach designed to achieve and was it effective? Was any additional need or risk identified at the time of Elias’s birth? Did the circumstances trigger any re-assessment of need? How effective was the new birth visit and what factors shaped the service provided? Overall, did decisions take account of relevant information about the full family background and history? When do we understand that Elias was injured, bearing in mind the limitations of what can be reasonably inferred from medical evidence? Were there opportunities during this period for professionals to have observed signs of these injuries? Did professionals take the right action to identify risk to Elias and other children in the family and act on their assessments during the period between his admission to hospital and his death? Timeframe 1.2.6 The timeframe for this review has not met with statutory timescales. There was some delay between Elias’s death and the start of the SCR. The parallel process (please see section below) impacted initially; there was then a further substantial delay due to difficulties in the local authority procurement arrangement. Parallel Processes 1.2.7 Elias’s parents were subject to criminal proceedings; both have been tried and convicted. Elias’s father was found guilty of murder and allowing the death of a child but not guilty of neglect. Elias’s mother was found guilty of allowing the death of a child but not guilty of murder/manslaughter. The Local Authority took necessary steps to protect Elias’s siblings 4 Family participation 1.2.8 Mother and father were contacted via their offender managers, firstly to inform them of the review and latterly to invite them to be part of the review process; neither expressed a wish to participate. Limitations 1.2.9 There have been a number of limitations to this review. The majority of professionals involved with the family have moved on. As a consequence, the lead reviewer has had limited opportunities to understand professional practice in context, thus limiting her ability to identify the factors that influenced the nature and quality of work with families. In order to mitigate these limitations, the lead reviewer has made use of internal audits, previous recent local SCRs and external inspections to understand whether issues likely relate to this case only, or are indicators of wider systemic issues. 1.3 Agencies involved 1.3.1 The following is a list of the agencies involved with the family and the services they offered. Where abbreviations have been identified these will be used throughout the report to denote the organisation the author is referring to: Barts Health NHS Trust (Acute, Midwifery, Health Visiting, School Health) Tower Hamlets (Children’s Social Care, Children’s Centre, Primary School) Metropolitan Police Service (MPS) Housing Great Ormond Street Hospital for Children NHS Foundation Trust (GOSH) London Ambulance Service (LAS) 1.4 Structure of the report 1.4.1 The report is structured as follows: Chapter 2 provides context: o details of the family composition and members of the household, o a description of what was known about the children, o the dynamics in the family, o an explanation of Symbrachydactyly and Autism Chapter 3 gives an outline of the circumstances of the review focusing on the key events and appraising practice which falls outside of the key focus points but where the author believes there is learning for agencies. Chapter 4 contains analysis of the key focus points, findings and recommendations. Chapter 5 provides the conclusion. 5 2 CONTEXT 2.1 Family composition 2.1.1 Elias lived with his mother, sibling and three half siblings at the time of his death. 2.1.2 It is not clear whether father 2 was living full time in the family home at this time. Father 2 was married to mother 2 who was his second wife under Islamic/Shariah law. Father 2 had another wife and family who also lived locally. It is not believed father 2’s other children were ever part of this household. TABLE 1: Household composition TABLE 2: Significant others referred to in the report The children 2.1.3 There were five children within the household. The older three were children of the relationship between mother and father 1. The two younger children were from the relationship between mother and father 2. The older children had or were all attending the same primary school; the eldest child had moved to an alternate school prior to this incident. The children were generally well presented in school; they attended breakfast clubs. The family home lacked toys for the children but it was clean and tidy and, when checked, there was food in the cupboards; they appeared happy. Child A had a diagnosis of Autism and Elias was born with a congenital abnormality to his hand (Symbrachydactyly). The lead reviewer has not had an opportunity to meet either the children, or the teachers involved with the children, to gain greater understanding. Family Dynamics 2.1.4 Mother was of Bangladeshi origin. She reported to professionals that most of her family remained in Bangladesh, limiting her support network. Mother reported her marriage to father 1 was an arranged marriage; there had been domestic violence (father 1 to mother) in the relationship. Mother made a number of attempts to leave Term used in report Relationships Age in July 2016 Child A Half sibling 9 Child B Half sibling 7 Child C Half sibling 5 Child D Full sibling 15 months Elias Subject of the review 13 weeks Mother Mother of all the children 31 Term used in report Relationships Age in July 2016 Father 1 Father of Child A, B and C 38 Father 2 Father of Child D and Elias 36 6 the marriage but returned after short periods. In 2014 after 9 years of marriage, they separated for the final time, divorcing in March the same year. Mother commenced a relationship with father 2, the former best friend of father 1. Father 2 remained in a relationship with his first wife at the same time as mother. Father 2 and mother were married in Islam just prior to Elias’s birth. The children from both marriages attended the same school. 2.2 Symbrachydactyly Nature of the condition 2.2.1 Symbrachydactyly is a congenital (present at birth) hand anomaly, which affects a single upper limb. It is not inherited. It is characterised by short, stiff, webbed or missing fingers. The underlying muscles, tendons, ligaments and bones are all affected. The cause is unknown. There is no link to anything the mother did or did not do during pregnancy. Care and treatment 2.2.2 Symbrachydactyly can be treated with surgery, with the aim of improving hand function and appearance. However, it cannot give the child a normal looking hand. As well as surgery, there is also the option of prosthetics (an artificial hand or fingers). 2.3 Autism Nature of the condition 2.3.1 Autism spectrum disorder (ASD) is the name for a range of similar conditions, including Asperger’s syndrome, that affect a person's social interaction, communication, interests and behaviour.2 2.3.2 In children with ASD, the symptoms are present before three years of age, although a diagnosis can sometimes be made after the age of three. It is estimated that about 1 in every 100 people in the UK has ASD. More boys are diagnosed with the condition than girls. Care and treatment 2.3.3 There is no "cure" for ASD, but speech and language therapy, occupational therapy, educational support, plus a number of other interventions are available to help children and parents. 2.4 Background 2.4.1 The following section provides relevant background information held within key agency records for the period prior to the review period. This is provided to give further context. 2.4.2 During 2009-2010 mother made three allegations of domestic abuse (DA) regarding her then husband, father 1, stating he abused her; she expressed concern for the 2 https://www.nhs.uk/conditions/autism/ 7 safety of the children. On one occasion father 1 was arrested, following which mother withdrew her allegation. Mother’s allegations received a varied response from Children’s Social Care (CSC), which was not in line with expectations. On the first occasion, a referral was made to CSC and a decision made that an Initial Assessment was required; this ultimately led to no further action following assessment. On the second occasion, a decision was made that an Initial Assessment was required but this was not carried out. On the third occasion mother was sent a letter on what action she could take; there was no correspondence or interaction / contact with father 1. The couple’s arrangements at that time were mother had care of their daughter and father 1 had care of their son. Health and Education staff were not aware of these incidents. 2.4.3 In December 2012 father 1 was banned from school having assaulted a teacher who was trying to break up a fight between father 1 and another parent; father 1 threatened to return with a weapon. The referral was passed to CSC for assessment. A strategy discussion was decided upon but there is no record of it. School noted father 1 had some mental health problems; there is no record that this was shared with partner agencies. The case was closed 12 days later on the grounds that no risks to the child had been identified and parents lived separately. Health staff were not aware of this incident. 2.4.4 In June 2013, mother informed School Learning Support that she had moved back in with father 1 a month earlier, but now wished to flee the marital home because of Domestic Abuse. Mother was signposted to other agencies. CSC were reassured as mother said she was going to live elsewhere with the children. It was noted that “her decision recently to move back in with Dad” called her judgment into question. The manager noted that there should be checks to establish whether mother moved out. Four days later the Police e-mailed CSC to inform that the police visited in response to a phone call from father 1, who believed he had parental responsibility. Police witnessed mother removing the children and herself and established that there were no other concerns. The CSC manager noted: “This is a private matter regarding contact. There is no order in place to stop mother from taking the older child from father. Father will be seeking legal advice. No role for CSC. Information only.” 2.4.5 In March 2014, the Police informed CSC that mother had reported an attack by father 1. Father 1 was arrested but was too ill for custody. The case was closed when mother and children moved area; the local CSC were asked to support mother. 2.4.6 Later, Housing Options contacted CSC to inform them of the date of the last DA incident. The CSC manager noted that 3, 5 and 7-yr-old children were at home, noted the case history, and recommended a London Borough of Tower Hamlets (LBTH) assessment, which cannot be found. 8 3 OUTLINE OF THE CIRCUMSTANCES RESULTING IN THE REVIEW 3.1 Key Events 3.1.1 The following table is designed to give a brief outline of the case history focusing on key events in the lives of Elias and his siblings during the period under review. Sequence Date Event Episode 1 June 2014 Father 1 reported concerns with mother’s parenting of his children. Mother alleged a DA incident in the street, father 1 allegedly attempted to abduct Child C. CSC contacted school who had no concerns. The case was referred to the Crown Prosecution Service (CPS) and they made the decision that No Further Action (NFA) would be taken. A police Merlin3 was created for children coming to notice and this was shared with CSC on 4 days after the incident. Case closed. Episode 2 October 2014 Maternity booking, mother 12 weeks pregnant to father 2. Midwives believed mother’s children have a social worker because of DA in previous relationship and referred mother to Gateway Midwifery, who provide enhanced midwifery care to women being identified as vulnerable, and informed CSC of the pregnancy. Mother new to the area. Case held at duty. Father 2 has 4 other children with whom he has contact. Episode 3 January 2015 Father 1 alleged mother was mistreating the children and not feeding them properly. CSC made checks with school and health visiting; school had no concerns. Episode 4 February 2015 Gateway midwifery took a full history from mother. Mother was in a new relationship; father 2 had left mother pregnant, returning to his wife and family. Mother had no family support. Mother needed advice and support. A referral was made to CSC, and for a Family Support Worker (FSW). The case was allocated to a FSW, however, mother did not initially engage. At 29 weeks into the pregnancy, contact was established with the FSW and a referral made to the integrated pathway support team (IPST4 (pre MASH5)). School informed re pregnancy via SW (confidential). IPST advised they would contact mother to discuss who would look after the children at the birth and emailed the FSW advising them to hold a multi-agency Team Around the Child (TAC) meeting with all involved professionals, this was arranged. 3 Merlin is a database run by the Metropolitan Police that stores information on children who have become known to the police for any reason. 4 IPST – Integrated pathways and support team 5 MASH is Children’s Social Care’s front door 9 Sequence Date Event Episode 5 February 2015 Child C alleged physical abuse by mother. School referred to CSC. A strategy discussion led on to a S476 investigation. Child C had a child protection medical that deemed the injuries likely to be non-accidental. Despite verbal and written reports, the social worker believed the medical was inconclusive. Police were verbally told by the student social worker that the CP medical was inconclusive; they were not sent the report, and the Social Worker did not identify the error/ notify the Police. This belief led to closing of the case from a police perspective and a decision to manage the case as child in need from a CSC perspective. The case remained in TAC. Episode 6 February 2015 A Professionals/TAC meeting (1) was held. Mother has had a scan that deemed the unborn child small for gestational dates. Mother has been referred to and accepted by Maternity Mates.7 No Maternity Mates worker, SW or mother present. Issues discussed: Child protection referral Pregnancy Child C playing violent games unsupervised on a console Child A no plimsolls or PE kit Child A’s autism Child B being shouted at by mum Mother’s debts Mother’s need for support especially at point of birth Episode 7 March 2015 Second TAC/professionals meeting (2) was held. Health visitor sent apologies. The recent CP medical is acknowledged but no discussion is had re the findings. The family are isolated, previous DA by ex-partner is noted. Support is to be provided by Homestart, family support worker and Maternity Mates. A week later the HV receives a copy of the CP medical and phones the SW re a date for the suggested CP conference. Father 1 reported concerns about mother’s new partner abusing the children to CSC. No action is recorded. Information shared with partner agencies. Third TAC/professionals meeting (3) was held. Mother and social worker were not present. Health visitor rang the social worker. The SW indicated that her manager had decided the case would be managed in CIN. Discussion held regarding plans for birth. 6 S47 – Section 47 of the Children Act 1989 is initiated to decide whether and what type of action is required to safeguard and promote the welfare of a child who is suspected of, or likely to be, suffering significant harm. 7 Maternity Mates work alongside midwives and other health professionals to help the mum and baby receive the best possible care. 10 Sequence Date Event Episode 8 April 2015 Mother indicated she and father 2 are now Islamically married. Child D is born before arrival of professionals. TAC meeting (4) mother not present – 3 days post-natal. Confusion as to whether this is a TAC, professional or CIN meeting. The health visitor conducted a new birth visit, mother was asked about domestic abuse, which she denied. Living separately from her new baby’s father but stated a good social network of friends, mother’s family live in Bangladesh and father’s family have yet to see Child D. Episode 9 June 2015 CSC close the case – the case was to remain in TAC, however, there were no further meetings. Episode 10 December 2015 Mother pregnant – late booking at 14/40 gestation. Mother attended scans but received no other antenatal care. Mother stated no safeguarding concerns. Episode 11 February 2016 Child D is admitted to hospital for 3 days with an abscess, she is cared for by mother during her stay. Child D received antibiotics in hospital and then at home. Episode 12 Mar 2016 The children’s centre closed the case. Elias is born before the midwife arrived, it is noted the distal section of all fingers on the right hand are missing. Elias is referred to plastic surgery. Episode 13 April 2016 The health visitor completed a new birth visit – no concerns are noted other than those known. Mother indicated there is no domestic abuse between the couple and that they are living separately but father is supportive. Father 2 was not present. Episode 14 May 2016 Elias was not taken to an appointment for immunisations, he received a further appointment, attended and was immunised. Episode 15 June 2016 Elias was taken to his plastics appointment; mother was informed of the plan of care. Elias was to be reviewed in a year and for surgery aged 2. Episode 16 July 2016 Mother contacted her brother-in-law, stating that Elias was unconscious; he advised her to call for an ambulance. Elias was taken to Royal London hospital (RLH) by London Ambulance Service (LAS) suffering cardiac arrest; he had visible burns to his leg. Doctors believed Elias’s injuries to be non-accidental and contacted the police. Mother attended the hospital with Elias and was subsequently arrested for Grievous Bodily Harm. Father remained at home in charge of Child D. 11 Sequence Date Event Police arrested father for Grievous Bodily Harm. All siblings were taken into Police Protection. Father’s own children were visited by police and found to be safe and well. 3.2 Evaluation of practice falling outside of the key focus points Allegations and counter allegations 3.2.1 There was evidence of fractured relationships between mother and father 1. Contacts from father 1 provided an opportunity for CSC to carry out a fuller assessment of the circumstances in which the children were living, the level of risk and the impact of parents’ behaviours on the children, and whether mother was: caring for the children adequately, able to protect the children able to protect herself. These incidents were looked at in isolation from information already held within CSC regarding DA incidents between the couple. On the first occasion, the children’s school were contacted but no other agency. The second episode received a more proportionate response with both school and health visiting being contacted, but neither allegation led to a fuller assessment. These were missed opportunities. The family GP was not contacted on any occasion. Referral from Gateway midwifery to IPST 3.2.2 Mother presented herself as 12 weeks pregnant with Child D to father 2. The booking midwife believed mother’s children had a social worker because of domestic abuse within her previous relationship and for that reason, and mother’s additional needs, mother was referred to Gateway Midwifery and IPST (Integrated Pathway Support Team). 3.2.3 This referral contained full and relevant information. IPST decided FSW involvement and TAC was most appropriate but referred on to CSC for support around the birth. They asked to be kept informed of progress, which is somewhat confusing as cases are not open to IPST. This suggests heightened concern from the IPST worker. 3.2.4 Mother was reportedly new to the area. CSC indicated the case had always been held at duty. Father 2 was noted to have 4 other children with whom he had contact. 12 4 ANALYSIS OF THE KEY ISSUES, FINDINGS AND RECOMMENDATIONS 4.1 Introduction 4.1.1 The following section will discuss and analyse the key issues identified by the SCR, highlighting the findings of this serious case review, with additional associated recommendations for the LSCB. The findings relate to what we have learnt about the strengths and weaknesses in multi-agency safeguarding systems and the recommendations, if taken forward, are designed to address these. 4.2 How effective was the response of social care, police and health colleagues to the reported physical abuse of Elias’s half-sibling Child C in February 2015? Was this reflective of normal practice? What factors shaped the response? 4.2.1 Child C alleged physical abuse by his mother; Child C had a large bruise on the ear said to be caused by his mother hitting him with a stick four days earlier. Child B told school staff that mother had hit Child C with a wooden spoon a day earlier, whilst at home, after he jumped on her legs. 4.2.2 The initial response by agencies to Child C’s allegations was robust: School acted swiftly identifying risk and made a referral to IPST in line with local safeguarding procedures Procedures were followed in determining a strategy discussion was needed to determine the next steps The decision to conduct a S47 joint investigation was in line with policy and procedures All the children and mother were appropriately interviewed separately 4.2.3 The CSC manager noted the previous history and decided a strategy discussion was appropriate. A S47 joint investigation was agreed by CSC and the police. 4.2.4 Mother was spoken to by the police and the duty social worker; she denied assaulting Child C indicating Child C had “banged his ear on the living room door whilst playing”. Mother also denied physically punishing the children. Of note, mother was seven months pregnant at this time; it has not been possible to establish whether this influenced any professional’s thinking or practice. 4.2.5 The social worker made an assessment of whether all the children were happy to go home and concluded they were, and indicated there appeared to be no fear; it is not fully understood what the social worker meant by this statement. 4.2.6 The subsequent assessment of risk did not meet expected standards. The assessment did not fully take account of what was previously known about the family, the recent allegations made by father 1, and was conducted without speaking to father 1, who had joint parental responsibility for the children even though he was estranged. There was no comprehensive assessment of the risks and there was not sufficient consideration of whether any actions were required to keep all the 13 children safe prior to receipt of a medical opinion on the injury, left all the children at risk of harm. 4.2.7 The assessment and decisions made gave greater credence to the explanation of mother, than the statements of the children, who were consistent with their explanations and corroborated each other. There was a lack of understanding in relation to the life of the child and too much focus on mother. 4.2.8 The findings in this case are consistent with local independent auditing of practice in the period under review. Having deemed the London Borough of Tower Hamlets “outstanding” or “good” in all areas in their 2012 inspection8 there was no further inspection until January 2017 at which time Ofsted found all areas were inadequate or required improvement. It is difficult to pin point exactly when practice changed however Ofsted 9 in the report, in relation to the 2017 inspection, comment about the findings of an audit of section 47 child protection enquiries carried out internally in May 2016 as a result of concerns identified by the newly appointed Director of Children’s Services. This audit identified significant weaknesses in safeguarding practice, including poor assessment of risk, an over-reliance on parental explanations and a lack of professional curiosity and judgement. This, coupled with significant increases in staff turnover in the assessment and intervention team from 10% in 2015 to 30% in 2016, led to establishment of the improvement and inspection board in September 2016. 4.2.9 These weaknesses continued to feature in a subsequent audit carried out in December 2016, and were common features in a number of cases seen by inspectors in January 2017. 4.2.10 The child protection medical was arranged and completed in a timely manner however, the process was not robust. The social worker accompanying Child C was a student and not the assessing social worker who interviewed Child C and the family the day previously. The information the student social worker could share with the paediatrician was limited. 4.2.11 The lead reviewer was informed that there would usually be two paediatricians present during a child protection medical however due to a changeover of trainee doctors there was no one available to accompany the consultant. 4.2.12 The paediatrician gave verbal findings to the student social worker that the injury was probably non-accidental in origin and recommended photographs be taken by the local health trust medical illustration service; this would require Child C being taken to another site. The paediatrician explained her request for a photographic record of the injuries was in preparation for any possible prosecution. There is no evidence the injuries were ever photographed by medical illustration. 8 Ofsted (2012) Inspection of safeguarding and looked after children services 9 Ofsted (2017) Inspection of services for children in need of help and protection, children looked after and care leavers and Review of the effectiveness of the Local Safeguarding Children Board 14 4.2.13 The information shared between the student social worker and the assessing social worker was not documented. This verbal communication was crucial to subsequent decisions made. The assessing social worker recorded that the child protection medical was inconclusive; this was incorrect. This was a common problem. 10 4.2.14 The paediatrician put all the findings into a report. The paediatrician suggested CSC should complete the S47 and ensure Child C’s safety, provide advice on appropriate forms of discipline and support mother to access support around social isolation and pregnancy; it was noted that an older child had ASD – a child protection conference was recommended if Child C remained in mother’s care. 4.2.15 There was a 15-day delay between the CP medical being completed and the report being sent out to CSC, believed to be affected by an administrative backlog. Confusion about who the family GP was prevented the report being sent to the GP and the police were not on the routine copy list at that time. 4.2.16 CSC wrongly recorded that the child protection medical had found the “injury was inconclusive”. A written safeguarding agreement was signed by mother regarding use of physical punishment. The case was closed three and a half months later indicating there was “no role for CSC”. However, the social worker, in the LBTH assessment, in the child protection section, concluded that the hitting ‘probably’ happened. This conclusion was not considered by the team manager in the subsequent decision to close the case. 4.2.17 The police and CSC closed down the section 47 enquiry based on a belief that the child protection medical was inconclusive, before the written report from the paediatrician was received and without direct contact with the Paediatrician. There was an over reliance on medical proof of injury in this decision and a seeming dismissal of the explanations of the children. 4.2.18 Once received, the child protection medical report was uploaded on the system; there is no evidence to indicate it was seen. Subsequently, actions were taken which were at odds with the findings of the medical. It is therefore reasonable to assume it was either ignored or not seen. 4.2.19 A decision was made that the case should be managed as Child in Need, this was not followed through; not all members of the TAC were made aware of this decision, therefore the case remained in TAC with no evidence of a formal decision to step the case down to TAC. The fact that a social worker was continuing to do an LBTH assessment parallel to the TAC was an additional confusion. 4.2.20 The content of the child protection medical report, and the current situation of the family, does not appear to have been sufficiently considered at the point the case was closed by the practice manager (PM) four months later. The case closure record 10 Ofsted, in its 2017 inspection found that, “Case recording by social workers and managers in many children’s case files is so poor that it is not possible to tell how decisions are reached regarding children’s lives or how intervention is reducing risk”. 15 states, “mother working well with TAC” this was factually incorrect as mother had not attended TAC meetings. The case closure record also states “child protection medical completed and pictures taken. Injury was inconclusive”, this again was factually incorrect. Case closure provides managers with an opportunity to reflect on all the information on file and ensure that children are safe. The rationale for case closure in this case was based on incorrect information 4.2.21 The CSC panel member identified concerns that a section 47 enquiry would be closed down at PM level. Ofsted’s 11 inspection found “Senior managers have not been effective in addressing poor practice by first and second-line managers. An entrenched culture of non-compliance with basic social work standards continues to be a significant weakness. This has led to delays in progressing work effectively, which have left some children in situations of escalating and actual risk of harm”. Finding 1: in this episode, there was a failure of the systems and processes designed to safeguard children; inaccurate recording compounded the issues. This left Child C and his two older siblings (one of whom had an identified disability and was therefore more vulnerable) at risk of harm. Recommendation 1: LSCB needs to be assured that standards in relation to safeguarding children are now satisfactory, that child protection medicals are now being conducted in line with best professional practice and that interagency working around medicals is robust. 4.3 Arrangements for early help/Team Around the Child support for the family following the reported episode of physical abuse 4.3.1 Before the reported episode of physical abuse, a TAC was thought to be the appropriate offer for the family, and related to the need to support mother in her care of the children and the imminent arrival of Child D. 4.3.2 During the section 47 enquiry, the previously arranged TAC meeting went ahead as a professionals meeting. It was well attended by professionals, however both mother and the social worker were absent, said to be attending the child protection medical. A great deal of important information was shared within this meeting. School indicated mother needed emotional and social support. Mother was pregnant with Child D. Mother was no longer involved with father 2; he had returned to his wife and family. Mother had been referred to and accepted by Maternity Mates. The safeguarding issues were discussed, preparation for the birth of Child D was also discussed. Concerns were expressed about who would look after Child A, B and C whilst mother delivered Child D; attendees were unclear regarding the plan. School raised additional concerns that Child C had been playing violent games unsupervised on a console, one of the children only had one pair of shoes and no plimsolls for PE 11 Ofsted (2017) Inspection of services for children in need of help and protection, children looked after and care leavers and Review of the effectiveness of the Local Safeguarding Children Board 16 clothes. An SEN meeting for Child A, due to his Autism, indicated no concerns with progress. The children all attended breakfast and after school clubs. Mother had credit card debts and was not receiving financial support from father 1. There had been a recent incident when Child B was being shouted at by mother and did not know what to do; Child B was supported by school staff. All the professionals present expressed concern for the family as they were struggling. 4.3.3 It is not clear whether these additional concerns were ever shared with the social worker as concerns regarding the dynamics between mother, father 1 and father 2, mother shouting at Child B and mother being in debt, do not feature in the core assessment. It might have been better to postpone and reconvene the professionals meeting so the new information and the CP medical could be discussed as well. 4.3.4 At the second TAC meeting the HV sent apologies but other agencies and mother attended. Whilst the child protection medical was acknowledged, no discussions were had regarding the findings. The meeting acknowledged the family’s isolation, and previous domestic abuse by ex-partner. Support was to be provided by Homestart, family support and Maternity Mates. 4.3.5 Four weeks after the child protection medical, the report was emailed to the HV, who followed up by telephoning the SW and asking what the plans were for a child protection conference; this was good practice however the SW was on leave. 4.3.6 The third TAC became a professionals review meeting, as the SW and mother were again not present. During the meeting, the HV rang the SW, as she was concerned the SW might not be aware of the paediatrician’s request for the case to be discussed at conference, if Child C was to remain in mother’s care, and consideration for child protection medicals of the other children. The HV did not mention the medical opinion “Child C gives a clear and consistent history that mother hurt him with a stick”, and that “in view of the history and presentation, physical abuse is likely”. Social care’s understanding of thresholds and different levels of intervention was not consistent at this time and seemed to have been interpreted to suit the local authority’s lack of capacity. The SW indicated that the team manager had decided the case met the threshold for Child in Need (CIN) and a TAC would support the family. 4.3.7 It is not clear what was meant by this; a TAC meeting was arranged for the following month. There was no challenge of this decision by any professionals or discussion by the HV with the Named Nurse Child Protection within her employing Trust or the paediatrician who had carried out the medical. The SW shared that father 1 had reported concerns about mother’s care of the children to CSC. 4.3.8 Mother had agreed to TAC on the basis she was concerned about the care of her children at the time of Child D’s birth. There was much confusion over who would care for the children during delivery of Child D. The Gateway team provided information regarding a birth plan to midwifery which states ‘the children will go into foster care whilst mother is in labour as she has no family or friends to support her’ and that CSC needed to be alerted following birth. A robust plan was not established and mother expressed her frustration 37 weeks into the pregnancy. 17 4.3.9 CSC records indicate they were aware mother did not attend the first TAC following step down. This was raised with the allocated SW who discussed it with managers; management response was to continue to endorse TAC and continue with LBTH. This was another opportunity to consider convening an ICPC. 4.3.10 Over the next two weeks the FSW, emailed all members of the TAC on two occasions to update them, firstly that father’s sister will support her with the children on the day and after the birth of Child D, and that mother and father were now Islamically married. Mother was concerned how father 2’s other wife would respond but felt supported by father 2’s family. Mother indicated there was a good relationship between father 2 and her other children, suggesting greater involvement than previously known. This did not lead to further assessment. 4.3.11 Child D was born before arrival of the midwife, at home, in an unplanned home birth, in April 2015. Child D and mother were taken to hospital for checks but discharged later the same day, CSC and Gateway midwifery were informed the following day. The FSW informed all TAC members via email the following day after discovering, during a telephone call with mother, that Child D had been born. 4.3.12 The fourth TAC meeting was held a week later but as mother did not attend this was again a professionals review meeting, the SW indicated that there was a lack of toys for the children, the FSW was assisting mother with debt support agency, Homestart were supporting with a weekly visit. The chair fed back that mother was interviewed by CSC and the Police, resulting in no evidence of physical abuse with a plan to close the case the following month. It was thought likely that Child C had hurt himself on the doorframe as reported by mother; there was no challenge to this explanation. The FSW and health visitor agreed to share the lead professional role and planned to meet in 3 months. 4.3.13 In June, the case was closed to CSC; partner agencies were not informed. The SW concluded that hitting probably happened however, there was nothing recorded regarding this in the Team Managers decision to close the case. The step up/ step down process did not work in this case. 4.3.14 The case remained in TAC but there were no further meetings held. 4.3.15 Discussions and decisions were being taken by professionals in TAC meetings without knowing the intentions of CSC and without the agreement of mother. The social worker was present at one TAC meeting; CSC SW’s do not usually attend TAC meetings. 4.3.16 Whilst TAC meetings were held regularly initially, there was no clear decision to stop the meetings. It is recorded at a TAC/professionals meeting in April 2015, 7 days after the birth of Child D, that there will be a TAC meeting in three months. No date was planned and when the meeting did not take place no professional questioned why. 18 4.3.17 The Children’s Centre worker contacted CSC in August 2015 and was informed that CSC had closed the case in June. CSC advised that the FSW held another TAC meeting. It cannot be established whether the FSW was made aware of the need to reconvene a TAC but this never happened and so the TAC fizzled out. 4.3.18 In September, mother agreed to Children’s Centre case closure; mother was happy for closing summaries to be sent to the professionals involved but refused TAC. There is a record of closing summaries being sent, but no corresponding record of receipt by any agency. Finding 2: The interface between CIN and TAC did not work well in this case. The decision that the case should be CIN but managed in TAC was flawed; the case should have remained, at the very least, in CIN. The case being managed in TAC, whilst remaining open to CSC, with continued social worker involvement caused confusion. The meetings held should have been led by CSC with the social worker as the lead professional. Because the case was managed in TAC, the safety of the children was not the primary focus, rather mother’s need for support. However, mother’s support needs were also not met, as there was a lack of robust planning. Mother expressed her dissatisfaction with CSC for the lack of support around the birth of Child D; this likely influenced her decision to refuse TAC during Elias’s pregnancy. When a date for a TAC meeting was not set, no member of the TAC followed this up with the lead professionals. Recommendation 2a: THSCB to seek assurance from CSC that there is clear separation between CIN and TAC, and that all CIN cases are being managed within CSC with a CSC SW acting as lead professional, and no CIN cases are being managed via TAC. Recommendation 2b: THSCB and its partners to ensure the interface between CP, CIN and TAC is understood by all professionals working with children in Tower Hamlets. Recommendation 2c: THSCB to seek assurance that the application of thresholds is now consistent. 4.4 How effective was the identification of need and risk during the mother’s pregnancy with Elias? How effective are local arrangements for identifying need and risk more widely? 4.4.1 In December 2015 mother booked in late for Elias’s pregnancy at a one-stop clinic following referral by the GP. Mother had moved GP shortly after becoming pregnant with Child D. No risk factors were identified in the GP referral; however this becomes understandable as no child protection or safeguarding issues were noted on the GP records for any of the children or mother. The GP did not receive the child protection medical report (see section 4.2). The GP had not been informed of Gateway Team’s involvement during Child D’s pregnancy so was unable to factor this into later 19 pregnancy’s. The usual flow of information is that if women are under the Gateway Team, the GP will be informed of their involvement. 4.4.2 Barts12 received the GP’s referral for Elias’s pregnancy, no concerns were noted for the ante-natal department and, as there was no disclosure of DA by mother, normal processes were followed. Normal process is reliant on mothers making appointments at the GP practice for the midwife. However, mother did not make any appointments therefore the midwife was unaware of mother’s pregnancy; thus no ante-natal care was given. As a consequence, mothers non-attendance was not picked up; of note GPs do not have a formal DNA policy for adults. No meetings are held between GPs and Midwives to share information regarding pregnant women unless there are identified issues. Copies of previous midwifery bookings should be available on CRS (hospital system). 4.4.3 Mother had an anomaly scan at 20 weeks which was normal. Due to poor imaging, a repeat scan was planned but mother did not attend, however she attended a foetal well-being scan in January 2016; no abnormalities were noted. Mother attended the GP practice for a glucose tolerance test (GTT) arranged on booking; the result was noted on the GP record indicating some care, but the lack of midwifery care was not identified. This was a missed opportunity. 4.4.4 In January 2016, an opportunity presented for communication with midwifery services. School contacted the FSW, sharing third party information that mother was pregnant. School were advised if they had any concerns they should report these to CSC or DWP.13 School reported they were not concerned about the children‘s wellbeing; the HV was documented as having given an update; she also had no concerns about the family. There is no corresponding entry in the health visiting records; no one made contact with midwifery. 4.4.5 The only other contact with professionals was an A&E attendance for Child D in February 2016. Child D was admitted with an abscess and remained an inpatient for three days on antibiotics, during which time mother was regularly present; there is no mention of mother being heavily pregnant. 4.4.6 In March 2016 the HV contacted mother following a contact from the children’s centre indicating the case was being closed. The HV believed Gateway midwifery were involved but made no contact with them; this was a missed opportunity. The HV planned to offer a universal plus service. Mother indicated she had no concerns re Child C who was now in fulltime school; there had been no contact between Child C and father 1 in a year. The HV discussed domestic abuse and mother stated she had no contact with father 1 and stated the father of Child D still lived with his first wife; she denied domestic abuse by him. 4.4.7 There is a marked contrast in the level of professional involvement during the pregnancy of Child D and that of Elias. Review of the midwifery records shows 12 Barts Health NHS Trust 13 DWP – Department of Work and Pensions 20 mother was booked according to the pathway that she was referred for, with care to be shared between the GP and midwifery. The GP referral had indicated a complex family set up but had not mentioned any previous safeguarding concerns and was assessed as low risk. 4.4.8 The current system requires either the GP to inform the midwife within their referral or for the midwife, on booking, to access electronic patient records to know the previous history and previous care delivered. The midwife did not look up the previous pregnancy history available in the electronic patient records. The absence of midwifery care means no assessment of need or risk took place during this pregnancy. Finding 3: The system around midwifery care was disjointed with a lack of communication between midwifery teams and between midwives and GPs. No professional who was made aware of the pregnancy made contact with midwifery services to establish who was leading on mother’s care. In addition, there was an over reliance on mothers to make midwifery appointments. Recommendation 3a: Midwifery services to improve their joint working with GPs and review the current pathways to ensure a robust system is put in place so all health professionals are clear which pregnant women are in their care. Notification of attendances/non-attendance must be shared when care is being provided via multiple health disciplines. Recommendation 3b: All women should be given their next antenatal appointment prior to leaving the booking appointment. All GPs to be notified of the pregnancy of all women registered in their care. Difficulties in, and lack of, communication is one of the most common findings in serious case reviews nationally. Recommendation 3c: All professionals to be reminded of the need to share all relevant information with all relevant parties and the potential negative consequences of not doing so. 4.5 Was any additional need or risk identified at the time of Elias’s birth? Did the circumstances trigger any re-assessment of need? 4.5.1 Child D was born before arrival (BBA) of the midwife, at home. The risk of having a further unplanned BBA home birth increases when mothers have had multiple births or have had a previously swift birth; both applied in this case. BBA can however result when mothers are trying to conceal births or are struggling to come to terms with a pregnancy; concealed pregnancy was not a factor in Child D’s pregnancy. However, the reasons for Child D’s BBA were not established; this would have been relevant to know for Elias’s pregnancy. The lack of information sharing and community midwifery involvement meant the opportunity to develop a 21 management plan to reduce the risk of reoccurrence or planning for a home birth in this pregnancy was missed. Mother’s lack of midwifery input during the antenatal period did not come to light and professionals were not alert to previous Maternity Mates and Gateway involvement thus nothing suggested a need to assess parent’s attitude to their situation. 4.5.2 In the post-natal period, Mother and baby had a total of 5 post-natal visits between home and post-natal clinic, mother and baby were checked and an assessment of baby wellbeing was completed. Mother was seen until day 14, which was good practice. The community midwife would have either had to have had prior knowledge of concerns, accessed previous records or contacted colleagues for previous concerns to now come to light. The lack of antenatal midwifery care is not highlighted and apart from the BBA and one failed scan attendance, there was nothing of note during this pregnancy. 4.5.3 Elias was born with missing digits. Research has shown that the birth of a baby with a visible congenital disfigurement requires parents to adjust to a baby that they may perceive as being ‘imperfect’, whilst letting go of their hopes for the perfect baby they had expected. Their responses have been described in terms of bereavement for the expected baby who has been lost, complicated by the need to adapt to the baby who has been born: 14 Whilst that may seem odd to many, the parents did lose a child—the “normal,” healthy child that they were expecting15. 4.5.4 Attitudes to disability can be affected by cultural attitudes and religious beliefs and interpreted in different ways. Research with South Asian parents with a child with autism Warner (1999)16 found that the influence of parents’ Bangladeshi background was most noticeable in their feelings about the child’s disability. Warner noted that two mothers she interviewed indicated a sense of being blamed for having a disabled child and one talked about seeking help from a religious person (pir) in Bangladesh. Jegatheesan et al. (2010)17 emphasised that Asian families’ explanations of having a child with a disability were intertwined with distinct cultural and religious beliefs. 4.5.5 The early responses of the parents can be observed as similar to grief; they often experience varying degrees of denial, anger and tearful distress. In a study18 all the parents described some sense of shock, but there was also evidence of denial. The factor which was significant in the analysis of parental adjustment was perceived family support. This mother had little family support. More thought should have been given to the emotional impact of Elias’s condition on his parents. Elias was, however, reviewed by the neonatal team due to the missing digits of the right hand and a referral made to plastic surgery. 14 Solnit & Stark 1963. 15 Lemacks, J. et al (2013) Insights from parents about caring for a child with birth defects. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3774449/ 16 Warner, R. (1999). The views of Bangladeshi parents on the special school attended by their young children with severe learning difficulties. British Journal of Special Education, 26, 218-223. 17 Jegatheesan, B., Miller P.G., & Fowler, S.A. (2010b). Autism From a Religious Perpsctive: A study of Parental Beliefs in South Asian Muslim Immigrant Families. Focus on Autism and Other Developmental Disabilities, 25, 98- 109. 18 Bradbury. E.T. and Hewison.J. (1994) Early parental adjustment to visible congenital disfigurement. 22 4.5.6 It has not been possible to establish the impact of Elias’ condition on mother and father 2. There was nothing within health records to suggest this was considered. Finding 4: There was insufficient focus during contacts and in assessments of the emotional impact of Elias and Child A’s diagnoses on their parents. Recommendation 4: THSCB to seek assurance from health and partner agencies that the emotional impact on parents of having a child born with any abnormality/disability features within consultations and assessments with recognition of any risks to the child. 4.6 How effective was the new birth visit and what factors shaped the service provided? 4.6.1 The named health visitor did not do the new birth visit herself, allocating the visit to a ‘very good’ colleague. During the latter stages of the mother’s pregnancy the health visiting service had been transferred to another health provider, leading to a considerable period of anxiety and uncertainty for staff, making work on the front line difficult. The family’s named health visitor, who was the most senior member of her team, felt the need to offer support to colleagues and had a high caseload. The health visitor recalled asking her colleague to read the records before making the visit. The health visitor advised her colleague that there would also be a 13-month old child there to be reviewed. This was deemed routine work. The health visitor believed that Gateway midwives were involved in this pregnancy. It appears a lack of information sharing between health services impacted on the quality of care that could be provided. 4.6.2 The health visitor’s colleague conducted the visit, everything was documented. Whilst father was named, he was not present during the visit and no further information is documented. Elias’s fingers were checked (some were under developed). The two colleagues discussed the plan for follow up care, which should have been picked up in the antenatal period, at birth, or by the midwife. Mother had advised of a follow up hospital appointment. The health visitor established when the next contact visit would be and which other key agencies were involved. The plan was that Elias would be seen by paediatric plastics and have a 6 week check review. Discussion regarding the impact of Elias’s condition on mother and father 2 is not documented and believed not to have been discussed (see section 4.5). 4.6.3 The health visitor conducted the 6 week review for Elias, seeing Child D as well. The usual 6 week review process meant the family would go with baby to clinic, baby would be undressed so that growth monitoring could take place in a private room, then the family would see the health visitor, then see a family support worker from the children’s centre (re children’s services in the area and register), then they would see the GP, and finally the Practice Nurse for BCG immunisations. The review was 23 done this way to support the family and aid multi-agency communication/working. The inviting letter advises both parents to attend and allow an hour. 4.6.4 Father 2 was unknown to any of the professionals involved and there is no record of the role he had with the children. Absent fathers present a challenge to professionals who can become overly reliant on mothers being honest about their situations. The health visitor wondered how mother was managing as the sole carer as she believed there was no other person involved at that time. Both children were well presented. The health visitor noted mother was responsive to each child’s needs, and had the letter with the plastic surgery appointment, this demonstrated her capabilities and was noted. The health visitor communicated to the GP that the family had a plastics appointment booked for baby’s hand. 4.6.5 The new provider inherited a situation which was far from satisfactory. The HV told the SCR that she recognised how the new organisation was attempting to introduce a safer, tighter structure; child protection supervision had always been mandatory. Gradually staffing concerns were addressed and new forms of supervision and support were introduced. The service became a much better place to work, but the period that coincided with the latter stages of the mother’s pregnancy and Elias’s life, had been very tough. Finding 5: There was insufficient focus on fathers, household composition and the functioning of the household during HV contacts and within HV assessments. Records did not assist, with no section to prompt these discussions. Recommendation 5: Health services to review documentation and assessment tools and include household composition and functioning of the household. THSCB to seek assurance that this recommendation has been advanced and is proving effective. 4.7 What steps were taken when Elias’s parents did not subsequently bring him to appointments? 4.7.1 In the weeks following Elias’s birth, the mother made herself available for home visits. Mother was advised to attend appointments, register Elias with the GP and register the birth. 4.7.2 Mother followed the plan, taking Elias to a postnatal check, registering with the GP and attending reviews with the health visitor and the GP. 4.7.3 The only appointment mother did not take Elias for was an immunisation appointment; this was followed up as per policy and 10 days later Elias attended for immunisations. 4.7.4 In June 2016, Elias attended his appointment with the plastic surgeon; he was noted to have congenital hypoplasia of his right hand digits. A plan was made for x-rays and 24 clinical photography to be taken and for review in 1 year, with treatment to start from the age of 2, a week later a letter explaining the plan was received by the GP. 4.7.5 Mother would have been viewed as responsive. Finding 6: Having initially thought that Elias had not been taken to appointments the review has established this was not the case and has identified an example of good practice in that policies relating to non-attendance were followed on the sole occasion mother did not take Elias to an appointment, with effect. 4.8 When do we understand that Elias was injured, bearing in mind the limitations of what can be reasonably inferred from medical evidence? Were there opportunities during this period for professionals to have observed signs of these injuries? 4.8.1 It is believed that some of the injuries were inflicted on Elias during the month prior to his death, though it cannot be stated with certainty exactly when. The only professional who saw Elias during this period was the plastic surgeon, as neither the local authority nor community health services were involved at that point. The surgeon had not been alerted to any prior safeguarding concerns and noted nothing of concern at the appointment. 4.8.2 Whilst it is normal practice to undress and weigh all babies within clinics where children are being seen by paediatricians, this was not the case in the paediatric plastics clinic, unless the surgeon had concerns. Because of the site of Elias’s Symbrachydactyly, the plastic surgeon had no need to remove any clothing and, even if this had been done, it is by no means certain that in such a small baby any signs of injury would have been seen. Finding 7: It cannot be certain when the injuries to Elias occurred. The opportunity for professionals to observe Elias for signs of injury was limited to the one contact that was focused on the treatment that would be required for the baby’s hand. Even if Elias had been fully examined on that occasion, the nature of his injuries and the age of the baby made it unlikely that signs of abuse would have been apparent. 4.9 Did professionals take the right action to identify risk to Elias and the other children in the family and act on their assessments during the period between his admission to hospital and his death? 4.9.1 LAS immediately identified concerns on entering the family home in response to the 999 call. The couple did not appear concerned. Father was on the phone with LAS control; the controller was counting out compressions for him but he was lying on the bed and did not have Elias in sight. Elias had multiple injuries and paramedics noted scratches on Child D. Elias was in cardiac arrest and was taken to hospital 25 immediately. Emergency Department (ED) doctors believed Elias’s injuries were non-accidental and contacted the police. A strategy discussion took place. Within 15 minutes of Elias’s arrival, the police attended ED and arrested mother. Police then attended the family home and arrested father 2 who had sole care of Child D. Child A, B and C were at school; the police liaised with school, making arrangements to take all the children into Police Protection. In class discussion, Child C indicated Elias had “slept for the whole day yesterday” and was sleeping when Child C came to school. Father 2’s children were all visited and found to be safe and well. 4.9.2 LAS faxed their concerns regarding the scratches on Child D’s back to CSC at 13:29 the same day. 4.9.3 The day following admission, the hospital e-mailed CSC with detailed information about Elias’s life threatening injuries, a strategy meeting took place. Two days after admission Elias died. The following day interim care orders were granted for Child A, B, C and D. Finding 8: Services followed the London Child Protection Procedures appropriately referring and responding to Elias and Child D’s injuries. It could be argued that Child D should not have been left in father 2’s care whilst Elias was being transferred to hospital, however the ambulance crew’s priority at this point was to preserve Elias’s life and the police were contacted soon after Elias entered hospital. 26 5 CONCLUSIONS 5.1.1 The professionals who continue to work in Tower Hamlets and agreed to be part of this process have been deeply affected by the death of Elias and the subsequent conviction and imprisonment of his parents. 5.1.2 Mother was seen as someone doing her best for her children, indeed it was felt mother was doing well on her own. Mother was observed by professionals to be attentive to the children and was, on the whole, taking the children to their appointments. Father 2 features little in any records of contact or assessments, and the level of his involvement with the children in this household was never clearly established. 5.1.3 There was mismanagement of the incident of physical abuse in 2015 within Children’s Social Care and partner agencies. The children’s voices were sought, heard and listened to, but not given appropriate weight. The children were consistent in stating mother had hit Child C with an implement; however, it was the voice of mother that was believed. 5.1.4 Systems and processes around Child Protection medicals at this time were not robust; it remains unclear as to whether Child C’s injuries were ever photographed by Medical Illustration. The child protection medical report stating the medical opinion that “in view of the history and presentation, physical abuse is likely” was at best misinterpreted, at worst never read. Children’s Social Care workers believed the medical was inconclusive. Advice given for the other children in the family to have child protection medicals, and if Child C was to return to mothers care an Initial Child Protection Conference to be held, was not followed. Clear evidence of abuse with injuries consistent with the child/ren’s explanations was lost. 5.1.5 Mother agreed to a Team Around the Child approach to support on the grounds she would need help when Child D was born with care of her other children. Team Around the Child requires parents to engage; in the months that Team Around the Child meetings were held mother attended only one, reducing Team Around the Child meetings to professionals only meetings. There was good professional attendance and evidence that professionals were working with mother, however there was no lead professional allocated until the last meeting, no challenge regarding mother’s non-attendance and no consideration that the case needed to be stepped up. 5.1.6 A robust plan to address care of the children during Child D’s birth was never developed leading to mother making her own alternate arrangements late in pregnancy. In short, it is difficult to establish any additional benefit for the children and mother from the Team Around the Child approach. Allocation of a Lead Professional at the first Team Around the Child meeting is essential. The impact of the lack of an allocated lead professional and lack of multi-agency approach cannot be under estimated. In this case, it led to a lack of co-ordination and clarity for both professionals and mother and reduced opportunities for communication between professions and teams. A lead professional would have been well placed to challenge single agency decisions. 27 5.1.7 Systems within midwifery allowed a mother to go through Elias’s whole pregnancy with no midwifery care save antenatal scans and a blood test. Mother was at risk of a born before arrival delivery, with potential risks to both mother and child. Lack of robust systems and processes and poor inter-agency communication led to a lack of midwifery care, which ultimately meant there was no plan in place to manage this potential risky situation safely. 5.1.8 The lack of recognition of the potential psychological impact of Elias’s missing digits on his parents was not fully explored; a more holistic approach to assessing and managing Elias within the context of his family was needed. End. 28 6. APPENDIX 1 – GLOSSARY OF TERMS & ABBREVIATIONS A&E Accident and Emergency ASD Autism Spectrum Disorder BBA Born Before Arrival CAF Common Assessment Framework CIN Child in Need CP Child Protection CSC Children’s Social Care DNA Did Not Attend DA ED Domestic Abuse Emergency Department FSW Family Support Worker GP General Practitioner HV Health Visitor IPST Integrated pathways and support team LA Local Authority MASH Multi-Agency Safeguarding Hub TAC Team Around the Child |
NC52283 | Sexual abuse of two sisters aged 14-years-old and 13-years-old by their father over a period of six years. Both children were placed with a foster family, and a police investigation was initiated. Learning focuses on: home education of children; working effectively to identify and address sexual abuse and exploitation; understanding adult sexual offending behaviour and evaluating the risks of likely and future harm; supporting children to seek help from professionals; children communicating that something is wrong through their behaviour; interviews with children which do not follow guidance are likely to undermine effective safeguarding, decision-making in the family courts and criminal processes; recognising and addressing the impact of domestic abuse; safeguarding children from being physically harmed, characterised as "physical chastisement or physical punishment"; delivering culturally competent practice; the importance of a structured approach to children's experience of parental neglect over time. Recommendations include: make a recommendation to the National Panel to complete a thematic review of serious case reviews, rapid reviews and child safeguarding practice reviews that relate to home educated children; scrutinise how partner agencies are equipping their staff to understand and support children's help seeking behaviour; issue a child centred position statement about the appropriateness of physical chastisement and provide guidance about what safeguarding responses are required; understand and scrutinise how supervision arrangements promote professional curiosity, are child centred, and address fixed thinking across partner agencies.
| Serious Case Review No: 2021/C9189 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. 1 NSPCC on Behalf of an unnamed Safeguarding Children’s Partnership Child Safeguarding Practice Review Hatty and Jen Family J Jane Wiffin July 2021 This review is dedicated to the bravery and courage of Hatty and Jen who experienced significant harm but found a way to tell adults what was happening to them. This is not an easy thing for those who are being abused and harmed at home. 2 CONTENTS Pages 1. Introduction 4-6 Why this Child Practice Safeguarding Review (CSPR)1 is being undertaken Process of the review Family involvement 2. Narrative chronology of professional involvement and family background 6-12 3. Analysis, findings, and recommendations 13-15 15-20 20-21 21-23 24-25 26-27 27-28 Finding 1: Home education of children Finding 2: Working effectively to identify and address sexual abuse and exploitation Finding 3: Recognising and addressing the impact of domestic abuse Finding 4: Safeguarding children from being physically harmed, characterised as “physical chastisement or physical punishment” Finding 5: Delivering culturally competent practice Finding 6: Working to address the long-term neglect of children Finding 7: Recognising and addressing fixed professional thinking 1 In England, child safeguarding practice reviews (previously known as serious case reviews) should be considered for serious child safeguarding cases where abuse or neglect of a child is known or suspected. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf pg. 84 3 1. Introduction Why this Child Safeguarding Practice Review (CSPR) is being undertaken. 1.1 This independently led Child Safeguarding Practice Review is about Hatty (aged 14) and Jen (aged 13) who reported being sexually abused by their father over a period of six years. Immediate safeguarding action was taken; they were placed with a foster family and a police investigation commenced, which is ongoing. 1.2 The local Safeguarding Children Partnership2 in area 1 (SCP) undertook a Rapid Review of the contact agencies had with Hatty and Jen and concluded that their circumstances met the criteria for a serious child safeguarding incident as set out in Working Together 20183 and that a local CSPR would be commissioned. The Safeguarding Children Partnership Learning Group noted that Jen was being home educated and that this was one of two incidents where children were being home educated and where there were concerns about sexual abuse and neglect where children were being home educated. This raised questions and concerns about the potential invisibility of home educated children, possibly leaving them without support or adults to talk to outside the home when they have worries or concerns and/or are experiencing abuse. 1.3 With a thematic focus the review examined elective home education and how agencies can more effectively safeguard this group of children. The review also considered the involvement of multi-agency partners with this family over time. It is important to note that multi agency involvement with this family commenced when mother was pregnant with Hatty, some 15 years ago. While the historic nature of some of this involvement means that practice has since changed significantly, particularly in relation to safeguarding children who are the victims of sexual exploitation, where contemporary research suggests that an issue remains relevant to the national safeguarding landscape this learning has been included. Process of the review 1.4 The methodology adopted for this CSPR was a hybrid systems approach with a focus on evaluating the practice response to the children, identifying improvements needed locally and nationally to safeguard and promote the welfare of children, and to consider whether there is a need for policy and practice change in any identified area. This approach is consistent with the purpose of CSPRs as outlined in Working Together 2018. 2 The Children and Social Work Act 2017 introduced the requirement that local safeguarding children boards be replaced with new local safeguarding children partnerships led by three safeguarding partners – the Local Authority, Clinical Commissioning Group and Police; this is called the Safeguarding Children Partnership. 3 Working Together 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/779401/Working_Together_to_Safeguard-Children.pdf Chapter 4, pg. 81 4 1.5 All key agencies were asked to provide a chronology of their involvement with Hatty and Jen and their family over the period from 2010 to the disclosure of sexual abuse in 2020. The family spent some time in local authority area 2 (LA2) and they have provided a chronology. Interviews were conducted with the professionals who had recent contact with Hatty, Jen and their father. These professionals provided useful insights and reflections on the family circumstances and the lives of the girls. Staff from the school that Hatty and Jen had previously attended knew them well and felt deeply about their wellbeing. Finding out they have been abused and harmed was difficult for them. 1.6 The CSPR was overseen by a panel of agency representatives (CSPR panel) who met regularly and who contributed to the analysis of the available information, helped to consider practice themes, and provided appropriate robust and sensitive challenge. The CSPR was chaired efficiently and compassionately by the SCP Chair of the Learning and Thematic Review Group, managed very efficiently by the Partnership Board Manager, and administered effectively. I would like to thank everyone for their hard work and commitment at what has been a challenging time, with all the restrictions and increased demands caused by the Covid-19 pandemic. The independent reviewer is Jane Wiffin, who is independent of all agencies, and she is responsible for writing this overview report. Family involvement 1.7 The review considered the best way to include Hatty and Jen in this review. They have both experienced a lot of change and have had to tell many adults about their lives. They wish to settle into their new settled circumstances. Their views will be represented by those that know them well and in the context of the criminal proceedings. 1.8 Father is a potential subject of criminal proceedings and so it has not been appropriate to seek his views. 1.9 The independent reviewer spoke to mother at length. This has been a difficult time for her. She had not had contact with Hatty and Jen for many years. This is in the context of historical coercion and control by the father towards mother; she believed that he would be a good father with support from his extended family. She was shocked to hear about the allegations of abuse made by Hatty and Jen. Her reflections are in tune with some of the findings of this review. She reported being too young to understand that she was being sexually exploited by father She was a young parent who coped well initially. She completed an apprenticeship when the girls were little and got a good job. She said that father’s violence, coercion, and control undermined her and caused deep depression. She felt professionals did not 5 see this, hear her voice, or recognise her position. She feels a deep sense of responsibility for Hatty and Jen and what has happened. 2. Chronology of professional involvement with Hatty, Jen and their family Historical Information Jen and Hatty are dual heritage: Black British and British Asian. They have a large extended paternal family, with whom they had regular contact. They had limited contact with their mother from when their early years until very recently and they had no contact with their extended maternal family. 2.1 Hatty and Jen’s mother came into local authority care aged 13 and once in care she lost contact with her family. 2.2 During father’s contact with professionals and services there was little exploration of his family and their circumstances. He told the professionals that he had a complex and difficult relationship with his mother and had been physically abused as a child by his parents, he said he witnessed domestic violence and that he was violent to his mother in his teenage years. During the recent legal proceedings because of the allegations made by Hatty and Jen, many members of the female extended family shared a history of sexual abuse, domestic abuse, and physical abuse in childhood. 2.3 Throughout the written records for Hatty and Jen there are few descriptions about how father met mother. It is known that he was 20 and she was 14 and she was a child who was in the care of the local authority. This was determined as equating to sexual abuse and was reported to the police by her social worker. Father was cautioned for the offence of sexual activity with a child under 16 and placed on the sex offenders register for two years. When compared to today’s standards of practice, in relation to children who are sexually exploited, the actions taken by CS and police may seem to be standard practice. In reality, at this time, this practice was far from universal. As evidenced in the various enquiries4 and serious case reviews5 that have subsequently happened, children like mother who were being sexually exploited were seen as making ‘lifestyle choices’ to enter into these ‘relationships’. Therefore it is important to note that the actions taken by CS and police at this time was good practice. However, the importance of this case history needed to be kept in mind when providing services to the children and when making decisions about their care, but this issue of father’s sexual abuse of mother became lost overtime. 4 Such as: Independent Inquiry into Child Sexual Exploitation in Rotherham 1997 - 2013 Alexis Jay OBE 5 Such as: Serious Case Review into Child Sexual Exploitation in Oxfordshire: from the experiences of Children A, B, C, D, E, and F Oxford Safeguarding Children Board 2015 6 2.4 Mother was pregnant and aged nearly 16 when Hatty was born, Jen when she was 17. Mother lived with a foster family, but quickly moved to independent accommodation. Father lived some of the time with them. Chronology of professional involvement 2.5 This is a high-level summary of the historical involvement of Hatty, Jen and their family with professionals over a 10-year period. It does not include all contacts or meetings. Although these are historical events, they are important in understanding Hatty and Jen’s early lives and the cumulative impact on their teenage years. There will be little commentary on events, but important themes will be highlighted and discussed in the analysis and findings section. Living in Local Authority 1: a 12-month period Hatty aged 4, Jen 3. 2.6 When Hatty and Jen were 4 and 3, mother called the police because father had violently assaulted her; she reported this has not been the first incident. Father was arrested, charged, and sentenced to a one-year probation order and required to attend an integrated domestic abuse programme (IDAP6). An initial assessment7 was completed at this time by LA1 and this concluded that mother provided good care to Hatty, and Jen and a warm and caring relationship was observed between mother and the girls. Father left mother’s flat at this time, but over the next six months would move in and out when he had no other accommodation. This caused concern to the leaving care worker who supported mother. 2.7 Some months later father reported to the police that he had found Hatty and Jen at home alone at 8am; the door to the flat was locked and mother had been away all night. When the police arrived, there were concerns about the state of the flat and indications of neglect. Mother was arrested for child neglect, but this charge was not pursued. The girls were placed with foster carers for the next seven months and made subject to child protection plans for neglect8. Mother reported that she had been suffering from depression; father said he had been the main carer for the girls and mother did not dispute this, despite father not living permanently with them. It was agreed that parenting assessments would need to be completed. 2.8 The parenting assessment9 described mother as having a warm, loving, and caring relationship with the girls and that father’s parenting style was harsh, 6 IDAP is a nationally accredited community-based groupwork programme designed to reduce reoffending by adult male domestic violence offenders. 7 An Initial Assessment was a brief assessment of each child referred to children’s services to determine whether the child was a Child in Need of protection of additional services and the nature of any services required. This has been subsequently replaced with the single assessment process. 8 A child protection plan is drawn up at the initial child protection conference. It says what support and monitoring will be put in place when a child is at risk of significant harm because they have suffered, or are likely to suffer physical abuse, emotional abuse, sexual abuse, or neglect. 9 An assessment of parent's ability and capacity to provide good enough care for their child. The assessment will usually look at the parent's personal history, views, and attitudes towards parenting, understanding of child 7 critical and he did not engage with the girls. Mother expressed uncertainty in her ability to parent and commit to the girls; she had been inconsistent in her attendance in contact. Father expressed a strong desire to parent the girls. The parenting assessment concluded that father should have full care of Hatty and Jen, with the support of the extended family with whom they would live. Mother was to have regular supervised contact with Hatty and Jen. 2.9 Initially contact arrangements were that mother and father would see Hatty and Jen together, but mother reported domestic abuse by father to the police and father reported mother assaulted him and it was agreed that contact would be held separately. Move to Local Authority 2: an 11-month period Hatty aged 6, Jen 4. 2.10 Father and the two girls moved to live with the extended family in a new area (LA2). The family history was shared, an assessment completed and a child in need plan put in place. This was to support father in his parenting role and to encourage mother to maintain contact. There were regular child in need meetings10, home visits and Hatty and Jen were routinely seen on their own. Mother was not part of these plans, and there were inconsistencies in contact arrangements which remained unexplored. 2.11 A referral was made to CAMHS by Hatty and Jen’s GP because they were anxious and unsettled at school. This referral provided few details, except that the girls had been abandoned by their mother with whom they now had intermittent contact and they were described as upset, anxious and unsettled by this. Family therapy with father and the girls was agreed and would be ongoing for the next few years. 2.12 Father reported concerns about his mental wellbeing to his GP and he was referred to the local psychiatric community mental health team11. He was seen by a psychiatrist and reported a troubled childhood, long-standing depressed mood and feeling overwhelmed by his current family responsibilities. He was prescribed anti-depressants and the plan was support through psychotherapy. Father did not attend subsequent appointments because he said he was feeling better and said he no longer needed support. He had no further contact with adult mental health services. 2.13 There was serious conflict between father and extended family members which threatened the stability of the arrangements for Hatty and Jen. These were development and a child's needs, the resourcefulness of the parent to seek help and support, and who forms their support network. This will then form the basis of a report with a recommendation to the court in care proceedings or a local authority decision about who should care long-term for the child and what support a parent would require caring for their child. 10 These meetings are convened regularly, bringing together the multi-agency network. 11 Community mental health teams (CMHTs) support people with mental health problems living in the community, and their carers. The team may include a community psychiatric nurse (CPN), a psychologist, an occupational therapist, a counsellor, and a community support worker, as well as a social worker. Often a member of the team will be appointed as a care coordinator, to keep in regular contact and help plan care. 8 resolved, but there were ongoing family tensions, conflicts and violence which impacted on Hatty and Jen’s wellbeing. One of these was Jen telling school that father had hit her. This was investigated by their social worker; father denied that this had happened, and Jen withdrew her allegation. The conclusion was that this was likely physical chastisement and the child in need plan continued. 2.14 Father was accused of a significant physical assault by a female member of his family, which involved the police. Father was asked to leave, and he and the girls were homeless. Move back to LA1 and support through an early help plan: a period of 9 months Hatty aged 6, Jen 5. 2.15 The family were provided with temporary accommodation in LA1. LA2 continued to provide support to the family; the children were seen regularly and reported to be happy and settled and father was described as more confident in his parenting. CAMHS continued to play an important role in supporting the family. 2.16 Father was discussed at a multi-agency risk assessment conference (MARAC)12 because of the recent assault on a female family member. The conclusion was that father posed a high risk of future domestic abuse. LA2 ceased their work with Hatty and Jen at this time and LA1 put in place an early help plan focused on parenting support. Family therapy and individual support continued at CAMHS. The CAMHS team tried to include mother in the work by suggesting individual sessions with the family therapist, but mother was not able to engage with this. 2.17 Father sought to have the contact order13 in place for mother revoked. A section 7 report14 was commissioned and undertaken by a student social worker (LA1 SSW1). This report highlighted the recent family history and the views of Hatty, Jen, father, mother, and the extended family. Jen and Hatty talked positively about their life with father. Jen reported concern that father sometimes slapped them and Hatty referred to arguments which she did not like. They both reported missing their mother and the role that father played in deciding when they would 12A MARAC is a meeting where information is shared on the highest risk domestic abuse cases between representatives of local police, health, child protection, housing practitioners, Independent Domestic Violence Advisors (IDVAs), probation and other specialists from the statutory and voluntary sectors. After sharing all relevant information they have about a victim, the representatives discuss options for increasing the safety of the victim and turn these into a coordinated action plan. The primary focus of the MARAC is to safeguard the adult victim. The MARAC will also make links with other fora to safeguard children and manage the behaviour of the perpetrator. 13 A contact order specifies how often the parent who does not live with the child should see the child or children and the terms of that contact. 14 A Section 7 report is ordered by the Court when they want information about a child’s welfare, what is best for the child and sometimes where there are certain risk factors or concerns raised in relation to a child, parent or other relative. A social worker will provide an independent assessment of a situation and will report these findings to the Court. The Court usually stipulates what they want the worker to focus on in their report. 9 see her. Father reported that mother had been unreliable in attending contact; mother reported this was because was father was controlling and had prevented contact. 2.18 The private law proceedings15 discharged the contact order in place for mother and concluded that the parents needed to agree contact arrangements between them. Father proposed that the contact arrangements remain the same, with mother seeing the girls one evening a week and having telephone calls. Mother now had a full-time job, and she was providing financial support to father for Hatty and Jen. 2.19 Father was convicted of harassment of mother and received a two-year restraining order16 with father not to have any contact with mother under any circumstances. There was now no professionals oversight to consider what this meant for contact arrangements. Continued support from CAMHS: a period of two years Hatty aged 7, Jen 6. 2.20 For the next two years Hatty and Jen lived with Father in temporary accommodation in LA1 and they continued to be supported by CAMHS and their school. There were regular family therapy sessions and CAMHS started an assessment of Hatty and Jen for child psychotherapy17. The stated aim of the psychotherapy was to support the girls regarding their feelings of abandonment by mother, her unreliability and absence. The girls were regular attenders of the sessions with the psychotherapist which were recorded in terms of their play. Early on Hatty and Jen played out situations that indicated their distress and this is discussed further in the analysis section. After two years the contact with CAMHS service came to an end. A referral by a family member to the NSPCC: a period of 6 weeks Hatty aged 9, Jen 8. 2.21 Almost immediately after the CAMHS support ended an extended family member made a referral to the NSPCC. This included concerns about neglect, father’s aggression, a lack of emotional care for the girls and that father was preventing contact with mother. LA1 started a single assessment18; father 15 Private law means a court case that is just between family members, such as parents or other relatives – and which does not involve a Local Authority or other state agency. 16 Restraining orders are court orders issued by a judge at the end of criminal proceedings to prevent someone from causing harm to someone else, in situations involving domestic violence, harassment, stalking or sexual assault. Restraining orders put restrictions on the offender, for the purpose of refraining them from causing further trouble to the victim. 17 The local CAMHS service described child psychotherapy as helping children and young people to make sense of sad, angry, painful, or confusing feelings and thoughts. Its focus is to improve relationships at home and on behaviour, as children become less preoccupied or better able to concentrate. Most children can then make better use of opportunities at school. Child psychotherapists are trained to help children understand feelings that are not possible to speak out loud. They do this through play, drawing and talking about events and experiences. 18 When children and young people are referred into children's social care for assessment and meet the threshold, they are allocated to a qualified social worker to undertake a single assessment which should identify their needs and risks and understand the impact of any parental behaviour on them as an individual. 10 refused consent for the school the girls attended to be contacted on the basis that he had a good relationship with them, and they would already have shared concerns if they had any. The assessment noted that the flat was in a poor state of repair, without basic amenities. The sleeping arrangements seemed chaotic. Father reported this was all due to financial constraints. Hatty and Jen said they were unhappy about the living arrangements, and they missed their mother. Mother said that father was not enabling her to see Hatty and Jen. The conclusion of the assessment was that the referral concerns had not been substantiated and no further action was considered necessary. The issue of distinguishing genuine economic hardship from poor emotional care and neglect is discussed in the analysis section. School support: a period of 4 years 2.22 For the next 4 years the family had no further contact with any specialist services. The primary school the girls attended were unaware of any historic concerns about sexual abuse, domestic abuse, violence, fractured family relationships or possible issues of neglect. Over the following years they had some concerns about Hatty and Jen. These included them being hungry at school, being unkempt at times and they were often unable to get hold of father to discuss concerns with him. Advice was sought from the multi-agency safeguarding hub (MASH19) about a lack of supervision for Jen after school. The school felt that all these concerns were poverty related, and they believed that father was at times struggling as a single parent. Concerns were always discussed with him, and practical support provided. 2.23 When Jen was in her last term of primary school, her learning mentor became aware that she did not have a secondary school place. Contact was made with father who said that Jen had not received an offer from her preferred school, and he planned to home educate her until a place there became available. The learning mentor liaised with all appropriate agencies regarding this, including expressing her view that home education was not right for Jen because of the amount of support school currently provided which would be absent going forward. The junior school thought carefully about Jen and her social and emotional needs; they organised for Jen to help with after-school homework club and art club to ensure that she had contact outside of the home and to support her emotional wellbeing. 2.24 The Elective Home education (EHE) service contacted father to organise a meeting and a home visit was agreed. At this visit the EHE teacher was satisfied with the learning materials provided for Jen. There were no concerns about their accommodation which was assessed as suitable for home education. Jen 19 Multi-agency safeguarding hubs (MASH) are a hub of key agencies (which can include children's services, police, health, education, probation, and youth offending) which are co-located or have an agreed protocol in place to promote better information-sharing, decision-making and communication in relation to concerns about children. The aim is that referrals are responded to in a coordinated, appropriate, and timely way. 11 said that she liked being home educated and that she could take her time without lots of other children around. The EHE teacher noted that Jen seemed very anxious, was struggling to contain her emotions and she cried at one point. Father was seen to respond appropriately to reassure her, and he said that Jen put a lot of pressure on herself to succeed. 2.25 The EHE teacher contacted the learning mentor at the junior school to talk this over and to ask if there had been any child protection concerns. The learning mentor said that she did not think this home education was the right plan for Jen, but there had not been any safeguarding concerns. She decided that no further action was necessary at this time and said she would visit Jen again in 6 months to check on progress. This home visit got moved twice by father and was planned for 9 months later and never took place because the allegations of sexual abuse had been made. 2.26 Hatty told professionals that her father had been sexually abusing them for many years and when interviewed Jen also reported a long history of sexual abuse. Father was arrested and Hatty and Jen were placed with a foster family. A joint police/children’s services child protection inquiry started, and an Achieving Best Evidence interview was conducted. At the conclusion of the Finding of Fact hearing later in 2020 the presiding judge was critical of the initial police/children’s services interviews with Hatty and Jen and the subsequent ABE interview. This meant that the ABE interview has had to be undertaken again. Criminal proceedings are ongoing. 12 3. Analysis and findings 3.1 The purpose of a local Child Safeguarding Practice Review is to look at the circumstances of children who have been harmed and to consider whether there are lessons to be learned about how agencies work, both individually and collectively, to safeguard and promote the welfare of children and to consider any necessary changes to practice or processes as a result. This CSPR was initiated because of the serious allegations made by Hatty and Jen about being sexually abused by their father; this was in the context of Jen being home educated. This is one of two reviews within this child safeguarding partnership where children who are home educated have made disclosures of sexual abuse. This raises important questions about the extent to which the current home education guidance ensures the safety and wellbeing of these children. This is underlined by the number of recent serious case reviews where home education is a factor where children have been harmed and abused. This was the review’s starting point, but in seeking to understand Hatty and Jen’s circumstances, it has emerged that here were several historical concerns. These are outlined below; although they are historical, they are part of Hatty, Jen and mother’s story and are important to consider in the context of the harm they experienced. Finding 1: Home education of children 3.2 At the point of Jen’s transfer from junior to secondary education, father decided that she would be home educated; he gave his rationale as waiting for a place at her preferred school. Jen’s junior school was concerned that this was not the right decision for Jen because of the amount of support they were providing to her. They were unaware of the family history, and although they worried about father’s ability to cope and his struggles financially, they did not have any safeguarding concerns. Jen’s school could see no way in which they could object to this; in England parents have the right to educate their children at home, but they encouraged father to register Jen as home educated to ensure some oversight of her needs and circumstances. In addition, they organised for her to come regularly into school. This was effective practice; there is no requirement for parents to register children as home educated, and this can increase their invisibility and isolation. 3.3 Once Jen was registered as home educated, Father agreed to meet the home education teacher and agreed ultimately to a home visit. The primary purpose of a home visit in these circumstances is to ensure that a child is being provided with an appropriate education. Section 7 of the Education Act 1996 makes clear the importance of children of compulsory school age receiving efficient full-time education that is suitable to their age, ability, and aptitude, and addresses any special educational needs. The home education teacher was satisfied with the evidence provided but was aware that Jen seemed stressed and a little 13 distressed. She judged that father responded in an appropriate way and checked with Jen’s school that there were no current safeguarding concerns. She did not feel that there were safeguarding concerns to be addressed. The home education teacher could have sought information from the MASH team, which would have provided her with background information. 3.3 Sections 10 and 11 of the Children Act 200420 give local authorities duties for safeguarding and promoting the wellbeing and welfare of children in their areas. This includes children educated at home. Section 175 of the Education Act 200221 requires authorities to plan for ensuring that their education functions are exercised with a view to safeguarding and promoting children’s welfare. Therefore, the general duties of local authorities in relation to safeguarding are the same for all children, however they are educated. In some circumstances elective home education may make it more possible for parents to prevent the independent oversight by professionals of children who are being harmed and neglected. 3.4 There have been several serious case reviews nationally22, 23, 24 & 25 that have highlighted home education as a factor in the abuse and neglect of children, although not necessarily a causal one. The main consistent finding of these many reviews is the invisibility of home educated children and their lack of contact with agencies who could monitor their safety and wellbeing. Most of these reviews suggest that parents actively prevented this contact. This is an important issue. There is considerable research which suggests that children find it difficult to tell anyone when they have been abused, particularly when they have been sexually abused. When they do tell, they usually choose a friend, a friend’s parent or family, someone trusted in their own family, a teacher, school mentor, school nurse or extra-curricular activity provider. For home educated children, there may be fewer opportunities for these contacts and therefore fewer opportunities to seek help about abuse. 3.5 The home education teacher had insufficient evidence to believe that Jen’s circumstances met the threshold for safeguarding action. Recent changes to the home education service means that there is easier access to the MASH and background information; the home education service now has routine safeguarding consultation sessions and they can bring children about whom they have concerns or worries to a regular meeting for discussion. These are all important steps; however, it remains of concern that there are children with vulnerabilities, but which does not immediately meet the threshold for safeguarding action, who by virtue of their home educated status do not have access to school nurses or those who could evaluate their ongoing emotional and social wellbeing. 20 https://www.legislation.gov.uk/ukpga/2004/31/contents 21 https://www.legislation.gov.uk/ukpga/2002/32/contents 22 https://bbcdevwebfiles.blob.core.windows.net/webfiles/Files/case-reviews-home-education.pdf 23 http://www.northamptonshirescb.org.uk/scr/childab 24 https://www.cumbria.gov.uk/eLibrary/Content/Internet/537/6683/6687/17123/426059438.pdf 25 https://www.oscb.org.uk/practitioners-volunteers/serious-case-reviews/ 14 Recommendations: 1. The local home education policy should be refreshed to explicitly focus on child-centred practices and taking account of the findings of the two recent local CSPRs, the 2019 national guidance and the interplay between elective home education and children missing from education. 2. The Local Safeguarding Children Partnership to make a recommendation to the National Panel to complete a thematic review of serious case reviews, rapid reviews and CSPRs that relate to home educated children. Finding 2: Working effectively to identify and address sexual abuse and exploitation. 3.6 The sexual abuse and sexual exploitation of children and young people is a serious issue which has significant negative emotional and developmental consequences which can last throughout childhood and into adulthood. Prevalence studies for England and Wales suggest that some 15% of girls and 5% of boys experience some form of sexual abuse before the age of 1626. However, sexual abuse is a hidden crime and many of those who experience it do not report their experiences for several years, if at all. In fact, it seems that only around 1 in 8 cases of child sexual abuse reach the attention of statutory services, which means far more children are being sexually abused than agencies are currently identifying or safeguarding27. 3.7 There is considerable evidence that children subject to sexual abuse are not identified by professionals, that there is an over-reliance on children telling professionals what is happening to them, and when they do tell, their testimonies are often considered unreliable, and they do not stand up to scrutiny in comparison to denials by adults. There are many known barriers to children telling someone that they have been sexually abused including fear, shame, embarrassment, coercion, family cultural pride and lack of recognition that what is happening is abuse. The Children’s Commissioner and a recent thematic Joint Targeted Area Inspection28 have expressed concern about how effectively the safeguarding system meets the needs of this group of children. So, although some of what this review highlights are historic in nature, there are likely to be ongoing concerns about the complexities of addressing sexual abuse. 26 https://www.csacentre.org.uk/csa-centre-prod/assets/File/CSA%20Scale%20and%20Nature%20infographics%202nd%20edition.pdf 27 Children’s Commissioner report, 2015 https://www.childrenscommissioner.gov.uk/report/protecting-children-from-harm/ 28 https://www.gov.uk/government/publications/the-multi-agency-response-to-child-sexual-abuse-in-the-family-environment 15 Understanding adult sexual offending behaviour and evaluating the risks of likely and future harm 3.8 The first significant issue emerging from a review of Hatty, and Jen’s circumstances is the issue of father’s early sexual abuse of mother. This happened 16 years ago, and the passage of time means that there is little information about the circumstances in which father met mother, but it was when she was 14 and in the care of the local authority. At the age of 15 she was pregnant with Hatty. Father was an adult who had sexually offended against a child which should have alerted professionals to consider him a possible future sexual risk to children. Mother was a child/young person in the care of the state and as the corporate parent; the police were alerted by mother’s support worker to these concerns, and this led to action. Concerns about father’s sexual offending behaviour, potential grooming behaviour and likely coercion and control got lost. Over time the information about father’s sexual offending became vague and unclear. Father often misrepresented the age gap when he and mother met, and as time went on his sexual abuse of mother was not a known factor of concern or was euphemistically referred to. 3.9 It is striking that so many members of father’s family were themselves sexually abused in childhood. Father’s sister tried to tell her mother (MGM), but reported not being listened to. Maternal Grandmother reported that the sexual abuse she experienced had a profound impact on her life and she was not able to tell anyone about it. The learning here is that all professionals need to be alert to the possibility of child sexual abuse, be prepared to give children the opportunity and support necessary to talk about it and make sense of behaviour as communication. 3.10 This history of sexually offending against a child should always be taken seriously. In 2004 the Bichard inquiry reported that the sexual behaviour of Ian Huntley with children had not been taken seriously enough and professionals had been too ready to accept that these were equal and consenting relationships. This report focused on the importance of understanding adult males who prey on and groom young girls to sexually abuse and exploit them; this led to a clear framework for analysing underage sexual activity which was contained in the accompanying good practice guidance to Working Together 2006. There have been similar concerns emerging from the many inquiries across the country regarding child sexual exploitation, particularly those who are care experienced (in the care of the state) and the role of the corporate parent. There have been some very significant changes in statutory guidance, procedures, safeguarding practice and societal attitudes regarding the sexual exploitation of children but it remains important to continue to reflect in the context of contemporary practice whether professionals are currently equipped to assess the grooming behaviour of adults who are likely to/have sexually 16 abused a child to make an appropriate risk assessment and consider the implications for future harm rather than accept notions of a perceived relationship and consent. Father sexually abused mother: the lack of analysis of his offending behaviour and that the sexually abuse got lost in professional records, meant that no one considered that father might pose a sexual predatory risk to other children, including Hatty and Jen. Supporting children to seek help from professionals. 3.11 It is a core ambition of the safeguarding system that children and young people feel able to talk to family, friends, and professionals about any concerns they have. This concept of help-seeking behaviour is important. Help-seeking behaviour is a core part of child development, where babies and children learn over time how to seek help, get validated for that help seeking behaviour and learn who can be trusted. It is an essential skill. It is a developmental task which takes place over time and is supported by the response of parents/adults. This starts in babyhood when a baby cries and someone responds. Children who are abused, neglected or who receive inconsistent care over time are likely to have underdeveloped help-seeking behaviour or are actively discouraged or prevented from seeking help through threats, intimidation, or suggestions of impact on family. It is essential that professionals respond to children’s help-seeking behaviour generally, but specifically in the context of children raising concerns about safeguarding matters. The research evidence suggests that children will “test out” the response of professionals before making more serious allegations of harm. It is essential that in a child-centred system children’s concerns are listened to and responded to. 3.12 At the beginning of 2012 Jen told someone at school that she had been “beaten” by her father and this had been witnessed by a member of the family. Jen told the SW she had made the story up; the social worker noted that both girls seemed nervous, but there was insufficient reflection regarding whether the girls had been asked/intimidated into withdrawing the allegation and the conclusion of these enquiries implied that she had made up the story for attention. 3.13 The focus should have been on the fact that Jen was asking for help and the meaning of this explored further. Children want validation for their concerns and the message that harming children is wrong; they want to know what action will be taken, they want their need for help acknowledged and reinforced and there to be some repair of the harm experienced. This will enable them to develop help-seeking strategies in the future because they have been heard; the message is that telling people that something is wrong is the right thing to do and will lead to some action. It is critical that professionals respond proactively and with curiosity to children when they seek help, exploring and analysing the meaning for the child and the implications for their wellbeing. If their worries are 17 not acknowledged and their concerns not explored and understood, then they are less likely to seek help from professionals again. Behaviour as communication 3.14 Whilst the case events referred to in this section happened almost 10 years ago contemporary research suggests that children often think they have communicated that something is wrong for them or that they are being sexually abused through their behaviour; they hope professionals will notice, pick up on clues in their behaviour, and act. CAMHS recognised that much of Hatty, and Jen’s play and behaviour indicated distress. This was recorded and analysed in the context of their past abandonment by their mother, without any reflections on their current circumstances of living with father who had mental health difficulties and who was known to be violent to others. The girls’ behaviour observed during therapeutic sessions needed more exploration and connection to the known incidents of domestic abuse perpetrated by father. CAMHS had concerns about father’s behaviour and demeanour which were also recorded, this behaviour was concerning but not sufficiently analysed in the context of parenting and the need to provide consistent emotional care to Hatty and Jen. It is possible that the risks posed to the children were obscured from view in the context of the positive engagement and the therapeutic alliance that had been achieved. 3.15 The children’s preoccupation about toileting issues was not analysed, and it is meaning therefore not understood. If CAMHS had known that father had sexually abused mother, they might have understood Hatty and Jen’s behaviour differently. CAMHS should have received information about the history, and they should have sought more information about the past. Instead, they relied too heavily on what father said the issues were, which meant continued focus on mother and her behaviour, rather than on father and his behaviour. Investigating allegations of child sexual abuse 3.16 Once a child has alleged that they are being sexually abused there are clear procedures for the joint police/children’s services response and approach. A strategy meeting/discussion will ensure that there is multi-agency planning for an appropriate and child-centred response which enables the child to outline their allegations in their own way using their own words, without being prompted or questioned unduly. It is important that children do not have to repeat their allegations on too many occasions and that both initial interviews and likely follow-up visually recorded/Achieving Best Evidence (ABE) interviews are conducted by experienced professionals who have undergone appropriate training. The guidance for the conduct of initial interviews is clear and includes a strong emphasis on planning and preparation; the purpose of the initial questioning of the child is to get a brief account of the allegations and a more detailed account should not be pursued at this stage. The interviewers should 18 ask open ended questions, rather than forced choice, leading or multiple-choice questions, and the answers should be recorded accurately using the child’s words. 3.17 This interview is to establish the need for a visual recorded/Achieving Best Evidence interview as part of a police investigation. The ABE was intended to be delivered by both police and social work staff but can be led by either discipline. The ABE guidance is clear that issues such as language, ethnicity, disability, previous experience of services will influence this decision. It is critical that the ABE interview is conducted by experienced and trained interviewers of children, who are aware of the four phases outlined in the ABE guidance and who understand the importance of enabling the child to outline their allegation in a free narrative approach, using open ended questions. 3.18 The initial interview of Hatty and Jen by the police officer and social worker was not sufficiently planned, was too interrogative in nature, and too many detailed questions were asked. The subsequent ABE was not planned, used leading questions and the words used by the girls interpreted and recorded differently from what they said. This has caused the need for Hatty and Jen to have to undertake new ABE interviews as part of the ongoing criminal proceedings, causing them unnecessary stress. Poorly conducted interviews with children which do not follow the guidance are likely to undermine effective safeguarding, decision-making in the family courts and criminal processes, thus undermining children’s safety. 3.19 There have been several national court judgements highlighting that initial interviews go into too much detail and are interrogative in nature. This was the case here and implies a need for training and clarity of the purpose and process of these early interviews where child sexual abuse is a concern. There have also been several judgements29 30 31 32 about the conduct of Achieving Best Evidence Interviewers, where a failure to follow the interviewing guidelines means that courts are unable to rely on this as evidence. 3.20 This review has highlighted the importance of training, including skills in communicating with children, the process of the ABE and the style and approach needed. An audit has been completed by the police considering this case into how relevant guidance is being implemented regarding achieving best interest interviews (ABE). This has reported no issues, but given the national concerns about ABE interviewing, and the evidence from this review about the need for effective multi-agency practice in this area to ensure that children do 29 https://www.familylaw.co.uk/news_and_comment/evidence-of-sexual-abuse-in-children-proceedings-pt-2 30 https://www.familylawweek.co.uk/site.aspx?i=ed208530 31 https://www.familylawweek.co.uk/site.aspx?i=ed219146 32 Re W, Re F [2015] EWCA Civ 1300, Re E (A Child) [2016] EWCA Civ 473, Re Y and F (Children) Sexual Abuse Allegations) [2019] EWCA Civ 206 and in the judgments of MacDonald J in AS v TH and Others [2016] EWHC 532 (Fam) and Re P (Sexual Abuse: Finding of Fact Hearing) [2019] EWFC 27 19 not have to be re-interviewed and further traumatised, the child safeguarding partnership needs to consider what further action is necessary. Recommendations Individual agencies involved with Hatty, and Jen have reflected on this issue and implemented individual action plans. 3. The Local Safeguarding Children Partnership to scrutinize how partner agencies are equipping their staff to understand and support children demonstrating help seeking behaviour. 4. The Local Safeguarding Children Partnership to consider what multi-agency action may be needed locally to demonstrate consistent compliance with the ABE guidance. Finding 3: Recognising and addressing the impact of domestic abuse 3.21 There were many allegations over the years of father being domestically abusive to mother, to his sister and his mother. Each incident was responded to appropriately by the police and where possible, action taken. These incidents were not part of the analysis of the family’s circumstances. It is striking the extent to which father’s own view that the domestic abuse incidents were just disputes was accepted and the domestic abuse perpetrated by him was minimised. It was not factored into plans around contact between Hatty, Jen and mother, and not factored into an understanding of mother being inconsistent in seeing Hatty and Jen. Father’s self-report of her unreliability was accepted at face value. This needed to be more carefully analysed in the context of coercion and control arising from both the domestic and sexual abuse of mother by father. 3.22 Mother’s voice is absent from much of the specialist work that took place between 2010 and 2014 which included the Section 7 report when the history of DV was not mentioned despite mother’s report that father prevented her from seeing Hatty and Jen, and Hatty talking about father deciding when mother could see them. The conclusion of the assessment was supportive of father’s right to make decisions regarding the needs of Hatty and Jen. Again, father’s reports of mother as unreliable were accepted and not contextualised alongside coercion and control. 3.23 Hatty and Jen were present when several of the domestic abuse incidents perpetrated by father took place. There is little evidence that the impact on them was discussed or analysed beyond asking them if they were OK. CAMHS did discuss the potential impact of domestic abuse on Hatty and Jen, and they asked father to consider their needs. The recordings at the time show that CAMHS used language such as “physical altercation” which minimised the violent actions of father. CAMHS sought to understand mother’s role in the 20 family but did not consider the impact of domestic abuse and violence or its likely impact on her being able to be part of Hatty and Jen’s life. 3.24 There were indications within the psychotherapy sessions that Hatty and Jen were acting out some of the incidents of father’s domestic abuse that they had witnessed. In one session they played out a situation using teddy bears talking to the police, saying “there are bad people in the office”, the therapist being taken away by the police and the girls barricading themselves in the therapy room with the therapists. Hatty and Jen were noted to be very distressed. Yet there was no analysis of this behaviour, and the likely link to witnessing domestic abuse. The analysis remained fixed on the distress caused by mother’s absence and abandonment (see Finding 6 for an analysis of the evidence of fixed thinking on professional practice during the years 2010 to 2014). 3.25 These case events took place some years ago and there is no doubt that the safeguarding response to domestic abuse has changed considerably in the past 10 years. However, this is part of Hatty, and Jen’s life story and domestic abuse remains a widespread and serious issue33 which has a significantly negative impact on large number of children, their parents, and extended families34. It is therefore essential that there are systems and processes in place to address domestic abuse effectively and there evidence to suggest that these things are in place in the local area. 3.26 Nationally, research has shown that this is a complex area of practice. The Ofsted Joint Targeted Area Inspections of Domestic abuse (2016)35 highlighted the need for continued improvements in practice regarding the key issues that were emerging in this case: assessment, support for children, support to survivors and challenging a blaming approach, holding perpetrators responsible for their behaviour and the harm they cause, alongside taking domestic abuse seriously and ensuring it is not minimised or replaced by euphemistic language. Recommendations: This issue of how domestic abuse is addressed is an historic concern. It is still a serious issue but there have been changes in the recognition of its seriousness, its impact on those who are survivors, their parenting, and the direct impact on children. Therefore, this review makes no multi-agency 33 ONS (2016), March 2015 Crime Survey for England and Wales (CSEW) 34 Cleaver, H et al (2011) Children’s Needs – Parenting Capacity. London: The Stationary Office https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/182095/DFE-00108-2011-Childrens_Needs_Parenting_Capacity.pdf 35 HM Inspectorate of Probation, CQC, HMICFRS, Ofsted (2017): The multi-agency response to children living with domestic abuse. Reference no: 170036 21 recommendations; individual agencies involved with Hatty, and Jen have reflected on this issue and implemented individual action plans. Finding 4: Safeguarding children from being physically harmed, characterised as “physical chastisement or physical punishment”. “Quite simply, it (physical punishment) doesn’t work and it’s wrong. It doesn’t teach children why their behaviour was wrong or what they should do instead, and it tells them that it is OK to use physical force and aggression against other people”36. 3.27 There has been significant debate in England about whether it is legitimate for parents/carers/family members to use physical punishment in the context of disciplining their children; this is generally described as “reasonable physical chastisement”. This debate has focussed on the fact that “reasonable physical chastisement” is legal, that family history and culture influence this method of discipline and a belief that “physical chastisement” or physical punishment is used in the best interests of the child. There are several difficulties with this assertion. Children view physical punishment as the most severe type of discipline and report that it hurts both physically and emotionally37. Some describe feeling scared, sad, and unloved, and say that it negatively affected their relationship with their parents38, 39. 3.28 There is strong research evidence that physical punishment is bad for children and compromises their developmental outcomes into adulthood. It is associated with increased childhood aggression and antisocial behaviour. Physical punishment affects children’s emotional and mental health including depressive symptoms and anxiety. There is also evidence for a link between childhood physical punishment and adult aggression, antisocial behaviour, adult mental illness, and adult substance abuse. Research shows that the relationship between physical punishment and problem behaviour is reciprocal: physical punishment exacerbates existing problem behaviour, leading to a vicious circle of cascading conflict. Parents who use physical punishment in response to perceived problem behaviour are likely to make that behaviour worse. Physical punishment carries a worrying and serious risk of escalation into injurious abuse and maltreatment. The evidence supports the notion that 36 https://www.pat.nhs.uk/Default.aspx.LocID-022new0dm.RefLocID-022006001002.Lang-EN.htm 37 Sherbert Research. (2007). A study into children’s views on physical discipline and punishment. DCSF and COI. 38 Dobbs, T. A., Smith, A. B., & Taylor, N. J. (2006). "No, We Don't Get a Say, Children Just Suffer the Consequences": Children Talk about Family Discipline. International Journal of Children’s Rights, 14(2), 137. 39 Milne, E. (2009). “I don’t get sad, only when my mum smacks me”. Young Children give advice about family discipline. Children are Unbeatable. Retrieved from: http://www.childrenareunbeatable.org.uk/assets/pdfs/I%20dont%20get%20sad%20-%20report.pdf 22 physical punishment and physical abuse are part of a continuum of violence, differing only by severity or degree40. 3.29 Jen spoke to professionals about being physically hit by father; there was little professional exploration of why she raised this as an issue and its meaning to her. An assumption appears to have been made that father, as a parent, used physical punishment in Jen and Hatty’s best interest to address perceived behaviour concerns. What emerges from a review of the whole of the family history is that physical abuse and domestic abuse was a significant feature of the extended family life. Father and his siblings reported being physically abused and they witnessed the domestic abuse of their mother. Father said that he believed that the severity of the physical punishment he experienced caused him to be violent to his own mother, and this violence was so severe that he had to leave the family home at age 14. Father was domestically abusive to mother and his sister. Hatty and Jen lived in an environment where physical violence to adults and children was deemed acceptable. 3.30 Physically punishing children does not work as a strategy to address perceived behaviour difficulties and there is evidence that using violence to teach children promotes violent behaviour as a means of problem solving in childhood and adulthood. This information needs to be shared with parents and advice given about alternative approaches to discipline. 3.31 There should also be no automatic assumption made that a parent is using physical punishment as a response to a child’s behaviour or that it is part of the cultural context of the family. Each incident must be assessed and analysed from a child-centred perspective. Some physical punishment by parents is a loss of control, which can escalate to greater levels of violence, some is caused by a parent’s use of violence to control and humiliate, and some by their negative feelings towards the child. 3.32 Although this issue was a historical concern for Hatty and Jen, there remain ongoing debates about the rights of adults and the legality of physical punishment within contemporary safeguarding practice. The current London Child Protection procedures suggest that adults hitting a child without leaving a mark is acceptable practice which requires no professional action. The danger of this approach is that each incident may be treated in isolation, the cumulative harm not recognised and the meaning for the child and their attachment relationships not understood. Although the law suggests it is acceptable to physically punish children, safeguarding partnerships should have a child-centred view about its appropriateness and provide advice and guidance, and challenge where necessary. 40 Bunting L, Webb MA, Healy J (2008): The ‘smacking debate’ in Northern Ireland – messages from research. Northern Ireland Commissioner for Children and Young People. 23 “Research papers commonly conclude that ‘more research is necessary’. However, when the existing evidence is as strong as it is in the case of physical punishment and given that physical punishment is a clear human rights violation, there seems to be little value in calling for more research on its effects. To borrow Gershoff’s words: ‘We know enough now to stop hitting our children’”41. Recommendation Individual agencies involved with Hatty, and Jen have reflected on this issue and implemented individual action plans. 5. The Local Safeguarding Children Partnership to issue a child centred position statement about the appropriateness of physical chastisement and provide guidance about what safeguarding responses are required. Finding 5: Delivering culturally competent practice 3.33 This review has deliberately anonymised Hatty and Jen’s cultural heritage because of concerns that this would make their circumstances recognisable. They are of dual heritage and are non-white. There was little information about father or mother’s cultural context beyond descriptions of their ethnicity. There was an absence of information regarding what was important to father and his mother from a cultural perspective and no information regarding whether they were asked about their experiences of racism in the community or when in contact with services. 3.34 There was also no information about mother’s cultural heritage, and the impact of this part of Hatty and Jen’s cultural identity being absent because they were not living with her. The cultural identity needs of Hatty, and Jen were discussed in several of the assessments completed but ultimately no action was planned or taken. 3.35 Legislation42, guidance43 and research44 highlight the importance of identifying a child and their family’s cultural context and heritage, as well as their experiences of racism and discrimination alongside family strategies to address this. “Every Assessment should reflect the unique characteristics of the child within their family and community context. The Children Act 1989 promotes the view that all children and their parents should be considered as individuals and that 41 https://www.cypcs.org.uk/ufiles/Equally-Protected.pdf 42 Children Act 1989 www.legislation.gov.uk/ukpga/1989/41/contents 43 DOH (2000) Framework for the assessment of children in need and their families http://webarchive.nationalarchives.gov.uk/20130404002518/https://www.education.gov.uk/publications/eOrderingDownload/Framework%20for%20the%20assessment%20of%20children%20in%20need%20and%20their%20families.pdf 44 Thoburn, J et al (2004) Child Welfare Services for Minority Ethnic Families: The Research Reviewed: Jessica Kingsley press 24 family structures, culture, religion, ethnic origin should be respected”, Working Together 201545 3.36 This focus on cultural competence grew out of historic concerns regarding the professional safeguarding response to children and their families from Black and minoritized groups which was “colour-blind”46, meaning it often lacked a recognition of culture, personal47 and institutional racism48. This led to some children disproportionally coming into the care of the state and other children not being effectively safeguarded49. 3.37 There remain national concerns regarding many professionals’ ability to work proactively in a culturally competent way. The Hamza Khan SCR50 reflected that “the cultural and religious complexity of the family was not enquired into. This is surprising given the local diversity of culture, religion and language”. Brandon and colleagues have found in the biennial reviews of SCRs51 that issues of culture and ethnicity were a common theme, which was not adequately explored in safeguarding practice. 3.38 Cultural competence is the ability and confidence of all professionals to explore and ask questions about the cultural context and practices of the different children and families that they work with. This includes understanding and addressing racism and discrimination and recognising that cultural identity will be treated with understanding and respect. 3.39 It does not mean that professionals can fall back on simplistic notions of culture to avoid making difficult decisions about when and whether to intervene with families or to allow stereotypes and discriminatory attitudes to influence practice. 3.40 Culturally competent workers recognise every individual as unique and equally worthwhile. Assessments, plans, and interventions need to include a discussion of health beliefs, process of immigration, attitudes to professionals and attitude to family relationships. Alongside this it is important to explore a family’s experience of racism and discrimination and consider its impact on family life, 45 DfE (2015) Working Together to Safeguard Children: London https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 46 Phillips, M. (2002) Issues of ethnicity and culture. In: Wilson, K., James, A. (eds) The Child Protection Handbook (2nd edn). Edinburgh/London: Ballière Tindall 47 Prejudice, discrimination, or antagonism directed against someone of a different race based on the belief that one’s own race is superior: Oxford University Dictionary 48 [Institutional racism is] the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture, or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness, and racist stereotyping which disadvantage minority ethnic people. (Macpherson, 1999b: 6.34) 49 Thoburn, j et al (2004) Child Welfare Services for Minority Ethnic Families: The Research Reviewed: Jessica Kingsley Press 50 http://bradfordscb.org.uk/?page_id=158 51https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/184053/DFE-RR226_Report.pdf 25 access to services and opportunities. The culturagram tool52 can be a helpful tool in exploring these issues. Recommendation Individual agencies involved with Hatty, and Jen have reflected on this issue and implemented individual action plans. 6. The Local Safeguarding Children Partnership to develop a multi-agency position statement about expectations for culturally competent practice and provide support to improve agencies’ practice. Finding 6: Working to address the long-term neglect of children. 3.41 The neglect of children’s needs by those responsible for their care and nurturing of their emotional wellbeing is a serious issue which has significantly negative developmental consequences for children in the short-term and has the potential to limit their adult lives in the longer term. It has become clear over time that early neglect needs addressing and taking seriously. This is an area where practice has changed and developed, locally and nationally, over the last 10 years. 3.42 The issue of neglect is a key aspect of Hatty and Jen’s life story. They were born to a young mother who was herself still a child and who was in the care of the state because of abuse and neglect. She was subject to domestic abuse from father who had sexually abused her. These events happened several years ago, and it is beyond the remit of this review to explore the support she was offered at this time, but it is clear she was under pressure and early action was necessary to support her; there were early concerns about mother’s neglect, rather than father’s influence. The influence of father and the harm he caused was an enduring feature of the neglect and trauma suffered by the children. One of the critical issues in these situations is to understand why neglect is happening, the cause, and to use this as the basis for intervention. Contemporary research suggests that young parenting, experience of abuse and neglect, domestic abuse and lack of social networks have a big part to play. These were the factors in mother’s life. As stated, understanding and responding to neglect has changed considerably over recent years. However, recent SCRs and contemporary research continue to identify that this remains an issue that still requires national attention. Therefore, for the purposes of national learning, the experiences of Hatty and Jen are important to bring to light. 3.43 Father took on full time care of Hatty and Jen ad there were ongoing concerns about how he was coping. These concerns were addressed, but neglect of the 52 Cultural Competency Toolkit: Health and Social Care https://www.hackney.gov.uk/Assets/Documents/Cultural-competencies-toolkit.pdf 26 girl’s needs was never highlighted, despite evidence of emotional neglect and physical abuse. An extended family member made a referral regarding physical and emotional neglect. This outlined Hatty and Jen as unhappy and asking for help. The home circumstances were in a poor state. Hatty and Jen expressed concern about the circumstances they were living in. Father reported that this was a poverty related issue, and this explanation was accepted. The issue of emotional neglect was not addressed, and the historic concerns of abuse and violence not factored into an analysis. The school the girls attended were unaware that this assessment was being undertaken. There is a balance to be struck between a parent’s rights to privacy and a child’s right to have the whole of their circumstances understood. The school saw Hatty and Jen every day and had taken on a supportive role. They needed to know about these concerns, so they could keep an eye on the wellbeing of the girls and offer support to father. 3.44 From this point onwards Hatty and Jen were known only to the schools they attended. There were ongoing concerns about what is described as “low level” neglect and a sense of poverty and isolation for a single parent. They felt that Hatty and Jen were progressing academically and socially. The school provided compensatory care to address things like them being hungry and the continued poor state of the home. Whilst the school discussed with MASH the specific issue of a lack of supervision for Jen after school, their niggling concerns needed to be shared with MASH in order to receive support in conceptualising this as a case of neglect and consider what more may be needed to improve Hatty and Jen’s lived experiences. 3.45 One of the core defining features of neglect is its pervasiveness, persistence, and cumulative harm. Hatty and Jen experienced a level of neglectful caregiving across the span of their whole lives. The impact of this is unclear. This review has highlighted the importance of a structured approach to children’s experience of parental neglect over time, with a focus on understanding cumulative impact for children, causal factors, interventions that lead to significant change and the likelihood that neglect can lead to other forms of abuse occurring. Recommendation Individual agencies involved with Hatty, and Jen have reflected on this issue and implemented individual action plans. There has been significant work locally to address child and adolescent neglect and in recognition of this one recommendation is made. 7. Where there are concerns about possible neglect, designated safeguarding leads in schools to routinely seek consultation with MASH and share all information in full. 27 Finding 7: Recognising and addressing fixed professional thinking One of the most common, problematic tendencies in human cognition … is a professional failure to review judgements and plans – once we have formed a view on what is going on, we often fail to notice or to dismiss evidence that challenges that picture.53 3.47 There is a substantial body of research evidence that has clearly identified the unconscious tendency for early evidence bias in human decision-making; that is, an initial summing up of a situation strongly influences the analysis of subsequent or new information leading to fixed thinking and faulty conclusions. Serious Case Reviews have repeatedly found that professionals were either unwilling or slow to revise their judgements in the face of new or contradictory evidence and that this selective interpretation of information, only using that which confirmed their preferred view about a particular case, became a “pervasive belief” which influenced the professional response. These pervasive beliefs were found to remain, even where there was considerable evidence of lack of progress or lack of success in the interventions and services offered. As Munro notes, “the single most important factor in minimising errors in safeguarding practice is for professionals to be enabled to admit that they might be wrong.” 3.48 There is considerable evidence that across the period when Hatty and Jen were known to specialist services there were pervasive views held about mother, that she had abandoned her children, was not committed to having a relationship with them, and was not interested in engaging with services. Across agencies this was seen to be the cause of the anxiety and distress that Hatty and Jen experienced. This belief cast a long shadow, meant the children did not see their mother for many years and did not have the opportunity to have a relationship with her. Concerns about father’s domestic abuse, physical punishment of the children, erratic behaviour and mental health difficulties were known, but not seen as the central issue having an impact on Hatty and Jen. 3.49 The pattern of seeing mother as the problem pervaded, stoked by father and in some small part the extended family yet there was evidence to the contrary which was disregarded. 3.50 Ultimately, mother lost contact with Hatty and Jen for many years. The absence of any specialist input meant that there was no reflection on why and what could be done about this. Father reported to Hatty and Jen that their mother did not want to see them. There was no voice that could provide the alternative view, 53 Fish, Munro and Bairstow (2009), Learning together to safeguarding children. Pg. 9 28 that mother did not feel safe to see Hatty and Jen because it would bring her back into contact with father and his controlling and coercive behaviour. 3.51 Professionals must be willing, encouraged and supported to challenge, and where necessary revise, their views throughout the period of any intervention. To achieve this, practitioners and their managers should routinely play their own ‘devil’s advocate’ in considering alternative actions, explanations, or hypotheses. Supervision should provide a safe but challenging space to oversee and review cases with the help of a fresh, experienced, pair of eyes and to systematically guard against either rigid adherence to a particular view. Recommendation Individual agencies involved with Hatty, and Jen have reflected on this issue and implemented individual action plans. 8. The Local Safeguarding Children Partnership needs to understand and scrutinize how current supervisory arrangements promote professional curiosity, are child centred, and thereby address fixed thinking across partner agencies. |
NC52798 | Serious neglect of two young people from two separate families. Learning themes include: disguised compliance and professional curiosity; escalating concerns at an earlier stage; the welfare of pupils who become long term absent from school; identifying potential neglect of young people and assessing the abilities of parents to respond appropriately; safeguarding pupils who are the subject of applications to be electively home educated; the voice of the child and action taken following repeated concerns from a parent followed by cancelled appointments; ensuring the safety of children whilst they are on CAMHS waiting lists; parental mental health and its impact on their ability to address the neglect of the young person. Recommendations to the Partnership include: ensure that all child protection training reminds practitioners that procedures and guidance apply to all children irrespective of age; include the risks related to prolonged periods in bed into existing child protection training; consider how practitioners/managers can be supported to reframe the concept of service users "failure to engage" to that of how can practitioners work persistently and creatively to engage children and their carers?; work with schools to identify training packages/requirements for attendance workers and seek to strengthen the arrangements for assessing the welfare of children not in school; seek assurance that all agencies understand the routes to an Early Help Assessment and that such assessments are completed where required; seek assurance that all practitioners are familiar with, and use where appropriate, the Graded Care Profile along with other tools that can be used when undertaking assessments.
| Title: Child safeguarding practice review: MDS20 and PDS20. LSCB: Derby and Derbyshire Safeguarding Children Partnership Author: Sue Gregory Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Derby and Derbyshire Safeguarding Children Partnership Child Safeguarding Practice Review MDS20 and PDS20 Author: Sue Gregory Final 17/07/2023 2 1. Introduction 1.1 This Child Safeguarding Practice Review (CSPR) has been commissioned by the Derby and Derbyshire Safeguarding Children Partnership (DDSCP) in accordance with Working Together to Safeguard Children 2018 and the Child Safeguarding Practice Review Panel: practice guidance (2019). 1.2 The review has considered the experience of two children from different families and different areas of Derbyshire. They will subsequently be referred to as young people, YP1 and YP2, in recognition of their age however they remain children as defined by the Children Act and the Derby and Derbyshire Child Protection Procedures. 1.3 YP1 was admitted to hospital after being found underweight and unkempt. They remained in hospital for two weeks before returning home to the care of their mother. YP1 had reportedly not left home for over a year. 1.4 YP2 was admitted to hospital with significant wounds relating to compromised skin integrity as a result of remaining in bed for a number of months. YP2 required extensive surgery and medical intervention and has remained in the care of the Local Authority since discharge from hospital. 1.5 School attendance, mental health and neglect are significant features in both cases. 1.6 The purpose of the joint review is to identify the learning from the individual circumstances of these young people and the systemic learning arising from their experiences that appear to have led to similar outcomes. 1.7 The aim of this joint review is to: - bring together the themes to provide better systemic learning whilst ensuring that the individual features of each case are not lost - identify improvement measures that should be taken to address where previous learning has not led to systemic practice improvement - deliver a strategic approach to learning and improvement that provides the partnership with clear priorities informed by both the two reviews and previous learning - provide evidence to embed learning and improvement in a way that local services for children and families are more reflective and achieve changes to practice that are consistent with the priorities arising from these reviews. 1.5 See Appendix 1 for the full terms of reference (ToR) 2. Format of this Report Part 3 describes the methodology for completing this CSPR Part 4 summarises the learning themes that have emerged during this review Part 5 outlines the review of each case Part 6 highlights the joint themes Part 7 presents the overall conclusions 3 Part 8 considers the action already taken Part 9 makes further recommendations 3. Methodology 3.1 Sue Gregory has been commissioned by the DDSCP as the independent author for the CSPR. 3.2 The author had access to the Rapid Review completed in respect of YP2, information requested from agencies in respect of YP1 and was provided the Local Authorities report of the internal review of practice relating to YP1. Detailed chronologies have not been reviewed and the focus has been on extracting broad learning in respect of reducing risk to older children. 3.3 This review was undertaken during a period of COVID restrictions and therefore all ‘meetings’ and ‘events’ referred to in this report were virtual. 3.4 Practitioner events were held in respect of each young person to consider key questions developed in line with the ToR. 3.5 The author also had conversations with individual managers and practitioners either because they were not present at the events or to follow up on issues raised. 3.6 Both young people and their parents were invited to contribute to the review. • YP1 felt unable to do so but their mother did have a telephone conversation with the author. The father did not respond. • YP2 initially contributed in writing and then met with the author. The foster carer did contribute and was able to support YP2 to do so. To date it has not been appropriate for the author to have contact with YP2’s mother. The father of YP2 has not responded. 3.7 A meeting was held with key managers from all organisations involved with YP1 and YP2 during which key points arising from all activity contributing to this review were considered. 4. Summary of key learning themes that emerged from the review 4.1 Personal and environmental factors can increase the vulnerability of anyone irrespective of age. Under 18years old are recognised as children under the provisions of the Children Act and are therefore recognised as vulnerable by the very fact of their age. It is important to remember that the provisions made in relevant legislation, guidance provided in Working Together and requirements as laid out in local multi agency procedures apply to all children under 18. 4.2 The risks of significant harm that individual children may face must be considered whether they are infants, younger children, or teenagers. Whilst it is recognised that the immediacy of the risks to older children may not always be as immediate as they might be for infants and younger children, they must still be considered, and also attention paid to potential medium and longer term risks. 4 4.3 Addressing the emotional wellbeing and mental health of all children can present needs and potential risks. Whilst it is necessary to consider the risks associated with self-harm and suicide there may be other risks presented to their physical health and wellbeing, such as those associated with: - social isolation and absence of appropriate physical care/self-care. - lack of exercise and appropriate diet (food and hydration) - remaining in bed and seriousness of the implications of breaches in skin integrity - being dependent on others for care and the capacity of parents to provide it 4.4 It is important to recognise the potential challenges of caring for a young person presenting with mental health issues and, therefore, to consider the parents/carers needs for support in developing strategies for meeting their child’s needs. Consideration has to be given to the parents/carer’s capacity, ability and willingness to provide for the child’s needs and practitioners need to remain open to the potential of neglect and other forms of abuse as defined in Working Together and Multi Agency Procedures. 4.5 Parents/carers own mental health may have an impact on their responses and capacity to meet their child’s needs and therefore should be explored and understood by those working with their children. Those working with parents with mental health issues should consider any potential impact on their ability to meet their child’s needs irrespective of the age of the child. 4.6 Education is an important aspect of life for children and the significance of school attendance is reflected in it being one of the key performance indicators for schools. When dealing with poor attendance it is important to consider: - What might be preventing the child attending school? - What are the implications and potential risks of not attending school in addition to missing education? - How might improvements in attendance be supported? - How can education be provided when a child is unable to attend school including when there are accepted mental health issues? 4.7 The importance of building relationships between practitioners and the young person. This requires skilled communication and may take some time but without it the voice of the child will remain unheard. Consideration needs to be given to: - How can practitioners be supported to be persistent when a young person refuses to see them or appears to not engage? - How can managers be supported to ensure effective actions and decisions are made when it appears that the young person and/ or parent will not engage, and required change is not achieved? - How do all practitioners ensure that they are hearing the voice of the child and not only that of the parent? This may include working with the child to seek consent for treatment (16 and 17 year olds) although this was not a specific learning point from practice considered in this review. 5 4.8 Assessments should be systemic and consider the child’s needs and risks, the capacity and ability of the parent/carer to meet those needs and environmental factors. 4.9 The importance of effective communication between practitioners, within and between agencies to ensure that relevant knowledge is shared to inform appropriate decision making and to support timely escalation where appropriate. • Particular attention should be paid at times of transition whether due to age of child, change of worker/service provider or reshaping of services. • Communication should be maintained between referrer and service provider to ensure that all relevant information is made available including information that becomes available after the initial referral. It is also important that the referrer knows whether services have been provided and/or taken up. 5. Review of cases YP1 5.1 Whilst this review considers activity between January 2019 and April 2020 there is background information in respect of YP1 that provides an important context in particular relating to interventions during 2018. 5.2 YP1 has always lived with his mother and older sibling. There is no record of father’s role in the family nor of any contact with practitioners. The first record of concerns relating to YP1 are found in 2010 (7 years old) when school referred them to CAMHS citing ‘behavioural difficulties and autistic tendencies’ although there was no formal diagnosis. 5.3 In 2013, the last year in primary school, a school health questionnaire recorded YP1 to have a BMI (Body Mass Index) of 14.09. BMI is a calculation that uses height and weight to estimate how much body fat someone has. BMI percentiles show how a child’s measurements compare to others with the same gender and age and help identify children who are gaining weight too slowly or quickly. At the age of 10 years YP1 was just under the 5th percentile indicating that he was slightly under the expected weight. Concerns were also noted about YP1’s emotional wellbeing and self- esteem. At the same time mother reported that YP1 regularly stated that he wished he was dead. The school nurse was unable to contact mother to discuss these concerns further. The mother informed the author that she was happy with the support that YP1 received in primary school. 5.4 YP1 started secondary school education in 2014 and remained at the same school where staff seem to have been unaware of the issues identified in primary school. There are no concerns highlighted until academic year 9 (2017/18) when YP1’s attitude towards learning and attendance started to deteriorate. An attendance record of 87% further declined to 29% in year 10 and was 0% in Year 11(September 2018 to July 2019) despite interventions through the school attendance service. In January 2018 they escalated their concerns about YP1’s attendance record, school refusal and the resulting challenges that mother was experiencing by referring to Childrens Services. Derbyshire County Council (DCC) had re shaped their Early 6 Help and Attendance services to schools through the Rethink Early Help Offer from 2015. It should be noted that the school initially signed up for a three-year package of support from DCC and set up their own Early Help service in August 2018. The period of time subject to this review covers this transition period. 5.5 The referral was accepted and YP1 was allocated to a worker in the Multi Agency Team (MAT) with the task of completing an Early Help Assessment (EHA). The case remained open until September 2018 at which point responsibility was transferred to the schools Early Help service. 5.6 The MAT worker first visited the home in February 2018 when YP1 was seen in bed and observed to look ‘thin’. Mother was advised to contact her GP re YP1’s weight and offered a Parenting Support Programme which she declined but did disclose that she suffered from clinical depression. There is no evidence that mother’s mental health was explored further or considered as part of the assessment, nor of the offer of parenting support being revisited. The EHA focussed on poor school attendance and YP1’s self- esteem. There is no evidence of a systemic approach to the assessment i.e. no family history, consideration of environmental and contextual information or assessment of mother’s capacity to meet the needs of YP1. There is no evidence of enquiries with agencies other than school which in effect did to focus on the evidence of concerns about YP1’s weight and emotional wellbeing. Attempts were made to arrange a joint home visit with a colleague to discuss army careers and a subsequent referral was made to a sports mentor and while neither were taken up the author questions the thinking and decision making about the appropriateness of these services at that point for YP1. The EHA was signed off by a manager on 20th April with an agreement that the case should proceed as an Individual Focus Plan rather than a Team Around the Family (TAF). It should be noted that there was already a TAF in place at the school and it would seem to have been more appropriate to continue with this plan with the MAT worker becoming the lead professional. However, the MAT worker did suggest a TAF meeting and arranged it for 22nd May to be held at the school. The invite to the school nurse is the first indication of contact between the MAT worker and a health professional. Comment: The assessment was not robust and did not meet the standards required by DCC. It focussed on a single issue and did not address the information in respect of YP1’s health and wellbeing, or mother’s capacity/ability to meet their needs. 5.7 At the first TAF meeting, it was noted that YP1 was engaging well with the school nurse and that mother should contact the GP to request a further home visit. Later in May mother was issued with a fine for YP1’s persistent absence. 5.8 The school nurse visited the home following the first TAF meeting. YP1’s weight is recorded as 6 stone 8lbs. The BMI of 13.97 which was lower than that recorded at age 10 years and well below the 5th percentile. This is considered underweight for a child of YP1’s age and gender at this stage. The school nurse also noted concerns about YP1’s poor dental hygiene, personal care, unbalanced diet, insufficient fluid intake, erratic sleep patterns, lack of motivation and social isolation. These concerns were escalated to the GP who made a follow up visit to the home. The GP did not think that the criteria for CAMHS service was met although did think 7 that YP1 was showing signs of depression. The school nurse visited the home again in August when YP1 was observed to look unkempt and the bedroom to be in a poor state with no sheets or pillowcases on the bed and dirty plates over the floor. There is no indication of action as a result of these findings. Comment: The concerns noted by the school nurse indicate potential neglect as defined in Working Together and the local procedures. There is no evidence that neglect was considered or that this information led to any change in the existing plan. 5.9 Further TAF meetings were held at school in July and September which noted that YP1 remained absent from school and growing concern about YP1’s emotional and physical health. While mother and grandmother attended these meetings there is no evidence of attempts to ensure that the child’s voice was present or heard. The MAT worker was absent from the last meeting, and it is of concern that there was no discussion about the transfer of responsibility for the case from Local Authority Children’s Services to the school as part of the changes to early help arrangements. The MAT worker did make a referral to the Emotional Wellbeing Service although this did not include the concerns about his weight or eating. The referral was accepted, and an Emotional Wellbeing worker visited the home but left when YP1 refused to come downstairs and subsequently closed the case. The case was closed to the MAT team with the school accepting responsibility. There is evidence that the MAT worker received regular supervision and that decisions including closure were signed off by the manager. Comment: The level of concerns in respect of the health and wellbeing of YP1, along with indicators of neglect, would indicate that the more appropriate decision would have been to escalate the case and not to transfer to the schools newly formed Early Help Service. 5.10 YP1 was not seen again until November 2018 when visited by a school attendance worker. Again, YP1 refused to leave the bedroom. The room was observed to be very small and again in the same poor state as that previously seen. YP1 told the worker that they were happy to stay in bed all day and couldn’t be bothered to eat. The attendance worker discussed their concerns with the school nurse and schools Early Help (EH) worker, and it was agreed that a meeting would be arranged. There is no evidence that any meeting took place. A home visit was carried out by the school nurse and EH worker, but no one answered the door. This was followed up by letters and in January mother told the EH worker in a telephone call that she was unhappy with the previous services and would not engage with them. A decision was made that the case be closed to Early Help and remain open to Attendance service. Comment: The lack of engagement by mother and that fact that there had been no change in YP1’s circumstances should have triggered escalation of the case. 5.11 Later the same month the school became aware that the family house was empty and their whereabouts unknown. A member of school staff referred the matter to the DCC Missing in Education Team and YP1’s name was removed from the school register. In March a member of this team informed the school that the family 8 had been located at a new address in the area and, while school records were amended, there is no evidence of anyone visiting the address. As a consequence, there is no information as to the circumstances of the move, context of new environment or the safety and wellbeing of YP1. Comment: A home visit should have been undertaken in light of the previous concerns and also that YP1 had not been seen by any practitioner for four months 5.12 The GP visited the home on 5th August 2019, the first time any practitioner had seen YP1 for nine months. An immediate referral was made to the single point of contact for CAMHS citing poor interaction, self-neglect, and low BMI. This resulted in an urgent home visit by a Consultant Psychiatrist and Lead Nurse. They in turn referred to DCC Childrens Services and YP1 was admitted to hospital on 8/10/19. At the age of 16 years YP1 weighed 6st 8lbs (the same as recorded 18 months earlier) with a BMI of 13.7, was described as unkempt with dirt ingrained all over their body. YP1 disclosed that they had not left the house for over a year, although evidence is that the family moved during that time so they must have at that point, had not showered spent the time playing on an x box and ate little as didn’t feel hungry. A subsequent Risk Strategy meeting concluded that the threshold for S47 of The Children Act had been met and that, following treatment in hospital, YP1 should return home subject to a robust plan. Comment: The decision of this meeting was based on evidence that had first been observed at the health assessment some six years earlier and had remained the lived experience of YP1 throughout this period of time. YP2 5.13 YP2 has always lived with their mother. The father left home when YP2 was an infant and contact between them had been sporadic. The sudden ending of all contact in July 2019 is cited by the mother as a cause of the anxiety and depression that YP2 experienced. The family had not come to the attention of services other than universal health and schools until YP2’s attendance started to deteriorate in Year 10 (86%). YP2 did not return to school after the summer holidays in 2019. 5.14 In September 2019 a member of school staff contacted YP2’s mother to arrange a meeting in school to discuss YP2 refusal to attend. Mother reported that YP2 was suffering from low levels of anxiety and was finding some subjects too difficult resulting in not wanting to attend school. A modified timetable was offered as well as the support of an Attendance officer to arrange for YP2 to be collected and brought to school. Following the response from the school, YP2 attended on 2nd and 3rd of October when they were reported to present as smartly dressed, happy, chatty and comfortable with going around school alone. Although there were no apparent difficulties on these two days, YP2 never returned to school. A member of school staff visited the home on 6th October, and this was followed by a telephone call from the mother the following day reporting that YP2 was in bed after being distressed during the night and that she had made an appointment to take YP2 to see a GP. Comment: The sudden ‘failure’ to attend school following the summer holidays, the mother’s reports of mental health issues for YP2 as well as the apparent discrepancy 9 between reported distress and presentation on the two days YP2 attended school should have triggered an EHA. 5.15 The mother accompanied YP2 to the GP appointment, within the week, during which she asked for a letter saying that YP2 was suffering from anxiety that she could give to school. The GP wrote the letter which the mother subsequently handed to school. The GP records indicate that the mother had consulted the practice on several occasions regarding YP2’s anxiety, panic attacks and low moods and that she had been advised to contact the school nurse regarding counselling. In September YP2 had been prescribed medication, described as ‘pill in the pocket’ to be used when needed to help with symptoms of anxiety. The GP, who had also trained as a psychiatrist, thought that YP2 did not meet the criteria to access specialist CAMHs services and referred her to a local voluntary sector provider for counselling. 5.16 YP2, accompanied by the mother, attended an initial assessment session at the counselling service on 16/10/19 after which she attended all planned sessions (8) until January 2020. YP2 reports that they had a good relationship with the therapist. YP2 and the mother completed the “Childrens Anxiety and Depression” tool. The results of which indicated that mother may not have fully understood the extent of YP2’s difficulties and, with their agreement, the therapist also worked with mother to help her understand and support her child. 5.17 The school Attendance officer made 6 telephone calls to mother during October but YP2 remained absent from school. The mother advised them that the GP had recommended that YP2 did not return until after the half term holidays and that they were now attending counselling sessions which she thought were having a positive effect. A member of school staff visited on the home on 11th November where YP2 was seen and spoken to. There were no observed concerns about YP2’s wellbeing. 5.18 School maintained contact with the mother during November and offered a reduced timetable to support re-engagement with school. Whilst the mother initially said that YP2 would return to school in December she later sent an email stating that YP2’s medication did not seem to be working and that she was concerned about their depression. The mother subsequently emailed the school to enquire about the possibility of out of school study and concern about the pressure being placed on YP2 to return to school. The mother had requested a second letter from the GP which was sent to the school to confirm that YP2 was suffering from anxiety and was having counselling. 5.19 The mother was unhappy when school staff explained to her in a telephone call that this was not sufficient to support Out of School tuition (OOST service provided by DCC) and stated that she would obtain another letter from the GP. This third letter was followed up by a telephone conversation between a member of school staff and the GP. The GP explained about the medication prescribed to YP2 and stated that there was no reason why they shouldn’t attend school while accessing counselling. The mother complained to the school about the conversation with the GP and requested a meeting with the Headteacher. 10 5.20 YP 2 was taken to the GP practice on Christmas Eve when they were seen by a different GP. YP2 is described as presenting as tearful with worsening symptoms. The decision was made to make a referral to CAMHs, and a prescription was given for medication to help re- establish a sleep pattern. The level of urgency for the CAMHS referral was noted as “routine” and the referral was processed by the practice on 6th January 2020. 5.21 Communication continued between school and the mother including a statutory attendance panel meeting on 7/1/20 which was also attended by YP2. Shortly after this the school requesting a meeting to discuss Elective Home Education (EHE). Although the response from school was, they would not advocate EHE for YP2, the mother sent another email stating that was her wish, and a referral was made to DCC the same day. There is no evidence of YP2’s view of this referral. Comment: School continued to offer support to affect a return to school while the GP was responding to mothers’ reports of YP’s mental health and requests for letter to school to explain non-attendance. The mother’s unhappiness about the direct contact between school staff and the GP along with her subsequent request for EHE could have triggered more respectful curiosity from practitioners. The author suggests that a multi-agency meeting involving the mother and YP2 should have been convened. A meeting would have also been an appropriate forum to inform the processing of the request for EHE. An EHA could have been triggered at any stage during this period which would have been an appropriate vehicle for sharing information, seeking to understand the underlying issues and what life was like for YP2, assessing the mother’s capacity/ability to meet YP2’s needs and thereby formulating a relevant plan. 5.22 The CAMHs duty worker followed up the referral by a telephone call with YP2 and their mother. The content of the conversations confirmed the GP’s view that the level of urgency was “routine”. They were given contact details for the duty worker and urgent care team in the event of a deterioration in YP’s mental health or an increase in risk. It would seem that ‘risk’ was associated with possible self-harm and suicidal thoughts and not wider harm. The referral was confirmed to the school by a CAMHs worker on 16/1/20 when it was explained that there was a waiting list of approximately 20 weeks. 5.23 The mother cancelled the appointment with the counselling service on 22/1/20 stating that YP2 was too ill to attend. 5.24 Not long after this there was another discussion between the mother and the GP who had made the CAMHs referral, during which she expressed her concern that the waiting time for CAMHs was too long as YP2 was now not leaving her bedroom. The GP discussed the situation with the practice safeguarding lead who suggested a referral to children’s social care. The mother felt that the involvement of another agency would upset YP2 and “refused” the referral. The referral was not made as was not considered as concerning a risk of ‘significant harm’. Comment: There is no evidence that the counselling service already providing therapy were consulted/informed or whether the specialist CAMHs service were informed that this service was being provided. It was good practice for the GP to 11 discuss with the safeguarding lead however it is suggested that the view that there was not a risk of significant harm may have been different if all information had been available through an EHA/plan. There is no evidence that this position was reviewed 5.25 YP2 attended an appointment at the counselling service on 29/1/20 although the mother had cancelled a home visit by the attendance worker stating that YP2 was too ill. YP2 talked to the therapist about an incident of self-harm the previous month and of having suicidal thoughts although not intending to act on them. The therapist was so concerned about the significant decline in the mental health of YP2 that she rang the GP practice to request an appointment for YP2 and the mother to attend that same afternoon. The therapist contacted the mother the next day who confirmed that they had attended the appointment with the GP and had another four weeks later. 5.26 The mother cancelled the next counselling session on 5/2/20 citing that YP2 was unwell, and it is recorded that YP2 “not brought” on the last appointment offered on 12/2/20. The therapist wrote to the GP on 8/2/20 noting a deterioration in YP2’s mental health and expressing concern about the “risk to her mental health of self-isolating in the bedroom”. Mother also contacted the GP in February to seek advice as YP2 was reported to be suffering with back pain. Comment: The therapist appropriately escalated their concerns in respect of YP2’s presentation to the GP/ referrer. There is no evidence that this was then relayed to specialist CAMHS to inform the processing of the referral and the priority it was afforded. This would have been an opportunity to revisit the consultation with the safeguarding lead. 5.27 On 21/2/20 the mother contacted the duty worker at CAMHS reporting that YP2 was remaining in bed, not leaving the house and was tearful during the night. She reported that YP2 may be self-harming as she had found blood on the sheets. The duty worker did not speak to YP2 but did agree to offer a ‘priority’ appointment within 6 weeks. 5.28 None of this information was relayed to the counselling service when Mother telephoned them on 4/3/20. The therapist spoke to YP2 who reported that there had been no further incidents of self-harm or suicidal thoughts. YP2 stated that although they wanted to return to counselling they did not want to do so at that time. It appears that the reasons for this were not explored further. YP2 was reminded of the details of a telephone help line service, that they had been given prior to the Christmas holidays, and how to access the counselling service in the future. YP2 reports that they attempted to call one of the helpline numbers at some point after this but that their mother took the phone off her. 5.29 The attendance worker visited the home on 11/3/20. The mother was asked if she was concerned about the risk of COVID19 at which she indicated that she did not want the worker to enter the house. YP2 was presented by the mother at an upstairs window and was seen to smile and wave. YP2 has stated that the mother made them put a clean top on to hide blood stains. 12 5.30 Two days later the mother again rang the CAMHs duty worker when, on the basis of information given by the mother, a judgement was made that YP2 did not meet the criteria for the Urgent Care Team and that the ‘priority’ appointment in place for 13/3/20 would continue. Despite the mother’s apparent concerns, she cancelled this home visit stating that YP2 had a bad back, although she reported an improvement in YP2’s condition and said that they were now leaving the bedroom. There was no contact with YP2 during the call. The appointment was rearranged for 26/3/20 although subsequently cancelled by CAMHs due to a blanket ban on home visits following the implementation of a national lockdown due to COVID19. A CAMHS clinician made 3 telephone calls to mother leaving messages asking her to contact them. There was no contact from mother until after YP2’s admission to hospital. Comment: There is absence of YP2’s voice throughout this period with only the therapist having a telephone conversation with them. The therapist also provided YP2 with contact details for helpline services which is an example of good practice and provided YP2 an opportunity to have a voice. There is no evidence of feedback from CAMHS to the GP (as the referrer) of the inability to visit. 5.31 YP2 reports that they had been developing wounds, as a consequence of remaining in bed, from as early as December 2019 and so was becoming increasingly physically unwell during early 2020. YP2 informed the author that their mother would make them shower and change before appointments with practitioners and when the grandmother visited at Christmas. YP2 believes that this resulted in the smell and potential sight of the wounds being hidden. Comment: Wounds caused by long periods in bed, commonly known as pressure sores, are usually caused when a person is unable to physically move and are more common in older people or those with fragile skin. 5.32 In late March the mother contacted the GP practice 3 times in 9 days: the first regarding a “sweat rash” on YP2 tummy which resulted in weeks course of antibiotics (YP2 states that mother made them take a photograph of a small area of their body to send the GP to illustrate the ‘rash’); second to report that the medication was causing nausea and diarrhoea; thirdly to report that YP2 was now suffering from lower back pain and swollen ankles. Exercise, including daily walks was advised. 5.33 On 9/4/20 the mother again contacted the GP this time reporting that YP2 was having difficulty urinating, had dark coloured urine and a discharge. She also stated that YP2 was pale, tired, and not leaving the house. Advice was given over the phone as face to face consultations were limited due to COVID restrictions. YP2 was not spoken to on any of these occasions. Comment: An EHA would have informed a multi-agency plan with an identified lead practitioner. This framework for communication and services may have identified patterns in mothers’ communication with agencies that could have triggered greater concern; recognised that YP2 had not been seen or spoken to by a practitioner, apart from through an upstairs window, since early February in spite of increasing calls from the mother and concerns raised by the therapist; identified contingency 13 plans if services were not accessed or delivered. It is recognised that managing services at a time of a pandemic and national lockdown is unprecedented in living memory however it is suggested that a clear multi agency plan would have assisted assessment of risk and decision making in respect of seeing YP2. 5.34 Six days later the mother dialled 999 and requested an ambulance. She reported that YP2 had been depressed and not allowed her to access the bedroom. The mother had managed to see her and discovered sores on her back and her underwear embedded in her skin. An EMAS crew responded within 7 minutes of the call and found YP2 in a very poor state. They had numerous wounds and found it difficult to stand. The clothing and bedroom were in poor condition. YP2 was taken to hospital and a safeguarding referral was made to DCC Childrens Services. Comment: The information was relayed to the police some time later which meant that potential evidence from the bedroom/home may have been lost. It is unknown whether this action may have been considered earlier if YP2 had have been a younger child and/or whether the circumstances had been viewed through the ‘lens’ of safeguarding /child protection. 5.35 The mother had herself been taking medication for depression and anxiety since 2007 when YP2 would have been 4 years old. A new GP took over her care from May 2019 and has continued to see her. This is a different GP, from the same practice, as that contacted by mother in respect of YP2. The mother complained of abdominal pains and was finding it hard to work at her job as a cleaner in a Care Home from which she had been signed off sick since March 2019. The GP referred the mother for a series of tests at the hospital, but it is unknown whether she attended, and the GP has no record of any results. The mother continued on antidepressants saying that she was anxious and had panic attacks. In August 2019 she informed the GP that her stepfather had died and that she was still awaiting an appointment for talking therapy. There is no mention of the loss of their grandfather in any information relating to YP2. Mother attended appointments with her GP each month. In November 2019 she reported chest pains and breathlessness and was referred to the hospital for tests. The GP also discussed weaning her off the antidepressant and it was agreed that the dosage should be reduced. In February mother told the GP that she had stress at home due to YP2’s mental health and that she was thinking of home schooling. On 4/3/20 mother informed her GP that she was having difficulty coping at home due to YP2 not being at school and waking her a number of times in the night. The mother was given the contact number for an online service for parents of children with mental health issues. Comment: There is no evidence of consideration of the impact of the mother’s mental health on her capacity/ability to be the sole carer of YP2 at any point since 2007. She had her own active health needs during the time frame considered by this review, none of which appear to have been known to practitioners working with YP2. This may have been revealed and considered if an EHA had been completed. 14 6. Joint themes from practitioner and managers meetings 6.1 The potential vulnerability and safeguarding needs of all children, irrespective of age, needs to be at the forefront of practitioner’s minds when responding to issues such as, but not exclusively, school attendance and mental health. It is vital that all practitioners and managers remember that the Children Act and the Child Protection Procedures apply to all children and that ‘Self Neglect’ is a category of risk in ‘Adults at Risk’ procedures and not applicable to children. 6.2 It is recognised that further consideration needs to be given managing situations where there is a perceived “failure” of children and/or parents to engage with services and that practitioners/managers need to be creative and persistent in addressing identified issues. 6.3 The Rethink Early Help Offer was subject to significant discussion throughput the review. Whilst the extensive preparation, discussion and implementation plans are acknowledged it remains a significant cultural, as well as organisational, change in the way that EH services are delivered. As part of the extensive package intended to support schools, and children’s services, in managing this change, DCC established a Transitions Team. It was noted that the team was not operational until after the change in service delivery due to the initial difficulties in appointing staff. Managers identified that new responsibilities for some school staff required new knowledge, skills, and a way of thinking about some issues as a consequence of which there is an ongoing need for more training and awareness raising. For some practitioners REHO brought new challenges e.g., managing relationships with families when trying to address welfare needs at the same time tackling attendance and implementing sanctions. 6.4 Managers describe the delivery of services as a “complex and bureaucratic” landscape. For example: There are two NHS Trusts providing specialist CAMHs services in Derbyshire, split by geography, with YP1 and 2 falling within the remit of different Trusts. A Specialist Community Advisor role has been established but managers were unclear how effectively they were used. There are numerous providers of emotional wellbeing and mental health services some of which school directly provide and some commissioned as part of the CAMHs pathway with some remaining outside of these arrangements as with that accessed by YP2. It was suggested that Rethink Early Help Offer had added to this complexity for some practitioners such as GP’s who now have multiple routes into Early Help. 6.5 Whilst attendance is a key performance indicator for schools it is recognised that addressing non-attendance should have a wider focus than effecting a return to school. Practitioners with responsibility for attendance need to be aware of the risks of harm that may be hidden or contributed to by not being school. Similarly, all practitioners need to consider the wider risks when addressing identified mental health issues. The physical risks of staying in bed for prolonged periods of time were not considered in these cases. Managers suggested the need for bespoke training for Attendance staff. 6.6 ‘Stronger Families, Safer Children’ provides a framework for the provision of children’s services in Derbyshire. There are well established multi agency 15 procedures and there is a raft of national and local tools available to support practice. 6.7 Questions were considered about the ability to provide services in a timely manner due to waiting lists and protocols to access some provision. The waiting list for a ‘routine’ appointment with specialist CAMHs was 20 weeks at the point YP2 was referred and 27 weeks at time of the time of this review. Appointments screened as ‘Priority’ are offered within 6 weeks with access to the Urgent Care Teams being much quicker. This also has an impact on access to other services such Out of School Teaching (Oost) which currently requires support from a Consultant Psychiatrist or Consultant Paediatrician. 6.8 It was observed that while parents have the right to make positive choices to electively home educate their children, it is also evident that some children are removed in circumstances that concern the school. It is reflected that additional guidance could be provided locally to help schools liaise with the Local Authority where there are concerns about individual children becoming electively home educated. The intent would be to enable appropriate safeguards to be established and involve other agencies, such as health providers, where needed. 7. Conclusions 7.1 The provisions of the Children Act, associated statutory guidance and multi-agency Child Protection procedures apply to all children up to, and including, 17 years old. While older children may be regarded as better able to look after themselves, as well as being able to exercise some degree of self-determination, they may have particular vulnerabilities and face the risk of significant harm. Their safety and welfare remains the responsibility of their parents and carers unless they are unable or unwilling to do so. The duty remains with the Local Authority and other partners to provide services to promote their welfare (s17 Children Act) and to make or cause enquiries to be made when there is reason to think that they may be suffering abuse or neglect (s47 Children Act). It is clear from information made available to this review that needs of YP1 and YP2 were not met and that there was sufficient concern to trigger enquiries in accordance with s47 of the Children Act prior to their admissions to hospital. The perception that these two children were ‘self-neglecting’ may have distracted practitioners from considering abuse/neglect and the parents’ capacity/ability to meet their needs. 7.2 Thirty children in their teenage years from thirteen families have been subject to review in Derby and Derbyshire between 2015 and the end of 2020. An audit of these thirteen reviews indicates that of these, 9 families (19 children) involved mental health concerns, 8 families (23 children) school attendance issues and that there was evidence of neglect in 7 families (21 children). 7.3 Concerns had been noted about the psychological and physical well being of YP1 over a period of 6 years. Although the concerns triggered an EHA in 2018, it is clear that this was insufficiently robust and that the decision to transfer responsibility to a newly formed EH service in school was inappropriate. The school continued to respond to the situation as an Attendance issue and, while the GP and School Nurse were seeing evidence that YP1 continued to be in a poor physical state, the primary 16 focus remained on their mental health. There was no evidence of the Graded Care Profile being used. The awareness of concerns in respect of YP2 emerged over a much shorter time with them not coming to the attention of services until September 2019 and escalated rapidly over seven months. School were primarily focused on attendance and attempts to get YP2 back into school while the GP responded to concerns in respect of mental health issues. There was only one conversation between school staff and the GP which was subsequently criticised by mother. The information available should have triggered an EHA which by that time was the responsibility of the school. This would have provided a focussed assessment of needs, and of mother’s capacity to meet them, as well as a provide a framework for effective communication and information sharing between practitioners, mother and YP2. 7.4 Both mothers had known mental health issues which were insufficiently considered in respect of their impact on their capacity/ability to parent their child. 7.5 There is a marked absence of the voice of the child and consideration of their lived experience in both cases. YP1’s claim that they preferred to stay in bed and that they weren’t hungry so didn’t eat much was too readily accepted while YP2’s mother’s account of her child’s needs appears to have been accepted at face value. YP2 was effectively not seen in the home environment by any practitioner for over 5 months and was only seen by the GP’s when mother took them for appointments at the surgery. While the therapist saw YP2 on their own on most occasions mother was always in the same building. No practitioner spoke to YP2 on the telephone apart from the therapist at the point mother notified them of ending the relationship. YP2 told this review that they feel that they had no voice. 7.6 Derbyshire has a robust framework of policies, procedures, and practice guidance with range of ‘tools’ available to support practitioners and managers in assessments, decision making and interventions. There is evidence that they were either not used or were insufficiently completed in both of these cases. 8. Actions 8.1 There has already been learning from this review. Practitioners and managers have actively participated and been able to reflect on their individual and organisations practice. Some of the actions to date are related directly to the cases while others have happened as part of the implementation of REHO and ongoing practice development 8.2 The DCC Transition team is operational and a Vulnerable Childrens panel has been established to support schools in delivering their Early Help services. 8.3 YP2’s school has strengthened the relationship between their Attendance officer and safeguarding lead. They have reframed their approach to tackling attendance issues to ensure that it is always seen through a lens of potential safeguarding concerns. Additional training has also been delivered. 8.4 Specialist CAMHs are currently reviewing the process for screening referrals and managing the waiting list. Consideration is being given as to how the Specialist 17 Community Advisor role can be better embedded in schools and used more effectively. 8.5 DCC has completed an internal review in respect of the practice related to their involvement with YP1 8.6 Schools have been reminded of the protocol for referral to school nursing service when attendance falls below 85% 9. Recommendations 9.1 It is recommended that Partnership: • Ensures that all child protection training reminds practitioners that procedures and guidance apply to all children irrespective of age • Include in multi-agency training: the risks related to prolonged periods in bed into existing child protection training. This to include specific reference to the significant risks arising from compromised skin integrity: the significance of weight and development for older children, as well as infants and young children, and the potential impact on long term well being • Considers how practitioners/managers can be supported to reframe the concept of service users “failure to engage” to that of how can practitioners work persistently and creatively to engage children and their carers? And to ensure that the inability to establish an effective relationship could in itself be an indicator of risk • Seeks assurance that the actions identified in section 8 are achievable and completed • Works with schools to identify bespoke training packages/requirements for Attendance workers • Seeks to strengthen the arrangements for assessing the welfare of children not in school. This to include: ➢ guidance for staff involved in the attendance process (including those responsibility for health issues) that improves the awareness of welfare/safeguarding needs and ensures that the child’s voice is sought and heard throughout ➢ guidance to improve the process for raising and assessing concerns when a child is withdrawn from school to electively home educate ➢ reviewing the referral requirements for Out of School Tuition (OOST) to ensure timely referrals and that education can be provided for vulnerable children ➢ using the Section 175/157 self -assessment process to obtain assurance from schools that measures have been implemented to improve awareness of welfare issues of children not in school 18 • Seeks assurance that all agencies understand the routes to an EHA and that such assessments are completed where required • Seeks assurance that all practitioners are familiar with, and use where appropriate, the Graded Care Profile along with other tools that can be used when undertaking assessments • Seeks assurance that the practice issues identified by the DCC internal review are addressed and that any lessons learnt are shared with relevant departments S Gregory Matthew Thomas Associates 19 Appendix 1 Derby and Derbyshire Safeguarding Children Partnership Terms of Reference Terms of reference for Serious Case Review MDS20/PDS 20 (anonymisation code) 1 Introduction This Child Safeguarding Practice Review is being commissioned by the Derby and Derbyshire safeguarding Children Partnership (DDSCP) in accordance with Working Together to Safeguard Children (2018) and the Child Safeguarding Practice Review Panel: practice guidance (2019). A multi-agency panel established by the DDSCP will conduct the review and report progress to the Partnership through its Chair. Membership will include representatives from key agencies with involvement. The review will consider the lived experience of two young people (secondary school age) from two separate families. The two young people experienced serious neglect. The purpose of the joint review is to draw out learning arising from both their individual circumstances and systemic learning arising from their experiences that appear from analysis arising from the Rapid Reviews to lead to similar outcomes. The joint review will • bring together the themes of the cases to provide better system learning whilst ensuring the individual features of each case are not lost • Identify improvement measures that should be taken to address where previous learning has not led to systemic practice improvement following previous case reviews • Deliver a strategic approach to learning and improvement that provides the partnership with clear priorities informed by both the two reviews and previous learning • Provide evidence to embed learning and improvement in a way that local services for children and families are more reflective and achieve changes to practice that are consistent with the priorities arising from the two reviews. The review will consider the learning arising about the services provided to: MDS20 - Subject Child YP1 PDS20 - Subject Child YP2 The review will: • Explore all areas of potential learning about the way in which local professionals and agencies work together to safeguard children including seeking the views of professionals involved in the cases • Determine the extent to which decisions and actions taken were child focussed and considered the children’s lived experience • Seek contributions to the review from appropriate family members and keep them informed of key aspects and progress • Identify any actions required by the DDSCP to promote learning to support and improve systems and practice. 20 Methodology The review will be completed in a proportionate way that enables the partnership to learn from the experiences of the family, practitioners involved in the case and relevant managers and promote a positive learning culture. The detail of the methodology will be linked to the key theme and explained below. • Learning events will be held with front line practitioners involved in each of the cases and separately with practitioners from other schools and Education Welfare services • At the learning events a series of exploratory questions linked to the themes below will draw out learning from these cases to improve how the partnership supports all schools and other services to carry out assessments of vulnerable pupils who are not attending schools • Learning events will be held with managers involved in the cases and strategic managers as needed • Parents and the young people themselves will be invited to participate in the review and be interviewed by the overview author • Reports may be commissioned from agencies to provide specific additional information not included in the Rapid Review. The specific requests for information may be identified following the practitioners’ meeting. There may be generic points for clarification and specific requests for individual agencies. A child safeguarding practice review report will be completed to provide: • A brief overview of what happened and the key circumstances of the lived experience for each young person in a way that does not identify them and is sufficient to understand the context for the learning and recommendations • A critique of how agencies worked together and analysis of good practice and systemic areas for development • Analysis of what would need to be done differently to prevent harm occurring to a child in similar circumstances; and • What needs to happen to ensure that agencies learn from this case. 2 The key themes and questions that the review seeks to answer These themes incorporate the areas identified by both rapid reviews and are presented thematically together as below: a) What advice and clarity about indicators of concern for staff would alert them to consult with other agencies, if early signs of disguised compliance emerge, and promote professional curiosity? b) Agencies continued to work at a low level potentially for too long and in both cases the reasons for drift and a lack of escalation need to be understood so that staff can identify concerns and know when to escalate them at an earlier stage. c) Understanding how systemic improvements could be made to the access to and the assessment of the welfare of pupils whose school attendance is deteriorating and who become long term absent from school. d) In one of the cases there is a need to understand what held back professional curiosity and in both cases strengthen arrangements for how staff, especially 21 school staff, are able to identify potential neglect of young people and assess the abilities of parents to respond appropriately. e) Identifying what action should be taken to improve the effectiveness of arrangements to safeguard pupils who are the subject of applications to be electively home educated (especially where this appears to occur in response to challenges to families about school attendance). f) Understanding how the voice of the child is used to inform referrals and evaluate whether further guidance should be issued to help clarify what action should be taken following repeated concerns from a parent followed by cancelled or failed appointments. g) In one of the cases identifying action that could help strengthen arrangements that ensure the safety of children whilst they are on CAMHS waiting lists was a feature that is to be included h) In one of the cases action was identified that arrangements and / or training needs are reviewed to ensure that partner agencies inform the police, in a timely manner, of any child abuse criminal offences that are suspected of having been committed. i) In both cases the review will consider whether there is learning emerging from the analysis of the individual experiences of the young person and their parent in respect of their race, ethnicity, gender, age, religion or disability. j) In one case there were concerns about the mental ill health of the parent and whether that had an impact on their ability to address the neglect of the young person’s Timeframe for the review The review covers the time period of January 2019 to April 2020. Any significant incident relevant to the case but prior to the start of the period may be included in the analysis completed by each agency. The review is undertaken by one reviewer appointed by the Review Panel. They will have responsibility for examining how the statutory duties of all relevant agencies were fulfilled and reporting on this to the Review Panel and the DDSCP. Review Panel members: • Derbyshire County Council including Children’s Social Care and Education Welfare Services • Derbyshire Police • Named GP • Designated Doctor • Derby and Derbyshire ICB • Hospitals – Chesterfield Royal Hospital including CAMHS • Health Services – Derbyshire Healthcare Foundation Trust; Derbyshire Community Health Services Trust • Education – Secondary School 1, Secondary School 2 3 Specific tasks of the Review Panel • Identify and commission a reviewer to work with the review panel in accordance with guidance for concise and extended reviews. 22 • Plan with agencies involved in the review for the completion of key tasks as required • Plan with the reviewer a learning event for practitioners and separately their managers (if directly involved in the case), to include identifying attendees and arrangements for preparing and supporting them pre and post event, and arrangements for feedback. • Plan with the reviewer/s contact arrangements with the children and family members prior to the event. • Receive and consider the draft overview report to ensure that the terms of reference have been met, the initial hypotheses addressed, and any additional learning is identified and included in the final report. • Agree conclusions from the review and an outline action plan and make arrangements for presentation to the DDSCP for consideration and agreement. • Plan arrangements to give feedback to family members and share the contents of the report following the conclusion of the review and before publication. 4 Tasks of the DDSCP • Consider and agree any learning points to be incorporated into the final report or the action plan. • Ensure the Review Panel complete the report and action plan. • Confirm arrangements for the management of the multi-agency action plan by the Review Panel subgroup, including how anticipated service improvements will be identified, monitored and reviewed. • Plan publication on DDSCP website. • Agree dissemination to agencies, relevant services and professionals. |
NC50860 | Death of an 11-week-4-day old boy after sharing a bed with his parents. An ambulance was called for Child K but medical professionals could not resuscitate him. Mother and father were arrested on suspicion of neglect by overlaying, but no charges were brought due to insufficient evidence. Mother had prolonged involvement with ante-natal services and had suffered from depression. She refused numerous meetings and check-ups from health visitors and maternity staff. Mother and father also failed to take Child K to several medical appointments. Siblings KS1 and KS2 had been on child protection plans for associated risks of significant harm linked to alcohol and domestic violence. Ethnicity and nationality of family not stated. Learning includes: it is important to explore and confirm the exact circumstances of previous children's services involvement and use that and other information to inform care planning; transferring information when children move to another area - especially if there has been statutory involvement with a child identified as a child in need or a child in need of protection should be required. Recommendations include: review the guidance and information about 'safe-sleeping' arrangements (including known risk factors, for example alcohol consumption) provided to all prospective and new parents (including fathers or partners) and to the practitioners who may work with them; and consider promoting public awareness through a media campaign; share historic information about a child, young person or family with relevant practitioners and services (where appropriate) and include this in all assessments.
| Title: Serious case review: Child K. LSCB: Hampshire Safeguarding Children Board Author: Phil Heasman Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Hampshire Safeguarding Children Board Serious Case Review Child K Report Author Phil Heasman BA (Hons), MA, MA, MSc, MPhil, CQSW 2 Contents 1) Rationale for the review – terms of reference p. 2 2) The review process p.4 3) Names used in the report and agencies in contact with Child K and his family p.5 4) Summary and analysis of involvement with the family and key events p.5 5) Practice, its organisation and management – issues and themes p.13 6) Recommendations p.25 7) Conclusion p.27 Appendices A) List of agencies providing agency reports 1) Rationale for the review and terms of reference 1.1 A Serious Case Review is one of several reviews and audits undertaken within the learning and improvement framework established by a Local Safeguarding Children Board. The purpose of such reviews is to drive developments in work to safeguard and promote the welfare of children (Working Together 2015 p.72) - learning about, consolidating and promoting good practice but also learning from situations where the review has been prompted by a serious incident or tragedy. 1.2 A review provides an opportunity to open a ‘window on the system’ especially at a multi-agency/service level. Any learning, perhaps especially from a situation with the most tragic of outcomes, needs to continue to strengthen the development of the various strands (individual practice, its organisation and management, governance and quality assurance within and between each partner agency) of a ‘safety net’ comprising the response with and for all children, young people and families. 1.3 A child (to be known as Child K throughout this report), aged 11 weeks and 4 days old, was found unresponsive whilst sharing his parents’ bed at the family’s home address. An ambulance was called but, tragically, efforts to resuscitate Child K by his parents and paramedics were unsuccessful. 1.4 Hampshire Safeguarding Children Board considered that the criteria had been met for a review (under regulation 5 (2) (a) and (b) (i) of the Local Safeguarding Children Boards’ Regulations 3 2006) as the situation potentially constituted: ‘a serious case where abuse is suspected and the child has died.’ (Letter to HSCB) 1.5 In this case, the parents were arrested initially on suspicion of committing an offence of neglect by overlaying (under Section 1(2)(b) of the Children & Young Persons Act 1933). To prove this offence the starting point has to be that there is evidence that the death of a child under 3 years of age was caused by suffocation. If the above can be proven, then it also has to be shown that: 1. The child was sharing a bed or other furniture item used for sleeping 2. The sharing was with one or more persons aged 16 years or over 3. That the person(s) sharing were under the influence of drink or a prohibited drug when they went to bed or at any later time before the suffocation 1.6 In this situation, the cause of death was unascertained, therefore suffocation could not be proven and the Crown Prosecution Service (CPS) concluded that there was insufficient evidence to progress past the first element of the offence. It should also be noted that the CPS was also asked to consider whether any offence of neglect under Section 1(1) of the Children & Young Persons Act 1933 had been committed; but the evidential threshold was also not met for any charge under that section. 1.7 Following a preliminary consideration of the possible circumstances of Child K’s death and information pertaining to the family’s situation and the involvement of various agencies with the family, terms of reference for the review were established. It was recommended that information should be considered dating from December 2014 until late January 2017, the date of Child K’s death in order that the review remained proportionate 1.8 The review panel was asked to explore a number of themes and related questions: 1) Engagement with families 1.1 How did agencies engage with the family? 1.2 At points where the family declined a service or started to disengage, how was this assessed by agencies and what did professionals do to engage the family? Did this raise concerns and were these concerns escalated? 1.3 What tools were utilised by frontline professionals to assist in engaging with hard to reach families? What was the impact of using the tools? 1.4 Were professionals considering the family holistically rather than individually; were links made to all the children? 1.5 What was the role of the father? 2) Alcohol associated risks 2.1 What was known by agencies about the previous concerns regarding alcohol misuse and how it impacted on the parenting? 2.2 Was alcohol use considered in light of the pregnancy, what was recorded and what was known about usage? 4 2.3 Was historical information used effectively? Was the impact of alcohol use and the risk to children considered? 3) Co sleeping 3.1 What co sleeping advice was given to the parents and at what stages? 3.2 Who provided the information and who was this delivered to? 3.3 Was a risk assessment regarding co-sleeping completed? What were the sleeping arrangements within the household? 4) Domestic Abuse 4.1 Was there any consideration given to Domestic Abuse, namely coercive control when considering the withdrawal/ non-engagement with services? 4.2 Was there any evidence of coercive control? How was this assessed? 2) The review process 2.1 A panel was appointed to plan and manage the review comprising named and designated safeguarding professionals from the local authority children’s social care service, a range of health services and the police. The panel was led by Phil Heasman who is independent of the case under review and of the organisations whose actions are being reviewed. 2.2 The process of the review included: preparation of agency reports by senior staff within each relevant agency including, variously: an indication of the agency’s roles and responsibilities; a detailed chronology (a narrative of events outlining the contact, involvement and work with the family); a consideration of emerging key practice issues and an analysis of learning and recommendations; compilation of a full, integrated chronology; meetings of the panel to review the information provided by relevant agencies; to address the terms of reference; to identify themes and issues; to identify key personnel to meet who could assist with developing an understanding of what practitioners did in their work with the family and the management and systems supporting it; to consider the information and circumstances of the situation and identify learning and recommendations; meetings by the lead reviewer and an appropriate panel member with relevant practitioners who had been involved with the family - both individually and then as a full group together - in order to understand the case from their perspective, including factors affecting practice and its organisation and management at the time; drafting of a review report for consideration by the Hampshire SCB Learning and Inquiry Group before submission of the report to the Hampshire Safeguarding Children Board. 2.3 It was agreed that on conclusion of the police investigation and other proceedings, a letter would be sent to Child K’s parents to inform them of the review and invite their contribution. 5 3) Names used in the report and agencies in contact with Child K and his family 3.1 For the purpose of the report, the child whose death led to the review will be known as Child K. The report refers additionally to other family members, referred to by their relationship to Child K: Child K’s mother (referred to as such throughout the report, including prior to Child K’s birth) Child K’s father (referred to as such throughout the report, including prior to Child K’s birth) Child K’s older siblings – ranging from pre-school to primary school age and referred to throughout the report as o Older sibling/Child KS1 o Older sibling/Child KS2 o Older sibling/Child KS3 o Older sibling/Child KS4 3.2 Several agencies, services and practitioners had contact with Child K, the older brothers and sisters and parents during the period covered by the review and practitioners and staff from the following services are referred to in the report: Health Visiting and Community Nursery Nursing GP practice at which all family members were registered Schools attended by oldest siblings School nursing service Child and Adolescent Mental Health Service (CAMHS) Children’s Social Care Children’s Reception Team (CRT Hampshire) Children’s Services Department – previous local authority Maternity services (hospital and community) Other health services: paediatrics, ophthalmology, physiotherapy 4) Summary and analysis of involvement with the family and key events 4.1 For the purpose of this report and understanding the involvement of practitioners and services with Child K, his siblings and parents, it seems appropriate to divide the period of time covered by the review into six sections representing: early involvement up to March 2015; a period covering concerns raised by several practitioners in March 2015; contact between Child K’s oldest sibling’s school and Children’s Social Care Children’s Reception Team in June 2015; the period in 2015/6 until Child K’s mother’s contact with ante-natal services; involvement with ante-natal services; the period following Child K’s birth until the incident that prompted the review. 6 4.2 The detail that follows, relating to each of these periods of time or circumstances, has been drawn from the integrated chronology, individual agency reports and the meetings with practitioners. 4.3 Whilst primarily descriptive, some analysis and commentary are included to highlight aspects of involvement with the family that will be explored in greater detail in section five: practice, its organisation and management - issues and themes. 4.4 Initial and early involvement up to March 2015 4.4.1 The review focused on the multi-agency work with the family from December 2014. However, information was provided to the review panel about involvement by the Hampshire health visiting service following notification in May 2014 that the family had moved into the area, summarised below. 4.4.2 Early contact included: a routine invitation for a ‘transfer in’ appointment that was missed by the parents and a second appointment cancelled by them; a home visit by a student health visitor for Child KS3’s two-year development review and a decision that health visiting services would be offered through the ‘universal’ health visiting programme which facilitates 5 key contacts from the antenatal period to a child’s 2-year health review; a further home visit by the student health visitor for Child KS4’s one-year development check, a follow-up for weight monitoring and a referral to an ophthalmologist – but with two missed appointments; information: from Child K’s parents about previous involvement with the Child and Adolescent Mental Health Service (CAMHS) in the area in which they had lived previously as a result of Child KS1’s ADHD; from children’s centre staff including concerns about the some of the children’s behaviour and its management; from Child K’s mother about her previous post-natal depression; from health records transferred on request from the health visiting service in the previous area which included: o information about a previous ‘domestic abuse incident’ in 2012 relating to alcohol intake by both parents (when Child KS3 was just over two months old). The student health visitor planned to discuss this information with the children’s mother at the next visit; o information about mother’s history of self-harm, previous domestic abuse related to alcohol use, post-natal depression and the oldest two children having been the subjects of child protection plans in the previous local authority. 4.4.3 ‘Vulnerabilities’ were noted at the time of the children’s development checks and meeting with the family, but there does not appear to be a record of what these were considered to be or an assessment of Child K’s mother’s past or present mental health and any implications for the children. There does not appear to have been a decision to review the designated health visiting service level in the light of the historic information received from the previous service area, or a consideration of the need for liaison with other services who were also currently providing services to the children and family. 7 4.4.4 From December 2014 the multi-agency involvement focused on Child KS1’s behaviour and its management (at home and school) and included, in December 2014, telephone calls, letters, meetings and appointments – with the parents individually but primarily with Child K’s father, including: an initial CAMHS consultation on moving in to the area, brought forward at Child K’s father’s request because of difficulties at his school; CAMHS risk assessment highlighted information about a history of vulnerability / neglect; Child KS1 was excluded from school and then withdrawn for three days during which his parents apparently adapted his diet, exercise and removed his medication; the school reported to the CAMHS specialist nurse that Child KS1 had been aggressive to other children and upending furniture when angry, had refused to go into school from the grounds or to any adults including his mother when she was called to the school, was shouting and screaming when his mother took him to the car (it was the class teacher who apparently eventually managed to calm Child KS1 down after about an hour and a half); CAMHS staff expressed concern about the risk that Child KS1 might present to others at school and his own vulnerability from other pupils; Child K’s father’s request for a medication review for Child KS1 including a request that medication be discontinued and that Child KS1 should have blood tests to help establish the cause of his behaviour; GP making a referral to a paediatrician in relation to Child KS1’s medication; Child K’s mother seeking an urgent appointment with a GP as she was not coping, that Child KS1’s behaviour was putting a strain on her and Child K’s father’s relationship (but that there was no domestic violence), refusing referral to children’s services for support because of what she thought Child K’s father’s reaction would be; GP suggesting to Child K’s father that a referral to children’s services could be made, which Child K’s father declined. 4.4.5 Prior to the end of term Child KS1’s attendance was increased in a planned way and Child KS1’s medication restarted. However, Child KS1 was not brought by his parents to a planned ADHD clinic appointment. The GP was informed of missed ophthalmology appointments for the youngest child. 4.4.6 School staff invited parents, the health visitor and CAMHS staff to a ‘multi-agency meeting’ planned for the start of the next term (after the Christmas school break) given an understanding that several people were involved with Child KS1 and to try to prevent further exclusions. Child K’s parents were concerned about him being bullied. It is not known on what formal basis this meeting was called and the focus would appear to be solely on Child K’s oldest brother, with school learning and support staff in attendance also. 4.4.7 There does not seem to have been a consideration of the history of previous social care involvement. Indeed, it is not clear whether school staff were made aware of this information at the time of the meeting although there is a record of the health visitor advising the head teacher later in March that Child KS1 and Child KS2 had previously been subjects of child protection plans. Similarly, there does not seem to have been a consideration of the HSCB 8 inter-agency ‘threshold criteria’ for services; of the further consideration of possibility of a referral to children’s social care; of whether Child KS1 might be considered a ‘child in need’ under the Children Act 1989 and related guidance in Working Together 2013 (the statutory guide to inter-agency work to safeguard and promote the welfare of children, in place at the time) or of an the expectation that the multi-agency work might be co-ordinated at an ‘early help’ level as set out in Working Together 2013. A home visit by parent behaviour support service was arranged, but it is not known whether this went ahead. 4.4.8 During the subsequent two months in early 2015 the situation at school appears to have been stable for Child KS1. One ADHD clinic appointment was kept at which medication was reviewed but Child KS1 was not brought to the planned appointment with the paediatrician. It was decided that CAMHS practitioners would continue to work with the family – a further appointment with the paediatrician was not offered. Child K’s parents reported to a GP at the practice (during a telephone call) that the situation was calmer. 4.4.9 There is also a record of the family being included in ‘Vulnerable Families’ discussions between the GP practice’s safeguarding lead and the practice’s liaison health visitor. The family were included in discussions at fourteen of these such meetings over the period covered by this review. No concerns were recorded at this time. Neither the safeguarding lead GP nor the liaison health visitor were the practitioners in their services in direct contact with the family and it is not clear under what guidance or requirements these meetings were held, the arrangements for them being informed by colleagues in direct contact with family members, for records to be made, or for the dissemination of decisions. It is also not clear whether families are aware that they are included in the discussions. 4.4.10 The school nursing service received and reviewed records from the previous area which included information about the two oldest children having been subjects of child protection plans for a period of 16 months (including at the time of Child KS2’s birth) ‘because of the impact of domestic violence, alcohol abuse and mother’s mental health problems’ (from the integrated chronology). It would appear that this information was not shared with the school by the school nurse. 4.4.11 Another school nurse from the service met with the safeguarding lead in the GP practice approximately two weeks later and was advised by the GP that Child KS1 had ADHD and autistic spectrum disorder, attends CAMHS and has a paediatrician. There would not appear to be evidence that the history of previous child protection planning linked to domestic abuse, alcohol misuse and maternal mental health was shared with the GP. However, the GP reported that Child KS2 was affected by her older sibling’s behaviour difficulties, was withdrawn and quiet; she was receiving additional educational support in school. 4.5 March 2015 4.5.1 In March 2015 there were multiple concerns identified by several practitioners in relation to the children and contact with family members by many services and practitioners including, not uncommonly, three different GPs from the practice seeing various members of the family at different times. The concerns included: 9 reports by Child K’s father that Child K’s oldest sibling had headaches as a result of the current medication plan, it was suggested that a review of the medication by a CAMHS psychiatrist would be requested; Child K’s mother bringing Child K’s siblings Child KS3 (now 2 years and 8 months) and Child KS4 (now 1 year and 5 months) to the GP practice with bruising to child KS4’s cheek and shin, scratches to her foot and a superficial older scratch to her thigh with bruising explained as occurring in the house which was being renovated; bruising to Child KS3’s right eyebrow – he said that he had fallen down steps at home It is reported that Child KS4 became upset whilst being undressed for the examination and was still crying when being re-dressed; child KS3 started to cry also and tried to comfort his sister; he apparently cowered whilst his mother dressed his sister (KS4) (from the integrated chronology); Child KS4 had a viral illness and ‘in-toeing’, for which the GP said a referral to a physiotherapist would be made; further concerns that same week again regarding the oldest child’s (Child KS1) medication and a request by Child K’s father to increase it, with the GP then seeking confirmation of the recommended dosage from the CAMHS team. This was recorded as a safeguarding concern within CAMHS following the information from the GP about the apparent dosage levels being administered by Child K’s father; a planned review meeting at school was cancelled ‘due to parents’ hostility to the meeting’ (from the integrated chronology). The health visitor reported this information to the GP suggesting that the school staff considered that ‘holding the meeting would damage the relationship with the parents’, but that Child KS1’s behaviour was improving and that Child KS2 was getting one-to-one help in the classroom; Child K’s father complained that a support worker at the children’s centre had apparently had a threatening manner towards the children’s mother – allegedly demanding that Child K’s mother attend groups with the two younger children; the parents were reported as refusing to attend further meetings and that they felt victimised. 4.5.2 During this period of approximately two weeks it would appear that there was considerable liaison between and within services: at least 15 different contacts (including telephone calls, formal and informal meetings/discussion, a letter and emails) between 14 different professionals (including four different GPs from the practice, two health visitors, the headteachers of both Child KS1’s and Child KS2’s schools, the children’s centre, the consultant paediatrician, the CAMHS psychiatrist and the safeguarding children specialist nurse) and at times with the parents. It is not clear how many times the children were seen or spoken to directly. 4.5.3 Concerns were recorded as being of a ‘safeguarding’ nature and advice sought from colleagues with specific safeguarding responsibilities. One of the GPs had discussed the safeguarding concerns with a consultant (an acute paediatrician) during an advisory discussion about Child KS 4’s ‘in-toeing’ presentation. It is noted in the integrated chronology that the consultant paediatrician advised that, as several professionals had concerns over a number of issues then there was cause for concern; that if there was any doubt at the point of addressing Child KS1’s medication and mother’s health then a referral to children’s services should be made (from the integrated chronology). 10 4.5.4 The health visitor sought supervision from the safeguarding children specialist nurse (Single Point of Contact/SPOC arrangement) regarding concerns and possible disengagement by the parents. The health visitor was advised to discuss the current issues with the GP and CAMHS practitioners and to refer to Children’s Services Department if they also had concerns. The possibility of a referral to the Early Help Hub (EHH) was discussed between the health visitor and the safeguarding specialist nurse, but the parents did not want this. 4.5.5 There does not appear to be a consideration of the expectation in Working Together 2013 (and directly included again also in the updated 2015 version published at this time) that the involvement by the several agencies with the family could or should be managed through a single inter-agency assessment, the designation of a lead professional and a co-ordinated plan of response and service provision (Working Together 2013 p. 12/13 and Working Together 2015 p.14). A referral to Children’s Services was not made. 4.6 June 2015 4.6.1 In early June 2015 the Children’s Reception Team (CRT – the team that acts as the first point of contact for professionals and families who are seeking to make a referral to Children’s Services) received a telephone call from Child KS1’s headteacher saying that Child KS1 had, the day before, ’disclosed that his parents punished him all the time and hit him on his private parts‘ and smacked his bottom really hard (from the integrated chronology and CRT records). During this contact the headteacher referred to a previous reference by Child KS1 to hitting, seven months prior to this incident. The status and intention of the contact from the school’s perspective is not known. 4.6.2 An Assistant Team Manager (social worker) reviewed the details provided by the school and the analysis from the CRT call taker and decided that there was no role for social care. This contact comprised the only information known about the family. More recent concerns (as outlined in the sections above) had not been referred and there had been no contact from the previous local authority. A decision was made not to progress the contact from the school to a formal referral and associated response. 4.6.3 It would appear that school staff did not provide and were not asked about background/historic information, information about other agencies’ involvement or circumstances beyond the immediate concerns. Similarly, it does not appear that there was a discussion about Child KS1’s cognitive capacity, the diagnosis and treatment for ADHD or a consideration of how this might specifically impact on the way that he communicated or presented information. It could be suggested that, as Child KS 1 had talked about being hit alongside lots of other subjects, then this may have reduced the school’s staff members’ and CRT practitioners’ sense of the veracity of what Child KS1 was saying and the possibility that this was a disclosure of an assault. 4.6.4 The headteacher was advised that he should discuss the concerns with Child KS1’s parents. The response to the contact from the school suggests that the information was not taken to constitute concern that Child KS1 may be ‘suffering or likely to suffer significant harm’ 11 warranting a process of investigation as set out in sn.47 of the Children Act 1989, Working Together 2015 or the HSCB child protection procedures. Consideration does not appear to have been given to the possibility of requesting a child protection medical following what could have been defined as a disclosure of physical abuse or assault. 4.6.5 The school do not now have a record of the incident, the contact with the Children’s Reception Team (CRT) or of the information shared by the school at the time. The extant CRT record does not suggest that information (provided by the health visitor to school staff in March: of previous social care involvement; that Child KS1 and Child KS2 had been subjects of child protection plans at one point in the previous local authority; or of more recent concerns) was shared by the headteacher with the CRT call-taker. The school also does not now appear to have a record of the discussion or the advice given by the CRT practitioner or manager (which may have included a view that what was being reported might constitute ‘lawful chastisement’ - from CRT records). 4.6.6 Unfortunately, there is no record of whether further discussion took place between the headteacher and Child K’s parents, or of any other subsequent action taken by school staff. It does not seem that the headteacher was asked to – and did not - re-contact the CRT to report on the outcome of the discussion with Child K’s mother. 4.7 The period of time in 2015/6 until Child K’s mother’s contact with ante-natal services 4.7.1 Over the next few months there was apparently limited contact with the children or parents outside of school provision. A CAMHS appointment was missed in July and the family were informed that, if there was no contact within two weeks then Child KS1’s ‘file would be closed’ (from the integrated chronology). Child K’s father contacted the clinic apologising for missing the appointment and a further one was planned and kept in October with continuing discussion with Child K’s father about Child KS1’s ADHD, its effect on his behaviour and its management – including a review of medication. In December the GP contacted Child K’s father by telephone as he had still not been brought for a medication review; the GP noted that this was becoming a safeguarding concern but Child KS1’s father clarified information about current circumstances and contact with CAMHS in October. 4.7.2 Child K’s youngest sister had her 2-year health review, this was undertaken by a nursery nurse and not a registered/qualified health visitor, though there had been identified vulnerabilities. It is perhaps significant that none of the formal development checks of Child K’s older siblings during the time of contact with the health visiting service were undertaken by a registered health visitor. No developmental gaps were highlighted for Child KS4 and it was planned that health visiting services would continue to be offered through the ‘universal’ level of provision. Child K’s mother refused a referral for ophthalmology for Child K’s sister regarding the family history of ‘lazy eye’. 4.7.3 In November Child K’s mother was seen by another GP at the practice because of symptoms of depression. There does not appear to have been a discussion about any impact of mother’s current mental health on the children directly or indirectly. Anti-depressants were prescribed but Child K’s mother later decided to stop taking these in January as she reported that she was hoping to become pregnant again. 12 4.7.4 The family continued to be included in ‘Vulnerable Families’ meetings at the GP practice (held monthly) involving the liaison health visitor and the safeguarding lead GP. No recent concerns were noted. 4.8 Involvement with ante-natal services from March 2016 4.8.1 In March 2016 Child K’s mother had an antenatal booking appointment with a community midwife and was asked, as part of the routine assessment, about any experience of domestic abuse, of substance misuse or whether she or Child K’s father had ever had a social worker or probation officer. Child K’s mother answered negatively to all these questions but did report her experience of depression and that she was currently under the care of the GP and had been prescribed anti-depressants. The maternity services booking form was sent to the health visiting service and it could have been identified from the form that Child K’s mother had not disclosed the child protection, alcohol, or domestic abuse history. 4.8.2 Child K’s mother kept all routine antenatal appointments with maternity services and staff - and there was discussion between the community midwife and Child K’s mother about her ‘low mood’. At one point, Child K’s mother told the midwife that she was relying on her mother for support but that her mother was finding it difficult to help. The community midwife noted that Child K’s mother reported that the behaviour of the oldest child (Child KS1) was impacting on the family, but there does not seem to be a consideration of why or how. At some of the appointments, some of Child K’s siblings were seen; no concerns about their presentation or wellbeing were recorded. 4.8.3 The GP liaison health visitor linked with the community midwife as part of routine practice although it is not clear under what policy, guidance or requirements these meetings were held - or of the arrangements for them to be informed by colleagues, for records to be made, or for the dissemination of decisions. It is also not clear whether families are aware that they are included in such cross-service discussions. It does not appear that information was shared with the community midwife by the liaison health visitor regarding previous involvement with the family (including the previous history of social care involvement and that the eldest two children had been subjects of child protection plans at one stage - indeed, this information would not appear to have been shared with or available to the maternity service practitioners at any time) or of any more recent concerns. 4.8.4 In September the health visiting team’s administrator contacted Child K’s mother to arrange an antenatal appointment but was told that she did not want an appointment and was too busy to speak to the health visitor directly. This is generally considered to be an unusual response to the health visiting service’s invitation for early contact during pregnancy. The health visitor also reported to the review that she was not aware of the record of previous concerns (historic and more recent) and vulnerabilities – either through accessing the records held by the service or from other sources. 4.9 Following Child K’s birth 4.9.1 Child K was delivered ‘in excellent condition’ with a ‘normal delivery’ and with no complications. Following routine observations of recovery from the delivery and with Child K feeding appropriately, he and his mother were discharged the following day. Information about 13 ‘safe sleeping’ and other health and care matters is provided routinely at the point of a baby’s and mother’s discharge from hospital but it is not clear whether both parents/partners (where appropriate) receive the information. 4.9.2 Routine midwifery visits and appointments were kept and did not identify any difficulties or concerns. Child K’s new born hearing screening was also completed. Again, however it would not appear that the maternity service staff were aware of previous concerns, the fact that Child K’s older siblings had been subjects of child protection plans or the more recent concerns and involvement by various services and practitioners since the family moved to the area in 2014 – including times when vulnerabilities had been noted or when concerns had been identified as ‘safeguarding’ and contact with Children’s Services considered or suggested. 4.9.3 The health visitor sought to arrange a new birth visit and early feeding review, ringing the home on five occasions. Child K’s mother contacted the health visitor (day 17 following the birth of Child K) reporting that Child K was well; a new birth visit was declined. Details were given to Child K’s mother by the health visitor of clinic days and times and although Child K’s mother indicated she would attend, there is no record that this happened. Again, awareness of previous concerns (historic and more recent) and vulnerabilities as well as the unusual refusal of antenatal contact may have provided a context to assess whether this situation might give cause for concern. 4.9.4 The family continued to be included in discussions of vulnerable families at the GP practice involving the liaison health visitor and safeguarding lead GP. It was noted that the allocated health visitor was not allowed access to the house but that ‘the midwife is happy’. Maternity service involvement and visits ended twelve days after Child K’s birth. 4.9.5 In addition to the safe sleeping advice given at the point of discharge from hospital, the information is reiterated during postnatal community midwife visits and includes the provision of an accompanying UNICEF leaflet. There is no record of Child K’s mother saying that Child K would sleep in the parents’ bed. The maternity service practitioners were unaware of the historic information and concerns relating to alcohol use and domestic abuse (including reference in the older children’s health visiting records from the previous area - that there had been a domestic abuse incident relating to alcohol intake by both parents when Child KS3 was 10 weeks and 2 days old). 4.9.6 Child K was brought to the GP practice for his 6-week check – at 10 weeks and 3 days old. No concerns about Child K or his mother were recorded. Two days later Child K was brought for his first set of immunisations by the practice nurse. 4.9.7 A week later (Child K was 11 weeks and 4 days old) Child K’s parents made an emergency call in the early hours of the morning as Child K was found unresponsive. Tragically, efforts to resuscitate Child K by his parents and paramedics were unsuccessful. 5) Practice, its organisation and management – issues and themes 5.1 This section of the report identifies and explores themes, issues and critical debates that have emerged from the scrutiny that a serious case review both requires and allows: bringing a sharp focus to bear on involvement with one particular child and family over a specific period of time. 14 5.2 Detailed reports were prepared by senior staff from key agencies and services. These reports were based on a consideration of records, meetings and discussions with practitioners. Information has also been drawn from formal (electronic) recording systems that usually remain separate and, less formally, from practitioners who had contact with Child K, his siblings and parents in the course of their work with many other children and families over the time covered by the review. 5.3 The themes and issues considered in this section have their root in what has appeared significant in this particular situation but may also be important in future work to help promote and safeguard the wellbeing of all children and young people. It is acknowledged that a review focusing on work with a particular family cannot ascertain whether the practice and its organisation and management in that particular situation was typical or atypical of usual practice. Similarly, where aspects of practice and its organisation and management have been highlighted as areas for development, it is perhaps difficult to say whether there is any connection with the outcome for Child K. 5.4 The analysis below is structured according to the terms of reference that the HSCB Learning and Inquiry Group identified from the initial consideration of Child K’s death. The key issues that emerged during the review process seem to fit well within these terms of reference. Many of the agency reports also directly addressed the terms of reference and associated questions and such an approach by all agency report writers is to be encouraged in future reviews as it can help bring a consistency to analysis enabling key themes to be pursued and tracked within and across all reports. Terms of reference 1: Engagement with families a) How did the agencies engage with the family? 5.5 It appears that there was limited engagement with the family as a whole with just one obvious recorded occasion when all members of the family were seen together by a practitioner (the student health visitor who undertook the two-year development check for Child K’s youngest sibling in 2014). It would appear that Child K’s father did not attend any antenatal appointments and the community midwife did not meet him. It is not clear whether one or more of the postnatal maternity service’s practitioners saw the family together after Child K’s and mother’s discharge from hospital. It may be the case that the whole family was not seen together by any qualified or registered health, social care or education practitioner during the period covered by the review. No one professional had designated responsibility for the whole family. 5.6 There is no evidence from any of the reports or conversations with practitioners that any practitioner discussed historic information, the circumstances of the previous child protection involvement or details of the past concerns that Child KS1 and Child KS2 had been considered to be at risk of significant harm necessitating child protection plans. None of the practitioners seemed to have details of the child protection plans or of work undertaken with Child K’s parents as a result of the plans, nor information about the circumstances of the decision that child protection plans were no longer needed in respect of Child K’s eldest siblings. Throughout the review period there does not seem to have been a formal or contemporary assessment of whether the historic concerns might still be current. 15 5.7 There is a record that Child K’s mother and father attended one meeting at the school together in January 2015 and there is a record of a telephone call by one of the GPs during which both parents were each spoken to separately during the conversation. According to the records and agency reports, all other meetings or discussions took place with one or other parent and sometimes with one or more of the children present. 5.8 It could be suggested that the way agencies engaged with the family was as a result of the dynamic and interaction of several factors: as required routinely e.g: health checks, developmental reviews, immunisations, registering with a service such as the midwifery service; as presenting specific issues or problems arose e.g: an accident or injury to one of the children sustained in school; particular concerns about child KS1’s behaviour; routine health advice either sought for one of Child K’s older siblings or for one of the parents; the perception by mother of Child K’s father’s likely response to the involvement of services e.g: the question of making a referral to children’s social care suggested by a GP; practitioners’ perception of likely response from the parents e.g: the school were concerned that staff members’ relationship with Child K’s parents needed managing sensitively and therefore agreeing with a parental request not to go ahead with a planned meeting; the suggestion to the GP (who asked the health visitor to visit in March 2015) that the health visitor is fairly sure that if a call was made to the parents, the request for a visit would not be accepted. on terms defined by Child K’s parents, including missed or declined appointments e.g: o not agreeing to a ‘transfer-in’ health visiting service appointment; o appointments sometimes taken up or sometimes missed with the ADHD clinic for Child KS1; o not wishing to attend children’s centre activities; o agreement to referral but no attendance at one of the children’s ophthalmology appointment; o not agreeing to a proposed referral for physiotherapy for one of the children; o agreeing only sometimes for information to be shared between CAMHS and Child KS1’s school; asking for a change in Child KS1’s medication; o registering with antenatal service; o not seeing the need for a pre-birth health visiting service appointment, o not responding to many requests from the health visitor to visit after Child K’s birth. 5.9 Given the limited multi-agency co-ordination of involvement with the family by the various key agencies and services and practitioners, it was perhaps unlikely that possible patterns of engagement/non-/disengagement could have been recognised or the potential impact on the children discerned over and above each separate situation. Nor, perhaps, was it possible to 16 develop a common approach or strategy for effective engagement with the family, especially the parents. 5.10 A further key issue perhaps arises if the question in the terms of reference is re-phrased ‘how did the agencies together engage with the family?’ The picture presented from the integrated chronology, the agency reports and the conversations with practitioners, is perhaps mainly one of individual practitioners, individual agencies and services (and sometimes teams and individuals within services) generally engaging with the family or the parents singly or in time-limited and occasional partnerships and communications – supported and managed by different recording and information management systems. 5.11 There does not appear to be a sense of a ‘team around the family’ as a whole, or of presenting issues being considered systemically – either with the system defined in terms of the family and all its members, or a wider system that might also include a ‘professional dimension’: school, health visiting service, GP practice, CAMHs etc. 5.12 There is little evidence that the work with the family was formalised. The somewhat critical mass of concerns in December 2014 and in March 2015 involved consideration of a more formal referral to children’s services that might have led to processes of assessment and co-ordination with a whole family/whole professional system emphasis. Similarly, the contact between Child KS1’s school headteacher and the Children’s Reception Team could have triggered a more formal assessment or investigative process in line with the provisions of Working Together 2015 and the HSCB procedures at the point of referral. 5.13 The possible consequences of the way that agencies (singly and together) seemed to engage with the family were that: concerns arising in relation to one child were not necessarily considered as potentially having implications for or an impact on other children. For example: Child KS1’s behaviour at one stage was described as being a risk to other pupils in school - this does not appear to have been seen as having relevance for his relationships with his younger siblings or being a potential risk to them. The management of Child KS1’s medication and sporadic engagement with services for him may represent a pattern of parental action that could have implications for the other children; there may have been a danger of responding to immediate presentations and issues rather than considering wider, underlying or contributory causes (e.g: Child KS1’s behaviour linked primarily to medication management – essentially an organic explanation); there may have been an emphasis on reacting to current presenting issues alone and not within a larger contextual understanding of the family. For example: the response to the school’s contact with the CRT - where a possible understanding and interpretation of Child KS1’s ADHD (and the implications for the way he perhaps processed and presented information) may have led to a minimising of what he said about being hit by his parents because this disclosure was mentioned in the course of other comments and topics; when antenatal and postnatal health visiting contact was not possible; when community midwives were involved following Child K’s birth but did not have historic information (including about the previous concerns about the risk of significant harm to the eldest two 17 children, of problematic substance use, of domestic abuse and of mother’s longstanding mental health difficulties). 5.14 Another opportunity to formalise and organise the multi-agency work with this family could certainly have been taken through the expectations and provisions in the 4LSCBs’ Maternity and Children’s Services Unborn Babies Safeguarding Protocol 2013 (due for revision in July 2015 but revised in December 2016) when practitioners became aware of Child K’s mother’s pregnancy. The protocol in use at the time advises that where there are ‘low level known risk factors’ (p.9) there should be: liaison between the GP and health visitor and all other relevant professionals; a meeting between involved professional and the family; a joint professional assessment; and a care plan agreed. If there is a ‘medium to high level of known risk factors’ then practitioners should consider undertaking a CAF (Common Assessment Framework assessment, the process and structure in use at the time that the protocol was established in 2013) and consider referring to Children’s Services Department. The listed concerns that may trigger the protocol include (section 4.1): ‘mental health support needs’, ‘known domestic abuse by any member of the family’ and ‘historical concerns such as previous neglect, other children subject to a child protection plan’. Section 5.2 suggests that ‘a referral should always be made if: A parent or other adult in the household is a person identified as presenting a risk, or potential risk to children. This may be due to domestic abuse, substance/alcohol abuse, mental health or learning disability Children in the household/family are currently subject to a Child Protection Plan or previous Child Protection concerns. 5.15 It seems significant that in meetings with practitioners and other information considered by the review, that there was little reference to national or local policies and procedures or guidance for practice and its management including: the HSCB Procedures Manual, related Hampshire Safeguarding Children Board and Children’s Trust Thresholds Chart/ ‘threshold guidance’, the Information Sharing and Confidentiality Policy (Hampshire Children’s Trust) and policies in relation to response to a child or young person presenting with bruising, or not being brought to appointments or (as above) the 4LSCBs’ Maternity and Children’s Services Unborn Babies Safeguarding Protocol. 5.16 In particular there does not seem to be overt reference to the provisions and guidance (and associated responsibilities and practice arrangements) set out in Working Together 2013/2015 (versions in use during the period of this review but with identical guidance and language in the relevant and respective sections drawn out below). 5.17 Working Together 2013/2015 refers to ‘a continuum of help and support to respond to the different levels of need of individual children and families’ (WT 2015 p. 15 para 14) with four main elements within the continuum and thresholds defined: a) ‘where need is relatively low’; b) ‘other emerging needs’; c) ‘where there are more complex needs’; 18 d) ‘where there are child protection concerns’. Each of these elements are linked with expectations of responses by services which are defined as: ‘universal’, ‘early help’, ‘child in need’, ‘child protection’ and have related and formally defined expectations of roles, responsibilities, powers duties and rights and associated management processes. 5.18 At various times there certainly may have been a question of where on this broad differentiated continuum of need/service response the children might have been located. For example, could the concerns about all or some of the children in March 2015 or Child KS1’s disclosure at school in June 2015 meet threshold criteria for ‘child protection concerns’; could Child KS1’s needs relating to his diagnosis of ADHD meet the criteria for services without whose provision he would be ‘unlikely to achieve or maintain a reasonable level of health and development, or whose health and development is likely to be significantly or further impaired’ (definition of ‘a child in need’ in sn. 17 of the Children Act and included in Working Together 2015 p. 18)? 5.19 However, Working Together 2013/2015 is clear that at the ‘early help’ level of concern and need (where ‘children and families may need support from a wide range of local agencies’) – then: ‘Where a child and family would benefit from coordinated support from more than one agency (e.g. education, health, housing, police) there should be an inter-agency assessment.’ This is to be undertaken by a ‘lead professional who should provide support to the child and family, act as an advocate on their behalf and coordinate the delivery of support services.’ 5.20 There is reference to the importance of services being ‘co-ordinated and not delivered in a piecemeal way’ (WT 2015 p.14); that the ‘early help assessment carried out for an individual child and their family should be clear about the action to be taken and services to be provided…. And aim to ensure that early help services are coordinated…’ (Working Together 2015 p.14). 5.21 Referral to Children’s Service ‘Early Help’ was considered at times but this seemed to imply a process of accessing services provided through the Early Help Hubs in place in Hampshire, rather than a sense that the processes identified in Working Together 2013/2015 might apply to the management of involvement with a family whether or not there is involvement by Early Help Hub practitioners, including, again: the designation of a lead professional (which WT 2015 suggests could be ‘a General Practitioner, family support worker, teacher, health visitor and/or special needs coordinator’); a single multi-agency assessment undertaken by the lead professional; the coordination of support services 5.22 In Hampshire, the ‘early help’ band of the safeguarding and promoting continuum set out in Working Together 2013/2015 is differentiated into two levels (level 2 and level 3 in the Hampshire Safeguarding Children Board and Children’s Trust Thresholds Chart in use during the period of the review and currently) with the ‘Early Help’ subsections defined as: 2: Early Help: has additional needs within the setting that can be met within identified resources through a single agency response and partnership working 19 3: Targeted Early Help: Has multiple needs requiring a multi-agency co-ordinated response However, a more recent Hampshire County Council paper in July 2016 (setting out new proposals in relation to Family Support Services) includes the following definition in relation to the Children’s Trust and Hampshire Safeguarding Children’s Board’s ‘threshold of need’ chart: ‘The ‘threshold of need’ chart therefore identifies 4 levels of need: Level 1 (universal) – all families and children where there are no specific needs; Level 2 (early help) – families where there is a need for support, but this can be met within a specific setting e.g. pre-school or school and by one single service or agency, i.e. a speech and language therapist providing advice and help; Level 3 (targeted early help for vulnerable families) – families and children with more needs requiring more than one service or agency to be involved; and Level 4 (children’s social care) – families and children with a high level of unmet and complex needs and meeting the threshold for children’s social care intervention.’ 5.23 Arrangements, processes and services that characterise a ‘level 3’ level of need or concern for a child or young person or family in Hampshire (according to the Hampshire Safeguarding Children Board and Children’s Trust Thresholds Chart) and related response, would seem to be well-defined with a clear sense of an assessment process (and accompanying proforma etc.) and the co-ordination of both a single assessment and a subsequent plan and provision of services through the identification and action of a designated lead professional. 5.24 It is perhaps less clear how on-going ‘partnership working’ (at Hampshire Thresholds Chart ‘level 2’ - but which also accords with Working Together 2013/2015’s guidance for all ‘early help’ work) by practitioners such as GPs, health visitors, school staff, maternity service staff, CAMHS practitioners and school nurses – and their respective services - is to be managed. 5.25 The current HSCB ‘Early Help’ website information suggests that ‘practitioners need to understand their role both when providing a service as a single agency (emerging additional need) and as part of a multi-agency response (targeted interagency).’ However, the practitioners involved with Child K’s family do not seem to have considered the expectation that they use the ‘Early help checklist’ and then potentially ‘consider commencing an Early Help Assessment to inform the support that is needed for the child and family from you and other agencies.’ (Early Help and Supporting Families Checklist July 2015) 5.26 It is not possible to know what could have been the impact on involvement with the family of applying the single category ‘early help’ level expectations set out in Working Together 2013/2015 to ‘partnership working’ (HSCB Level 2). In this case it may have: led to a single, holistic, systemic assessment using a conceptual model such as the Assessment Framework ‘triangle’ (as proposed in Working Together 2013/2015/2018) to identify strengths and difficulties past and present (to assess the particular health, development and wellbeing of each child; to assess whether her/his needs are being met; to assess parenting capacity and the potential impact of wider family and environmental 20 circumstances) which would then potentially have been available more readily to all GPs, all health visitors, all maternity services staff and have led potentially to the assessment and information being used and shared at key moments - such as the contact with CRT by Child KS 1’s school in June 2015; at times of more acute specific concern (e.g: March 2015, June 2015), enabling presenting issues to be seen in the context of past safeguarding concerns and information about the previous child protection plans so that an informed judgement could be made about any current relevance of historic information and implications for the current wellbeing of the children); helped identify one lead professional; potentially provided a framework for meetings; assisted with information sharing (and a greater transparency about this - for example, it is not clear that the parents were aware that the family was discussed at ‘vulnerable families’ meetings at the GP practice or at discussions between the liaison health visitor and community midwife); increased the opportunity for patterns of parental engagement or of dis-/non-engagement to have been identified; helped in considering parental and family dynamics – including issues pertaining to information regarding historic domestic abuse and alcohol use; helped coordinate services and work with the family. Engagement with families b) At points where the family declined a service or started to disengage, how was this assessed by agencies and what did professionals do to engage the family? Did this raise concerns and were these concerns escalated? 5.27 As identified in section 4, there were several occasions when the family either declined or were thought likely to decline a service (‘transfer-in appointment’ with the health visiting service; referral to Early Help Hub; physiotherapy; ophthalmology; referral to children’s services); disengaged or had a sporadic or selective pattern of engagement (with CAMHS, with school, with the health visitors, rejection and complaint about the children’s centre). It is difficult to discern a clear pattern, but a possible explanation might be that Child K’s parents primarily sought assistance and services when it was seen as beneficial or they considered that it was in the children’s interests. The perception of what was in the children’s best interests held by the parents did not perhaps accord at all times with the perception of the practitioners involved. 5.28 The possibility that when Child K’s mother declined further help it may have been because of Child K’s father’s influence does not appear to have been considered by the various practitioners involved or explored with her. Similarly, the possibility that sporadic or selective engagement was as a result of the differing perceptions of need (parents and practitioners, as above), or the result of the organisation of the parents, or even the result of a strategy to engage with just some services – does not seem to have been considered or tested. 5.29 The children were dependent on adults (primarily their parents) to meet their needs and Working Together 2015 sets out what children have said they need which includes: 21 ‘Vigilance: to have adults notice when things are troubling them. Understanding and action: to understand what is happening; to be heard and understood; and to have that understanding acted upon, Support: to be provided with support in their own right as well as a member of their family.’ This perhaps reinforces the importance of practitioners considering that a parent’s/parents’ capacity or level of willingness to engage may be inhibiting a child’s or children’s access or right to services that could promote their wellbeing (e.g: access to physiotherapy, CAMHS appointments, attending ophthalmology services, engagement with ante-natal and post-natal health visiting service, even heeding safe-sleeping advice etc.) - rather than representing a parent exercising parental choice. Such a recognition could lead to a referral of concern or other response. Guidance on countering what has been recognised as disguised non-compliance in some parents seems to highlight the critical need to keep a focus on the child or young person’s health and development as a primary indicator of effective engagement and to measure what parents and carers actually do, not what they say they agree to do, will do or are doing. (See NSPCC: ‘Disguised compliance: learning from case reviews. Summary of risk factors and learning for improved practice around families and disguised compliance guidance’, for example) 5.30 Perhaps because of the apparent limitations to partnership working or coordinating multi-agency services, it may not have been possible for issues or patterns of non-engagement, sporadic or selective engagement or disengagement to be recognised, tested or challenged if necessary. Engagement with families c) What tools were utilised by frontline professionals to assist in engaging with hard to reach families? What was the impact of using the tools? 5.31 It is not clear that any particular tools were identified or referred to but the development of policy and guidance e.g: Child and Family was not brought and disengagement guideline is welcomed and is likely to help practitioners respond to this issue effectively and within a well-defined procedure. Engagement with families d) Were professionals considering the family holistically rather than individually; were links made to all the children? 5.32 As considered above, it could be suggested that a holistic, ‘whole family’ or ‘think family’ perspective was not always taken perhaps either in relation to the consideration of difficulties or ‘problems’ (their cause and potential impact on all the children) or in terms of ‘solutions’ and responses. The one meeting which the parents attended together was at the school in January 2015. Whilst the health visitor and CAMHS practitioners were invited, this meeting was prompted by issues relating to Child K’s oldest brother’s behaviour – and to prevent any further exclusions. The 14 ‘vulnerable families’ meetings that included discussion of the family by the safeguarding lead GP and the liaison health visitor to the practice were not necessarily informed by a full and integrated picture of the family or each child’s situation either from within each of the two services, between the two services or more widely. 5.33 Aside from the suggestion that coordinating an assessment and an integrated response to the family through the ‘early help’ process and provisions recommended in Working Together 22 2013/15 might have helped promote a ‘whole family’ approach, then the more formal involvement of children’s services would probably have prompted a whole family assessment and more formal multi-agency coordination of all known information and perhaps services. Engagement with families e) What was the role of the father? 5.34 Child K’s father was active at times in working with CAMHS and to an extent the school in relation to Child K’s oldest brother’s ADHD, his behaviour and its management especially regarding medication levels. At times, Child K’s father was happy for information to be shared with school – but not at other times; it is unclear why that might be the case. 5.35 There was a suggestion raised in the reports that Child K’s father may have been concerned at the details of the discussion between the health visitor and Child K’s mother during the home visit in Autumn 2014. This was the one obvious time when a practitioner saw the whole family together. 5.36 Child K’s father complained about the children’s centre staff and Child K’s mother was reported as being sensitive to her husband’s likely reaction at the suggestion by a GP that a referral to children’s services for support could be helpful. When the GP also made this suggestion to Child K’s father it was rejected. 5.37 In March 2015 the health visitor informed the GP that a scheduled meeting at school was cancelled due to parents’ hostility to the meeting and that the school staff felt that holding the meeting would damage the relationship with the parents. 5.38 Given the absence of school records relating to the contact by the headteacher with the Children’s Reception Team in June 2015, it is not known whether the advice given to the headteacher (to talk further with Child K’s parents about the information disclosed by Child KS1) was followed and, if not, what informed the decision by school staff. Because this contact was not taken forward as a referral, there does not seem to be an expectation from the CRT that it would follow up further or that school would report back. Terms of reference theme 2) Alcohol associated risks Alcohol associated risks a) What was known by agencies about the previous concerns regarding alcohol misuse and how it impacted on the parenting? 5.39 Some of the agencies and practitioners were aware of information from counterpart services in the area in which the family had lived previously e.g: eldest two children’s health visiting records provided August 2014 and the mother’s records received in October 2014 after a request; school nursing service records; request from CAHMS for information from the previous area’s service, that was not forthcoming. 5.40 Records received included references to Child K’s eldest two siblings having been the subjects of child protection plans and that the associated risk of significant harm was apparently linked to alcohol use and domestic violence. Details do not seem to have been available of an incident or incidents, of assessments made, of plans and the process of work with the parents leading to the decision that child protection plans were first necessary and then no longer necessary. Historic information including concerns about problematic alcohol use was initially known to some services and practitioners but was not apparently always either sought, further shared or 23 available at the point where other practitioners were involved or became aware of the family e.g: when the headteacher contacted the CRT in June 2015; when the community midwifery service became involved from Child K’s mother’s registration before his birth; when the new health visitor was allocated for Child K; all GPs in the practice. Alcohol associated risks b) Was alcohol use considered in light of the pregnancy, what was recorded and what was known about usage? 5.41 Routine questions were asked at the point of Child K’s mother’s registration with the community midwife and the responses given were unlikely to prompt further detailed exploration (no problematic alcohol use, no issues relating to domestic abuse, no previous involvement with social care), especially without any background information. Alcohol associated risks c) Was historical information used effectively? Was the impact of alcohol use and the risk to children considered? 5.42 Historical information about the specific issue of alcohol use and associated information relating to domestic abuse, neglect and mother’s mental health and previous child protection involvement and plans was not known to all practitioners and therefore did not comprise an aspect of all current assessments including by the community midwife and in relation to a discussion about sleeping arrangements. 5.43 Information about the details of how past parental alcohol use might have impacted on the parents’ capacity to meet the children’s needs or have affected the children’s health, development and wellbeing would not appear to have formed part of any discussion with the parents by the practitioners who were aware of it. 5.44 In relation to all historic information and sharing information more generally, Working Together 2013/2015 is also clear about the importance of sharing information within and across practitioners and services to promote and safeguard children’s health, development and wellbeing: ‘Effective sharing of information between professionals and local agencies is essential for effective identification, assessment and service provision’ (Working Together 2015 p.16 para 22) across the whole continuum of need/concern/service provision and ‘Early information sharing is the key to providing effective early help where there are emerging problems’ (WT 2015 p.16 para 23). In this situation, information seemed to be shared between some practitioners within and between some services and agencies, but this does not seem to have been coordinated, transparent or always involve consideration of issues of consent by the family. 5.45 It would appear that at the point of contact between school and the Children’s Reception Team in June 2015, at the allocation of Child K’s health visitor toward the end of 2016 and with the involvement by maternity service staff both before and after Child K’s birth - both historic information and full information about more recent concerns, was not shared, sought or available - including within a single service such as health visiting, the GP practice or between sections of services such as the various branches comprising health services or Hampshire Children’s Services e.g: Children’s Centres, the Children’s Reception Team. 24 Terms of reference theme 3) Co-sleeping a) What co sleeping advice was given to the parents and at what stages? b) Who provided the information and who was this delivered to? 5.46 Discussion with the community midwife and information in the agency report suggested that advice about safe-sleeping, including the potential risks that might be associated with ‘co-sleeping’, would have been given routinely in discussion with Child K’s mother before discharging Child K and his mother from hospital and then again as part of the visits once home. There is no specific detail available about these conversations and it would appear generally that advice and discussion is primarily and usually undertaken with babies’ mothers. 5.47 Information from the maternity service staff does not indicate whether Child K’s father was present during the postnatal midwifery visits or was part of the discussion about care arrangements in general or sleeping arrangements more specifically. It is now understood that co-sleeping was a planned decision by Child K’s parents and had been their practice with the older children also. 5.48 The review panel’s discussion of the issue of co-sleeping included a consideration of the status, authority and consistency of advice and messages given within and across relevant services. It was suggested that perhaps this might be reviewed further against the best available evidence, both about the messages but also perhaps about the effectiveness of publicity and its related impact on behaviour including what may help parents understand the possibility and probability of risk of harm. 5.49 Perhaps in situations where it is known that there has been problematic alcohol or substance use (including an association with concerns about other children in the family as evidenced in previous child protection plans, for example), then a more formal discussion and risk assessment especially in relation to sleeping arrangements (and especially where co-sleeping is identified as a parental choice) should be carried out with a requirement that this is recorded as having taken place. 5.50 The status of the advice may be important to consider in relation to practitioners’ responses if they have concerns, especially about parental reaction to advice. Is the advice a ‘guideline’, a ‘recommendation’, a ‘summary of generally safe/safest practice’ or a ‘requirement’? If the latter, then there perhaps needs to be some consideration of what practitioners should do if they have concerns – including recording concerns and discussion with senior or supervising staff. When might a parent’s refusal to comply with advice and guidance potentially constitute neglect of a baby’s best interests, imply the actual or likelihood of significant harm and therefore potentially suggest further action within statutory guidelines? Was a risk assessment regarding co-sleeping completed? What were the sleeping arrangements within the household? 5.51 It does not appear that a formal risk assessment was completed or that there was specific discussion about the sleeping arrangements within the household. Enhanced partnership working, the identification of a lead professional, the coordination of multi-agency support based on a single shared assessment and through a shared, agreed and integrated plan could have increased the possibility that the community midwife was aware of the historical 25 information and assessed whether it still had relevance for the parents’ care of Child K. This may have helped inform advice, discussion and parental behaviour relating to care arrangements in general or the potential for alcohol use and co-sleeping arrangements in particular. Terms of reference theme 4) Domestic Abuse a) Was there any consideration given to Domestic Abuse, namely coercive control when considering the withdrawal/ non-engagement with services? b) Was there any evidence of coercive control? How was this assessed? 5.52 The records that had been received by some of the services and practitioners referred to domestic abuse but with apparent limited information about the circumstances, nature and severity or the impact on the children - other than to give professionals in the previous area cause for concern meeting the criteria for child protection processes and plans. However, when the health visiting records were received in October 2014 (alongside reference to mother’s long-term history of self-harm, post-natal depression, the older children being the subject of child protection plans in the previous local authority) there was also reference to previous domestic abuse with an incident in 2007 which led to Child K’s mother seeking a place in a refuge, but no reports of domestic abuse since 2012; yet this is still a period of five years. Child K’s mother reported to the GP that while her relationship with Child K’s father was strained by their oldest child’s behaviour, there was no domestic violence. The community midwife followed standard practice in asking about this issue at the antenatal registration appointment. 5.53 Nothing in the presentation of Child K’s brothers and sisters that have been noted in section 4 of this report led any of the practitioners to consider that there might be continuing concerns about domestic abuse, though Child K’s father did tell one practitioner that arguments between him and Child K’s mother could become ‘physical.’ No concerns about Child K’s health and development or mother’s engagement with midwifery services (pre- or post- Child K’s birth) prompted any of the midwives to have concerns that might have required further exploration or explanation. 5.54 There does not seem to be evidence that, at the point of withdrawing or non-engagement with services, the possibility of power exercised through coercive control within the parents’ relationship was considered or that information was given to suggest that that might be an issue. 5.53 Whether knowledge of the historical information that included reference to domestic abuse, the problematic use of alcohol and mother’s psychological wellbeing would have prompted a heightened sense of vulnerability, of risk of harm for the children or more specific and overt discussion of these issues, is difficult to say. Furthermore, whether a heightened sense of potential vulnerability in this process would have necessarily changed anything that practitioners did or said is difficult to say – other than to report that the health visitor and community midwife talked to during the review thought that it would have affected their assessment and actions. 6) Recommendations 26 6.1 The recommendations below have emerged from a consideration by the panel of the information from the agency reports, the integrated chronology prepared by the agencies, the meetings and conversations with practitioners and a related practitioners’ workshop. Unfortunately, at the time of writing the report it has not been possible to include the views, opinions and perspectives of Child K’s parents or consider the views of Child K’s older brothers and sisters, where this might have been appropriate. 6.2 Several of the agency reports included an analysis of ‘lessons learnt’ and ‘recommendations’ of particular relevance to the services, teams and practice within the agency. Examples were provided of changes and developments already implemented based on the agency reviews: the management and recording of health visiting/midwifery liaison meetings; training in the ‘Child and Family was not brought..’ guidelines; the importance of exploring and confirming the exact circumstances of previous children’s services involvement and using that and other information to inform care planning; the importance of sharing historical information; improving the coding and cross-reference access to information about safeguarding risks in GP records; developing the structure of ‘Vulnerable Families’ meetings; developing a template for maternal postnatal checks; training in relation to professional optimism and updating assessments and reviewing risk in the light of new information. 6.3 The panel are confident that these will help to develop practice and its organisation and management. Many of the recommendations in the individual agency reports accord with the terms of reference and questions that the review was asked to explore and with the recommendations of this overview report to the Safeguarding Board (in section 6.7 below). It is expected that each agency will track and audit the implementation of lessons and recommendations from both the respective agency reports and this overview. 6.4 The practitioner workshop included questions that the participants were asked to consider, including a question to elicit information about learning from their involvement with this situation and any additional recommendations that they might have. The responses included: the ability and importance of consultation and referral with children’s services/awareness of the consultation line for advice; requirement to transfer-on information when children move to another area – especially if there has been statutory involvement with a child identified as a child in need or a child in need of protection; collation of significant information within a service that works with several family members separately; guidance to parents about information sharing within and across services; workload review; clear escalation process if historic information is not obtained; summarised records at point of transfer; quality of conversations at point of discussion or referral using a common format e.g: SBAR – situation, background, analysis, recommendation; feedback to referrers; awareness of the local information sharing protocol; raising awareness of a ‘think family’ perspective. 6.5 ‘Transformative suggestions’ included: transfer and sharing information between local authorities and social care and health services, between schools etc. when families move especially when there has been statutory involvement with a child identified as a ‘child in need’ or within child protection procedures; guidance/flowchart/prompts for questions to be asked to assist in identifying risk and protective factors in the CRT; integrated health and social care records system; automatic ‘opt in’ of sharing information between agencies; fathers’ and 27 partners’ engagement with maternity services; a public health campaign regarding safe sleeping and alcohol; guidance about parental lack of consent to ‘early help’ services 6.6 Finally, the panel members and practitioners involved in the review provided information about current and on-going initiatives and developments informed by other recent reviews (at a local and national level) and audits of practice, for example: work to promote awareness, understanding and compliance with national and local policies and procedures e.g: the current HSCB ‘spotlight’ on the revised Unborn/Newborn Baby Safeguarding Protocol; enhanced assessment skills and confidence to challenge at the point of contact or referral; Child and family not brought… guidance; access to both clinical and safeguarding supervision; maintaining the primary focus on the child rather than the professional relationship with parents; the work on health information records’ alignment; the Early Help Hub/Family Support Service developments; the scrutiny of schools’ safeguarding arrangements through sn.175 audits. Some of these also link in to themes, issues and critical debates pertinent to this review and the recommendations below. 6.7 The specific recommendations from this overview report are primarily concerned with multi-agency and inter-agency matters and it is recommended that the Hampshire Safeguarding Children Board (HSCB): 1) invites all partner agencies to promote awareness of responsibilities and expectations for the management of arrangements for sharing information and records set out in the 4LSCB area ‘Protocol for Protecting Children who Move Across Local Authority Borders’; 2) asks the Early Help Board to review information and guidance to support and promote ‘partnership’ practice, arrangements and management at the HSCB and Children’s Trust Thresholds Chart ‘level 2’ level of need, concern and response; 3) promotes awareness within partner agencies of the need for all practitioners to: ascertain, understand and take into account the ‘voice’, experience and participation of all children, especially including those with additional communication and learning needs; consider all the children and young people in a family and take a ‘whole family’ perspective when primarily working with or providing services for specific family members; identify and liaise with other services and practitioners who have/had contact, who work/have worked with a child, young person or family when undertaking assessments or providing services; share historic information about a child, young person or family with relevant practitioners and services (where appropriate) and include this in all assessments; act confidently within the current safeguarding arrangements and procedures, including in relation to making a referral to Children’s Services, if it is considered that a child or young person is unable to have access to necessary services or may be at risk of harm through actions of parents or carers. 28 4) reviews the guidance and information about ‘safe-sleeping’ arrangements (including known risk factors, for example alcohol consumption) provided to all prospective and new parents (including fathers or partners) and to the practitioners who may work with them; and consider promoting public awareness through a media campaign. 7) Conclusion Many people have contributed to this review and their time and expertise is appreciated greatly, not least in the way that it has helped develop a greater understanding of involvement with Child K’s family and issues identified following his tragic death. It is acknowledged that developments identified in practice and its organisation and management that: a) have been implemented already; b) that comprise the recommendations within specific agencies; or c) that may follow in line with the recommendations above - may not have changed the outcome for Child K. However, the lessons and recommendations from this review aim to help contribute to the ongoing work to further develop, strengthen and enhance services and response to other children, young people and families. Appendix List of agencies providing agency reports and contributing to the review Health Foundation NHS Trust 5 Clinical Commissioning Groups Hospitals NHS Foundation Trust Local Constabulary CAMHS Partnership NHS Trust Local Authority Children’s Services |
NC52310 | Death of a 17-year-old girl by suicide, in February 2018 while an inpatient in a Child and Adolescent Mental Health Unit. Learning includes: need for a whole system approach where a young person is talking about taking their own life; need for a multi-agency approach to understanding dynamics, risks and the support needed for adults in a parenting role; challenges in responding to the complexity of mental health needs within one service led to a loss of focus on the risk of suicide. Recommendations: agencies should work together to clarify expected roles, responsibilities and practice when working with young people and their families where there are complex mental health needs; where a young person has a combination of risk factors including loss and rejection, possible past abuse, self-harm and suicide ideation, care plans should include a focus on risk of suicide; and a review of the supervision provided for staff to make sure that they have appropriate arrangements in place to support reflective, curious and authoritative safeguarding practice.
| Title: Serious case review: Child T. LSCB: Essex Safeguarding Children Board Author: Jane Wonnacott Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Essex Safeguarding Children Board Serious Case Review Child T Report Author Jane Wonnacott MSc MPhil CQSW AASW Director, Jane Wonnacott Safeguarding Consultancy Ltd ESCB SCR Child T Report Page 2 of 20 Contents INTRODUCTION AND REVIEW PROCESS ................................................................ 3 FAMILY BACKGROUND .............................................................................................. 4 CASE SUMMARY AND EVALUATION OF PRACTICE ............................................... 5 FINDINGS AND RECOMMENDATIONS .................................................................... 12 SUMMARY OF RECOMMENDATIONS ..................................................................... 17 APPENDIX 1: TERMS OF REFERENCE ................................................................... 18 APPENDIX 2: REPORT AUTHOR .............................................................................. 20 ESCB SCR Child T Report Page 3 of 20 INTRODUCTION AND REVIEW PROCESS 1.1 This serious case review was commissioned following the death of Child T, who was seventeen years old and a patient in a Child and Adolescent Mental Health Unit. Child T had taken her own life through hanging in February 2018. 1.2 Essex Safeguarding Children Board were aware that Child T had a significant number of vulnerabilities including a severe eating disorder and had been in receipt of community mental health services prior to her admission to the in-patient unit. 1.3 On 10th May 2018, the decision was taken to carry out a serious case review under the national guidance in place at that time1 and an independent lead reviewer was commissioned to carry out the review. The exact scope and terms of reference for the review were agreed in August 2018 taking account of information from the serious incident report prepared by the local mental health trust. 1.4 Also in August 2018, the inquest into Child T’s death concluded that Child T had killed herself by hanging. The Coroner added a narrative conclusion which noted two concerns about Child T’s care in hospital. These concerns2 were conveyed by the Coroner to the mental health trust via a Coroner Regulation 28 report3. 1.5 The independent lead reviewer worked with a review team comprising senior managers from local agencies. The team comprised: ➢ Area Manager: Eating Disorder Service: North East London NHS Foundation Trust- Emotional Wellbeing & Mental Health Service. ➢ Consultant Psychiatrist: Essex Partnership University NHS Foundation Trust. ➢ Designated Safeguarding Children Nurse - Local Clinical Commissioning Group (CCG) ➢ Detective Inspector: Essex Police. ➢ Safeguarding Manager for Schools and Early Years, Specialist Education Services, Essex County Council. ➢ Service Manager, Assessment & Intervention & Children with Disabilities, Essex County Council. 1.6 The agreed terms of reference are attached at Appendix One of this report. The timeframe for the detailed chronology and focus of the review was agreed as from October 2015 when Child T was aged 15, last saw her GP and was referred to mental health services through to her death in February 2018. 1.7 Chronologies of involvement were requested from the following agencies ➢ Anglian Community Enterprise – GP involvement ➢ East of England Ambulance Service ➢ Local Borough Council ➢ Local Clinical Commissioning Group – GP Involvement ➢ Essex County Council – Education Services 1 This guidance was Working Together to Safeguard Children 2015. 2 The two concerns were that Child T’s shoelaces had been returned to her and that the physical environment in the rooms at the hospital was dreary. 3 This is a report under Coroner’s Regulation 28 to prevent future deaths. ESCB SCR Child T Report Page 4 of 20 ➢ Essex Partnership University NHS Foundation Trust ➢ Essex Police ➢ Integrated care 111 service ➢ Hospital 1 ➢ Hospital 2 ➢ North East London NHS Foundation Trust ➢ School Nursing Service. 1.8 The lead reviewer also received the following written reports: ➢ results of the post-mortem ➢ the Coroner’s Regulation 28 report ➢ EPUT (Essex Partnership University NHS Trust) serious incident report 1.9 The independent lead reviewer convened a practitioner’s event in March 2019 and also contacted Child T’s mother to ask whether she would wish to contribute her views to the review through meeting in person of via a written contribution. An e-mail was received from Child T’s mother in April 2019 setting out a number of issues and concerns. These were used to inform the final findings of this report. 1.10 After completing three draft reports the independent lead reviewer was not able to complete the review and the current lead reviewer4 was appointed in May 2020 with a remit to review work that had been undertaken so far and complete the report. 1.11 The report was agreed by the Executive of the Essex Safeguarding Children’s Board in October 2020. 1.12 A telephone discussion with Child T’s mother prior to publication checked the accuracy of this report and agreed the level of family detail that it would be appropriate to include in the final version. FAMILY BACKGROUND 2.1 Child T was the youngest of three siblings. Their parents separated before Child T’s fourth birthday and she lived with her mother from this point onwards. She had no regular face to face contact with her father or his new family. 2.2 Throughout Child T’s primary school years, the family lived in Essex. After eighteen months of secondary education she moved school because she was at risk of exclusion due to poor behaviour and non-attendance. Her mother had told this review that she feels that more effort could have been made to understand why she was not participating in education rather than taking her out of class. 2.3 Child T settled well at her new school and was described as popular and friends with a group of confident outgoing girls. Attendance remained poor at 80%. 2.4 Just prior to Child T’s 14th birthday the family moved within Essex, hoping that this would be a fresh start for Child T. This move involved changing GP practice and 4 For a short biography please see Appendix Two ESCB SCR Child T Report Page 5 of 20 school. Child T struggled to settle in her new school and her Mother describes her experiencing “horrible stuff” in her time there. Records suggest this related to a problematic relationship with another pupil and she was seen twice by the GP with a history of vomiting in the mornings. She also attended accident and emergency and was also seen by nurse practitioner at the GP surgery with ongoing abdominal pain and vomiting and nausea. These were thought at that time to have a medical cause. 2.5 The problems at school prompted the family to move to stay with a friend in another area of Essex whilst arranging the sale of their house. Child T started at a third secondary school and was on the school roll there in October 2015 at the start of this review period. 2.6 Mother, Child T and an older Sibling eventually settled in their own property a few miles away in December 2016. Child T’s other older sibling lived locally with her partner and children. CASE SUMMARY AND EVALUATION OF PRACTICE 3.1 In October 2015, Child T was seen by her GP (practice 1) with a one-year history of self-harm, depression and anxiety and was referred to the local children’s Emotional Wellbeing and Mental Health Service (EWMHS). In line with local protocols the referral was “triaged”. This is a review of the written referral to decide as to whether an assessment is needed. The decision was that Child T should be assessed by the service and she was seen less than a month later. 3.2 Both Child T and Mother were seen individually by EWMHS and gave differing accounts of the problems and issues. Various stressors within family relationships were discussed and the assessment concluded that the problems experienced by Child T were relationship based and Mother was offered a place on the next Families Learning about Self-Harm (FLASH) course. EWMHS agreed to liaise with Child T’s school to ensure that she was accessing support. 3.3 This was a reasonable conclusion and plan but before the plan could be implemented, Mother decided to withdraw Child T from school because of concerns about the negative impact of a relationship with another pupil and the family moved out of the area. The GP did not receive a letter from EWMHS and was unaware of the outcome of the EWMHS assessment. The potential implications of the family not accessing any of the suggested support was therefore not followed up. 3.4 Child T started at a new school in Year 10 in January 2016 and in February registered with a new GP practice. There is no indication from the GP new patient screening that they were aware of the previous referral to child mental health services. 3.5 Child T’s school attendance was disrupted by time off sick, mainly with reports of stomach pains. She had been seen twice by the GP surgery and an appointment was ESCB SCR Child T Report Page 6 of 20 arranged for a consultation with the appropriate specialist consultant for her medical condition. 3.6 School described her as having a small friendship group and as quite ‘closed’ and private and difficult to read. She had no specific learning needs and was very keen and enthusiastic to work in childcare. By June 2016, her attendance was 80%. 3.7 In early February 2017 Mother told the school that she had noticed evidence that Child T had self-harmed and she would be taking her to the GP. Child T told the GP that she had been self-harming for some years and did not want any help. There is no evidence that the GP probed further regarding any suicidal thoughts and although they did leave an open door for Child T to return to the GP at any time, there was no proactive encouragement to use support services available. 3.8 One week after the GP consultation Child T was seen in the local accident and emergency department following an overdose. She was admitted overnight, received appropriate medical care and was assessed as fit for discharge after being seen by the EWMHS crisis team in the hospital. The EWMHS assessment identified her as high risk due to suicidal ideation, a four-year history of self-harm and constant low mood. A risk plan was agreed with Child T and her mother and she was referred to the EWMHS community crisis team. At this point the assumption was that risks could be managed adequately by Mother. There is no evidence within the chronology that any immediate alert was sent to the GP or permission was sought to discuss the risks with Child T’s school. 3.9 The EWMHS community crisis team followed up by telephone after seven days and made sure that Child T was aware of the relevant EWMHS contact numbers. She was then discharged from the crisis service. The next day Mother informed the school to tell them about the overdose and that EWMHS were involved. The school immediately contacted EWMHS and were informed that Child T would be discussed at a meeting the next day. At the meeting it was agreed that an urgent initial assessment would take place within ten days. 3.10 Before the assessment Mother had further contact with the school which raised their concerns as to whether they were able to keep Child T safe. They again contacted EWMHS, asking for a discussion after the assessment had taken place as they had “safeguarding concerns”. There was a follow up call from the school to EWMHS asking for information to inform a risk assessment but no evidence that this discussion took place. From this point the school sent work home and Child T did not return to school. 3.11 During this period there was an opportunity for a more joined up approach to understanding the influences on Child T’s behaviour and planned collaboration and across agencies, most notably between mental health, school and the GP. 3.12 During the EWMHS assessment, Child T disclosed that since the age of eight she had been obsessed with her diet and had subsequently developed eating disorder symptoms. This resulted in a referral to the eating disorder service. There were four ESCB SCR Child T Report Page 7 of 20 more appointments with the community EWMHS team during which time they became more concerned about her symptoms and expedited an urgent appointment with the eating disorder service. 3.13 The assessment by the eating disorder team in early April 2017 was that Child T was high risk. A letter was sent to the school and GP to inform them that she had been seen by the service. The GP was also informed by the local accident and emergency that Child T had been seen with chest pains possibly the result of not eating. 3.14 Following Child T’s assessment by the eating disorder service the practitioner queried whether the community team should also be involved to manage the more generic mental health issues. This was discussed by the multi-disciplinary team who concluded that her issues related to an eating disorder and therefore the case should be managed by the eating disorder service. 3.15 During the summer of 2017 there is evidence that the school tried to support Child T by sending work home and liaising with EWMHS to obtain support for exams to be invigilated at home. Mother has told the review that the family did not experience this as supportive, rather feeling overwhelmed and inundated with work. 3.16 From April to December 2017 Child T was seen at least weekly by the eating disorder service. She was seen regularly by the same psychologist with a careful handover during holiday periods to a colleague. The pattern throughout this period was of Child T reporting binging and purging and concerns about the impact of this on her physical health. These concerns led to liaison with the GP and regular blood tests. 3.17 Although the GP was appropriately involved in monitoring her physical health needs there is less evidence of GP consultations fully considering her emotional health. For example, when Child T consulted the GP about a facial skin condition there was no exploration by the GP as to a possible link with her eating disorder, self-harm behaviour and worries about her appearance. A month later she was seen with her mother due to a drop in blood pressure and although the GP noticed signs of self-harm, she was not seen alone to explore this further. 3.18 The reports of the sessions with the psychologist document persistent problems relating to family relationships and dynamics but, although the eating disorder service use a family intervention model, and the psychologist was very experienced in this model of work, it is not clear from the records seen for this review, to what extent treatment focused on this aspect of Child T’s life. From the perspective of Child T’s mother, the focus was on the eating disorder rather than looking more broadly at why this was occurring and helping the family to cope. 3.19 Child T’s progress was regularly reviewed by the multi-disciplinary team and deemed to be high risk. This risk was managed by the eating disorder service. For example, when in August 2017 the psychologist noted that she had self-harmed to stop vomiting, the possibility of an in-patient referral was explored with Child T and her mother. A risk assessment was carried out and Child T’s Mother was given advice to ESCB SCR Child T Report Page 8 of 20 remove all tablets from the home due to her daughters’ suicidal thoughts. Soon after that episode there was another crisis where Child T threatened suicide which led to a consultation with the team’s psychiatrist and a recommendation that she commence anti-depressant medication. During this crisis for the first time Child T disclosed that she was using her eating disorder to “kill herself slowly”. 3.20 There were further discussions with Child T regarding in-patient treatment as her condition began to deteriorate during the autumn of 2017. During this period, she refused to take the anti-depressant medication as it stemmed the urge to purge, and tensions continued between Child T and her mother about managing this behaviour. 3.21 In early autumn Child T spoke to the psychologist about a memory that “something had happened” with a male adult when she was a child. Following a family holiday a few weeks later, Mother told the psychologist that Child T insinuated that she may have experienced sexual abuse in her past but did not want to talk about it. Child T also self-harmed on the holiday. There was insufficient information to warrant a formal child protection response at that point, but this was an opportunity for mental health practitioners to be curious about Child T’s comments and ask questions aimed at exploring this further. There is no evidence that this happened and there is nothing in the therapists clinical or safeguarding supervision records to show that any concerns about Child T were discussed in supervision. Supervision is discussed further in Finding Three. 3.22 At the end of November, the psychologist told Child T that she was leaving the service in January 2018. It was anticipated that this would be hard for Child T due to the positive trusting relationship that had developed. Two days later Child T presented in accident and emergency with suicidal thoughts and having self-harmed by cutting herself with a razor blade. She explained that she was upset because her therapist was leaving. She was referred to the paediatric mental health liaison team and was then discharged and advised to follow up with her GP. Support was then offered over the weekend by the mental health crisis team and via a telephone call from her psychologist. A bed was found in the local psychiatric adolescent unit and Child T was admitted voluntarily at the start of the following week. The period before Child T was admitted to hospital is characterised by a timely response by the mental health service followed by sustained input from the eating disorder service via a consistent relationship with the same psychologist. There was also good communication with the GP regarding physical aspects of her care. The issue of whether her care should have sat solely within one team within mental health services is discussed further in Finding Two of this report. There is less evidence of a joined-up approach across professional boundaries when considering Child T’s relationships and the factors impacting on her emotional wellbeing and mental health. Issues that have emerged from the information submitted to this review are: 1. The need for greater liaison and communication between the child mental health service, Child T’s school and the GP to enable a more holistic approach to understanding and meeting her needs in all settings. ESCB SCR Child T Report Page 9 of 20 2. The need for a better understanding of family history, stresses across the whole family system, the interaction between them and how these impacted on Child T’s mental health. 3. The possibility of a coordinated early help response which actively supported Child T’s mother in her caregiving role. 4. Effective supervision which promoted professional curiosity and ensured that there was sufficient exploration of any emerging safeguarding concerns relating to possible past abuse. Child T’s treatment and care in hospital 3.23 Child T was admitted to a psychiatric adolescent unit and in view of her continued weight loss, eating disorder and suicidal thoughts, a risk assessment and body mapping was completed on admission. 3.24 Child T was enrolled in the on-site school. She interacted well with other young people and presented as a caring, empathetic person, particularly with others more vulnerable than herself. Child T engaged with a range of therapies and care plans were developed in seven different areas: ➢ admission ➢ physical health ➢ leave ➢ smoking ➢ Mental Health Act ➢ Self-Harm ➢ medication. 3.25 Notably there was no care plan specifically focused on her suicidal ideation although suicide risk was noted as being present throughout her time on the unit. 3.26 Her care and treatment included the development of a meal plan and hourly checks increased to 1:1 nursing observation for one hour after meals. Sleeping difficulties were noted as well as compensatory behaviours of cleaning and tidying at unusual times (often at night). 3.27 Periods of leave were subsequently granted under the care of Child T’s mother and these are described in the mental health records as challenging for her mother to contend with. There were issues with the maintenance of boundaries, sticking to meal plan, binging/purging and acquiring laxatives. A specific period of leave was granted over Christmas, but Child T returned to the ward early. Notes indicate that this was because of her mother’s concerns about her binging and purging but her mother recalls that Child T asked to return. Throughout this time Child T was an informal (voluntary) patient in the unit. 3.28 When she returned, the weight loss that had been noted prior to Christmas was reviewed by the multidisciplinary team and the plan was to increase the intensity of her plan of care. Child T was not agreeable to this and the consultant psychiatrist ESCB SCR Child T Report Page 10 of 20 took the decision that Child T should be detained under the Mental Health Act 1983 initially under Section 5(2) and subsequently Section 35. 3.29 On 29th December 2017 when Child T’s mother was visiting the ward, Child T attempted to ligature in front of Mother with a headphone cable. Mother alerted staff and the situation was deescalated. Following this, the serious incident report completed by the mental health trust notes that Child T’s presentation was one of compliance punctuated by brief intense periods of challenge. Notably: 1. On 6th January kicking, punching, and banging her head on doors. 2. On 12th January 2018 on return from a period of leave from the ward with her mother Child T was searched and a small blade and 3 tablets (prescribed medication) were found concealed in a pack of pens. 3. On 20th January leave was suspended because Child T persuaded her Mother to leave her unaccompanied at the cinema with friends. 3.30 On 24th January, Child T was informed that the psychologist from the eating disorder service would be visiting to say goodbye the next day. That night she was up all-night cleaning her room including the air vents in the ceiling. With hindsight this may have been significant due to the circumstances of her death but would not have been regarded as particularly unusual behaviour at the time. 3.31 The visit from the eating disorder therapist to say goodbye was clearly difficult for Child T and Child T’s mother told the review that she was devasted to have lost this trusting relationship. What is not clear, is how this event was understood and assessed in relation to any increased risk to Child T. There is no record of a plan to mitigate any increased risk within the Psychiatric adolescent unit notes. 3.32 There were opportunities to explore further Child T’s suicidal thoughts but no record that this took place. For example, a few days after the goodbye meeting with the therapist a nursing report records that another patient was speaking to Child T how her brother took his own life. This would have been an opportunity to talk to both young people about the meaning of this conversation. The most significant practice issue emerging from this period is the lack of specific focus on the risk associated with Child T’s suicidal ideation. This should have been assessed separately from the risk of self-harm and her eating disorder and a risk management plan put in place at points of significant stress – including the departure of her therapist and tensions within the family. Events leading up to the serious incident 3.33 On the 1st February 2018, following a family therapy session, Child T became highly distressed, throwing her plate of food on the floor and screaming. Staff intervention de-escalated the situation and she later settled. It was also disclosed she had used a pencil sharpener blade to self-harm, provided by a fellow patient. 5 Section 5 (2) allows for a voluntary in patient to be detained in hospital for assessment for up to 72hrs. Section 5 (3) applies when there is a need for treatment and can apply for a maximum of 6 months. ESCB SCR Child T Report Page 11 of 20 3.34 On the 5th February 2018, Child T started banging her head against a mirror whilst looking at herself and describing sensations of feeling “out of it” and “not feeling like herself.” When Child T returned from weekend leave two days later, she appeared hyperactive, her eyes were red, and she smelt of alcohol. She was breathalysed and drug tested, both tests were negative. Child T’s mother telephoned the unit at 10pm to say the reason they returned late from leave was four ‘Senna’ laxatives were found on the car seat after arriving back at the hospital. Child T denied they were hers, but later admitted she stole them from a supermarket a week previously. She insisted she had not taken any, had put them in her pocket and had forgotten about them. This was discussed at a clinical review meeting with a decision to make no change to the management plan, but for the incidents to be further discussed with a family therapist and within the multi-disciplinary team meeting the following week. Child T was later found by staff in her bedroom, curled up crying and distressed because of family issues and her Mother not being available so she could not go on leave the next weekend. 3.35 Later that day Child T’s mother visited her in the unit and recalls Child T being in a good mood and appeared very happy. 3.36 On Sunday 11th February 2018, Child T was upset after a telephone call as she had heard that a friend had taken an overdose but later that evening she was laughing and joking with the staff. She stayed on the ward longer than usual as there was a social event before going to her bedroom at 10.30pm. 3.37 The hospital log records that there were then checks on Child T in her bedroom at 11pm, 12am, and 1am. When she was checked at 2am, staff noted a ‘lump’ in the bed which seemed too large for her. On closer inspection, staff noticed she had put clothes in her bed to give the impression she was in the bed sleeping. Child T was then found with a ligature (black shoelaces taken from her trainers) around her neck, suspended from the light fitting in her bathroom. She had used the sanitary bin as a climbing tool. A message was written on the bathroom mirror by Child T. 3.38 Staff commenced CPR and called an ambulance which arrived soon afterwards and attempted the resuscitation of Child T without success and she was pronounced dead at the scene at 2.43am. 3.39 Investigations after the event revealed that the 12am check had been a conversation with Child T who was in the bathroom – she was not seen. The 1am check had not taken place. During this period there were again issues identified in respect of the impact of family relationships and dynamics on Child T and there were challenges in understanding the complexity of her behaviour and developing an effective response. The Serious Incident Report noted a changeable presentation and fluctuating risk throughout her time on the unit ESCB SCR Child T Report Page 12 of 20 Although Child T was detained under Section 3, home leave was arranged. This should have been fully risk assessed, including Mother’s capacity to keep her safe but there is no such assessment clearly set out within the records. The lessons relating to the specific circumstances of Child T’s death have been reviewed by the mental health trust and the coroner. Practice issues have been identified in respect of suicide prevention and immediate actions taken were: ➢ Replacement of sanitary bins with cardboard ones which are less weight bearing and a lower height. ➢ Ceiling furniture and switches sealed with anti-pick mastic to reduce the risk of tampering. ➢ Improvement in the way the light fittings of the in the bathroom are secured ➢ Introduction of preventing suicide by ligature e-learning for all Trust staff. ➢ Review of any necessary HR responses in relation to the failure to complete the expected checks at 12am and 1am. FINDINGS AND RECOMMENDATIONS 4.1 Child T’s records describe a young person with empathy, a dry sense of humour and ability to do well at school. Alongside this there are also reports of a troubled young person displaying signs of distress through an eating disorder and self-harm. Understanding the depth of her distress and the cluster of factors that made her vulnerable to suicide was a challenge for all those that knew her. Situations where family and professionals are working with the combination of eating disorders and mental health concerns are complicated. They are likely to result in conflictual complex relationships and all the findings in this report should be understood within that context. It is important to note that Child T’s mother at times felt helpless and unsure where to turn to for help and support. 4.2 The overarching finding of this review is the need for a whole system approach where a young person is talking about taking their own life. This is in order to understand the balance between clusters of stressors, vulnerabilities and the capacity of the family and young person to develop the level of resilience required to thrive and survive. Throughout this case, across all settings, there was a tendency to expect Child T’s mother to keep her safe without the full understanding of stresses within the family and assumptions were made about what help might be most useful. Mother’s input to the review made it clear that she felt the help given to Child T fell short in many areas. Findings One and Two address working with level of complexity evident in this case. 4.3 Managing risk in such situations is emotionally demanding work for practitioners involved and there are examples of professionals really trying to help Child T. What is less clear is how far supervision was used to support practitioners to manage this emotional impact, reflect on their work and identify risks. This is addressed in Finding Three. ESCB SCR Child T Report Page 13 of 20 Finding One This was a complex family situation which needed a multi-agency approach to understanding dynamics, risks and the support needed for adults in a parenting role. 4.4 Information suggests that Child T’s mother would have been experiencing a number of challenges in meeting the needs of all her children. Details are limited in reports seen for this review, but there is little evidence that a whole family support service was available and offered to the family at the time when Child T first began to experience difficulties from around the age of 12 onwards. 4.5 At the time Child T came to the attention of the GP and EWMHS with mental health concerns there was an opportunity for a coordinated approach which addressed the specific individual needs of Child T alongside provision of support to the whole family. Child T’s mother was offered help from a group for families learning about self-harm but when she did not take up this offer it would have been helpful to explore from her perspective what help and support might be most useful. This was important as before Child T was admitted to the in-patient unit practitioners were relying on her mother to manage risk and keep her safe. 4.6 There was an opportunity for a more joined up approach when Child T was struggling to remain in school although from the school’s perspective they were receiving mixed messages as Child T was apparently still wanting to take some of her exams and the school was attempting to support with that. The school were worried about whether they could keep her safe and did try to engage with EWMHS in order to understand of how to best meet her needs. The school clearly tried to help by sending work home and arranging home invigilation for exams, but this was perceived by Mother as overwhelming and resulted in Child T withdrawing from education at this point. 4.7 In summary, there is no evidence that there was an assessment of Mother’s support needs and her capacity to keep Child T safe. This was particularly relevant when Child T was visiting home from the inpatient unit. What is known is that from time to time Mother felt overwhelmed and found it particularly hard to maintain boundaries and expectations when Child T was on home leave from hospital and from time to time this led to giving a more positive account of home leave than had been the case. 4.8 The term “disguised compliance” can too readily be used to explain Child T and her mother’s apparent failure to always be honest about Child T’s behaviour whilst on home leave. This is an overused term which evolved from a complex idea related to a specific analysis of child deaths and unfortunately, it has become a label effectively blaming families for “pulling the wool” over the eyes of professionals. This has moved the spotlight away from the way in which behaviours of practitioners and services may support these behaviours. In this case, rather than simply applying a label, it is vital to reflect on what could have been done differently to enable a really effective working relationship with Child T’s mother by all the practitioners in contact with her. This requires professionals to take a challenging and questioning approach, i.e. ESCB SCR Child T Report Page 14 of 20 professionally curious practice which will be supported by effective support and supervision. This is discussed further in Finding Three. Recommendation One Essex Safeguarding Children Board should work with partner agencies to make sure that there is wrap around support for families where a child has a complex mental health condition and this support is based upon a full multi-agency assessment of needs within the whole family. Finding Two There were challenges in responding to the complexity of mental health needs within one service and there was consequently a loss of focus on risk of suicide. 4.9 Throughout Child T’s involvement with mental health services it was clear that her needs were complex and required a focus (separately and together) on eating disorder, self-harm and risk of suicide. All three required an understanding of the factors both in the past and present that were contributing to her condition. 4.10 This level of complexity is not uncommon in young people who take their own lives and can mask the degree to which risk of suicide has become high. This presents a challenge for all professionals as “the life trajectories and histories of adolescents who commit suicide are likely to be similar to those of adolescents who express their unhappiness through other types of high-risk behaviour”6. 4.11 What has been found7 is that when a young person has taken their own life, factors that were present often included previous self-harm, loss and rejection in early life and that vulnerabilities were compounded by the cumulative effect of abuse and neglect and the challenges of adolescent development. Services need to understand the risks associated with these factors through a full understanding of early history and exploring the causes of behaviours through multi agency support. 4.12 As discussed in Finding One above, this multi-agency approach was not in place and after an initial assessment by the crisis team and community mental health team, work was led by the eating disorder service. The level of input and the strength of the relationship that was forged with her therapist was positive but there was some debate as to whether the community team should also have been involved in order to ensure sufficient response to the totality of her mental health needs. A broader approach could have had the benefit of assessing risk when it was known that her therapist was leaving and then working with the in-patient unit to develop a risk management plan. 4.13 Within the inpatient unit it is notable that the focus was on self-harm linked to the eating disorder and medical needs. The meaning of Child T’s suicidal ideation and risk of suicide was not seen as a separate issue requiring ongoing assessment and 6 Sidebotham et al (2016) Pathways to harm, pathways to protection, a triennial analysis of serious case reviews. London: Department for Education Page 100 7 Op.Cit Page 118 ESCB SCR Child T Report Page 15 of 20 planning. This is perhaps not unreasonable within the context of knowledge that many people who self-harm do not wish to end their lives8. In addition, a recent academic paper noted that although suicidal thoughts and non-suicidal self-harm are strong predictors of suicide attempts only a third of adolescents who have suicidal thoughts go on to make a suicidal attempt. Factors involved in suicidal thoughts are distinct from those involved in the transition from thoughts to attempts. 9 However, this study went on to report that adolescents are likely to be high risk of moving from thoughts to action where both suicidal thoughts and non-suicidal self-harm are present. Other important factors are drug use and sleep problems. This suggests that in the case of Child T, the range of risk factors, past and present should have led to a separate focus on the risk that she may take her own life. 4.14 Specifically, there should have been a more formal risk assessment in relation to home leave when Child T was under Section 3 and included within this assessment Mother’s capacity to keep her safe. Recommendation Two Agencies across Essex should work together to clarify expected roles, responsibilities and practice when working with young people and their families where there are complex mental health needs in order to ensure that there is a full understanding of life history, risk factors and a coordinated response. Recommendation Three Where a young person has a combination of risk factors including loss and rejection, possible past abuse, self-harm and suicide ideation, care plans in both community and in-patient settings should include a specific focus on risk of suicide. Finding Three Supervision systems did not provide sufficient opportunity to reflect on practice and to ensure that safeguarding concerns were considered and acted upon 4.15 Along with disguised compliance, professional curiosity can be an overused term. Whilst all good safeguarding practitioners should be professionally curious this can be challenging in a fast-paced environment without space to stop and think. It also requires a degree of self-awareness and capacity or consider the assumptions and biases that might be driving professional behaviour. It is not enough to tell people to be professionally curious, they need the time, space, and support to be so. 4.16 There are a number of points in the records where a more curious approach was warranted yet there is no evidence that any practitioner was receiving supervision which gave them time to think, challenged their thinking, encouraged them to consider the assumptions that might have been influencing their responses and therefore supported then in asking professionally curious questions. 8 https://www.nhs.uk/conditions/self-harm/ 9 https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30030-6/fulltext ESCB SCR Child T Report Page 16 of 20 4.17 At an early stage, the GP made an appropriate referral to mental health services but from that point onwards the focus of GPs was on physical health. There seems to have been no opportunity stop and to consider the overall safety of Child T, and the potential link between physical symptoms and emotional wellbeing. 4.18 There is some suggestion within the records that Child T alluded to alleged sexual abuse by a family member when she was a child. This issue was not followed up in any depth by the mental health service and there is no evidence that the therapist discussed the possible implications within any supervision forum. This is significant for two reasons: 1. A fuller understanding of any abuse experienced by Child T could have led to a better understanding of the factors underlying her behaviour and therefore been used in planning therapeutic responses. There were challenges in achieving this as, although self-harm may be an indicator of sexual abuse it is also widely acknowledged that sexual abuse is rarely disclosed until it is safe to do so. Practitioners do however need to be alert to the possibility of sexual abuse and any indication that the child may be ready to talk about their experiences. 2. It is possible that the adult she spoke about could pose a current risk to children. 4.19 There are no easy ways to respond in these circumstances but there should at least have been full and thorough reflective discussion within supervision to explore alternatives and record the reasons why a certain course of action had been agreed. Supervision is well established within mental health services and all psychologists should receive clinical supervision. It is not clear whether this was received in this case and if so whether there was sufficient focus on child safeguarding practice. 4.20 Child T’s mother has asked why more consideration wasn’t given within schools as to why Child T was struggling. Supervision is less well established within schools although the important role it can play in keeping children safe is now better understood with guidance for inspectors stating there should be evidence that: Staff and other adults receive regular supervision and support if they are working directly and regularly with children and learners whose safety and welfare are at risk.10 There is evidence that Child T’s final school were worried as to whether they could keep her safe and took steps to liaise with the mental health service. When the school did not get a response to their queries this was not pursued or escalated – an opportunity for the Designated Safeguarding Lead to be supported in their role through supervision may have been helpful. This would have included considering how best to engage others in the professional network where there are safeguarding concerns 4.21 Within the hospital, there are several points where staff could have questioned the meaning of her behaviour, for example when she tied a ligature in front of her mother, when she was awake during the night after her goodbye session with her therapist and when she was discussing suicide methods with another patient. There 10 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/828763/Inspecting_safeguarding_in_early_years__education_and_skills.pdf ESCB SCR Child T Report Page 17 of 20 was no evidence within the reports seen by this review that staff received supervision which promoted a questioning and curious approach in these circumstances. Recommendation Four Essex Safeguarding Children Board should ask partner agencies to review the supervision provided for staff and make sure that they have appropriate arrangements in place to support staff in reflective, curious and authoritative safeguarding practice. SUMMARY OF RECOMMENDATIONS Recommendation One Essex Safeguarding Children board should work with partner agencies to make sure that there is wrap around support for families where a child has a complex mental health condition and this support is based upon a full multi-agency assessment of needs within the whole family. Recommendation Two Agencies across Essex should work together to clarify expected roles, responsibilities and practice when working with young people and their families where there are complex mental health needs in order to ensure that there is a full understanding of life history, risk factors and a coordinated response. Recommendation Three Where a young person has a combination of risk factors including loss and rejection, possible past abuse, self-harm and suicide ideation, care plans in both community and in-patient settings should include a specific focus on risk of suicide. Recommendation Four Essex Safeguarding Children Board should ask partner agencies to review the supervision provided for staff and make sure that they have appropriate arrangements in place to support staff in reflective, curious and authoritative safeguarding practice. ESCB SCR Child T Report Page 18 of 20 APPENDIX 1: TERMS OF REFERENCE Serious Case Review Terms of Reference 1. Subject of Review Subject: Child T Family Members: Mother Sibling 1 Sibling 2 Father (estranged) 2. Reason for the Review Child T was a 17-year-old who took her own life in February 2018 whilst resident at a Child and Adolescent In-patient unit. Child T had a significant number of vulnerabilities including a severe eating disorder and suicidal ideation. Professionals from the Eating Disorder Team had been working with her in the community for seven months prior to her admission to the psychiatric adolescent unit in December 2017, which was initially on a voluntary basis. She was later sectioned under the Mental Health Act. The inquest in to death of Child T was held in front of a jury and concluded with a verdict of suicide with a narrative that Child T killed herself but that failings from the state contributed to her death. 3. Relevant time period for the review 27th October 2015 (when Child T was last seen by a GP and was referred to CAMHS) to 12th February 2018. 4. Review Team Representatives a) Essex Children Social Care b) Essex Police c) Essex Education d) Designated Nurse e) Mental Health Practitioner (EPUT) f) Eating Disorders Team representative (NELFT) ESCB SCR Child T Report Page 19 of 20 5. Issues and Questions to be considered This SCR was asked to focus on the following themes and questions A. Consideration of what support was being offered to Child T in the community from the start of the review period until she was admitted to the Psychiatric Adolescent Unit, in particular from mental health services and the GP. o What was the impact of this support? o Was information shared effectively between agencies? o Were the actions taken by agencies following the overdose in February 2017 appropriate? B. The care and support provided to Child T at the hospital including: o An understanding and analysis of Child T’s history of self-harm and suicidal ideation o The risk assessment – was the level of risk during the in-patent admission appropriately and accurately assessed? o An understanding of the potential risks in respect of home leave o Following of policies and procedures including observations of at-risk patients o Staffing and training of staff around awareness of risk o Consideration of whether the risk guidance needs revising C. Information concerning Child T and her family: o Did Child T’s Mother receive appropriate advice about the dangers of leaving Child T unsupervised and in relation to her eating disorder when she was given home leave? o Were there any communication failures between professionals working with Child T and her Mother and if so why did these failures occur? D. Consideration of the likely impact on Child T over the weekend before the incident in respect of her mother being away, a staff member with whom Child T had a good relationship leaving, and a friend having attempted suicide. Was this considered as an enhanced risk and what additional actions were or could have been taken to minimise the impact and risk for Child T? E. Was the voice of Child T heard and acted upon? ESCB SCR Child T Report Page 20 of 20 APPENDIX 2: REPORT AUTHOR Jane Wonnacott Jane qualified as a social worker in 1979 and has an MSc in social work practice, the Advanced Award in Social Work and an MPhil as a result of researching the impact of supervision on child protection practice. She has significant experience in the field of safeguarding at a local and national level. Since 1994 Jane has completed in excess of 150 serious case reviews, many of national significance. She has a particular interest in safeguarding practice within organisations and was the lead reviewer for two reviews into abuse in nurseries and the serious case reviews into St Paul’s School and Southbank International School London. She has contributed to the literature exploring effective safeguarding education settings. Jane is a member of the National Child Safeguarding Practice Review Panel pool of reviewers. As Director of In-Trac Training and Consultancy, Jane has been instrumental in developing a wide range of safeguarding training and oversaw In-Trac’s contribution to the development of the “Achieving Permanence” training materials for the Department of Education. She has a long-standing interest in supervision and developed a national supervision training programme for social workers with the late Tony Morrison. She has recently worked with colleagues to apply this model in school settings. |
NC046384 | Significant injuries to a 3-week-old child in October 2013. Child Y was presented to GP where it was noted that they were 'jerking'. Subsequent hospital admission and MRI scan indicated that Child Y had survived a subdural haemorrhage. Parents were arrested on suspicion of causing Grievous Bodily Harm; both were on police bail at the time review was published. Father was in care as a child and had a history of depression and anxiety and domestic abuse in relation to a former partner with whom he fathered two children. Father had no contact with either child and one of the children had been adopted. Mother had a history of domestic abuse as a child and was assaulted by her father when 10-weeks pregnant with Child Y. Prior to the incident, father was noted to have been handling Child Y roughly by GP but was later observed by midwife to be handling Child Y more gently. Identifies lessons, including: issues with maternity guidelines relating to domestic abuse in pregnancy including absence of timely review, inconsistencies in advice and insufficiently robust safeguarding supervision; importance of early handling and safety advice for parents; optimistic thinking; clinical focus of midwifery services impacting consideration of social risk factors; and importance of identifying the role and impact of fathers. Makes recommendations, including: increased home rather than clinic visits for new born babies, particularly for teenage and vulnerable parents; answerphones should not be relied on to disseminate information; and social care staff should be made aware of the implications of a further pregnancy where a parent has had a previous child adopted. Uses a mix of traditional methodology and a new learning approach.
| Title: Serious case review in respect of Child Y LSCB: Somerset Safeguarding Children Board Author: Ruby Parry Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page1 Serious Case Review in respect of Child Y on behalf of Somerset Safeguarding Children Board Ruby Parry Director of Consultancy Reconstruct Ltd. Final Report July 2015 Page2 Contents Introduction Page 3 Purpose of the review Pages 4 - 5 Terms of Reference Page 5 Methodology Page 5 - 7 Race, Culture, Religion Page 7 Narrative Pages 7-12 Analysis Pages 12-29 Lessons Learned Pages 29-35 Single Agency Recommendations Pages 35-38 LSCB Recommendations Pages 38-39 Page3 1. Introduction and Summary 1.1 Child Y was just over three weeks old when Child Y suffered significant injuries whilst living at the home address and in the care of Child Y’s parents. Child Y’s parents were arrested on suspicion of causing Grievous Bodily Harm to Child Y and a police investigation has been undertaken. Both parents remain on police bail pending further enquiries and in due course a Crown Prosecution Service review of the evidence. Child Y is currently in the care of the Local Authority and is having supervised contact with mother. 1.2 The father is a 22 year old former care leaver who has fathered two previous children with whom he has no contact. One of those children was adopted. The police were called to several arguments between the father and the mother of those children in the 2 years preceding the timescale of this review. Whilst Children’s Social Care had no active involvement at the time of the injuries to Child Y, the father was in receipt of care leaving support until his 21st birthday when this ceased by mutual agreement between the father and Children’s Social Care. 1.3 The mother was not previously known to social care other than through referrals from the police as a result of their attendance at domestic abuse incidents in 2006 involving her parents and more recently in 2010 – 12 involving her father and step-parents. There was also contact, from Children’s Special care with her school which did not result in any action from the department. 1.4 The police had received information in relation to both parents, separately, as a result of being called to domestic incidents, and to one such incident in which both parents of Child Y were present and the mother was assaulted by her own father whilst she was 10 weeks pregnant with the child who is the subject of this review. This assault was not reported to Children’s Social Care, nor was the Unborn Baby protocol instigated. 1.5 Although the midwife who booked the pre-natal care did have some information about the background of the parents she did not identify this as potentially increasing the risks to the unborn child and did not therefore make any referral to Children’s Social Care. 1.6 The significance of this information was not identified and therefore was not shared with the Health Visitor, this led to the case being allocated to a student health visitor as ‘first time parents with a new baby’. Without any information to suggest that there may be risks to the baby, the student health visitor did nevertheless identify increased vulnerability of the parents, very quickly, but did not identify risks to the safety of Child Y. The injuries to the baby occurred before any professional assessment had been completed and before any intervention had been put in place to safeguard Child Y effectively. Page4 2. Reasons for the Serious Case Review 2.1 Working Together to Safeguard Children 2013 is the statutory guidance provided by government to Local Safeguarding Children Boards and their constituent agencies, which sets out how agencies should work together. It states that Serious Case Reviews must be held for: “…every case where abuse or neglect is known or suspected and either: • a child dies; or • a child is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child.”1 2.2 The Independent Chair of Somerset Safeguarding Children Board determined that the circumstances of Child Y’s injuries met this criteria and this serious case review was commissioned in February 2014. 2.3 The purpose of a serious case review is: • To establish lessons to be learned from the case • To look at what actions and procedures may need to be changed • To improve inter-agency working and better safeguard children 2.4 The guidance is clear that: “Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children.” 2 2.5 With this in mind reviews should be conducted in a way which: • recognises the complex circumstances in which professionals work together to safeguard children; • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; 1 “Working Together to Safeguard Children: A Guide To Inter-Agency Working To Safeguard And Promote The Welfare Of Children.” Page 68 HM Government March 2013 2 “Working Together to Safeguard Children: A Guide To Inter-Agency Working To Safeguard And Promote The Welfare Of Children.” Page 68 HM Government March 2013 Page5 • is transparent about the way data is collected and analysed; and • makes use of relevant research and case evidence to inform the findings. The methodology for this review seeks to reflect these criteria by engaging with the family and the professionals involved at an early stage and throughout the process. 3. Terms of Reference The review covers the period 8th September 2012 – 1st October 2013, but also references previous history and information where this is directly relevant to the circumstances of Child Y’s life and injury. The terms of reference are to explore: a) What involvement did agencies have with the parents and child? b) Did all staff understand and implement the pre‐birth protocol? What evidence of this is there? c) Were agencies aware that the mother and father were victims of domestic abuse during the pregnancy and how did they respond to that information? d) Was previous history, including of domestic abuse, and previous children, ascertained regarding the parents? Was this information used to inform assessment, planning and decision‐making in respect of the unborn child? e) How did agencies fulfill statutory duties with regard to safeguarding in this case? 4. Methodology 4.1 In order to meet the requirements above, it was agreed that a mix of traditional methodology and a new learning approach would be used for this review. Agencies provided individual chronologies of events, and these were combined into an integrated chronology. 4.2 Ruby Parry from Reconstruct Ltd was appointed as the independent reviewer to write the overview report and to facilitate a learning process that reflects the guidance in Working Together 2013 4.3 Ruby is a former Assistant Director of Children’s Social Care with over 35 years of experience in social work and child protection, and she is a registered social worker. Both in her local authority career and as Director of Consultancy for Reconstruct since 2010 she has been involved in over 30 serious case reviews, Page6 either directly or by providing quality assurance and analysis. She therefore meets the criteria for independent reviewer. 4.4 Individual Management Reports were also requested from and provided by: • Avon And Somerset Constabulary • Somerset Children’s Social Care, Somerset County Council • Somerset Partnership NHS Foundation Trust • Somerset Clinical Commissioning Group (CCG) • Taunton And Somerset NHS Foundation Trust 4.5 These reports were considered at the first Panel meeting on 26th February 2014, which was also attended by the author. The panel comprised: Ruby Parry Independent Overview Report Author Lucy Watson Panel Chair - Director of Quality & Patient Safety, Somerset CCG Service Manager – Safeguarding, Children’s Social Care, Somerset County Council Named Midwife for Safeguarding, Great Western Hospital NHS Foundation Trust – commissioned by the LSCB to provide specialist advice to the review Interim Deputy Director of Children’s Services, Somerset County Council Service Manager – Community Safety, Somerset County Council Detective Inspector Avon and Somerset Constabulary Designated Nurse for Safeguarding Children and Children Looked After, Somerset CCG LSCB Audit Officer, Somerset County Council Designated Doctor for Safeguarding Children, Somerset CCG Safeguarding Administrator (taking notes), Somerset County Council 4.6 This was followed by a development event for all of the practitioners involved in this case which was held in April 2014. The session was facilitated by Ruby Parry and supported by the specialist midwife in order to: • Provide professionals with an opportunity to reflect on practice in this case in order to identify and share learning • Inform the serious case review report and agree any practice, procedural or systems change that needs to be covered in the recommendations • Provide constructive feedback to those involved Page7 4.7 The session was well attended with 12 professionals present, and provided important contextual information for the review as well as evidencing real learning amongst those present (see lessons learned section of this report). The feedback from the event has been positive, although the session would have benefitted from the attendance of a GP the absence of whom limited discussion of those aspects of the case. 4.8 The reviewer and the Safeguarding Manager from Somerset County Council met with Child Y’s mother in May 2014. The father was also invited to a meeting on that day but did not attend. 4.9 The initial report was then considered by a further Panel meeting held in May 2014 and also shared with the attendees at the learning event, so that their comments could influence the final review and the recommendations. 4.10 Whilst Child Y’s mother was invited to meet with the reviewer to discuss the outcome of the review, she unfortunately did not accept this invitation, so did not see the final report prior to it being signed off by the Panel submitted to the Independent Chair of the LSCB in September 2014. 5. Race, religion and culture 5.1 Child Y’s parents are both White British and no religion has been noted to play a significant part in their lives. If the definition of culture is accepted as being ‘the way we do things here’ then the family culture reflects that of a small rural town in the south west of England, with a close knit community and extended family on the mother’s side being close by. The mother describes this as being at times both supportive and intrusive, in that everyone knows everyone else, and with privacy being hard to maintain. 6. Narrative history 6.1 The time scale for the review is very brief and events moved very quickly. However, there is some relevant background information which precedes the circumstances of the injuries to Child Y. 6.2 There is a recorded domestic violence related incident in June 2010 between the mother’s mother and her partner. The mother of Child Y is named on the incident and would have been 15 years of age at the time. As previously stated, there were also three domestic abuse incidents reported to the police in 2006 involving verbal altercations between the Mother of Child Y’s parents. 6.3 In 2009 the mother’s school referred her to children’s social care following an incident where her step-father ‘pinned her to a wall’. There was a recommendation Page8 that this should be referred to the Local Service Team, but there is no record that this actually happened. 6.4 Between October 2010 and November 2011, there are 5 recorded domestic abuse related incidents between the father of Child Y and his then partner, who is the mother of his previous 2 children. These are recorded as verbal arguments and allegations of physical assault were not made. 6.5 There is also a recorded incident in February 2012, when the mother of Child Y reported that there had been an argument at home with her step mother. 6.6 In December 2012 the parents of Child Y were stopped and searched by the police and the father was found to have a small amount of cannabis on him and was warned. 6.7 Health notes for the father in September 2012 record that he had not attended his appointment at a counselling service for young people nor had he responded to their letter, so was not offered a further appointment. The GP gave him a copy of the letter from the service and he agreed to ring them. He was given antibiotics and medication for 6 weeks for 'depression and anxiety‘. The notes do not record further details of his mental state, social history or who he was living with. There is no mention of children. 6.8 The father was also referred urgently at this time to the dermatology department due to a mole on his back but failed to keep two appointments due to what he described as ‘money problems’. 6.9 The father is noted to have attended the surgery in January 2013 for ‘paternity testing’. This information does not appear to have been linked to his previous history. 6.10 The mother was registered at a different surgery. This was her first pregnancy. Her health notes record nothing of significance. 6.11 In February 2013 the mother called the police to a domestic dispute and assault at her home address when she was 10 weeks pregnant – her father slapped her face and threatened the father of Child Y over money he alleged his daughter owed him. This was not shared by the police with any other agency. 6.12 Health records show that the mother had problems early in her pregnancy with vomiting and stomach upset, and attended the GP for assistance with this. She presented as a gynaecology emergency to the accident and emergency department of Taunton and Somerset NHS Foundation Trust and was referred overnight to the gynaecology ward as she was complaining of abdominal pain. An ultrasound scan excluded an ectopic pregnancy and confirmed a viable pregnancy of approximately 5-6 weeks. She was then discharged home and advised to see her General Practitioner (GP) to book with the community midwife Page9 6.13 She then made frequent visits to the GP surgery with vague complaints or symptoms ‘of an unknown clinical cause’, usually with abdominal pain / reduced foetal movements / ‘query Urinary Tract Infection’ including a further hospital attendance where the symptoms resolved on arrival on the ward. 6.14 The mother and the father received maternity care from Taunton & Somerset NHS Foundation Trust. Their booking appointment was held in February 2013 at which a routine social assessment was undertaken as part of the booking process and the father disclosed he had previously been in care as a child. He told community midwife1 that he had two other children, one who lived with the paternal grandparents and one who was adopted. He had no contact with either child. 6.15 According to the maternity records the mother disclosed a stress in her pregnancy from her father, who was volatile, ‘mixed drinks’ and drank heavily. She shared that her father had slapped her face. It is documented that the mother needed help understanding her pregnancy notes and completing forms. 6.16 In August at 37+ weeks the mother was seen by community midwife 2. The father was also present at this appointment. The community midwife was concerned about the growth of the baby and referred the mother for an ultrasound scan to exclude a small baby. However, there is no documentation of a 2nd social risk assessment on page 2 of the maternity held records, where the information relating to the father's previous children and his time in care is documented, and community midwife 2 did not notice this information. 6.17 In early September 2013 at 10.00 in the morning, the father called the Labour Ward for advice about the mother, as he thought she was in labour. The couple arrived an hour and 12 minutes later, brought in by a female relative. The mother was in advanced labour and Child Y was born by normal delivery 13 minutes after her arrival on the labour ward. Child Y weighed 3070 grams. 6.18 The mother and Child Y were transferred to the postnatal ward where they remained for four hours prior to their transfer home to community midwifery care. Documentation surrounding the discharge arrangements for the Mother and Child Y is very brief. Hospital midwife 3 recalls that the couple was eager to go home. The following day the mother and Child Y returned to the ward for a postnatal and neonatal check, as arranged. 6.19 On day 2, post delivery, the mother was expected to attend her local hospital for a postnatal check with Child Y. She did not attend. Community midwife 2 contacted her by telephone and a telephone assessment took place with a plan for her to attend clinic the next day. 6.20 Child Y was subsequently seen on day 3 at home by community midwife 1. The father of Child Y was present. Child Y was then seen with both parents at the local community hospital on day 5 by community midwife 3, and on day 15 by community midwife 2. Child Y was discharged from midwifery care to the care of Page10 the health visitor on day 15. No concerns were identified by the community midwives who provided care to Child Y during these appointments. Child Y was breastfed and weight on discharge was above the birth weight. The handover of care to the health visitor was by voicemail and sending of the documentation, as was the usual process. 6.21 The case was allocated within the heath visiting practice to a student health visitor (SHV) who was on the third week of her final placement she attempted to make a home visit to conduct the Primary Birth Assessment. The family were not expecting SHV and did not allow her access to their flat. Instead the father left the flat and met with the SHV on the landing outside where a further date was agreed. The father’s rationale for not allowing the visit to go ahead at this time was that the midwifery service was still visiting and the timing was inconvenient. 6.22 The re-arranged visit went ahead and the Primary Birth Assessment visit was completed in line with Somerset Partnership NHS Foundation Trust standards. The SHV gave appropriate advice regarding breastfeeding, safe sleeping and minor childhood ailments. She referred the parents to the GP due to Child Y apparently having oral thrush. The SHV identified that the father dominated the conversation, even those parts of it dedicated to the mother’s breastfeeding. As a result she arranged a swift follow up visit for the family. The health records note that the SHV did not begin a formal Family Health Needs Assessment as per local protocol although there is evidence of appropriate assessment in the RiO electronic patient record. 6.23 Child Y was taken to the GP as suggested and the GP has written a statement for police describing the consultation including his concerns about the behaviour of Child Y's father. He reports the father saying 'my job is not to be your friend, my job is to teach you right from wrong' and perhaps handling Child Y a bit roughly. Child Y was examined and the GP found nappy area thrush as well as oral thrush . The GP rang the Health Visiting team, and left a message on their answer phone. He also sent an internal email to mother's GP, to inform him of this. Oral nystatin and hydrocortisone and miconazole cream were prescribed. 6.24 A telephone message was left on the duty health visitor answer phone for SHV by midwife 2 informing SHV that midwife 2 had concerns about the dynamics between the couple and the potential risk of post natal depression. She left her mobile telephone number as part of the message. The duty health visitor did not respond to this message or record it on the RiO progress notes. SHV did not record this message in the RiO progress notes or return the midwife’s call either, but filed the written message with the paper records. 6.25 Next day, the SHV received a follow up telephone call from the GP who reported that when he saw Child Y the previous day due to oral thrush and nappy rash he was concerned about the father’s rough handling of Child Y and his inappropriate language to the baby, as documented above. The GP requested that Page11 this family receive a high level of support from the health visiting service. SHV clearly documented this telephone call in the RiO electronic progress notes and discussed with HV1 prior to visiting the family again. 6.26 The SHV returned to the family home a few days later to complete a Neo-Natal hearing screening test. She was accompanied by HV1 as she needed to be assessed completing the hearing screening test, and she had shared with HV1 the concerns raised by the GP, community midwife 2, and her own observations. The father completed all of Child Y’s care needs during the contact. The mother reported that she had ceased breastfeeding due to having thrush herself and would seek advice from a GP later in the day. Both SHV and HV1 noted that the father was overtly gentle with Child Y and was talking very kindly to the baby. Both SHV and HV1 agreed that such an overt display of gentle handling indicated that the GP had raised his concerns with the father, and that the father had changed his style of handling Child Y as a result. The SHV successfully completed Child Y’s neonatal hearing screening test which was clear in both ears. She gave the mother appropriate advice regarding the treatment of thrush and breast care and signposted both parents to the Parent Held Child Health Record regarding further information on normal hearing and speech development. She also arranged the next planned health visitor visit to include the Teenage Parent Champion, who would be introduced to the family to offer them extra support and advice regarding positive parenting. 6.27 The next day, the father made an urgent appointment with the GP at 12:10 as Child Y at 19 days old, was 'pale and sweating, coming straight down' but the family did not attend until 14:15 as Child Y was 'being fed and changed.' This was too late for the morning surgery and the family were offered an appointment later that afternoon but declined. 'Dad decided to speak to Health Visitor this pm, he noted colour back and sleeping content. He will ring again if concerned'3 6.28 Later that day the father telephoned the SHV who agreed to see Child Y at the Minor Injury Unit of Bridgwater Community Hospital as the father was concerned that Child Y was pale and unwell. The father stated that he had been unable to make a GP appointment for Child Y and had been advised by the GP practice to contact the health visitor instead. The mother informed the SHV that she had not had any concerns about Child Y’s condition. SHV observed Child Y in the pram to review Child Y’s colour and touched Child Y’s cheek to check Child Y’s temperature. She did not request that Child Y was removed from the pram for a more thorough assessment as Child Y was asleep, and she had no access to an examination room at the clinic. Instead, she advised the couple to call NHS Direct, the Out of Hours GP service or to attend the Minor Injury Unit if they remained concerned about Child Y’s condition. 6.29 Four days later, the SHV returned a telephone message from the father, (left on her mobile early in the morning outside of office hours), who stated that Child Y 3 EMIS – GP surgery notes Page12 was pale, not taking as much milk as before and appeared to be shaking at times which he compared to an epileptic fit. SHV advised the father to make a GP appointment for Child Y. SHV noted in the electronic record that the next planned contact with the family was in a few days time. 6.30 The GP surgery recorded that the father made an appointment but later rang the surgery to say they were just leaving & would be late. They were subsequently seen by GP4 that afternoon and the father described a history of odd episodes of jerks from 05:30 that morning. The GP made a careful examination, including holding Child Y, and noted him ‘jerking’. He therefore made an urgent referral to a paediatrician at the hospital and agreed that the family would take Child Y there as they had a car waiting outside. The PA then rang the hospital twice to check that Child Y had arrived. 6.31 On attendance at hospital Child Y was examined and an MRI scan indicated that Child Y had survived a subdural haemorrhage, which is bleeding in the brain and is commonly associated with ‘shaken babies’. The injuries were subsequently noted to be up to seven days old, but some likely to be considerably more recent. 7. Analysis 7.1 As stated previously the review concerns a short period of time where events moved very quickly indeed. 7.2 Events will therefore be analysed briefly against the terms of reference, then within a research and evidence framework in order to draw conclusions and identify the lessons learned by professionals involved in the case as well as the learning for the wider membership of the Safeguarding Board. a) What involvement did agencies have with the parents and child? 7.3 The involvement of Children’s Social Care’s (CSC) with Child Y dates from the beginning of October 2013, when a referral was received from Musgrove Park Hospital (MPH) indicating that the baby had been admitted with seizures and suspected non accidental injuries due to shaking. Child Y was not referred to CSC prior to birth, nor prior to admittance to hospital on the above date. This is unfortunate as the department held information about both parents which would have raised some concerns about their vulnerability as parents and potential risk and support needs for their baby – see below. 7.4 The initial contact with CSC was made to the out of hours Emergency Duty Team (EDT), and was processed as a referral by Somerset Direct Telephone Contact Centre (SD). The Team leader at Somerset Direct correctly identified that due to the serious nature of the referral, a strategy discussion was needed. The referral was sent electronically to the CSC Area office where the Page13 assessment team leader had an initial strategy discussion with the Police Safeguarding and Coordination Unit (SCU) at which it was agreed that a ‘sit down’ strategy meeting was needed. This strategy meeting took place at 1pm on the same day at the hospital, and was attended by CSC, Police, Health Visiting Service and a Consultant Paediatrician from the hospital. 7.5 This meeting shared information from the above agencies, and a further strategy meeting between Police and CSC took place on the following day. The above meetings agreed that CSC needed to consider an application to the court for an Interim Care Order, in order to ensure the safety of Child Y, and a legal case discussion chaired by the CSC Area manager took place on the same day at which it was agreed that an application to the court was needed. 7.6 Child Y was moved to Paediatric Intensive Care Unit (PICU) in Bristol, and CSC case records indicate ongoing liaison between CSC and hospital staff. 7.7 Five days later, a further strategy meeting took place, attended by CSC, Police SCU, and Paediatrics (MPH). Information shared at the strategy meeting indicated that the injuries noted to Child Y were ‘highly suggestive’ of a Non Accidental Injury (NAI) caused by shaking. 7.8 A week later, a discharge planning meeting took place at the hospital, which agreed that Child Y would be discharged from hospital in to foster care on 17 October. The meeting was attended by CSC, Police, Children’s Physiotherapy, named Nurse for Safeguarding, Health visiting Service, the mother and the Consultant Paediatrician. 7.9 The following day, CSC made an application to the family court for an Interim care Order, which was agreed. This order allowed the Local authority to share parental responsibility with the parents of Child Y, whilst retaining the power to make decisions in Child Y’s best interests. 7.10 As outlined in the narrative of events, the police had some contact with both parents prior to the birth of Child Y. There were 3 calls to the police over 3 years in relation to the mother and 5 calls to the police in relation to the father and his previous partner, during 2010-11. This indicates that both the parents had experienced vocal and aggressive arguments and in the father’s case, he had been on occasion the perpetrator. However, only one of these incidents involved Child Y – the assault on the mother in February 2013 when she was 10 weeks pregnant with him, whereby her father slapped her face. This was closed by the officers when they had clarified that the victim, the mother, was not living with the perpetrator. 7.11 The main professional contact was with the health services. The parents were registered at 2 different surgeries and there were 4 GPs involved at various points with the parents and Child Y. Page14 7.12 The family also received maternity services from the Taunton and Somerset NHS Trust. This included ante-natal and post natal care from 3 midwives, as defined within NICE guidelines, although the level of assessment at the point of Child Y’s birth and hospital discharge was limited and did not include a social assessment as the mother did not wish to stay in hospital and left within 4 hours of the birth, declining any additional support. The family was then referred to their local health visiting practice, 14 days after the birth where they were allocated to a student health visitor who was three weeks into her final practice placement. 7.13 Two different hospitals also had care of the mother during pregnancy and then for Child Y at admission to hospital with the injuries which led to this review. However, although the mother was cared for in two different hospitals, this was with the same NHS Trust and care provider who provided maternity care on two sites b) Did all staff understand and implement the pre‐birth protocol? What evidence of this is there? 7.14 There is no evidence that the Unborn Baby Protocol was considered, because the risks were unrecognised by those involved. The protocol can be easily accessed by a maximum of 2 clicks on a computer mouse on the electronic South West Safeguarding Procedures web-site at www.online-procedures.co.uk/swcpp where it is clearly stated that “Under 1’s are 7 times more likely to be killed than other age groups’. There is also a very clear statement that “‘Wait and see’ is not a safe option and wastes valuable time to intervene.” 7.15 There were several opportunities where this protocol could have potentially have been instigated to protect the unborn child. 7.16 The first was when the police attended the domestic incident on in February 2013 when the mother was slapped across the face by her father and told the police that she was 10 weeks pregnant. She stated that this was not the first time her father had assaulted her and she had fear for herself and her unborn child. She described her father as controlling when she was living with him and if she did not do as she was told or do anything he did not like he would become angry or violent. She also alleged that over a year previously he had returned home drunk and had become angry, grabbed her around the throat and his 'wife' intervened. She alleged that he drank alcohol a lot, and had assaulted other family members (mother, her new partner and mother's best friend).The officers advised the mother to get checked out at hospital. The police DASH risk assessment was completed correctly and all relevant questions were asked. The police officers assessed a medium level of future risk and passed the information to the Police Safeguarding Unit which did not notify CSC about this incident. 7.17 The police IMR confirms that police staff working within the Public Protection Unit are generally aware that there is a pre-birth protocol available on the South West Child Protection Procedures web site. The IMR states that the staff at all three of the Police Safeguarding and Co-ordination Units were also aware of these Page15 Page1 procedures and of the need to inform partner agencies of incidents involving pregnant women. However, the author acknowledges that: “there is limited knowledge of the protocol amongst wider Police staff and it is invariably uniform officers who attend such incidents”. Whilst “The safeguarding units provide a test and check second risk assessment process to ensure that relevant referrals are made to Children’s Services for domestic abuse incidents involving pregnant females as it is part of the questioning on the DASH risk assessment”(police IMR para.4.2) the DASH in this case did not result in consideration of the protocol. This was because the attending officers did not identify any ongoing or significant risk to the victim or to the unborn child and graded the DASH as medium risk. The significance of the unborn child was not picked up either by the attending officers or the unit, and no referral was made to Children’s Services in line with the protocol. 7.18 The learning event also identified some confusion about the threshold for using the protocol as the unborn child was only 10 weeks gestation at this point. The protocol on the website states that: “You should follow up concerns from as soon as possible, by 12 weeks gestation”. This seems very clear, but is dependent on a professional identifying that there is a concern in the first place and this did not happen at any point during the pregnancy. 7.19 Staff at the hospital also missed this opportunity in January 2013 when the mother presented with unspecified stomach pains. She was swiftly moved to the Women’s Health Unit in line with hospital protocol and there is no evidence that domestic abuse was routinely considered there as good practice would suggest. Unspecified stomach pain in pregnancy is a known indicator of potential domestic abuse but in fairness would need to have been considered alongside other risk factors, about which the hospital had no information, and staff do not appear to have enquired about this aspect of mother’s social history. 7.20 The third opportunity to instigate the protocol was following the assessment at the maternity booking appointment in February 2013 where the father shared some of his history with community midwife 1 and the mother also related her history of domestic abuse and associated stress. At the learning event community midwife 1 confirmed that at the time she was not familiar with the protocol, but did consider whether she should refer the family to social services. She decided not to do so as they were so open, apparently honest and very much a partnership. She felt that she ’wanted to give them a chance to make a go of it’, having seen parents who had far more obvious difficulties including drug abuse have their children returned to them by social care. She found them to be very plausible and did not give sufficient weight to the history they shared with her or see this in terms of risk factors, although she did record this information on the maternity held notes. This optimism is a mistake she regrets and will not make again. Having met the mother it is easy to see why community midwife 1 would have been optimistic – she presents as being very child focussed and sensible and also totally delighted to have been pregnant. 7.21 The fourth opportunity was when the 2nd risk assessment was carried out by community midwife 2 and again no social risks were identified. There was no formal sharing of the joint caseload and therefore no direct midwife to midwife handover of Page16 the case that may have acted as a failsafe and alerted either midwife of the need to escalate/investigate further, in view of the fathers’ disclosure. Community midwife 2 did not refer back to the original booking assessment where his disclosure relating to his previous children was documented and another opportunity was missed. c) Were agencies aware that the mother and father were victims of domestic abuse during the pregnancy and how did they respond to that information? 7.22 As above, the full extent of this information was known solely to the police. The police IMR notes that: “From a Police perspective there is no evidence or information to confirm that this information was used to inform assessment, planning and decision making in respect of the unborn child. The incidents not subject of the terms of reference for this IMR have been recorded correctly. There is evidence for some of these incidents that appropriate referrals have been made to Children’s Services. For many of the incidents a DASH risk assessment was not completed. In hindsight this is a missed opportunity to identify risk factors.” 7.23 The details of the earlier incidents were shared with Children’s Services, but unfortunately the one incident in which the fact of the mother’s pregnancy and her relationship with the father was noted was not shared with them. It is standard practice in Somerset Children’s Services that all domestic abuse notifications from the police are subject to internal records checks. This would have identified the father as a former care leaver with a history of significant difficulties and an adopted child and the mother as a vulnerable young person due to a history of domestic abuse between her parents. The combination of the history of the two parents should have raised concerns and may well have resulted in multi-agency action to safeguard their unborn child. 7.24 The mother’s GP and community midwife 1 were aware of the assault on the mother by her father in February 2013 but not of any other incident, and this by itself would not necessarily have alerted any professional to potential risk. 7.25 Community midwife1 was reassured in conversation with the mother that she had no contact with her father and therefore did not see the single incident as domestic abuse or as a risk to either her or the unborn child. Community midwife 2 did not then ask the domestic abuse question when she completed the second assessment on her 5th contact with the couple at week 37. 7.26 Community midwife 2 became concerned about the father’s dominant presentation following the birth of the baby and contacted the health visiting services to alert them to this during the transition period to that service. This is the only occasion in which the possibility of domestic violence or abuse within the relationship was considered. 7.27 Prior to this the issue of domestic violence or abuse was not discussed with the mother either when she attended GP appointments or in her appointments with other health professionals through her pregnancy – for example when she attended hospital for the second time in June 2013 with concerns about abdominal pain, and on her visits to the midwife for ante-natal care in April and August, when the Page17 chronology records that she was not accompanied by the father. Good practice states that this is a standard question that should be asked of any pregnant woman, and also in this case because there were two presentations with abdominal pain which may have indicated abuse. The mother’s history of domestic abuse within her own family may also have made her more vulnerable and more tolerant of further abuse, which is an additional risk factor. 7.28 The importance of the understanding of professionals and of the general public about what constitutes domestic abuse is a key factor arising from this review. On arrest, the mother told the police that there had been no domestic abuse in her relationship. She subsequently advised the reviewer that had she been asked about this before she would have said the same. She had witnessed violence in the relationship between her parents and had this as her reference point for what constitutes domestic abuse. However, since Child Y’s injuries she has looked at some leaflets and has contacted a domestic violence charity as she now understands that much of the father’s behaviour towards her was in fact abusive. 7.29 The mother of Child Y described a highly controlling partner who withheld her money and dictated who she could see and where she could go, undermined her confidence and isolated her, and who would fly into a rage if he thought that she was talking to other men. She also described his jealousy when the baby was born and was taking up so much of her attention. 7.30 The NHS Choices web site describes domestic abuse in the following way: Domestic Violence is officially classified as "any incident of threatening behaviour, violence or abuse between adults who are or have been in a relationship together, or between family members, regardless of gender or sexuality". We think of domestic violence as hitting, slapping and beating, but it can also include emotional abuse as well as forced marriage and so-called "honour crimes". It's abuse if your partner or a family member: • threatens you • shoves or pushes you • makes you fear for your physical safety • puts you down, or attempts to undermine your self-esteem • controls you, for example by stopping you seeing your friends and family • is jealous and possessive, such as being suspicious of your friendships and conversations • frightens you Page18 7.31 The mother stated that she understood domestic abuse as being physical violence and as the father had not hit her she did not recognise that she was being abused. Professionals would have had to ask her very specific questions covering the bullet points above to elicit any positive response from her. Simply asking if she was frightened of her partner or if he was abusive to her would not have been enough. 7.32 This is important because research tells us that women who live with controlling and abusive partners often blame themselves, and struggle to protect their children from the impact of the abuse. Indeed domestic abuse is a significant risk factor in the emotional and physical abuse of children and in neglect. 4 This is particularly important in relation to babies who are most vulnerable to death and serious injury.5 7.33 The same NHS web-site states that: “Thirty percent of this abuse starts in pregnancy, and existing abuse may get worse during pregnancy or after giving birth. Domestic abuse during pregnancy puts you and your unborn child in danger. It increases the risk of miscarriage, infection, premature birth, and injury or death to the baby.” 7.34 The website features a midwife talking about this issue which suggests that the NHS nationally takes the role of midwives in detection seriously. It is of concern that this did not translate into local practice and the feedback from health staff identified that this web-site is not widely referenced by frontline staff, so that this definition of abuse may not be well understood by them. The midwives in this case describe a clinically focused service in which a huge range of clinical questions have to be asked and entered on to the records at each appointment, in line with national policy. 7.35 One midwife stated that “..sometimes, if you haven’t got that little switch, if you haven’t experienced this before, you will give the benefit of the doubt and miss things….” Unfortunately other serious case reviews support this perspective, in that front line midwives are not always the best trained and supported to recognise and deal with this issue – this is discussed further in the lessons learned section of this report. 4 For example, Cleaver, H. Unell, I. and Aldgate, J.: Children’s Needs – Parenting Capacity. The Impact Of Parental Mental Illness, Learning Disability, Problem Alcohol, Drug Abuse And Domestic Violence On Children’s Safety. (2nd Edition) 2011 London The Stationery Office 5 Brandon et al “Analysing Child Deaths and Serious Injury Through Abuse and Neglect: What Can We Learn? A Biennial Review Of Serious Case Reviews (2003-5, 2006- 8, 2009-11) Page19 7.36 It is also of concern that the national web site interchanges the use of the terms ‘domestic abuse’ with ‘domestic violence’ as this gives a confused message and can be interpreted by the public and by professionals as being about violence – a very serious and dangerous issue - rather than the control and emotional abuse which is a feature of such abusive relationships and often a precursor to physical violence. The national definition on the Gov.uk website is “domestic violence and abuse”. d) Was previous history, including of domestic abuse, and previous children, ascertained regarding the parents? Was this information used to inform assessment, planning and decision‐making in respect of the unborn child? 7.37 The Somerset Clinical Commissioning Group IMR records the following: “The father had been registered at Surgery 2 since 2004. His past history from the Vision computerised record clearly records his troubled childhood, history of fire setting, depression and self-harm, involvement with CAMHS, and time spent in Care. He has a past history of several overdoses, requiring hospital admissions; he was seen by Somerset’s Mental Health Crisis Team in 2011. He was referred to Right Steps Counselling Service several times for anxiety and depression, but did not engage with them. There is no record of violence or drug misuse. He has 1 daughter who has been adopted. He took medication for depression(sic)daily very sporadically, but no prescriptions ……have been issued since December 2012. Over the period of the review he had two face to face appointments with GPs, and two telephone appointments. These consultations often contained multiple problems to be dealt with. The father was certified as unfit to work because of anxiety and depression in September 2012.” 7.38 Surgery 2 was the only professional agency involved at the time that had this information. The GP did not know that the father was about to become a parent again as he did not tell them and the mother was registered at a different practice, Surgery 1, as was Child Y when born. There was no point at which this information was requested or accessed by any of the other health professionals involved, all of whom used different case record systems which did not provide cross practice or service information about patients. This was usual practice. Page20 7.39 However, the fathers’ RiO electronic mental health records were reviewed following the incident and revealed much fuller information that would have been significant if it had been available to professionals prior to the injuries to Child Y – midwives do not have access to RiO but health visitors do have access: (The father) was not a first time parent but has two older children, a six year old male child who lives with a grandparent and a four year old female child who has been adopted. He.. does not have contact with either child. In fact..he..and his previous partner, were placed in a Parenting Assessment Unit following the birth of their daughter due to concerns about their ability to safely parent the child due to their anger issues and joint drug misuse. The placement was not successful. (The father) has a significant risk history of violence and aggression and had convictions for shoplifting by the time he was fourteen years old. He had been excluded from school. He was referred to Somerset Partnership CAMHS in 2004 when his mother was unable to cope with his escalating difficult behaviour some of which was directed at his two younger half-sisters. His relationship with his mother deteriorated and he later become Looked After by the Local Authority… By the age of sixteen years he had developed a depressive illness, self-harmed and attempted suicide several times; he was referred to the Somerset Partnership Crisis Resolution, Psychiatric Liaison and Community Mental Health Teams on several occasions. (He) reported using cannabis from the age of eleven years….experienced periods of homelessness after being evicted from (his housing) for aggressive behaviour.” 7.40 Health visitors are usually informed of all pregnancies via caseload and due dates, and should have been aware of this pregnancy. However, the Somerset Partnership IMR states that the Health Visiting Service was not informed of the mother’s pregnancy by either the GP or midwife. Instead the first notification the service received was from Child Health when Child Y was born. As a result there was no opportunity for an ante-natal assessment to be carried out in the ante-natal period by the Health Visiting service, missing a chance to identify the father’s previous risk history – this would have included accessing the Rio records. 7.41 Although the SHV did check the Rio records, she did not have a date of birth for the father and did not access Mental Health records – see below. This important background information did not therefore come to light, and the professionals involved worked only with what was presented to them. 7.42 Surgery 1 had no information about the father. The information held on the mother’s medical notes was that “The mother had no current mental health illness and there was no family history of mental health disorders.” It is recorded by the GP and by community midwife 1 that when asked about street drugs and alcohol she said she did not use either. They therefore had no apparent reason for concern. 7.43 At the booking appointment the IMR notes that midwife 1 “documented that she discussed healthy eating, vitamins, employment rights, maternity benefits, Page21 effects of smoking on mother and baby, travel safety and seat belts, stresses in pregnancy, support at home, sex in pregnancy & exercise, all of which are required in this initial appointment. The father disclosed he had previously been in care as a child, and had two other children, one who lived with the paternal grandparents and one who was adopted. He had no contact with either child. The mother disclosed a stress in her pregnancy from her father, who was volatile, ‘mixed drinks’ and drank heavily. It is documented that (the mother) needed help understanding her pregnancy notes and completing forms”. Community midwife 1 disputed that the mother disclosed this information at booking, but she did record it as a ‘third hand’ comment on the midwifery held notes. The midwife did not know about the father’s history of domestic abuse, or his mental health issues and aggression and did not therefore understand the relevance of the information in terms of potential risks to the baby. 7.44 Community midwife 1 also noted that the mother needed help with the forms and leaflets and had a learning difficulty of some kind, although the midwives later stated that this was no more than for many other patients with whom they were working. 7.45 As above, community midwife 1 felt that they were a pleasant and plausible young couple who ‘deserved a chance’ and she did not enquire about social services involvement or seek to refer the couple on for further support. This is a training and supervision issue that is further discussed in ‘lessons learned’ at Section 8 of this report. 7.46 The Taunton and Somerset NHS Foundation Trust IMR records that: “At 37+ weeks (the mother) was seen by community midwife 2. The father was also present at this appointment. The community midwife was concerned about the growth of the baby and referred (the mother) for an ultrasound scan to exclude a small baby. A 2nd risk assessment was carried out and no social risks were identified. However, there is no documentation of a 2nd social risk assessment on page 2 of the maternity hand held notes, where the information relating to the father’s previous children and his time in care is documented. This information does not therefore appear to be included in any future discussions or written records about the couple – there was also no liaison ( about this case)between the two midwives.” 7.47 As previously stated, community midwife 2, who job shares with community midwife 1 and shares a case load with her, carried out the second risk assessment and did not note any concerns at the time so completed the relevant sections in the patient held notes but did not add to the maternity held notes or note their contents. She did not therefore note the background and like community midwife1 she was reassured in conversation with the mother that she had no contact with her father and therefore did not see the one incident as a risk to either the mother or the unborn child. Page22 7.48 The community midwives stated that they discussed their caseload daily at work. They also had formal meetings to discuss ‘problem’ cases monthly with the two Health Visitors assigned to the Doctor’s surgery at the time. As no risks had been recognised this case was not identified by either midwife as needing discussion in that forum. 7.49 As stated previously Children’s Social Care held significant information about both parents. This included the following: • In 2006 the police made three referrals of verbal altercations, two with violence, between the mother’s parents who were in the process of splitting up. • In 2009 they received a referral from the mother’s school regarding an argument between the mother and her step-father, which resulted in the mother being physically restrained by her step-father. No further action was taken by CSC. Case notes indicate that a referral to the Local Service Team should be made to support with the mother’s behaviour problems, however there is no evidence to indicate that this referral was made. • In 2010 there was a further referral from the Police regarding a domestic incident between the mother’s mother and step-father. Step-father is alleged to have assaulted the mother’s mother and smashed items in the home. The referral included significant and concerning details of domestic violence. He had never assaulted the mother of Child Y but had his ex-wife. The CSC database indicates that the family was visited by a social worker and no ongoing involvement was identified as being necessary. No assessment was recorded however. • In 2011 the mother’s school again referred her to CSC as one of her friends alleged that she had been assaulted during a visit to London. CSC discussed the situation with school staff and agreed that the school would provide support to the mother if needed. • Finally in 2012 there was a referral from MARAC as the mother’s father and step-mother were discussed there. No actions were noted for CSC, and they took no further action. 7.50 In relation to the father, CSC records show the following: • The father of Child Y was looked after by the local authority from October 2005 to March 2007. He spent the majority of this time in residential care, but was accommodated within a foster placement briefly. The father went on to be supported by the Leaving Care service until he was age 21, when this contact ended by mutual consent. The father had been voluntarily accommodated due to the breakdown of his relationship with his mother, who felt she could not manage his behaviour in the home environment. As a child, the father engaged in low level criminality, and was known to use cannabis, with his mother’s agreement. Page23 • The father has two other children that are known to CSC. The first was born to a young woman who was in care with him. The father did not at any stage provide care for this child, whose mother was in a relationship with another man. • The second child was referred to CSC by the maternity unit shortly after its birth. There was no CSC involvement with this child pre-birth. Due to the serious concerns raised about the father and the child’s mother’s ability to provide safe and positive care for this child, both parents and the child went to a residential parenting assessment placement. The father left this placement and did not seek any further assessment with regard to caring for his child who went on to be adopted. 7.51 As Children’s Social Care were not contacted by other professionals at any point, this information was not pulled together and there was at no point therefore any collation or assessment of risk factors that would have alerted professionals to the need to jointly plan for the safety and welfare of the baby. 7.52 However, worryingly, the mother described to the reviewer a visit with the father to the social worker for his adopted baby to collect pictures of the child. The mother was visibly pregnant at that time and the couple told the worker about the pregnancy and their joy that they were to be parents. It is of concern that this worker did not note the significance of this information given the history of the father and refer the couple to the children’s social care duty team for assessment and support. e) How did agencies fulfil statutory duties with regard to safeguarding in this case? 7.53 None of the agencies involved can be said to have acted proactively to safeguard Child Y and opportunities to do so in the ante-natal and birth period were missed. 7.54 Research undertaken by Reconstruct, and presented on the South West Child Protection Procedures website identifies a number of risk factors which may have been identified in this case: “When to be concerned • Worries about either parent’s current behaviour, e.g. known mental health concern or substance misuse • Concerns either parent/carer may not be able to care for the baby to an acceptable standard, e.g. significant learning difficulty, previous neglect or other children subject to child protection plans/taken into care • The behaviour of others (including fathers) may pose a threat to the unborn baby, e.g. domestic abuse or known allegation or conviction for offences against children under 18 years of age Page24 • The impact of one parent’s behaviour on another may be reducing their ability to care for the baby to an acceptable standard • If the mother is unable or unwilling to say who the father of the child is” In addition the following individual factors applied: Mother • History of family discord and violence, • Family breakdown • Historical abuse • Young parent • Isolated Father • Family breakdown • Young parent • History of care • Previous children subject to care proceedings • Drug use • Mental health problems – depression and anxiety 7.55 However, no health professional was aware of all of these factors and information was not brought together to inform planning as there was no contact with social care where much of this information was stored about the parents on their individual records. Social Care was at no point formally informed that the mother and father had gotten together and were having a baby, although there was a missed opportunity when, according to the mother, the parents attended a social care office to collect photographs of the fathers’ adopted baby and shared with that worker their impending parenthood. 7.56 Therefore although there had been significant involvement by Children’s social care with the father prior to his leaving care, they were not involved with Child Y until notified Child Y’s injuries in early October 2013. This is hugely unfortunate as they were not therefore in a position to safeguard Child Y. However, the visit to the adoption service in April 2013 when the parents shared their joy at the prospect of being parents was a missed opportunity to safeguard the unborn baby and instigate the Unborn Baby Protocol. 7.57 The action taken by CSC when notified of Child Y’s injuries is in line with guidance in Working Together 2013, which indicates that a social worker must make a decision regarding further action within 24 hours of receipt of the referral. Working Together also indicates that where there is concern that a child may have suffered Page25 significant harm, a multi-agency strategy discussion should take place to ensure the child’ welfare and plan future action. 7.58 Where the local authority is concerned that a child may have suffered significant harm, an assessment of the child must be completed within a maximum time scale of 45 days. In this case, a Child and Family Assessment was completed, 15 working days after the receipt of the initial referral. 7.59 In relation to the police, the IMR notes that the incidents not subject of the terms of reference for the review had been recorded correctly. There is evidence for some of these incidents that appropriate referrals had been made to Children’s Social Care. For many of the incidents a DASH risk assessment was not completed. In hindsight this is a missed opportunity to identify risk factors. 7.60 The midwifery service had determined early on that the couple were trying hard to meet the needs of their unborn child and were ‘given the benefit of the doubt’. This view of the couple meant that no risks were identified to inform the allocation of health visiting and the actions that followed. The fact of the father’s care leaver status and previous child did not make it onto any transfer notes to the health visiting service, and indeed no transfer notes, electronic records or handover discussion were provided to the allocated Student Health Visitor. 7.61 When the mother was in advanced labour in the hospital the Taunton and Somerset NHS Foundation Trust IMR identifies that “One of the midwives described feeling “there was something about”, the behaviour of (the father). She described his behaviour as not appropriate, in terms of him trying to focus attention on himself. (The mother) was in advanced labour and (the father) wanted to talk about his own experience of labour in relation to the births of his previous children, which she felt was odd. The midwife was concerned enough to check the high risk folder on labour ward (in which copies of any pre-birth safeguarding planning are kept). She found nothing relating to (the mother) and was therefore reassured.”(3.11) 7.62 Review of the booking paperwork at this point may well (combined with the concerns about the father’s behaviour) have triggered her to escalate or discuss her concerns with a senior midwife. It is also unfortunate that the absence of previous recorded concerns served to reassure the midwife that her own judgement was not worth further follow up. In addition, the birth of Child Y so soon after arrival meant that there was no opportunity for a fuller health and social care assessment which mother’s early age and the midwife’s concerns should have triggered. 7.63 The IMR goes on to state that the mother and Child Y were transferred to the postnatal ward, where they remained for four hours prior to their discharge home to community midwifery care. The booking and subsequent social risk assessments were not reviewed or taken into account at all prior to transfer home. In particular, Page26 there was no consideration of the mother’s age (18) and the fact that she may need additional support because of this. The couple were very keen to go home as soon as possible. The IMR author states that it is very unusual for teenage mothers to request such an early discharge; however this was not challenged at all despite the lack of any real assessment of health and social care needs. Assumptions were made that because there had been no referrals/safeguarding alerts that there were no additional support needs or issues. Review of the booking disclosure may have triggered further investigation but this did not occur and what assessment there was at this point was therefore severely limited. 7.64 The mother has stated that she had a fear of the hospital because her grandmother had died there recently and this caused stress for her. She felt that this would impact on Child Y and therefore pressed to be allowed home. 7.65 Following Child Y’s birth a SHV was allocated this family at the weekly allocation meeting held by the Health Visiting team in which she was based. Her experience of the allocation process was that new births were allocated on a random basis, dependant on the existing workload held by the Health Visitor receiving the new case. New cases had not been reviewed prior to allocation taking place to identify potential or actual risk factors and other likely complexities, and the lack of any handover from the maternity services meant that what information there was available was not shared, including the fact that these were teenage parents and whether a referral had therefore been made to the Teenage Pregnancy Link Health Visitor. 7.66 The IMR found that since the reorganisation of HV services into “hubs” there has been a local agreement with the Teenage Pregnancy Link Health Visitor for the midwife to send a copy of the front page of the eClipse Booking Form as a process for informing the HV service of teenagers (instead of the communication form being used by midwifery). This agreement therefore introduced yet more confusion. The health visiting services state that no form was received by them, although there is a copy of this form in the notes annotated “FAO teenage Link HV” and the community midwives confirm that it was sent. However there is no fail safe process for ensuring the HV has received the form and no process for community midwife follow up. Furthermore the Student Health Visitor was not aware that a local agreement was in place for the Midwifery service to share this information with the Teenage Pregnancy Link Health Visitor. 7.67 The receipt of a communication form (or indeed the eClipse form) would have initiated a visit from the Teenage Link HV to visit the mother while she was pregnant. 7.68 Without any of this in place the case therefore appeared to be perfectly suitable for a Student Health Visitor in the consolidated element of her training for three weeks at the time. Had there been some checking of the Rio system prior to allocation, the father’s history may have come out and there may well have been a Page27 different outcome. As a minimum, it may have been considered more appropriate to allocate the case directly to the Young Parent Champion ensuring that the family would not have an early change of health professional and providing continuity of care with an experienced health professional. 7.69 However the Somerset Partnership Foundation Trust IMR states that: At the time of this incident the Health Visiting service were still embedding the basics of the RiO system into everyday practice and fathers were not routinely entered onto the system. Following the initial RiO training there had been confusion amongst some staff groups regarding access to existing mental health services RiO records in cases where such information could usefully inform Family Health Needs Assessments, particularly in regard to parenting capacity. 7.70 Whilst this has now been resolved, checking of the system would have revealed the fathers’ previous history with CAMHS, but not his current mental health issues at that time. In fact, the SHV did check Rio but had not been provided with the date of birth for the father and did not therefore obtain any helpful information in any case. 7.71 Furthermore she was not advised to liaise with the midwife and GP to ascertain any relevant background information before visiting the family. 7.72 The SHV therefore believed this to be the couple’s first child and they did not advise her otherwise. Her actions are then consistent with this belief. There is however ample evidence that she had identified them as vulnerable very quickly, and had offered a much higher level of visiting than the norm as a result. She also referred them to the Young Parents Champion6 within 2 weeks of meeting them. This was good practice, in the absence of information to tell her that there were a number of high risk factors within the family. 7.73 SHV’s Practice Teacher stated when interviewed by the IMR author that in her opinion the Bridgwater Health Visiting team at the time of this incident only received 60% of ante natal booking information and that relationships with the local midwifery teams were not robust with ongoing disagreement about how liaison information including booking information should be shared. A meeting between the midwifery team leader and health visitor team leader had made an agreement on how this would work with information being sent from the Eclipse system. The service commissioner at the learning event considered that this had been addressed. However discussion between the health visiting and midwifery participants made it clear that this was not the case and that confusion continued between practitioners about how this should happen. Clearly there is a learning point here about 6 Somerset Partnership operates an enhanced sustainable care pathway for young parents which the midwifery service can refer into in the ante natal period. This service offers young parents increased levels of contact with a specially trained Young Parent Champion, focusing on a model of enhanced support delivered by the right person at the right time, providing effective signposting to resources and encouraging positive parenting roles Page28 commissioners checking back with front line practitioners to understand how things work on the ground, and not just within written policy guidelines. 7.74 There was also a misunderstanding in the communication between the GP and the SHV which undermined effective safeguarding of Child Y. 7.75 As above, the SHV had received a telephone call from the GP who reported that when he saw Child Y the previous day due to oral thrush and nappy rash he was concerned about the father’s rough handling of Child Y and his inappropriate language to the baby. The GP requested that this family receive a high level of support from the health visiting service. The SHV clearly documented this telephone call in the RiO electronic progress notes but did not clarify with the GP whether he had discussed his concerns regarding the handling of Child Y with the father and whether he had considered making a formal referral to Children’s Social Care given the nature of his concerns. She also did not see the significance of this information as she had no context of parental history to heighten her awareness of risks and therefore did not consider sharing this information with Children’s Social Care herself. She did however share it with HV1 who accompanied her on her visit to the family. 7.76 The issue of the GP contact with the health visitor also requires further consideration. The GP left a telephone message and then did not speak to the SHV until the next day. Delays of this nature are critical for such young babies. It would seem reasonable to expect that a GP would be aware of the high level of vulnerability of babies of this age and should have therefore considered the safeguarding implications and the need for a referral to children’s social care, especially when he was unable to talk to a health visitor on the day that his concerns arose. As a minimum, the subsequent discussion with the student health visitor should have raised referral as a possibility. Instead he appears to have considered the family as being in need of support and that he had discharged his statutory duties by passing his concerns to the health visiting service. This was a missed opportunity to alert social care to the situation. 7.77 Unfortunately this error was compounded when both health visitors made the assumption that the GP must have talked to the father about his concerns as he was so gentle with the baby in front of them. They accepted this at face value and did not check either with the father or with the GP that this matter had been discussed. This was another missed opportunity to safeguard Child Y and further reflects the lack of background information held by them – awareness of which may have made them more robust in following up this issue. 7.78 In this vein of missed and misunderstood communication, the SHV did not consider the possibility of arranging an assessment with a Nurse Practitioner when she met the family in the Minor Injury Unit in spite of the father’s expressed concerns about Child Y’s health, the couple’s relative parenting inexperience and Child Y’s Page29 increased vulnerability and susceptibility to infection due to his young age and immature immune system. Her inexperience meant that she did not think to check the father’s story that they could not get a GP appointment. 7.79 The parents had placed the SHV in an impossible situation by turning up at very short notice in a clinic where she had no facilities. Her lack of experience also meant that she agreed to this arrangement and did not consider how suspicious this behaviour was. The SHV has learned from this experience not to attempt to examine a baby in their pram but rather to refer immediately to a clinician who is better placed to properly examine, diagnose and treat any problems in a baby of this age. 7.80 While it is clear from SHV’s records and in subsequent interviews with her that she had correctly identified the family as “vulnerable” and in need of extra support, she had not translated the vulnerabilities into likely risk for Child Y. Given the very short time scale within which Child Y suffered injuries it is impossible to predict whether her practice would have changed to this focus in due course. 7.81 The SHV description of her first successful visit to the family in September 2013 is also worth noting. The SHV stated that this visit had been cut short because a rental officer had come to the door to offer the couple an opportunity to view a vacant flat which they had been waiting for. She described the father “jumping up and down with happiness” – child-like in his response to this news. This was why she had not been able to complete the Family Needs Assessment. 7.82 This ‘child-like’ behaviour was also described by the mother, who told the reviewer that the father had been “playing with Child Y and throwing Child Y up and down like a doll” when only a week old. This is highly concerning as it indicates a total lack of understanding about the vulnerability of tiny babies and may well have resulted in injury. This information has been shared with the police, and underlines the importance of early safety and handling advice to new parents. 7.83 No-one involved with the couple held all of the relevant information. This would have required multi-agency information sharing such as that required by the Unborn Baby Protocol or indeed by consideration of a Common Assessment, but at no point was it recognised that the couple met the threshold or criteria for either of these. 8. Lessons learned 8.1 As above, there are some very clear lessons learned and unfortunately they are not new and this is unlikely to be the last serious case review in which they are raised. 8.2 The Taunton and Somerset NHS Foundation Trust IMR states that “there was no direct individual failure to fulfil statutory safeguarding duties”. Unfortunately I do Page30 not agree with this conclusion, but I do acknowledge the difficult circumstances in which the GP and the midwives found themselves and the fact that their learning from this case means that those involved will never again make this kind of error. 8.3 The Trust has carried out an audit of practice in midwifery and identified a need to improve in: - • Training and equipping midwives to recognise and act upon potential safeguarding concerns • Training and equipping midwives to recognise and act upon domestic violence and abuse concerns • Providing effective safeguarding supervision for midwives • Communication between midwives and communication between midwives and health visitors. • Monitoring and providing assurance relating to the above. 8.4 Specifically the Trust identified a number of issues with Trust Maternity Guidelines relating to domestic abuse in pregnancy and to teenage pregnancy. This includes the absence of timely review and inconsistencies in advice given. • The Trust Domestic Abuse in Pregnancy guideline is out of date and does not accurately reflect/describe existing documentation (tracer card) used by the community midwives to record if/when the question about domestic abuse7 has been asked. • The Trust Maternity Teenage Pregnancy Guideline is unclear about the age parameters for teenage referral for Obstetric input and conflicts with another document, namely the “Request for Consultant Obstetrician Care/Advice referral form” used to request an appointment with a Consultant Obstetrician (the guidance states age 18 and the referral form states age 16). It also does not adequately define “learning difficulties” and or potential impact and/or action required. This caused confusion and inconsistent practice. • Safeguarding Children training is mandatory for midwives. Reported compliance is very high (96%) and the midwives who provided antenatal care were in date with their attendance at Trust mandatory training. However the content of current safeguarding training for midwives was found to be not in line with current intercollegiate guidance (level 2 rather than 3). • There is not a robust programme of domestic abuse training for midwives in place • Practitioners need a greater awareness of the concept of respectful disbelief in domestic violence situations 8.5 The use of safeguarding supervision within midwifery was also not robust. The Trust has trained Safeguarding Supervisors and has Named Professionals whom midwives can access for safeguarding supervision. In the community setting 7 The IMR and recommendations refer to ‘domestic violence’. I have changed this to ‘domestic violence and abuse’ in keeping with my recommendation at Section 9 of this report. Page31 this was via the safeguarding midwife attending team meetings. However, the IMR has highlighted that if midwives did not attend team meetings or the monthly meeting was re-scheduled they generally did not access clinical supervision unless they were concerned about an unborn baby or young woman. 8.6 The IMR found no process for reviewing entire caseloads to provide a failsafe to ensure that child protection concerns had not been missed (as was the case in this instance). This would reduce the risk of safeguarding concerns not being identified (you cannot highlight what you don’t recognize). In addition the investigation found that the monitoring process for safeguarding supervision was inadequate. 8.7 There is also room for considerable improvement in the communication between midwives and Health Visitors (HV) as there is currently no face to face communication between midwives about their shared caseloads and no process for handover of care. 8.8 Whilst a copy of the front of the Eclipse form was sent to HV at booking, there was no other engagement between the Health Visiting service and either the GP or midwifery service in the ante natal period. However the Somerset Partnership Foundation Trust states that at this time there were agreed processes in place across Somerset whereby booking information and any identified vulnerability factors would be shared with all relevant multi agency professionals including the relevant Health Visiting team by the midwifery team in a timely manner to ensure the pregnant mother was highlighted as a priority for an early intervention and support including ante natal Health Visitor assessment. A formal Midwifery Communication Form had been developed by the Somerset Maternity Services Liaison Committee, (MSLC), approximately two years previously, with agreement by Somerset Partnership NHS Foundation Trust, Taunton and Somerset NHS Foundation Trust and Yeovil District Hospital NHS Foundation Trust that it would be utilised by all health staff involved in ante natal care as the tool of choice for sharing risk and concern information. The form included “teenage parent”, “parental drug misuse” and “parental mental health issues” as concerns to be communicated to other involved professionals including health visitors, GPs and Children’s Social Care. The form should have been used as the mother was a teenage parent. 8.9 However, analysis of the “communication form” system indicates that it does not work well mainly because of two similar forms being in place. One is county wide and one Trust wide. Both contain similar but not identical information. The use of two forms has caused confusion and carries the risk of neither being completed as in this case. The county wide system is designed to promote information sharing (including concerns about potentially vulnerable cases, including teenage mothers) between midwives and health visitors. 8.10 Although there is an acknowledged expectation that health visitors and midwives should meet regularly to discuss caseloads and to highlight vulnerable Page32 families, there are no standards relating to this. The investigation found no evidence of any formal meetings of this nature. 8.11 A recent audit provided to the LSCB and supported by ongoing internal audit does evidence that staff at the Trust do understand the pre-birth protocol. However, the investigation found that it was not implemented in this case as referral triggers were missed. 8.12 Somerset Partnership has a robust Domestic Abuse Policy. Clear communication processes are in place between the Trust and Avon and Somerset Police to share information about domestic abuse incidents where young children and/or pregnant women have been involved in the incident or are linked to it in some way. This information is shared with the Trust Safeguarding Children Nurses who in turn disseminates the information with the relevant health visitor or school nurse and reviews the incidents during planned child protection clinical supervision to ensure the correct actions have been taken that are protective to the children involved. In this case no such information had been received from the Police involving either the father or mother of Child Y as either victim or perpetrator in a domestic abuse incident. 8.13 Somerset Partnership NHS Foundation Trust also has a robust Child Protection system in place. The Trust Safeguarding Children Policy and Procedure is available to all staff on the Trust intranet and is reviewed annually. Regional policies and procedures for safeguarding children are regularly updated and easily accessible, (www.swcpp.org.uk). 8.14 As a qualified nurse SHV is accountable for her practice in her own right; however the supervising health visitor was also accountable for those cases she delegated to SHV and she should have ensured that there were robust arrangements in place to manage feedback of the outcomes of any contacts undertaken independently, relaying any factors of concern. SHV was clear that no such arrangements had been put in place to manage regular caseload feedback, reflection and discussion. This may have enabled her to identify the emerging risks in the case more quickly, although it is acknowledged that a very short period of time elapsed between allocation of the case and Child Y’s injuries. 8.15 The RiO electronic record was introduced to the Somerset Partnership Health Visiting Service in November 2012 although it had previously been successfully utilised for a number of years within Somerset Partnership Mental Health Services. Amongst other actions RiO provides practitioners with the ability to “link” parents and children together; for example a child’s record can contain a link to other family members providing this has been manually entered by the practitioner. This process relies on staff searching RiO to identify if the parents have already been registered onto RiO by other Somerset Partnership health services. Page33 8.16 Initial RiO training for Health Visiting staff was provided in the Autumn of 2012. Staff were taught that in the ante natal period and early post natal period mothers and children were to be registered on RiO but fathers were not registered unless there was a specific health need or they had already been known to another service and this information had been shared with the health visitor. Where a Family Health Needs Assessment did not indicate any unmet health needs in relation to the father it would not be standard practice to either register them on RiO or review RiO to see if an existing Mental Health Services record existed for them. 8.17 At the time of this incident the Health Visiting service were still embedding the basics of the RiO system into everyday practice. Following the initial RiO training there had been confusion amongst some staff groups regarding access to existing mental health services RiO records in cases where such information could usefully inform Family Health Needs Assessments, particularly in regard to parenting capacity. However as staff became more competent with the RiO system and confidentiality issues were reviewed they identified that it was necessary to register all fathers and this remains the current practice within the Trust. 8.18 In this case SHV did not review the fathers’ mental health RiO records, later stating that this had not occurred to her but if it had she would not have accessed them as she would have been concerned about a breach of confidentiality. The father’s history in terms of his older children was recorded on RiO although the record had not been flagged to indicate a child protection issue although the flagging process is well known to RiO users. 8.19 The Somerset Partnership Health Visiting IMR states that the Service was not informed of the mother’s pregnancy by either the GP or midwife, and that the first notification the service received was from Child Health when Child Y was born. However the community midwife service state that they were informed as are all pregnancies with a copy of the front page of the eclipse booking form. This system does not appear to have worked on this occasion and as a result there was no opportunity for an ante natal assessment to be carried out in the ante natal period by the Health Visiting service, missing a chance to identify the father’s previous risk history. Clarification of this system is therefore required to ensure that no children fall ‘through the net’ in terms of early notification to the health visiting service. 8.20 What all of these issues amount to is a lack of pro-active vigilance and understanding in relation to the nature of risk to new born babies, compounded by systems which did not support such vigilance, and human error in believing the best of people. This can be translated as: • The need to publicise the unborn baby protocol on the South West Safeguarding Procedures to all professionals, together with the research that underpins this protocol. It is of note that the number of hits onto this site prior to these events was minimal Page34 • The importance of carefully recording concerns and of checking records at every point of contact with parents where some element of professional judgement is required about the potential vulnerabilities and risks associated with unborn and new babies • The importance of early handling and safety advice for parents of new born babies • That front line staff will be taken in by plausible and likeable characters and will want to believe the best of people, because we recruit caring people to the caring professions and it is difficult for them to be challenging of what people say. This is referred to as the rule of optimism8 and is compounded in services which are not focussed on social risk factors. Midwifery services, for example, are primarily clinically focussed and not geared up for consideration of non-clinical risks in the same way that might be expected in other direct children’s services. However, they play a crucial role, and this needs to be consistently addressed through focussed and reflective clinical safeguarding supervision that keeps these issues at the foreground of practice. The quality of safeguarding supervision and training needs to be continuously audited to ensure that it is fit for purpose to support them in this crucial function. • Failures of communication and sharing of information are compounded by differing and complex record systems within the health community that do not talk to each other • The importance of always following through on concerns expressed by colleagues and not making assumptions without doing so – checking back with the source of such concerns to ensure that they have been properly understood. • The need to ensure that GPs are aware of the thresholds for referral to children’s social care particularly in relation to new born infants, and to ensure that their expressed concerns are clearly understood and followed up • The importance of professionals understanding the complex nature of domestic violence and abuse and the need to ask very specific and wide ranging questions about relationships in order to assist victims to recognise themselves as such. • The need for clear and consistent transfer of cases and information between the midwifery and health visiting services, including the gathering and screening of information to identify potential risks prior to the allocation of health visiting resources to families with new born children. 8 John Eeeklaar, Topsy Murray and Robert Dingwall: The Protection of Children.1983, later referenced by the NSPCC and introduced into social work literature through the 1990s and latterly the Daniel Pelka Serious Case Review Page35 • The importance of identifying the role and impact of fathers on the ability of mothers to safely parent cannot be underestimated. GPs and other professionals need to share information about fathers where background or historical concerns exist, and to be advised when a male becomes known within the health service as a father. • The use of the pre-CAF checklist would have assisted the midwives to identify the range of concerns and may have resulted in a CAF as a minimum, but this was not considered and needs to be better promoted as a tool to aid decision- making and information sharing across services with the permission of parents. Refusal to give permission would add to concerns and may then promote more proactive consideration of potential risks to children. 8.21 The Serious Case Review Panel also agreed that the model used for carrying out this review has been a positive one which has promoted learning for those involved in the case and has also brought a depth of understanding to the context of events which would otherwise have been lacking. The Panel recommends that the approach be adopted for future reviews. 9. Single Agency Recommendations 9.1 The single agency recommendations are taken from the IMRs and are listed below. However I additionally recommend the following: 9.1.2 Taunton and Somerset NHS Foundation Trust should positively consider the use of increased home rather than hospital or clinic visits for new born babies, particularly for teenage and vulnerable parents to assess how they are coping in the home environment and to ensure that safety and handling advice is understood. 9.1.3 Taunton and Somerset NHS Foundation Trust should consider how the CAF and pre-CAF checklist can be used in midwifery services to assist professionals in focussing on the assessment of social needs and risks associated with pregnancy and early parenthood. 9.1.4 Somerset Children’s Social Care should ensure that all staff are aware of the implications of a further pregnancy where the parent has had a baby adopted already and should access the Unborn Baby Protocol or seek advice from the safeguarding manager. 9.1.5 All domestic incidents reported to the police regarding pregnant women should be shared with Children’s Social Care, Midwifery and Health Visiting Services to enable them to be considered as part of a wider holistic assessment. 9.1.6 The discharge process for mothers and babies where there are concerns should consist of a verbal conversation between the midwifery and health Page36 visiting professionals as a minimum standard. Answer phones should not be relied on to disseminate information regarding risk to babies. 9.1.7 Somerset CCG should ensure that all GPs are reminded of the processes for sharing key information about vulnerable women and children, for addressing concerns to parents where it is safe to do so and for making referrals to Children’s Social Care when concerns have been identified. This should include the need for such referrals to be timely given the high level of vulnerability of infants to injury and poor outcomes. 9.2 Avon and Somerset Police i. It is recommended that the protocol regarding unborn babies is re‐circulated to all Public Protection Units (PPU’s) and Safeguarding and Co‐Ordination Units (SCU’s) in order to act as a reminder of the necessity to share incidents of this nature to partner agencies and also to recognise the risk involved. ii. This should also be disseminated to front‐line uniformed officers who are often the first officers at the scene of these types of incidents. 9.3 Taunton and Somerset NHS Foundation Trust i. Team leaders will monitor caseloads to ensure appropriate practice (in place – including retrospective review) ii. All social risk assessments will be checked for completeness prior to discharge (in place) iii. Briefing paper on Domestic Abuse to be circulated to all midwives (completed) iv. Implementation of a system of face to face handover of shared caseloads between midwives (in place) v. Implement and support a programme of Safeguarding training to allow all midwives to achieve level 3 competencies vi. Pending the above, arrange and support attendance at a designated study day(s) for midwives to urgently increase their knowledge and understanding of Domestic Abuse vii. Implement and support a robust system of safeguarding supervision for all midwives viii. Update guideline on “Domestic Abuse in Pregnancy” (to include the adoption of a flowchart highlighting routine questioning about domestic violence, documentation of questioning, patient information, support agencies and referral process if the woman discloses) ix. Revise Pregnant Teenager guideline and related Consultant Referral Pro- forma to have the same criteria for referral/s x. Design and implement a Maternity specific Safeguarding flow chart as appendix to Trust Policy xi. Design and implement a single cross-county electronic communication form Page37 xii. Improve communication and collaborative working between midwifery and Health Visiting teams by regular meetings between the leads of these two services xiii. Introduce a pilot programme of link professionals in midwifery teams run along the same lines as safeguarding link professionals in other clinical areas who provide peer support and supervision. 9.4 Somerset Partnership Foundation Trust i. Somerset Partnership will provide formal feedback to all staff involved in this incident using the Significant Event Audit, (SEA), process to ensure staff will have learnt lessons from the incident with the aim of improving the quality and safety of services provided to vulnerable children and their families. ii. Somerset Partnership will review the capacity of the Bridgwater Health Visiting team in terms of staffing levels and ensure there is parity of workload across the Health Visiting service. iii. Somerset Partnership must work with its multi-agency partners to ensure current midwifery / Health Visiting liaison processes are reviewed and improved to ensure Health Visitors are informed of all pregnant women within appropriate time scales to allow timely and comprehensive ante natal assessments to be completed by Health Visitors iv. Somerset Partnership will review the following elements of the student Health Visitor training experience to ensure current guidance is relevant and robust. This will include review of: • assessment of competence to practice processes • handover processes between taught and consolidated practice • access to regular and ad hoc clinical supervision provided by Practice Teachers • access to child protection clinical supervision provided by the Trust Safeguarding Children Team • allocation of relevant cases • the role and responsibilities of the Practice Mentor v. Somerset Partnership will ensure that student Health Visitors are clear about their roles, responsibilities and limitations whilst undergoing the Health Visitor training programme within Somerset Partnership, particularly in relation to child protection and safeguarding casework vi. Somerset Partnership will ensure that Health Visitor staff are updated on the correct use of the Family Health Needs Assessment process and the requirement to thoroughly assess parenting capacity and analyse the results in terms of likely risk to any children vii. Somerset Partnership will ensure that local Health Visitor processes are reviewed and updated in relation to the assessment and management of risk, particularly those risks related to teenage parents Page38 viii. Somerset Partnership will ensure that all the themes from this review are disseminated to relevant staff groups to ensure lessons are learned. 9.5 Children’s Social Care i. CSC pre-birth guidance should be updated to more explicitly highlight key risk factors associated with harm to babies. ii. CSC guidance should consider amending it’s pre-birth guidance to ensure that a Child and Family assessment is carried out on mandatory basis for all young parents who have spent time being looked after by the local authority, or have had children removed from their care previously. 9.6 Somerset Clinical Commissioning Group i. Commend the team at Surgery1 for their flexible and inclusive approach to providing appointments for Child Y, and for the thorough examination and swift action taken ii. Circulate the pre-birth protocol to all GPs, and incorporate this into GP Safeguarding Children education, with reminders to ‘see the child behind the adult’ as well as ‘the adult behind the child’, and to practice ‘professional curiosity’, including the importance of taking a social history when seeing pregnant women iii. Emphasise the importance of reviewing the mental state and the compliance with medication for parents with mental health problems when they attend the surgery iv. Review the management of domestic abuse presenting to Accident & Emergency departments v. Ensure General Practices have clear policies on filing discharge summaries that include reference to domestic violence vi. Review communication between Midwifery teams and GPs, ensuring that there is a clear process for information to be routinely shared in both directions vii. Ask Somerset GP Educational Trust to provide a mental health study day for GPs, to include review and follow up of patients with mental health problems, and how to consider patients in their social and family setting 10. Recommendations for Somerset Safeguarding Children Board 1. The LSCB should promote and audit the use of the Unborn Baby Protocol and the accessibility of the on-line child protection procedures generally. 2. The LSCB should consider the development of multi-agency core safeguarding supervision quality standards and practice which can be audited on a regular basis. 3. The LSCB should consider the further promotion of domestic abuse training and in particular a focus on ‘asking the difficult questions’ to increase practitioner awareness and confidence in approaching potential victims about Page39 this issue. The vulnerability of pregnant women and infants should be emphasised. 4. The LSCB should ensure the dissemination of learning from this review within its’ learning and improvement framework: a. Locally via the Chief Executive Officers of member agencies, and the Safeguarding Adults Board, and b. Nationally, by sending a copy of this report to the Nursing and Midwifery Council and the Local Supervising Authority for NHS England to raise the profile of safeguarding in midwifery practice, and of domestic violence and abuse specifically. 5. The LSCB should require all partners to confirm that they are promoting the importance of the role and impact of fathers in their children’s lives and that information about fathers is sought and shared to inform all work with families. 6. The LSCB should promote the use of the pre-CAF checklist and the CAF process for young parents. 7. The Chair of the LSCB should write to government to request that language in relation to domestic violence and abuse is common across all departments and in all publications and web-sites. Ruby Parry Ruby Parry Director of Consultancy Reconstruct Ltd. 5th August 2014 www.reconstruct.co.uk |
NC52479 | Thematic review of five cases involving non-accidental injury to infants under 1-year-old. Themes include: local effectiveness of system wide, universal and early intervention programmes; the scope of midwifery involvement and relationships with parents; commissioning and contracting midwifery services with clinical commissioning groups; quality assurance mechanisms, practice audits and service quality with parents and babies under one-year-old; the effectiveness of intra-agency working, transitions, handovers and information sharing; professional recognition of the inherent vulnerability of babies under one-year-old; professional recognition, triggers and intervention thresholds and the nature of response to vulnerable families; pre-birth assessments and thresholds for Continuum of Need; the importance of adopting a Whole Family approach; and how well the role of fathers and the importance of engagement is recognised by professionals. Learning includes: the early months of infant life can be a period of potential maximum risk to the infant; ensure there is a secure, universal first line of defence, for example an ante- and post-natal safety planning programme such as ICON (an early intervention programme designed to prevent abusive head trauma, which addresses caregiver frustration with crying infants); additional first lines of defence involving universal services such as midwifery, general practitioners, and health visiting could complement and reinforce early intervention programmes; fathers and male care givers can be marginalised by some agencies, they should be routinely included in service interventions, notwithstanding considerations of any safety issues around domestic abuse, coercion and control.
| Title: Thematic review: the non-accidental injuries to babies under one year old. LSCB: Cheshire West and Chester Safeguarding Children Partnership Author: Paul Sharkey Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Cheshire West and Chester Safeguarding Children Partnership Final Report Thematic Review: The Non-Accidental Injuries to Babies Under One Year Old Independent Author and Reviewer: Paul Sharkey (MPA) October 2021 1 Contents Page Introduction and Purpose of Review 2 The Five Infants 2 Overarching Review Questions, Key Themes and Scope 3 Panel Composition 4 Context and Literature Review: Non-Accidental Injuries to Infants 5 Abuse Head Trauma 5 Themes; Analysis, Findings and Recommendations 8 Early Intervention Programmes: ICON 8 Non-ICON Services 12 Midwifery Services 15 Midwifery Services: Commissioning and Contracting 19 Vulnerable Families and Safeguarding Pathways 20 Pre-Birth Assessments 21 Engagement of Fathers and Male Care Givers 22 Professional Disagreement: Challenge and Escalation 23 Summary and Conclusions 23 Key Lessons for Policy and Practice: Locally and Nationally 24 Glossary of Terms 25 References 25 Appendix 1 (Methodology) 26 2 Cheshire West and Chester Safeguarding Children Partnership Thematic Review of Non-Accidental Injury to Babies Under One Year Old1 1. Introduction and Purpose of the Review 1.1 This thematic review was commissioned by the Cheshire West and Chester Safeguarding Chil-dren Partnership (herein referred to as the Partnership) on the 27 September 2019. It followed inci-dents earlier in the year of non-accidental injury (NAI), whilst in parental care, to five babies under one year old; two of whom were subject to rapid reviews. 1.2 Given the cluster of NAI episodes, the Partnership came to the view that greater learning could be gained by undertaking a thematic review, rather than separate child safeguarding practice re-views. Its purpose was to, ‘Identify any improvements required to policy and practice, so as to maximise the safeguarding of babies under one year old; by undertaking a systemic analysis of emerging themes coming from several instances of recent non-accidental injury and serious harm to infants in Cheshire West and Chester’. 1.3 An independent reviewer was commissioned in January 2020 to undertake the review and a panel was duly convened by the Partnership Business Manager. There was an intention to have completed the review by July 2020; within the six months set down by Government Guidance in ‘Working Together 2018’. Unfortunately, this was not possible due to the advent of coronavirus 19 in early 2020 and the resultant Governmental public health measures in March, restricting contact, in addition to the increased pressures on professionals’ time. 1.4 The Panel met in late February 2020 with the lead reviewer to scope the review and develop some terms of reference, key lines of enquiry and significant themes. These were agreed at its May 2020 meeting. 2. The Five Infants 2.1 It was not the intention of this review to conduct detailed analysis of individual infants, but the panel felt it was necessary to understand sufficient about each of their lived experiences to be able to identify key themes that warranted further exploration within the review. Two of the infants were the subjects of Rapid Reviews and therefore Panel considered both reports which were based on a range of multi-agency information and identified local learning. For the other three infants, Panel utilised information contained in Children’s Social Care Records and the Children and Families As-sessments which were completed in response to the injuries they sustained. This has enabled the panel to draw on multi-agency information shared with Children’s Social Care. 2 2.2 The infants in this review were all born healthy, and none were considered premature. One infant is known to have suffered with reflux, there were no other health conditions noted prior to injuries. The infants ranged in age from 3 weeks to 12 weeks old at the time they sustained their injuries. All five infants were male and White British. Only one of the infants lived with a sibling, the others were first born to their parents. Two of the five infants were planned pregnancies, although it is noted that 1 Herein, referred to as ‘Infants’. 2 NB. The families of the infants have not been involved in this review, most notably because the Police investigations in respect of the two infants subject to the rapid reviews are ongoing. 3 the parents of the other three infants all described feeling happy and excited at the prospect of becoming parents. 2.3 The injuries sustained by the infants varied in nature and severity and as a result, so too did the long-term impact of their injuries. Two infants suffered injuries consistent with Abusive Head Trauma (AHT), with resultant brain injury and significant ongoing health needs. One infant suffered a frac-tured skull as a result of falling from a table the parent had placed the baby on. This infant had been included in the review as the initial accounts from parents were not consistent with the nature of the injuries. It was subsequently accepted that the injuries were unintentional but reflective of a serious lapse in judgement. One infant had evidence of bruising to the face and two fractured ribs. 2.4 Four of the infants lived with both biological parents at the time their injuries were sustained; one infant lived with mother in supported accommodation. Two sets of parents were also noted to live with the infant’s grandparents (although it is recorded that neither grandparents were at home when the incidents occurred). The review heard that three of the infants were believed to have been injured by their fathers. This is based on self-report or police charges which at the time of writing (September 2021) are awaiting trial. One of the infants could have been injured by either parent and one of the mother’s was charged with neglect; again the matter is yet to be tested in court. 2.5 One or both parents for three of the infants had a history of offending and it was deemed relevant to note that these included acts of violence or public disorder perhaps indicative of poor anger man-agement. It is also notable that only one of the infants was open to Children’s Social Care at the time the injuries were sustained; the other four had not been known or previously referred in respect of safeguarding concerns. However, this was contested in one of the rapid reviews as the hospital stated that they had contacted Children’s Social Care and were told the concerns did not meet the threshold. However, Children’s Social Care has no record of this contact. As such, four of the infants had no pre-birth assessment completed prior to their arrival. 2.6 What is apparent is that for three of the infants, at least one parent, and in one instance both parents, had been known to Children’s Social Care when they were children. Two parents of different infants had themselves been children in care. Even for those parents with no prior involvement with services, information available to the panel indicated that for four infants, one or both parents had experiences of Adverse Childhood Experiences (ACEs) as they grew up. This included death of their parents, witnessing domestic abuse between their parents and being victim of sexual abuse and neglect. 2.7 The review explored the presence of the complex trio (parental substance misuse, domestic abuse, mental health) and noted that there was evidence of domestic abuse in only one couple’s relationship. Parental substance misuse was a factor for two infants and parental mental health fea-tured for three of the infants; for one baby this was a factor for both parents. The review also explored the prevalence of parental learning difficulties and noted two infants had a parent that had learning difficulties, one of whom had attended a special school as a child. 2.8 The review heard that since commissioning this thematic review two more infants had suffered non-accidental injury. The review had progressed too far for the children to be included but learning from the respective rapid reviews was used to shape the questions asked of practitioners for this review and forms part of the wider learning identified through this review. 3. Overarching Review Questions 3.1 Having considered the five infants’ individual circumstances the panel set out to explore the following overarching questions and identified a number of key themes (as set out in 3.5 below). 3.2 What arrangements are there to safeguard the babies from harm and promote their welfare? 4 3.3 What support is available to babies under one and their parents/carers and what does it look like? 3.4 How effective is the current service offer to babies under one and their families, including those deemed vulnerable? Key Themes 3.5 (i) Local effectiveness of system wide/universal/early intervention programmes. (ii) The scope of midwifery involvement and relationships with parents. (iii) Commissioning and contracting midwifery services with Clinical Commissioning Groups. (iv) Quality assurance mechanisms; practice audits and service quality with parents and babies un-der one year old. (v) The effectiveness of inter-agency working; transitions, handovers and information sharing. (vi) The professional recognition of the inherent vulnerability of babies under one year old. (vii) The professional recognition, triggers and intervention thresholds and the nature of response to Vulnerable families. (viii) Vulnerable Families and Safeguarding Pathways; HCP, NICE and Working Together 2018 Guidance. Are they present locally and how is ‘vulnerable’ defined and understood? (ix) Pre-birth assessments and thresholds and Continuum of Need. (x) The importance of adopting a, ‘Whole Family’, approach. (xi) How well is the role of fathers and the importance of engagement recognised by professionals? (xii) The role of Public Health messages (I-CON, Don’t Shake the Baby, Safe Sleeping) (xiii) Challenging assessments and decisions of I-ART3 as expert. Scope 3.6 The review focused on infant NAI and excluded sudden unexpected death in infancy (SUDI) 4, albeit there are overlapping themes. In this respect, the Child Safeguarding Practice Review Panel (henceforth referred to as the, SUDI report; July 2020) report contains a wealth of insights and learn-ing relevant to this review. 4. Panel Composition Senior Manager, Safeguarding and Quality Assurance Unit-Cheshire West and Chester Police Reviewing Officer, Cheshire Police Designated Nurse for Safeguarding Children, Cheshire Clinical Commissioning Groups Senior Manager, Cheshire West and Chester Children’s Social Care Senior Manager, Early Help and Prevention Cheshire West and Chester Designated Doctor for Safeguarding and Child Deaths Service Manager, Safeguarding Children in Education Business Manager, Cheshire West and Chester Safeguarding Children Partnership Business Co-Ordinator, Cheshire West and Chester Safeguarding Children Partnership Independent Lead Reviewer/Chair: Paul Sharkey5 3 Integrated Access and Referral Team 4 See the Child Safeguarding Practice Review Panel; July 2020; Final Report; ‘Out of Routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk off significant harm’ 5 Mr. Sharkey had no prior involvement with the CWAC SCP or any of the constituent partner agencies. 5 5. Context and Literature Review: Non-Accidental Injuries to Infants 5.1 Non-accidental injury (NAI) is defined as ‘any abuse inflicted on a person or knowingly not pre-vented by a care giver (where) the injury is not consistent with the account of its occurrence’ (Rizwan.M et al, 2017). NAI is a significant cause of injury to children under 2 years old (Davies, C. et al: 2018); with 76.3% of severely injured children suffering trauma because of suspected child abuse occurring in infants under the age of one. Brandon et al (2016) found that ‘infancy remains the period of highest risk for serious and fatal child maltreatment; there is a particular risk of fatality for both boys and girls during infancy ’(p.40). 5.2 Common forms of infant NAI typically include head injuries (abusive head trauma/AHT) through shaking, skeletal fractures (especially to ribs, vertebrate and limbs), thermal injuries (burns, scalds and acid), ingestions and poisoning (bleach, methadone, drugs and salt), soft tissue injuries (bruises, bites and lacerations) especially to non-independently mobile infants, asphyxiations and cardiac ar-rest. 5.3 Two of the five infants (both of whom were subject to rapid reviews) suffered abusive head trauma (AHT) at four and five weeks respectively. 6 AHT: Definition and Incidence 5.4 Turning firstly to abusive head trauma (AHT) or shaken baby syndrome (SBS). This is a severe form of child maltreatment that can often have serious or even fatal consequences for infants and is the number one cause of death (Taylor et al/Birmingham Children’s Hospital). It is defined as, ‘an injury to the skull or intracranial contents of a baby or child younger than five years due to intentional abrupt impact and/or violent shaking incidence of infant’ (Lopes et al: 2013). AHT incidence in the UK is up to 25/100,000 live births per year (Jones, 2020) rising to 36/100,000 in babies under six months (Smith: 2016). Smith (2016), states that AHT affects one in 4000-5000 infants per annum and that, in practice, an average size district general hospital in the UK can expect to see a case every one or two years. 5.5 Given the above incidence and frequency it was of some concern that the two infants mentioned above suffered AHT in close proximity and presentation; thankfully (so far as is known) with no iden-tified long-term effects. Consequences of AHT 5.6 Typically, AHT can result in bleeds in the brain and behind the eyes (subdural hematoma, retinal hemorrhage), fluid build-up around the brain causing intra-cranial pressure (brain edema), and sometimes fractures of the long bones or ribs, with little or no evidence of trauma (Barr:2018). Lopes et al (2018) cite a (US) figure of 25% -30% of children who die from AHT and only 15% who survive without any significant consequences. Immediate effects include respiratory arrest or impairment, irritability, seizures, stiff posture, decreased levels of consciousness, vomiting, decreased appetite, an inability to suck or swallow, cardiac arrest, or death. Long term outcomes can include, learning difficulties, vision problems (including blindness), hearing and physical disabilities, cerebral palsy, speech problems, seizures, cognitive impairment, and death. 5.7 Although AHT can occur in older children and even in adults, around 80% of cases occur before the age of one year (Barr: 2018) with a peak incidence at around three months. Victims are predom-inately male (Child Abuse Review; May-June 2020) 7. One in fourteen cases is fatal before hospital discharge and half of severely injured survivors will die before the age of 21 (Smith: 2016). Lopes et al (2018) suggest that infants have an increased susceptibility to serious injury at between two to four months because compared to older children, babies are more often alone with their care givers, need constant care and cannot provide reports on their history. The increased susceptibility to AHT 6 See section 2 above 7 All of the five infants in the current cohort were male. 6 is due to the infant head being relatively bigger and the brain relatively heavier for their body. Also, neck muscles are not yet fully developed and strengthened, since the ability to sustain the head upright develops around 2-4 months of life. Risk Factors 5.8 Smith (2016) references two studies suggesting that males represent 70% of perpetrators and that fathers and male surrogates are nearly five times as likely as mothers to shake an infant.8 Other risk factors include, lone parent families, families from low socio-economic backgrounds, societal and family stress ( domestic abuse, parental mental health and substance misuse), multiple births, developmental delay and a childhood history of abuse/adverse childhood experiences (ACE) with the perpetrator ( Barr:2012, Lopes: 2013). Additionally, characteristics with the infant, such as being male, under one year old, prematurity and low birth weight appear to increase the probability of AHT. Race and ethnicity are not thought to be risk factors (Barr:2012). 5.9 Lopes et al (2018) cites a three-component model by Stephens et al (2012) as a means of un-derstanding the causes of AHT, namely, factors related to the infant, situational-pre-disposing- fac-tors and those appertaining to the caregiver; all of which interact and result in injury to the baby. Child development characteristics relating to the infant can include crying patterns and separation anxiety. Situational factors would include stressful situations related to social and familial isolation and lack of support, drug and alcohol misuse, domestic abuse, parental mental health, poverty and housing issues and difficulties in pregnancy. Care-giver factors may include lack of knowledge and inexperience concerning the baby’s normal pattern of crying, the inherent risks to the infant of shak-ing, frustration tolerance, lack of experience as a care giver to other children, psychopathological factors, and jealousy of the relationship between the baby and other care givers. 5.10 Within the interplay of the three-component model, the professional consensus (Child Abuse Review: 2020) suggests that the baby’s crying pattern appears to be the main trigger factor for the occurrence of AHT. Shaking by the care giver is used as a means of either calming the infant or disciplining. Several of the above risk factors were present in the circumstances around the AHT injuries to the two infants subject to the rapid reviews. 5.11 Of significant concern regarding shaking (in addition to the aforementioned serious damage to the infant) is the effect on both the perpetrator and the baby, compared to other forms of infant abuse. Barr points out that slapping a baby will usually result in the perpetrator experiencing a stinging sensation with a likely increase in the infant’s crying, thus signaling to the care giver that they have acted in an inappropriate manner, having lost control. Shaking is less likely to result in any pain sensation to the perpetrator, whilst often leading to the baby stopping crying due to the concussion like brain injury. The shaking dynamic reinforces a positive feedback cycle which rewards the care giver by improved infant behaviour (stopping crying) and no negative consequences to the care giver. 5.12 Barr suggests that this dynamic may promote repeated shaking over time thus seriously com-pounding the harm done to the infant. He cites evidence of 55% repeated shaking and a range from 2 to 30 times (with a mean of 10 times). Daily shaking occurred for several weeks in 20% of cases and was repeated because it stopped crying in all cases. A further consequence of AHT relates to the discrepancy between the incidence of clinically recognised and unrecognised cases, given that shaking may not always result in obvious signs of injury and damage to the baby. Less severe cases may not come to medical professionals’ attention and thus not diagnosed, leading to under recogni-tion of the maltreatment and an unknown number of infants developing milder forms of motor dys-function, sensory compromise, or cognitive loss (Barr: 2012). 8 See the very important and recently published ‘Safeguarding children under 1 year old from non-accidental injury; National review into babies seriously harmed or killed by their father male carer’, Child Safeguarding Practice Review Panel, 16.09.21. Also note 30 below. 7 5.13 Barr cites prior shaking in 30%-70% of cases at the time of AHT diagnosis, thus suggesting that significant abuse had happened without coming to medical attention. Even on first presentation 31% of cases were missed with 28% of the missed cases being repeat injuries following the original missed diagnosis. Barr concludes that, ‘Coupled with the high incidence of repeated shaking as a common care giver strategy, such observations reinforce the importance of primary and universal prevention strategies. Infants’ Crying Pattern 5.14 It is well established that crying acts as a key communicating function in securing an infant’s survival, health and development with its caregiver. Studies (Lopes, 2018) suggest an infant crying pattern marked by an increase in the daily duration of crying in the first weeks of an infant’s life, reaching a peak at around the sixth week. Thereafter, there is a marked decrease in daily crying, with a corresponding decrease of inconsolable crying after the fourth month; the crying becoming more intentional and related to environmental events. 5.15 AHT is often likely to happen during the peak period of an infant’s crying at between 1-4 months. The crying appears to be inconsolable to the caregiver who feels that there is something ‘wrong’ with the infant (colic, being ‘naughty’), leading to overwhelming feelings of powerlessness, lack of control and frustration which then trips over into shaking and the quieting of the baby. The reinforcing effect for the care giver then results in repeated and multiple shaking episodes with devastating conse-quences for the baby. Additional studies established a direct relationship between peak infant crying and the incidence of AHT (Barr; 2012), thus demonstrating empirical evidence for infant crying as a precipitation factor in this form of infant maltreatment. 5.16 Most importantly, current professional thinking has re-interpreted inconsolable infant crying as a typical behavioural development in normal infants and not usually a sign of anything wrong or abnormal with the baby. AHT, within this perspective can be seen as the, ‘consequence of failure in an otherwise common, iterative and developmentally normal infant-care giver interaction’. (Barr:2012:) Given this fundamental reframe of infant crying it can be seen that AHT is preventable. Prevention of AHT 5.17 Following on from Barr’s conclusion in paragraph 6.13 regarding the importance of primary and secondary prevention strategies to counter the incidence of AHT, the professional literature (Rebbe et al: 2020; Smith:2016) suggests that Public Health can provide a useful framework for child mal-treatment prevention. The framework entails a four-stage approach starting with (1) surveillance to define the problem in the population, followed by (2) the identification of risk and protective factors in order to (3) develop and test protective strategies, which can be (4) adopted widely. Barr contends that, ‘prevention strategies need to be primary (delivered before occurrence) and universal (delivered to all parents of newborns and not targeted at just some parents)’ (Barr: 2012: 17298). 5.18 Essentially, there is a key window of opportunity for the prevention of AHT via a Public Health preventative strategy, broadly in line with the Prevent and Protect model (SUDI report; July 2020). This would aim to change the knowledge and behaviour of care givers, and society in general, re-garding the normal development of infants and the significance of early increased infant crying. Such a strategy needs to focus on two key issues, namely (1) teaching parents how to respond to infant crying and the attendant dangers of shaking babies - on a universal preventative basis; and (2) addressing social and professional factors related to AHT awareness and risk factor mitigation- when additional needs are identified and safeguarding is required (corresponding to CWAC Universal Plus, Partnership Plus and Statutory Social Work on the CoN) 5.19 Until recently, there was no instance of a fully co-ordinated multi-agency programme aimed at preventing AHT, albeit the NSPCC had launched a resource pack for professionals in 2016 (Protect-ing Babies and Toddlers). Smith (2016), following a study tour of the US and Canada in 2016 where 8 she studied several public health AHT preventative initiatives; subsequently developed the ICON9 programme. This has since been adopted in Hampshire, Gloucestershire, Lancashire and im-portantly to this review, Pan-Cheshire, including Cheshire West and Chester. 6. Themes: Analysis and Findings 6.1 The Effectiveness of Local System Wide, Universal, Early Intervention Programmes The ICON Programme 6.1.1 This section will focus on the CWAC ICON programme as a public health approach to the prevention of AHT as a type of infant NAI, notwithstanding the other forms of injury mentioned above in paragraph 6.2; the prevention of which will be looked at in a later section. 6.1.2 The ICON programme is based upon four core principles, namely that infant crying is normal and peaks in intensity at between 4 to 8 weeks, the recognition of care giver feelings of frustration and powerlessness, simple coping and control strategies and most importantly, to never shake the baby. The programme (Smith; August 2020) works by delivering the four key messages of the ICON acronym to all parents/caregivers, at a, ‘reachable moment’, (see SUDI report; July 2020) for mid-wives, health visitors, GPs and other professionals within mainstream services, to engage par-ents/caregivers through a set of five, ‘Touch Points’. 6.1 3 The first is prior to hospital discharge when both parents/caregivers are taken through the four key messages through a variety of mediums including, verbal script/information, leaflets/printed ma-terial, social media and video.10 A key consideration is the need to include fathers and male care givers in the programme given the raised likelihood of AHT perpetrators being male. A second touch point ‘reminder’ of the four messages is delivered by the community midwife within the first 10 day visiting period. A third message comes through the health visitor at an early stage (fourteen days) in their involvement when enquiries can be made about parental coping strategies with the infant’s crying, especially reinforcing the no shaking imperative. A fourth touch point reminder comes a few weeks later followed by the fifth at the 6–8-week GP development check. Smith (August; 2020) is currently developing two additional touch points incorporating interventions at High Schools and by ante-natal maternity services. Effectiveness: Does Prevention Work? 6.1.4 There is evidence from North American programmes that, ‘A co-ordinated, hospital-based par-ent education programme targeting parents of all newborn infants can significantly reduce the inci-dence of AHT in children less than 36 months’ (Smith: Training for Trainers)11. Bechtel et al (2020) 12 evaluated the Take 5 Safety Plan for Crying given to care givers of newborns at Yale New Haven Hospital (Connecticut; USA). They found that the infants whose care givers had received the pro-gramme were 79% less likely to have suffered AHT. Bechtel et al concluded that Take 5 had the potential to prevent AHT in infants 13, albeit that further study, using a randomised controlled meth-odology was needed to confirm whether exposure to the Take 5 programme reduced the occurrence of AHT in the first year of life. 9 ICON stands for I-infant crying is normal; C-comforting methods can help; O-its ok to walk away; N-never, ever shake a baby. 10 Additional infant safety messages such as those around safe sleeping can also be included. 11 Cited from Dias et al (2005) Preventing Abusive Head Trauma Infants and Children; a hospital-based prevention program; Paediatrics; 115: 470-477; Altman et al (2010); Parent Education by Maternity Nurses and Prevention of AHT. 12 See Child Abuse Review, Vol 29: 282-290 (2020). 13 But see ‘ Limitations’Child Abuse Review Vol 29: p 288. 9 6.1.5 In the UK the Hampshire ICON programme was evaluated after one year of operation (Jones; 2020). The programme was initiated in September 2018 with a public launch in January 2019 that included a social media campaign and public information sharing events that reached a range of multi-agency professionals, parents, carers and grandparents. It was too early to have determined whether the programme had resulted in decreased incidence of AHT given that it had only been in operation for a year. Other key performance indicators were measured. These included 100% of 25 care givers remembering the key message, not to shake the baby, 19 out of 25 (76%) who reported changing their behaviour in relation to their baby crying after receiving the ICON information. Re-garding embedding the ICON messages, 95% of GP practices (on an 86% survey return) in Hamp-shire reported having discussed crying at the six-week review compared to only 10% in 2018 at the time of the pilot, with 84% of GPs reporting full awareness of the ICON programme one year on. 6.1.6 Arguably, these are positive, albeit early and partial indications for the potential of good out-comes, namely a decrease in infant AHT. It will be interesting to see what progress has been made in say 3-5 years-time. In any event, the progress made by the Hampshire project would seem to offer a wealth of useful learning for other areas in the early stages of ICON implementation, including CWAC safeguarding partnership. Cheshire West and Chester (CWAC) Safeguarding Children Partnership (SCP) Development of ICON 6.1.7 The CWAC SCP, following initial development of the ICON scheme by a Pan Cheshire group14 in the second half of 2019, produced and circulated an ICON leaflet (based upon the Hampshire leaflet) in September 2019, which was further promoted in 2020, during the covid19 pandemic. Am-bassador training ( agency representatives trained in the ICON programme-using the ICON slides and material from Hampshire- and expected to cascade their knowledge within their organisation) took place in November/December 2019 and led to 63 professionals ( acute and community staff, 0-19 NHS staff ( midwives, Family Nurse Partnership, health visiting teams, neonatal intensive care ( NICU) staff, paediatric nurses, emergency department staff, children’s services ( social workers, family support workers and early years), the HMP mother and baby staff, police and probation, re-ceiving training. 6.1.8 In July 2020, the steering group was informed that training had been implemented within all agencies, including early help in Cheshire West, all of the health visiting and Family Nurse Partner-ship teams, the Acute Hospital Trusts midwifery services, paediatric, neonatal and accident and emergency staff groups. Training was also delivered between July and September 2020 to the per-inatal mental health team and CAMHs, GPs and practice nurses. Several briefing sessions were delivered to 28 local authority family intervention workers from Early Help and Prevention. The local authority designated district manager attended the steering group in addition to the district practice lead for casework also having responsibility regarding Early Help and intervention involvement in the ICON programme. 6.1.9 Regarding Starting Well, the agency consultant nurse took the strategic lead on implementing ICON across the service. Train the trainer sessions for staff took place in the autumn of 2019 when the ICON message was cascaded across the service. Each district has trainers in the ICON message and new starters to the service receive ICON training. Health visiting staff are trained in NBO (New-born Behavioural Observations) assessment which supports the development of positive parent/in-fant relationships and also provide further opportunities to discuss infant communication so that par-ent can intervene early in the event of their baby showing early signs of distress. Starting Well is currently undertaking an audit of parents to assess whether the ICON messages have been,’ heard’. 6.1.10 None of the parents/care givers of the two infants identified as having suffered from AHT/mal-treatment in the summer of 2019 had the benefit of exposure to the ICON programme which started later in the year. 14 Composed of representation from health, midwifery, 0-19, Children’s Social Care, early help, named GP and the training manager 10 6.1.11 During the lockdown period of 2020, the SCP promoted ICON information via its website, social media and the newsletters, that included a website parent’s page. The CWAC SCP ICON project was officially launched on the 22 October 2020 with the participation of Dr. Suzanne Smith. This included the importance of including fathers and male care givers. Warrington Hospitals (War-rington and Halton) presently host the Pan Cheshire ICON which appears to be a very comprehen-sive and useful resource. Recent Developments 6.1.12 An initial evaluation of the Cheshire West and Chester ICON programme15 is well underway and due for completion later this year. A report with findings is scheduled to be presented to the SCP executive for its scrutiny in due course. Mention was made by the panel that the local ICON pro-gramme had been in operation for a relatively short period of time and that numbers were small. It was suggested that there should be further evaluations over the medium to long term to provide evidence of what differences if any, the programme was making to reducing the incidence of infant AHT. 6.1.13 Further issues for the steering group include use of the, ‘Dad Pad’, (An app guide for young fathers developed with the NHS) to reinforce previous video messages, the identification and target-ing of those agencies (including the voluntary sector) where staff have not attended training sessions and considering including Safe Sleep and Safe Handling messages along with the ICON pro-gramme. 6.1.14 The electronic medicine information system (EMIS) in Cheshire West has been updated to enable the ICON message to be coded and reported on in regard to delivery, thus keeping a track on when (and by whom) messages have been given. The recently revised personal child health record (PCHR) has a comprehensive section on ICON. These are now in circulation and support clinicians in highlighting the key messages in addition to providing a quick and easy reference point for parents during the current Covid-19 pandemic. 6.1.15 Evidence from the practitioners’ learning event suggested that ICON is well embedded and understood by health and early help practitioners (health visitors, midwifery, family nurse partnership and family intervention workers) albeit there would seem to be a, ‘mixed picture’, with GP practices. This finding would suggest the need for systemic dissemination of the ICON concept across the local GP practice network, given the key role that GPs play within the universal offer. There was some evidence that parents may not have necessarily recognised the term,’ ICON’, but that many under-stood the key principles when GPs discussed these with them. 6.1.16 There were reported gaps in Police knowledge requiring more awareness raising. 6.1.17 There was a suggestion that it was important to identify the optimum time to share the ICON messages with both parents (and male carers), usually at around 25 weeks into the pregnancy. Post-natal messages could be repeated and reinforced by the health visitor. The use of user-friendly online information written in plain English (but also other appropriate languages) was highlighted. It was noted that there would be value in re-instating post-natal support groups and the involvement of peers, covid 19 permitting and when safe to do so. 6.1.18 Key ICON messages could be promoted in libraries, mother and tots groups and across other appropriate community networks, especially the normalisation of the ‘crying curve’. 15 It is understood that two acute trusts located in neighbouring Cheshire localities were also in-volved in the ICON programme. 11 6.1.19 Notwithstanding the above evidence of progress with the CWAC ICON programme, this re-view would suggest that consideration be given to some of the findings (see paragraphs 5.8 to 5.12) from the SUDI report; July 2020. Albeit in relation to promoting preventative messages to parents about safe sleeping this review would argue that there are parallels with dissemination of the key ICON messages. So, for example, ’better use could be made of social media to provide information….in relation to safer sleep-ing………(and) that information for parents needed to be more direct and hard-hitting in explaining the consequences of an unsafe sleep environment. Research evidence suggests that parents are more likely to respond to safer sleep advice where they understand that there is a clear link between advice and risk’ (SUDI report; July 2020, paragraphs 5.8/5.9) 6.1.20 A further very interesting finding suggested that, ‘Some of the most promising interventions involve the use of peer educators, such as parents from within vulnerable communities or young people’. (SUDI report; July 2020, paragraph 5.30) Findings 6.1.21 Universal and early intervention safety planning programmes for caregiver frustration with infant crying, such as the ICON initiative, are, potentially, a key element in the prevention of non-accidental injury to infants; and may help reduce the likelihood of AHT. 6.1.22 The evidence provided to this review would suggest that the Cheshire West and Chester ICON programme is well advanced, (notwithstanding the constraints of the current covid 19 regula-tions), underpinned by extensive training and dissemination of the key messages to a wide range of professionals and agencies. It would seem that the infrastructure is in place to deliver a coordinated, preventive, universal, multi-agency, whole systems programme to disseminate and track-via EMIS- the key ICON messages to parents and caregivers at the five touch points. 6.1.23 Systemic dissemination of the ICON concept needs to happen across the local GP practice network given the key role that GPs play within the Universal offer. 6.1.24 There were reported gaps in Police knowledge, particularly in relation to knowledge about ICON, indicating more awareness raising is required. 6.1. 25 Consideration should be given to the appropriate use of social media and a more hard-hitting style in delivery to parents that makes the link between the ICON messages and consequential risk to infants. The potential and sensitive use of peer educators could be explored 6.1.26 Self-evidently, in order for there to be an effective dissemination of the ICON messages there needs to be an integrated, joined up approach with the relevant agencies and professionals involved in the Universal/Preventative offer; but importantly, also within the Universal Plus and Partnership Plus elements of the CWAC SCP Continuum of Need and between them. A strategic whole system joined up approach would not only facilitate an effective implementation of the ICON programme but could also meet the needs of vulnerable infants and their families at Universal Plus and Partnership Plus, thus resulting in better outcomes for children and the reduction of demand on Statutory Social Work (children in need-S.17 and child protection/looked after children-S.47) services. 6.1.27 The ICON evaluation mentioned previously at 6.1.12, should provide a useful progress review of the Programme, particularly in relation to the consistency and extent to which parents/caregivers are given the key messages at the five touch points, taking them on board and enacting them. 12 Recommendations 6.1.28 The forthcoming CWAC ICON evaluation should be scrutinised by the CWAC SCP in regard (amongst other things) to establishing, (1) Programme outcome effectiveness-the ‘So what’ question- regarding AHT injuries to infants. (2) That the Programme is effectively integrated across the CWAC SCP Continuum of Need. (3) The sensitive use of social media, a more, ‘hard hitting’ style of message giving and deployment of peer educators should be explored to enhance the effectiveness of the programme. (4) That any actions from the evaluation are incorporated into the action plan of this the-matic review. (5) Considering the possibility of future follow up evaluations to determine Programme effectiveness, or otherwise, over the longer term (5-10 years). 6.1.29 The CCG should assure the SCP that a systemic dissemination of the ICON programme has included the local GP network and Midwifery Services. 6.1.30 The Local Authority should assure the SCP that there is systemic dissemination of the ICON programme across Health Visiting Services. 6.1.31 The Cheshire Police should assure the SCP that any gaps in Police knowledge regarding the ICON programme should be addressed as soon as possible. 6.2 Local System Wide, Non-ICON Programmes That Are Involved with Parents/Care Givers at the Ante and Post Natal Stage of Birth: Extent of Integration 6.2.1 The three non-independently mobile infants16not subject to rapid reviews variously sustained bruising and bone fractures. This section of the review will thus focus on system wide, preventative and early help approaches (non-ICON) to mitigating the incidence of infant NAI in relation to non-AHT injuries as mentioned in paragraph 5.2 above.17 6.2.2 In some instances, the provision of universal (as per the CWAC SCP Continuum of Need ‘CON’ threshold) services to parents, such as midwifery, health visiting and GP services, may not be suffi-cient to either meet their needs or address predisposing vulnerabilities, stressors and attendant risks. These would include a range of pre-disposing vulnerabilities and risks,18 young first-time parents, lack of family and social network support, poverty, social isolation, lack of suitable housing, parental conflict, domestic abuse, mental health and substance abuse, effects of living with the covid19 pan-demic and low infant birthweight. 6.2.3 It is at this stage in the prevent and protect model that Universal Plus (Single agency interven-tion) and Partnership Plus (Multi-Agency) Team around the Family (TAF), as per the Continuum of Need) services are required to mitigate emerging problems and risks. In these situations, it is imper-ative that there are well integrated, early help and prevention systems and processes in place (and if necessary, safeguarding measures) to recognise and respond to unmet/additional need and emerging risks. 16 See, ‘Bruising in Children who are NOT Independently Mobile’, April 2018, West Cheshire SCB 17 See Cheshire West and Chester Council/West Chester Children’s Trust (2017-2020), refreshed January 2019, Early Help Strategy. 18 Common but not exclusive risks and stressors. 13 6.2.4 What then are the local (CWAC) services at Universal Plus and Partnership Plus available to mitigate risk, meet the needs of vulnerable parents/caregivers and support them at the ante and post-natal period, especially over the early period of infancy; and how well integrated are they? 6.2.5 In essence, Universal Plus and Partnership Plus services are met by the 0-19 Starting Well 19 and the local authority (CWAC) Early Help and Preventative Services respectively, with support of other agencies as necessary. In regard to infants and their parents/carers, Starting Well provides support through, family nurse partnerships, health visiting and children’s centres (core offer). Early Help and Prevention has three service delivery arms, namely: • Family casework and domestic violence and abuse (DVA) • Schools and Partnerships • Community safety and youth services Service delivery is configured geographically via three separate districts, these being, Ellesmere Port, Northwich/Winsford and Chester. Children and families requiring Universal Plus and Partner-ship Plus support and DVA services, including those with infants under one, can access family in-tervention workers (managed by district practice leads) as part of a Team around the Family (TaF) plan. Both the CWAC and Starting Well services work within the local authority Partnership agree-ment of early help and prevention and Continuum of Need (CoN) framework. 20 Intra and Inter-Agency Integration 6.2.6 A joined up intra and inter approach between agencies and professionals across the CoN needs to be underpinned by appropriate and effective integrative processes. Such processes would include common understandings across the system regarding needs/risk assessments (Early Help/ Pre-Birth/ TAF/ Universal Plus/Partnership Plus assessments), a working definition of ‘vulnerability/ vulnerable families, knowledge of the ‘Think Family’ concept, the CWAC Continuum of Need, inter-operable communications/information sharing systems and a sound knowledge of the range and offer of services available to vulnerable families with infants. 6.2.7 In principle,21 it would seem that there is an effective degree of intra and inter agency integra-tion. This is evidenced within Starting Well, by what is described as a, ‘seamless’ offer across the 0-19 age range, involving the allocation of a single health practitioner for the family who will follow them through their ‘journey’. This negates, for example, the need for any ‘referrals’ from health visi-tors to early years workers. Care is co-ordinated through an allocation process within Starting Well. Families identified as needing early help following an assessment at the universal, Healthy Child Programme core contacts, are offered targeted group work or home learning on an individual basis through the Children’s Centre core offer. 6.2.8 There is a single health record (EMIS-electronic management information system) ensuring continuity of information sharing within the agency. EMIS is also the recording system in use by local GP practices, most of whom are part of an information sharing agreement that allows access to a shared view of the EMIS record. This supports integration, co-ordination and continuity across the Starting Well service and with GP provision. 6.2.9 Where in place, GP practices have a link health visitor to support effective communication between it and Starting Well; in addition to attendance at multi-disciplinary team (MDT) meetings, which can focus on families needing Partnership Plus support. However, these arrangements are not consistent. 19 Commissioned by the local authority and provided by Cheshire and Wirral Partnership NHS Foundation Trust. 20 As per the Early Help Strategy, see note 13. 21 This followed a discussion with senior managers from the two agencies regarding integration. 14 6.2.10 Moreover, as previously mentioned, these professionals can play a key role in reinforcing at appropriate touch points, the key ICON messages and ensure that parents/care givers (especially fathers and male care givers) have safety strategies for coping with intense infant crying and are implementing them. 6.2.11 Evidence of interagency integration can be demonstrated by the following examples. Regard-ing Starting Well and midwifery, an essential link in the context of this review, Starting Well receive notification from midwifery, provided by the two CWAC acute hospital trusts22, of pregnant women at the ante-natal stage. Information can include identification of additional needs and any vulnerabil-ities. Starting Well can offer an ante-natal face to face contact with families who have been identified by midwifery as vulnerable or who are primigravida (a woman who is pregnant for the first time). A needs/ vulnerability assessment under the TaF framework can be undertaken if required and with the family’s consent. This would enable a TaF plan of parental/carer support to be given by Starting Well and the midwife, aimed at mitigating at an early stage any risks or adverse impacts to the unborn child/baby. 6.2.12 Additionally, the midwifery service is integral to the Children’s Centre core offer and are able to deliver ante-natal clinics from all of the centres. As mentioned below at paragraph 7.3.8, the En-hanced Midwifery Team at Hospital Trust 1 can take referrals regarding any significant child protec-tion concerns. In this event, they can liaise, as appropriate, with the family GP, Starting Well, the health visitor, family nurse partnership and Children’s Social Care. 6.2.13 Regarding TaF assessments and plans, these can be initiated and co-ordinated by any prac-titioner from either agency (Starting Well/Early Help) where a family is identified as having two or more unmet needs as per the CoN framework. Senior managers from both agencies meet monthly to discuss and facilitate TaF cases and any relevant practice issues. There are also weekly multi- agency case management meetings held under the auspices of the local authority Integrated Access and Referral Team (i-ART) which include representatives from both agencies, the purpose of which is to take forward actions and ensure that a TaF has been started. 6.2.13 Regarding electronic information systems, Starting Well, as previously mentioned use the EMIS which is linked to the same system used by GP practices. The local authority Early Help ser-vice uses e-TAF which is a module within ‘Liquid Logic’ (used by Children’s Services) and can be accessed by Starting Well via a token/authenticator process; albeit the two systems are not inter-operable. That said, TAF assessments can be completed in e-TAF and copies then attached to the EMIS record system. 6.2.14 There are pathway processes for both ‘stepping up’ to Children’s Social Care and back down to Starting Well. Following a manager-to-manager meeting and agreement between them a family can be stepped down into the Starting Well e-TAF tray which is then picked up through the e-TAF system and allocated.23 6.2.15 Evidence from the practitioners’ learning event regarding inter-agency integration, suggested that agencies and their practitioners had taken on board, understood and engaged with the, ‘Think Family’ concept. Albeit this was not always the case with adult facing services and comments were made about the need to,’ reconsider and refresh relationships with adult services’, regarding ‘Think Family’. It was encouraging to hear that there were very positive relationships between Early Help and Starting Well, albeit there were some issues with meeting intervention thresholds. Co-location was suggested as a means of improving information sharing and strengthening working relation-ships. In the event of professional disagreements, the SCP escalation process was available for use by practitioners, including discussions with agency safeguarding leads as part of the process. 6.2.16 Relevant lessons from these key practice episodes would be firstly for the CWAC SCP to be assured that the ‘Think Family’ message is well embedded in adult social care and mental health 23 See CWAC TaF Guidance. 15 services. Secondly, for Early Help and Starting Well to review the threshold criteria so that families can access, ‘the right care at the right time in the right place’ (Principle 3, NHS Commissioning for Carers Principles) at Universal Plus and Partnership Plus of the CoN. Thirdly, to consider the efficacy or otherwise of Early Help/Starting Well service co-location as a means of service enhancement. 6.2.17 In addition, practitioner knowledge regarding the inherent vulnerability of infants24 and dy-namic risk are essential tools in the prevention and protection of infants. The evidence from the practitioners’ learning event was that, in general, these issues were well understood and articulated in practice. However, attention was drawn to the importance of incorporating the inherent vulnera-bility of infants concept into the training of peripheral workers such as new police starters and hous-ing officers, whilst recognising the challenges of this in regard to large workforce turnovers. It was noted that practitioners were increasingly referring families for vulnerability rather than determining whether the case met the threshold, which was seen as a positive development. Interestingly, pa-rental participation in virtual meetings was better than in pre-covid 19 face to face meetings, albeit, there was a greater recognition of parents’ ability to disguise their vulnerability. Findings 6.2.18 Well integrated Universal Plus and Partnership Plus services at both intra and inter-agency level are (along with universal/ICON services) key to effective mitigation and the minimisation of non-accidental injury to infants. Within the CWAC SCP, Partnership Plus support is mainly provided jointly by Starting Well and the local authority’s Early Help and Prevention services. Schools also have a key role in support where infants have older school age siblings. 6.2.19 Evidence provided at both strategic and operational levels suggest that current systems, pro-cesses and practice underpin an effective degree of intra and inter-agency integration within the Partnership Plus offer. GP and midwifery services (provided by the two acute hospital trusts operat-ing in the CWAC area) are linked to Partnership Plus services via EMIS, the electronic information sharing platform and health visitor attachments to GP practices. 6.2.20 The, ‘Think Family’, approach appeared well embedded within the broad range of children’s services. However, this was less the case with adult facing services, including adult social care and mental health; where it was identified at the practitioners’ learning event (PLE) that there was a need to ‘reconsider and refresh relationships with adult services’. In this regard these two agencies should review the CoN to provide assurance to the SCP that they understand and can effectively apply it. 6.2.21 There was a suggestion from the PLE that Starting Well and Early Help and Prevention could usefully review the threshold criteria for families to access the right care at the right time in the right place. Co-location, where possible, could be considered. 6.2.22 Where in place, GP practices have a link health visitor to support effective communication between it and Starting Well; in addition to attendance at multi-disciplinary team (MDT) meetings, which can focus on families at Partnership Plus. However, these arrangements are not consistent. 6.2.23 The ’inherent vulnerability’, of infants was well understood by children’s services practitioners, albeit the concept needed to be included in the training of peripheral workers such as new police starters and housing officers. Recommendations 24‘Babies are disproportionally vulnerable to abuse and neglect. In England they are seven times more likely to be killed than older children. 36% of serious case reviews involve a baby under one’. See, 'The 1001 Critical Days-The Importance of the Conception to Age Two Period; A Cross Party Manifesto; page 5. 16 6.2.23 The ‘Think Family’ concept needs to be disseminated and better embedded within adult social care and mental health services. These services should provide assurance to the SCP that they understand the CoN and can effectively apply it. 6.2.24 The SCP should seek assurance from Starting Well Services and Early Help and Prevention that they are applying the criteria and CoN thresholds appropriately to ensure that vulnerable families can effectively access the right service at the right time in the right place. They should consider whether some co-location, where possible, could improve access and service outcomes. 6.2.25 The Local Authority and CCG should take steps to assure the SCP that the current arrange-ments for GP practices to have a link health visitor are appropriately joined up throughout the local GP network. 6.2.26 The concept of the, ‘inherent vulnerability’, of infants needs to be included in the training of peripheral workers, such as new start police and housing officers. 6.3 The Role of the Midwifery Service, Early Intervention, Prevention of NAI and Relation-ships with Parents 6.3.1 Midwives (both hospital and community based) are the lead professionals for the care and support of women and new-born infants, partners and families and make a key contribution to the quality and safety of maternity care (Nursing and Midwifery Council: 2019). Their intervention at an early stage of a women’s pregnancy-at the 8-10 week booking appointment- places them in a key position not only to promote the mother and unborn child’s health and safe birth, but also to anticipate and recognise any emerging issues and additional care needs, including support to the mother and father; and safeguarding matters relating to the infant, both pre and post birth. In the event of such issues arising the midwife has a responsibility -in collaboration with the parents - to manage, escalate and refer onto other inter-disciplinary and multi-agency colleagues. 6.3.2 The five infants in this review received services from four different midwifery providers, two of which were in the Cheshire footprint and the other a neighbouring authority. Three providers were mainstream hospitals, the other was an independent provider. The independent midwifery company provided contracted community midwifery services for several NHS commissioning Trusts in the North West (and Essex), including Cheshire. It provided a single midwife to see women through ante-natal, birth and post-natal care and focused on home births where possible. Unfortunately, the company collapsed in late July 2019. Independent Midwifery Service 6.3.3 One of the five infants was involved with the independent midwifery service. It was not the role of this review to look in detail at individual child health records. However, assurance was sought that, generally speaking and when necessary, safeguarding concerns and information were shared ap-propriately. The review saw evidence through the submission of a quarterly dashboard that safe-guarding referrals were made and monitored and that there was evidence of communication be-tween the independent midwifery service, acute providers and the designated nurse for safeguarding children regarding safeguarding cases. Findings 6.3.4 A copy of the commissioning schedule demonstrated that the clinical commissioning group required compliance with Cheshire West and Chester Safeguarding Children Partnership guidance, a quarterly dashboard was submitted evidencing safeguarding activity and compliance with intercol-legiate safeguarding training. The expected level of compliance with safeguarding training was 90%. This episode highlights the need for commissioning agencies, in this case the Strong Start Partner-ship, Cheshire CCG to ensure services operating across multiple local authorities are aware of local 17 initiatives e.g., the CoN threshold, ICON and early help; given its very significant role at the early stages of ante natal, birth and post-natal infant development. This is a key learning point. Recommendation 6.3.5 That the Safeguarding Children Partnership seek assurance from Commissioners, including Cheshire CCG, that services; particularly those which are commissioned across multiple local au-thority areas, are aware of local key pathways and interventions i.e., the CoN threshold, early help offers (including ICON). The Two Hospital Trusts 6.3.6 Regarding the two Hospital Trust midwifery services, the review was informed that the eight weeks’ booking appointment is the crucial entry point into the maternity system by the mother. The midwife undertakes a holistic assessment of the mother’s clinical and wider social and psychological needs. A care plan is developed with the mother (also to include the father/male care giver) and any significant medical information shared with the GP. The assessment and care plan would include consideration of any additional or unmet needs and potential risks to the infant beyond the universal services. Hospital Trust 1 6.3.7 With regard to Hospital Trust 1, a referral can be made, in the event of significant concerns, to its Enhanced Midwifery Team (EMT) which is a targeted service for ‘vulnerable’ families that seeks to safeguard the unborn/newborn infant, the mother and the family. Referral criteria would include, previous or current CSC involvement, unwanted pregnancy/adoption, disclosure of domestic abuse, stalking and harassment (DASH), parental substance abuse and mental health issues. The EMT would liaise in a timely way with the maternity department to facilitate a seamless service and include other partner agencies such as the 0-19 Starting Well Service and the GP when needed. In the event of safeguarding concerns and other vulnerabilities emerging, the EMT would share a Safeguarding Adult and Children Midwifery Notification form with the health visitor/Family Nurse Partnership and the GP at 25-28 weeks gestation. There are referral procedures for pre-birth assessments in the event of concerns around significant harm. 6.3.8 Clearly, these processes are key elements in any strategy seeking to prevent NAI/infant mal-treatment. One of the infants in this review received services from Hospital Trust 1. The Rapid Re-view highlighted that no multi-agency referral form (MARF) for a pre-birth assessment had been submitted to CSC iART (Information, assessment and referral team), as per CWAC SCP guidance, when mother presented for her ante natal care, despite the presence of known risk markers and other concerns that warranted a written referral. The hospital dispute this stating that they had con-tacted CSC but were advised that the threshold for a pre-birth assessment was not met. Neither agency record was sufficiently detailed to confirm the accuracy of information provided and this was learning from the Rapid Review. 6.3.9 The mother was referred at an early stage by the midwifery service to the Family Nurse Part-nership for support. Unfortunately, due to non-engagement from the Mother and Family Nurse Part-nership staff sickness, the 28-week criteria for service had passed and she was inappropriately re-ferred onto the health visitor (0-19 Starting Well Service) within the universal offer. Findings 18 6.3.10 Hospital Trust 1 documented arrangements and processes25 would seem fit for purpose in relation to the initial assessment of the mother’s clinical and wider holistic needs, early identification of any potential unmet needs and, if necessary, a referral onto the Enhanced Midwifery Team in the event of any safeguarding/vulnerability issues. 6.3.11 Self-evidently, the assessment appears to be beyond a narrow focus on measuring and mon-itoring of clinical factors. Liaison and information sharing with tier 2/3 agencies including GPs are provided for. 6.3.12 There was no mention of whether parents are routinely referred to the ICON programme. However, over recent times the ICON programme has been implemented in Cheshire. The recent evaluation (see paragraph 6.1.28 above) will demonstrate compliance with all touch points within the programme. 6.3.13 The problems in making a pre-birth referral, referred to above, would suggest the need to review and if necessary, address any interface difficulties with the CSC i-ART, including use of the CWAC dispute resolution/ challenge and escalation process. (see section 6.8 below) 6.3.14 In relation to the MARF issue cited above (paragraph 6.3.9) the lessons are two-fold; agency records must specify which professionals communicated with one another and regardless of whether iART had indicated threshold for a pre-birth assessment was not reached, this should have been escalated by Midwifery Services. Hospital Trust 2 6.3.15 Evidence from Hospital Trust 2 suggests that, firstly, it has an ICON programme which is, ‘actively and robustly promoted within midwifery and will continue to be further embedded’ (Hospital Trust Report: 7). Reportedly, the ICON messages are routinely given out through the leaflet at book-ing, discharge from hospital 2 and at the neo-natal unit post-delivery. There is evidence to suggest that parental absorption of the key messages may be more effective through direct, face to face contact, using a video presentation and the use of appropriate social media, rather than the giving of a leaflet (SUDI report; July 2020) Hospital Trust 2 is seeking ways on how to improve the way in which the completion of this work is recorded in maternity records. The ICON programme is also included in safeguarding training. 6.3.16 An initial booking meeting at around 8 weeks of the pregnancy is used to undertake the clinical and holistic assessment when the ICON message is discussed. Screening questions identify any needs for early support for mental health, social and safeguarding issues. If necessary, the midwife, with the mother’s consent, can refer onto Family Nurse Practitioner; and if appropriate and following a discussion with the Safeguarding Children Team, CSC safeguarding services and a pre-birth as-sessment in line with local guidance. Arrangements exist to undertake a single agency team around the family (TAF) led by the community midwife or a referral for Early Intervention and Prevention involvement from other partner agencies. 6.3.17 Midwives regularly work in multi-agency settings including TAF/Child in Need/Strategy meet-ings and Child Protection Care Conferences. In the event of a TAF or safeguarding/domestic abuse issues, a maternity safeguarding pro-forma is entered onto the electronic maternity records; in addi-tion to placing an alert, thus allowing all professionals involved in delivering care to the mother know-ing what is happening. This is said to be well established and fully embedded at Hospital Trust 2; new midwives quickly familiarise themselves with the alert system. Clinical supervision by the safe-guarding children team is provided to midwives where there are ongoing safeguarding matters. Safeguarding training is mandatory. 6.3.18 Post-natal care is provided by the community midwife who should be aware of any issues from the safeguarding children pro forma alert. Visits take place on days one and five after discharge 25 See Hospital 1 report prepared for this review. 19 (with a telephone call from a maternity support worker at 2 days to ensure that baby feeding is proceeding well). Where there is a safeguarding children pro-forma in place a multi-agency dis-charge planning meeting is held prior to the discharge of mother and infant. This would include a transfer of care from the hospital to the community midwife, with a handover to the health visitor at between 10-14 days. 6.3.19 The Hospital Trust 2 report mentions that, throughout the maternity care episode, the midwife will make every attempt to include the partner, any existing children and other family members ( as per the mother’s wishes) in the care planning, within a ‘ Think Family’ perspective. Reportedly, from the first contact at the booking appointment, every effort is made to identify the identity of the baby’s father and establish any potential risk; in addition to any parental vulnerabilities and subsequent additional services. It was not clear whether the Hospital Trust 2 midwifery ICON programme in-cluded touch points with the community midwife. Findings 6.3.20 Evidence indicates that, firstly, the ICON is seemingly well developed with touch points at the booking appointment, pre and post discharge. Useful learning could be gained by the Hospital Trust 2 midwifery service considering the findings of the recent ICON evaluation as to effectiveness, de-gree of integration into the wider safeguarding/CoN system including feedback from parents and whether there has been a reduction in infant AHT/maltreatment. The same would apply to Hospital Trust 1. (See Recommendation at paragraph 6.1.28 above) 6.3.21 Secondly, in principle, there would seem to be robust systems and processes in place to enable effective safeguarding of mothers and infants, recognise parental vulnerabilities and offer additional support and prevention interventions at Universal Plus and Partnership Plus and statutory services where necessary. The adoption of a ‘Think Family’ is said to be well rooted. 6.3.22 Thirdly, the midwifery involvement with mothers appears to be comprehensive, holistic and not solely confined to the measurement and monitoring of clinical/medical factors. Recommendations 6.3.24 The SCP should undertake a case audit to assure itself of the effectiveness and extent of integration of the current midwifery services into the wider CON/safeguarding system. This could be more effective if it was done as part of a multi-agency tri-angulation audit in order to compare the information held by all agencies. 6.4 Commissioning and Contracting of Midwifery Services by Clinical Commissioning Group 6.4.1 The Clinical Commissioning Group report for this review states that NHS Standard contracts are in place for all maternity providers that detail: • Service specification • Safeguarding standards • Key performance indicators • Quality requirements Monitoring Process 6.4.2 The contracts are monitored monthly with the providers, thus enabling any matters to be raised formally, recorded and responded to in a structured manner. Specific issues are tabled through a formal agenda in advance which ensures that the relevant representation is present when needed. 20 In the event of any quality, safeguarding or performance concerns, the provider is notified and re-quested to respond by a set time. Contract managers can raise issues outside of the formal system of contract meetings by issuing a contract letter asking concerns to be addressed and convening a separate meeting if needed. 6.4.3 Underpinning the safeguarding monitoring process, the clinical commissioning group has an assurance process whereby providers must complete an annual self-assessment audit (see Com-missioned Service Standards for Safeguarding Children/ Looked After Children and Adults at Risk, Version 6, 04.03.2020). The completed audit is reviewed by the CCG who provide feedback on any non-compliance along with an improvement action plan. Any assurance breaches are discussed at the Quality and Safeguarding/ Contract meeting and in the event of significant failure are escalated to the CWAC safeguarding children partnership, and if necessary, NHS England Cheshire and Mer-seyside sub-regional team quality surveillance group. Strong Start Partnership Programme 6.4.4 Under newly established governance arrangements the Cheshire CCG has developed the Strong Start Partnership Programme which manages the contracting and commissioning of services for women and children, including maternity services. Members of the Partnership Programme in-clude commissioning and lead providers and other key partners including the CWAC SCP26. It aims to be accountable for overseeing the delivery of the Strong Start Programme that seeks to achieve improved outcomes for babies, children and young people (see Strong Start Partnership - Terms of Reference; (6.7.20) for a list of objectives). 6.4.5 Of some significance, this review notes that there will be a requirement for midwifery service providers to demonstrate compliance with midwifery service standards27, thus strengthening current quality assurance of midwifery services. 6.4.6 The Review was told that there is a learning cycle of continuous improvement provided by the Cheshire CCG sharing learning from serious incidents and producing quality reports for the CCG Quality and Safety Committee. Strong Start has a dashboard that includes all midwifery key perfor-mance indicators (KPIs), including the two acute hospital trusts (HT1, HT2) and other commissioned services. Commissioning arrangements currently address the need for service compliance and inte-gration with CWAC SCP safeguarding policies and procedures and the wider local safeguarding system. Findings 6.4.7 Cheshire CCG’s monitoring and assurance processes (the Strong Start Partnership) regarding service providers’ safeguarding performance would seem to contain the appropriate arrangements to achieve safe practice. 28 Recommendations 6.4.8 None 6.5 Vulnerable Families and Safeguarding Pathways: The Continuum of Need (CoN) and the Application of Thresholds 26 Through the link with the designated nurse for safeguarding who sits on the SSP partnership and the CWAC SCP. See, Strong Start Partnership-Terms of Reference, page 3, 6.7.20 27 These are delivery of the standards as set out in, ‘Better Births-Saving Babies Lives Care Bun-dle version 2’ delivery of CNST-10 Safety Actions and will also include the requirements the Ock-enden Report. 28 Updated in 2020 but in place for many years. 21 6.5.1 Working Together 2018 does not define the term, ‘vulnerable’, albeit it is in use (see page 8, paragraph 12). The Oxford English Dictionary definition is, ‘weak and easily hurt physically and emo-tionally’. The College of Policing defines the term as, “A person is vulnerable if, as a result of their situation or circumstances, they are unable to take care of or protect themselves or others from harm or exploitation.” 6.5.2 The Starting Well Service views vulnerability as those families where additional need(s) are evident or where there are complex needs and\or identified risks. Recourse to the CWAC SCP Con-tinuum of Need is made to determine the extent of a vulnerable family’s need (one additional need equates to a Universal Plus - Single Agency); two or more can result in support coordinated through a multi-agency TAF at Partnership Plus), complex needs and risk of significant harm/child abuse will lead to statutory CSC intervention through a Child in Need/CiN or Child Protection Plan/Care Pro-ceedings under the Children Act 1989. 6.5.3 Cheshire Police use the Vulnerable Person Assessment (VPA) tool for assessing vulnerability at the time of a critical incident. This would include attending an incident involving a pregnant woman (e.g. in a domestic abuse and violence situation) or where there was a young child/infant, and where vulnerability or risk of harm was evident. 6.5.4 The review was informed that Cheshire Police was developing a new VPA that seeks to high-light the vulnerability of infants/under ones and pregnant women. This will target the information that childcare agencies (CSC, midwifery, home visiting, GPs) need for further interventions, including the voice of the child. Officers will be encouraged to take a more holistic approach to VPAs regarding pregnant women and unborn/post-natal children and not assess individual incidents in isolation but rather, within a more holistic/ bigger picture context.29 Additional training regarding awareness spe-cifically around the issues of abuse/NAI/AHT of infants and the unborn, to include the idea of the officer being, ‘the voice of the child’, was welcomed by the review. 6.5.5 The review was told that the VPA tool has been progressed continuously and is updated every 2-3 months. Discussion 6.5.6 Given the complexities of current policing and the myriad demands on police officers, espe-cially in regard to public protection issues, the review was encouraged to learn that Cheshire Police was making improvements to its VPAs, in addition to having cited the ICON initiative and its key messages. There would appear to be well established procedures, via the VPA to notify CSC/i-ART when officers come across domestic abuse and concerns about children, including infants. It is sug-gested (in line with the Chief Constable’s weekly orders, see note 27 below) that further work is done on submitting VPAs for childcare concerns at Early Help and Prevention, additional to the mandatory criteria, statutory child protection. Getting support for families may prevent child maltreatment in children under one year. Specific training around infant maltreatment was seen as helpful. Midwifery 6.5.7 As discussed previously, the midwifery service understands vulnerability within the context of the Continuum of Need (CoN) and interventions that correspond to universal, universal plus, part-nership plus and statutory social work. The CoN and pre-birth assessment tools are the key child welfare and safeguarding pathways. Findings 29 A message to Cheshire police officers was included in the Chief Constable’s weekly orders of the week ending, Friday 7 2020, to this effect. This included dissemination of the ICON message. 22 6.5.8 There is no accepted uniform working definition of ‘vulnerability’ in regard to infants and their families, used by the CWAC SCP and partner agencies. 6.5.9 The term seems to be implicitly understood and differentially operationalised by professionals and agencies as a function of their interpretation of the Continuum of Need. This results in a degree of variation in how the CoN is used by professionals to assess need/risk and decide on the appro-priate level of service intervention, including no intervention. Recommendation 6.5.10 The SCP should seek to develop a common definition and understanding of vulnerability across the partnership and achieve a reasonably consistent level of service intervention within the CoN, that correspond to assessed needs and risks. 6.6 Pre-Birth Assessments 6.6.1 There is a well-established pre-birth assessment procedure and set of guidance contained on the CWAC SCP website. This sets out a clear pathway for progressing the assessment, including points at which key decisions can be made regarding next steps and service/intervention outcomes for the child and family. It emphasises the need for relevant professionals (midwives, GPs, hospital ante-natal services, health visitors) to be familiar with potential indicators of harm to the unborn child/infant; and/or the family’s need for additional support to safely progress the pregnancy and care for the new baby. The assessment should start in the early ante-natal period. It should include de-tails, where possible, of the mother’s partner and his/her wider family and environment. A clear set of referral criteria to CSC is set out at page 7 of the guidance. 30A pre-discharge meeting should take place, along with a clear plan before the infant leaves hospital. 6.6.2 Regarding the effectiveness of early intervention and referrals to CSC, the review was pre-sented with an audit of five pre-birth assessments completed during the early part of the covid 19 regulations, between 01.03.20-22.07.20. Most assessments (3/5) were judged as adhering to prac-tice standards with appropriate outcomes. All but one (4/5) involved the father/partner in the process. Regarding midwifery, all of the cases had accessed safeguarding supervision with evidence of a clear relationship between midwifery and the i-ART (Integrated access and referral team) at the point of the mother’s booking with the midwifery service. The audit concluded that, overall, there was a positive picture of multi-agency practice. Findings 6.6.3 The local guidance on pre-birth assessments is comprehensive, detailed and has a clear path-way regarding progress and decision making. 6.6.4 The audit evidence presented to the review (albeit a relatively small sample of 5 cases) sug-gests that the pre-birth guidance is being effectively used by professionals. Agreed practice stand-ards are being achieved in majority of cases, with positive outcomes for children and good multi-agency practice. It was encouraging to see that in 4/5 cases (80%) fathers/male care givers were included in the assessment process. Recommendation 6.6.5 Given the small sample the SCP should undertake a larger audit of pre-birth assessment prac-tice in order to confirm (or otherwise) the positive picture from the first audit. 30 In the case of one of the infants subject to a rapid review there were several relevant risk factors that warranted a referral to CSC. The guidance explicitly states that, ‘referrals to CSC must always be made in the following circumstances (see section 4.3 for these). 23 6.7 Engagement of Fathers and Male Care Givers31 6.7.1 There is a wealth of evidence and learning from previous serious case reviews and professional studies (NSPCC; Caring Dads) highlighting the importance of including fathers and male care givers (so called ‘Invisible men’) in working with professionals regarding their children’s well-being and safety. An important caveat being as long as this does not compromise the safety and wellbeing of women and children from domestic abuse and violence, male coercion and control. 6.7.2 Previous mention has been made of the imperative of involving fathers and male care givers in the ICON programme, given that 70% of perpetrators are male. Inclusion only of the mother of the unborn child will be unlikely to mitigate the key risk from the male and thus be ineffective in prevent-ing infant AHT/maltreatment. 6.7.3 As previously noted, most pre-birth assessments include males. Child and Family assessments (see CSC review report) involve fathers, albeit not always consistently. Self-evidently, practice needs to routinely include males in Child and Family work, where it is safe to do so and consistent with the child’s paramount interests. 6.7.4 The practitioners’ learning event noted that fathers and male carers tended to be marginalised by professionals and were not involved with ante and post-natal services, including ICON as much as they could be. The impact of Covid 19 attendance regulations had not improved the situation. It was questioned whether professionals made enough effort to identify the father if he was not present at ante and post-natal appointments. There was a need to pro-actively include fathers and male carers more at both ante and post-natal stages and seek to give them a voice, including those males who were not the biological parent. Generally, there was a need to adopt a more holistic, ‘Think Family’, approach. 6.7.5 This position is reinforced by learning from the Rapid reviews, one of which note “very limited information was known by Midwfiery Services about Dad, and not uncommonly, he was not present at the majority of antenatal visits”; also, that “there was a lack of engagement by agencies with father both in respect of assessment and intervention”. Conversely, in the second review, agencies had a good knowledge of father’s history which had been openly shared with them, including a diagnosis of Post-Traumatic Stress Disorder and a request from Father for support in managing his anger. Whilst this information was known, it was not analysed in the context of the additional stressor that a new baby can bring and the impact on fathers’ capacity to care. No intervention or additional sup-port was offered to father. 6.7.6. The recently published report by the Child Safeguarding Practice Review Panel (see note 29 above) contains a wealth of findings and recommendations salient to this review. Findings 6.7.6 Evidence from the PLE strongly suggested that fathers/male carers tend to be marginalised from ante and post-natal services, including the local ICON programme. 6.7.7 In most cases, fathers/males are included in pre-birth assessments. There is some incon-sistency regarding Child and Family assessments. Recommendations 6.7.8 Maternity services and Local Authority health visiting should seek to proactively involve fa-thers/male carers in all interventions, consistent with the mother and child’s safety. 31 See’ Safeguarding children under 1 year old from non-accidental injury; National review into ba-bies seriously harmed or killed by their father male carer’, Child Safeguarding Practice Review Panel, 16.09.21. 24 6.7 9 Consistent with the mother and child’s safety, the current CWAC ICON initiative should ensure, as is the stated intention of the initiative, that fathers/male care givers are routinely included in the programme, from start to finish. 6.7.10 Practice guidance, learning and development should emphasise the imperative of routinely involving fathers and male care givers in the assessment and planning processes for their children, notwithstanding consideration of any safety issues. This would apply to all health and children’s services. 6.8 Challenge and Escalation Regarding Professional Disagreements in Decision Making 6.8.1 This issue arose in one of the rapid review cases when there was a strong case for the mid-wifery service, through use of the escalation process, to have challenged the i-ART response that there were insufficient grounds to make a pre-birth assessment. 6.8.2 The Pan Cheshire SCP escalation procedures regarding professional disagreement of decision making is well established. It includes clear guidance about the four stages for escalation and reso-lution which is replicated in the i-ART manual’s four step process for dispute resolution. 6.8.3 External agencies such as midwifery, as a first step, can discuss a decision outcome with a team manager or senior social worker. If not satisfied, the issue can be escalated up the manage-ment chain to the SCP Chair who will make a recommendation for the most appropriate way forward. Findings 6.8.4 Clear guidance is in place regarding professional disagreement and escalation. It may be that the SCP needs to remind agencies of its existence and use when necessary. Recommendations 6.8.5 That the CWAC SCP continues to promote the existence and use of the Challenge and Esca-lation procedures. 7.0 Summary and Conclusions 7.1 This thematic review arose following a cluster of NAI incidents in Cheshire West and Chester to five infants in the summer of 2019. After due consideration involving two rapid reviews, the CWAC Safeguarding Children Partnership decided on the 27 September 2019 to commission a thematic review into the non-accidental injury to babies under one year of age. 7.2 A panel and independent reviewer/chair were duly convened and met initially in late February 2020; progressing the review during 2020/21, notwithstanding the challenges to process from covid 19 and associated regulations. 7.3 Regarding the three overarching questions from section 3 the evidence of this review suggests; 7.3.1 Current Arrangements to Safeguard Infants from Harm; Promote their Welfare and Support their Parents/Carers (questions 1 and 2) 7.3.1.1 There are currently (August 2021) a range of services in place within the CWAC SCP Con-tinuum of Need spectrum aimed at preventing and protecting infants from suffering harm. These include, the relatively new ICON service, operated by the two hospital trusts (HT1 and HT2), which seeks to prevent infant abusive head trauma (AHT) through parental/professional ante and post-natal contact via the five touch points. Universal Programmes like ICON are a key element in the layers of defence (as per appendix 1, paragraph 5.5 below) that makes up the integrated service system aimed at mitigating risk of infant AHT and non-accidental injury. 25 7.3.1.2 An evaluation of the local ICON programme has been recently completed and is due to be presented to the CWAC SCP in early October 2021. 7.3.1.3 Midwifery services from the two hospital trusts and local GP practices also provide important universal provision -first line of defence- against infant non-accidental injury. 7.3.1.4 Underpinning the ICON initiative are early help and prevention services. These include the 0-19 Starting Well programme aimed at responding to families with additional needs and the local authority family intervention service. Statutory social work services (Child in Need and Child Protec-tion) are provided by CWAC Children’s Social Care and supported, when necessary, Cheshire Po-lice. 7.3.2 The Effectiveness of the Current Service Offer to Infants and their Families, including those Deemed Vulnerable (question 3) 7.3.2.1 There is evidence from the HT2 data that there were no non-accidental head injuries to chil-dren under one year old from September 2019 to March 2021 and that infant NAI numbers were down from the previous year. Data from HT1 suggested that there was one confirmed NAI to an infant caused whilst in parental care.32 However, it is suggested that the ‘raw’ data would need to be contextualised through a robust public health analysis to give an accurate and meaningful account of the state of NAIs to infants in the CWAC area33, and thus the effectiveness or otherwise of the current service offer to babies under one and their families. 7.3.2.2 Evidence provided at both strategic and operational levels suggest that current systems, processes and practice underpin an effective degree of intra and inter-agency integration within Partnership Plus responses. GP and midwifery services (across both HT1 and HT2) are linked to Partnership Plus via EMIS, the electronic information sharing platform and health visitor attachments to GP practices. 8.0 Key Lessons for Policy and Practice: Locally and Nationally 8.1 Infant crying is normal and peaks at between 4 to 8 weeks. However, the early months of infant, inherent vulnerability’, can be a potential maximum period of risk to the infant. 8.2 A ‘prevent and protect’ model of an integrated service offers across the CWAC SCP Continuum of Need - similar in outline to that set out in the SUDI report; July 2020- is a key element in minimising and mitigating non-accidental injury to infants under one. 8.3 Ensure there is a secure, universal, first line of defence. A universal ante and post-natal safety planning programme such as ICON, which addresses caregiver frustration with crying infants, is a key element in preventing infant NAI and can help reduce the likelihood of AHT. 8.4 Additional first lines of defence involving universal services such as midwifery, GPs and health visiting should complement and reinforce the ICON programme. They should be attuned to the in-herent vulnerability of infants, be familiar with how to recognise and respond to unmet/additional need in families requiring Universal Plus or Partnership Plus support and dynamic risk, requiring a referral to CSC for a pre-birth assessment. 8.5 Services within Universal Plus or Partnership Plus on the CoN spectrum (namely, those provided by Starting Well and Early Help and Prevention) should be optimally integrated both intra and inter agency. They should be underpinned by a range of integrative and effective processes such as those cited in paragraph 6.2.6 above, including familiarity with how to make (and receive) pre-birth assess-ment referrals. 32 Time scale was from 31.10.19 to 11.3.21 33 A longitudinal study over a reasonably long period of time, say 5-10 years. 26 8.6 The Think Family concept should be thoroughly disseminated to and embedded by adult facing services, including mental health. 8.7 Fathers and male care givers have a tendency to be marginalised by some services. They should be routinely included in service interventions, including ICON, notwithstanding consideration of any safety issues around domestic abuse, coercion and control. 9.0 Glossary of Terms AHT; Abusive head trauma CAMHs; Children and adolescent mental health service CCG; Clinical Commissioning Group CoN; Continuum of Need CNST; Clinical Negligence Scheme for Trusts CSC; Children’s Social Care CWAC; Cheshire West and Chester DASH; Domestic abuse, stalking, harassment and honour violence DVA; Domestic violence and abuse EMIS; Electronic medicine information system EMT; Enhanced Midwifery Team GP; General Practitioner HMP; Her Majesty’s Prison (Service) KPI; Key performance indicators NAI; Non accidental injury NICU; Neo-natal intensive care unit NHS; National Health Service PLE; Practitioners’ Learning event HCP; Healthy Child Program MARF; Multi-agency risk form MCHFT; Mid Cheshire Hospitals NHS Foundation Trust MDT; Multi-disciplinary team NICE; National Institute for Health and Care Excellence I-CON; Infant crying is normal, Comforting methods can help, Its ok to walk away, Never ever shake a baby i-ART; Integrated, access and referral team NWAS; North west ambulance service PCHR; Personal child health record SCP; Safeguarding Children Partnership SUDI; Sudden unexpected death in infancy SBS; Shaken baby syndrome TaF; Team around the Family UPP; Universal Partnership Plus UP; Universal Plus NSPCC; National Society for the Prevention of Cruelty to Children VPA; Vulnerable Person’s Assessment 10.0 References Altman RL et al: 2010; ‘Parent Education by Maternity Nurses and Prevention of Abusive Head Trauma’; Pediatrics: 128;e 1164 Barr RG: 2012: ‘Preventing Abusive Head Trauma Resulting From a Failure of Normal Interaction Between Infants and their Caregivers’; Proceedings of the National Academy of Sciences of the USA; 109 (supply) 17294-17301 Barr RG: 2018: ‘Eight year outcome of implementation of Abusive Head Trauma prevention’; Child Abuse and Neglect; 84 (106-114) 27 Bechtel K et al:2011: ‘Impact of an educational intervention on caregivers’ beliefs about infant cry-ing and knowledge of shaken baby syndrome’. Academic Pediatrics 11(6) 481-486 Brandon M et al: May 2016; ‘Pathways to harm, pathways to protection : a triennial analysis of se-rious case reviews 2011 to 2014’ ; Final report; University of Warwick; University of East Anglia: Department for Education Brandon M et al: March 2020: ‘Complexity and challenge: a triennial analysis of SCRs 2014-2017’: Final report; Department for Education Child Abuse Review; May-June 2020: Special Issue: Abusive Head Trauma: Recognition, Re-sponse and Prevention. Child Safeguarding Practice Review Panel; July 2020, Out of routine: a review of sudden death in infancy (SUDI) in families where the children are considered at risk of significant harm’ Crown cop-yright Child Safeguarding Practice Review Panel; September 2021: ‘The Myth of Invisible Men’; Safe-guarding children under 1 from non-accidental injury caused by male carers’. Department for Education: 2018: ‘Working Together to Safeguard Children; A guide to inter-agency working to safeguard and promote the welfare of children’ Dias et al: 2005: ‘Preventing Abusive Head Trauma Infants and Young Children; a Hospital Based Prevention Programme’; Pediatrics 115: 470-477 Lopes NRL et al; 2013: ‘Abusive Head Trauma in Children; a Literature Review’; Journal de Pedi-atria; 89(5) 426-33 Lopes NRL et al: 2018: ‘Pediatric Abusive Head Trauma Prevention Initiatives, A Literature Re-view’, Trauma, Violence and Abuse, 19(5), 555-566 NSPCC: 2016: ‘Protecting Babies and Toddlers’ NSPCC: 2016:‘Caring Dads, Safer Children’ Ofsted 2019: Cheshire West and Chester, Inspection of Children’s Social Care Services Rebbe R et al: 2020: ‘Incidence and Risk Factors for Abusive Head Trauma: A Population Based Study’; Child Abuse Review 29; 171-181 Rizwan M et al: ‘Non accidental injury in disguise; a paediatric enigma. International Journal of In-tegrated Care; 2017, 17(5) Smith S: 2016: ‘Abusive Head Trauma, The Case for Prevention: The Dulverton Trust Smith S: 2020; ICON, Babies cry, you can cope; The research evidence base for the prevention of Abusive Head Trauma and opportunities for development’ Taylor et al; Non-Accidental and Neglectful Injury in Children: Patterns and Typology, Birmingham Women and Children’s NHS Foundation Trust A Cross Party Manifesto: Leadsom A et al: ‘The 1001 Critical Days-The Importance of the Concep-tion to Age Two Period’: www.1001criticaldays.co.uk Welsh Government: 2012: ‘Protection Children Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews’, www. cymru.gov.uk West Cheshire Children’s Trust (2019): ‘Early Help Strategy’: Cheshire West and Chester Council Appendix 1: Methodology 11.1 This review uses a whole systems approach that involves an understanding of how things (el-ements and system) are related and how they influence one another within a whole. In this case how the various agencies in the multi-service offer to infants, pre and post-birth, and their parents; namely midwifery, GP, health visitors, maternity services, children’s social care, early help and prevention, clinical commissioning group (CCG), etc, co-ordinate (or not) with each other to minimise non-acci-dental injuries to infants. 11.2 The approach seeks to focus on a critical analysis of the strengths and weaknesses of the multi-agency service offer using the information from the five infants’ cases set out above but will not provide a detailed review of each individual case. 11.3 The review is informed by elements of the, ‘Welsh model’ (Protecting Children in Wales, 2012) and the ‘Pathways to harm, pathways to protection’ framework; (Brandon et al, March 2020, pp 23- 28 24, NB See ‘Serious Case Reviews: Research into Practice, by Peter Sidebotham: seriouscasere-views.rip.org.uk, for an excellent video presentation of systems methodology and the pathways to harm model). 11.4 The approach uses the notion of organisational barriers and enablers that either hinder or em-power practitioners to make safe decisions and take actions that may lead to adverse or optimum safeguarding and welfare outcomes for children. The model seeks to analyse the intra and inter agency systems and processes that can provide opportunities to support prevention and protection, in addition to the pre-disposing vulnerabilities and risks for families that set the context for a ‘situa-tional’ trigger event such as infant crying, leading to infant NAI/maltreatment. 11.5 This review also uses the concept of, ‘layers of defence’ in minimising and mitigating harm to babies under one. Thus, the four stages of intervention contained in the CWAC SCP Continuum of Need (CoN) framework, namely, Universal, Universal Plus, Partnership Plus and Statutory Social Work intervention would correspond to four layers of defence. The ‘Prevent and Protect’ model of Infant NAI 11.6 The review has been informed by the, ‘Prevent and Protect’ model of systems and processes to support prevention and protection from SUDI (see parts 3 and 4; pages17-24 of the SUDI report July 2020); and is a refinement of the original ‘pathways to harm, pathways to protection framework’. This review argues that the Prevent and Protect model can be usefully applied to an understanding of infant NAI; using the ‘continuum of risk’ concept and the notions of ‘opportunities for prevention’ at the population level (corresponding to the Universal within the CWAC Continuum of Need frame-work) and ‘opportunities for protection’ responding to predisposing needs and risks of families with additional needs (Universal Plus and Partnership Plus CWAC continuum of need) and Statutory Social Work (Child in Need/Child Protection) safeguarding/child in need) intervention for families with children at risk of harm. 11.7 This report has also been underpinned by the review panel members considering the themes and questions contained in section 3 above and providing their analyses following remote panel meetings of July and October 2020. A rough first draft was provided by the lead reviewer in January 2021 to the panel for initial critique and a second draft was completed in April 2021. An on-line practitioners’ learning event (PLE) was held on the 15 July 2021. The learning has been incorporated into the analyses of the key themes. The panel considered a third draft in September 2021 and amendments were made resulting in draft 4, the current version. 11.8 The findings and lessons of this review were informed by the evidence presented in the short reports from members of the panel or practice leads, conversations between the Independent Author and Practice Leads and the Practice Learning Event. Because of the constraints imposed by covid 19 regulations and staff time demands, only a limited amount of hard data was able to be collected from audits 34so as to triangulate with the evidence from the panel and the PLE. The review is aware of the positive Ofsted Children’s Services Inspection report or May 2019 which, in relation to co-ordinated, inter-agency working noted at page 1 that, ‘There are strong partnerships in place, at both strategic and operational levels, and this leads to proactive and coordinated intervention for children. 34 This refers to a small-scale audit of five pre-birth assessments cited at paragraph 6.6.2 above. 29 |
NC52224 | Serious assault of a child in care by an adult in 2019, resulting in life-changing injuries. The perpetrator was the son of a member of the residential unit staff where PS lived. PS experienced many adverse childhood experiences (ACEs), including physical and emotional abuse. At 7-years-old he was removed from Mother's care and lived with his paternal grandparents under a Special Guardianship Order (SGO). PS was described as a troubled child, and in 2017 his grandparents felt unable to cope with his aggressive behaviour. Following several placements in foster care and in a residential care home, PS was placed in the residential unit where he stayed until the assault. Ethnicity or nationality not stated. Learning includes: it's critical that families involved in SGO placements receive information, advice and training on ACEs and the strategies they need to adopt to maintain the placement; agencies should have acted as responsible adults and asked for a previous assault of PS to be investigated. Victims of crime often are fearful of retribution. Recommendations include: ensure that the 'voice of the child' is routinely captured during assessments; ensure that measures used to determine suitability of residential settings for placing children are fit for purpose; ensure that newly-qualified social workers and practitioners working directly with children and families receive formal monthly supervision; staff working with children such as PS should be trained to spot and respond to early signs of exploitation, such as cash in hand work; staff and managers should know and be able to apply the principles of trauma-informed practice.
| Serious Case Review No: 2021/C8893 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. Child Safeguarding Practice Review PS Lead Reviewer: Jan Pickles OBE Official LCSPR -PS FOR PUBLICATION - March 2021 1 Contents 1.Glossary ......................................................................................................................... 2 2. The LCSPR Process, Author and Review Panel ............................................................ 2 3.Terms of Reference. ....................................................................................................... 3 3.1 Aim of the Review .................................................................................................... 3 3.2 Time Period to be Considered by the Review and Rationale: .................................. 3 3.3 Key Issues to be Addressed by the Review:............................................................. 3 4. The Facts ...................................................................................................................... 3 5. The child and family views ............................................................................................. 8 6. Key Decisions .............................................................................................................. 10 7. Analysis of events ........................................................................................................ 14 8. Wider significance ....................................................................................................... 16 9. Learning from events ................................................................................................... 17 10. Good Practice ............................................................................................................ 19 11. Recommendations for change ................................................................................... 20 Official LCSPR -PS FOR PUBLICATION - March 2021 2 1.Glossary ACEs Adverse Childhood Experiences: A Public Health model which identifies multiple negative experiences in childhood that impact on a person’s resilience to cope with life. A&E Accident and Emergency Unit CAMHS Child and Adolescent Mental Health Services LCSPR Local Child Safeguarding Practice Review MST Multi Systemic Therapy CSC Children’s Social Care Services LSP Local Safeguarding Partnership SGO Special Guardianship Order came into being in 2005 following the Adoption and Children Act 2002 used to legally place children in the care of usually extended family 2. The LCSPR Process, Author and Review Panel This LCSPR was convened in 2019 and was due to report in 2020. The panel met, and the relevant agencies produced their Information Reports in a timely way. The family and PS were interviewed at length and a draft LCSPR was submitted. However, due to the Covid-19 pandemic the report was delayed and, due to lockdown restrictions, the family did not have sight of the report until early 2021 which was undertaken virtually. However, during these difficult periods, an easy read feedback letter was drafted to be shared with PS at the appropriate point by his key workers at the request of PS. The lead reviewer is an experienced reviewer with a significant background in Safeguarding and Public Protection. She is a qualified and Registered Social Worker and has undertaken a range of roles in the public sector including as Assistant Police and Crime Commissioner for South Wales Police. She currently holds two Ministerial appointments in Wales as a member of the National Independent Safeguarding Board and as an Independent Member of an NHS Trust. She also Chairs the UK Advisory Board for the Centre for Expertise in Child Sexual Abuse. The Review Team Agency Role 1. Clinical Commissioning Group Designated Nurse 2 NHS Trust Named Nurse Safeguarding Children 3 Children’s Social Care Services Director 4 Police Child Abuse Team 6 Local Safeguarding Partnership Business Manager CSPR Officer 7 CAMHS (Attended the first panel meeting in September 2019) Safeguarding Lead Official LCSPR -PS FOR PUBLICATION - March 2021 3 3.Terms of Reference 3.1 Aim of the Review • The aim of this Review is to identify improvements that can be made to better safeguard children and to prevent, or reduce the risk, of recurrence of similar incidents. • The Review will undertake a rigorous and objective analysis of what happened and why. It will consider whether there are systematic issues, and whether and how policy and practice need to change. • It should be noted that the Review is not being conducted to hold individuals, organisations or agencies to account as there are separate processes for this. 3.2 Time Period to be Considered by the Review and Rationale: Following discussions by the panel it was agreed to extend the period under review from late summer 2017 to 2019. The wider context in which paternal grandparents came to care for PS was significant and therefore this review has attempted to provide that context to aid an understanding of these tragic events. 3.3 Key Issues to be Addressed by the Review: 1.Were PS’s views identified and considered by services involved in the review period? 2.Were PS’s grandparents appropriately consulted and involved in care planning for PS? 3.Were correct procedures followed regarding the making of referrals following the first assault in 2019 on PS? 4.Was an up-to-date assessment of PS’s needs available to all agencies involved in his care and completed in line with agency policies and procedures? 5.Was an up-to-date assessment of the risks posed to and by PS available to all agencies involved in his care and decision making? 6.To what degree and to what effect did agencies work together to ensure the best outcomes for PS? 7.To what degree and effect was management oversight of assessments, contact with PS and significant others established or sought at key points? 8. As PS was placed in care in another area, to what degree did this effect the level of supervision, care and oversight of his case? 4. The Facts 4.1 PS was seriously assaulted in 2019 by an adult perpetrator. The assault was captured on CCTV and suggested premeditation by the perpetrator. The injuries PS sustained were life threatening and PS was taken to hospital for lifesaving surgery. PS has made a remarkable recovery due to the skills of the NHS staff and his own tenacity. PS has suffered life-changing injuries from this attack and is awaiting further surgery and ongoing treatment. The perpetrator was imprisoned with an additional term on license. The perpetrator was the son of a member of the Care Home staff where PS was a resident. That member of staff has been charged with offences within Section 53 of the Regulation of Investigatory Powers Act 2000 (c.23) (RIP or RIPA) as the staff member failed to provide the passcode to their phone as requested as part of the Police enquiry. The member of staff had their employment terminated with immediate effect and is currently awaiting trial. Official LCSPR -PS FOR PUBLICATION - March 2021 4 4.2 As a child PS experienced a high number of ‘Adverse Childhood Experiences’ (ACEs) in his life. His birth parents were both young and are believed to have lived together briefly before separating when PS was under 2 years old. During this time, it is recorded the Police attended the home due to reports of incidents of domestic abuse. The report from Children’s Social Care (CSC) records state that PS, although no older than 8 years himself, took responsibility for caring for the younger siblings in the family. 4.3 At 7 years old, following a disclosure made to the school that mother’s partner had kicked, punched and threatened to throw him into a canal, PS and another sibling were removed from mother’s care and placed temporarily with paternal grandparents. According to CSC, parents received custodial sentences in response to the abuse inflicted on their children and PS and sibling went to live with paternal grandparents on an interim basis. Eighteen months later this arrangement was formalised when PS was made subject to a Special Guardianship Order because of the physical and emotional abuse experienced at the hands of mother and her partner. Records indicate that mother had a significant substance misuse problem and that biological father, with whom there was no significant contact, died from cardiac problems. PS remained in the care of his paternal grandparents until he was in his mid-teens and over these years experienced a period of stability due to the support and love they provided. 4.4 Police records indicate that PS’s mother had several partners whilst PS and his brother were in her care. They show also that she had several pregnancies with various partners, was young and had significant substance misuse problems. Domestic abuse was noted as being a feature within these relationships. 4.5 The Special Guardianship Order to the care of paternal grandparents was made when PS was 8 years old and the case was closed three months later by Children’s Services. However, according to PS and the family he was a troubled child due to the neglect and abuse experienced from birth. PS was described as quick to anger, obsessive and defiant. As a result of a request for help in 2017, CSC became involved with PS as a Child in Need. The CSC report states that the last six months of PS’s time with grandparents under the SGO were particularly difficult for the family due to PS’s deteriorating behaviour and that they felt unsupported by the intervention of CSC. It is recorded that CSC were considering closing the case due to the non-engagement of the grandparents. 4.6 The grandparents coped until PS’s behaviour became threatening and aggressive to them and his younger brother, and he had to be restrained. There were also concerns about his relationship with a younger female. These allegations were investigated jointly by the Police and CSC as a Section 47 Enquiry. This led to a series of interventions by CSC coordinated by a multi systemic therapy (MST) team and the specialist family support team. In addition, a Child in Need meeting was convened in 2017 in which it was noted: “There was lot of tension between Grandad and Social Worker due to feeling that CSC had let them down during the period of the Guardianship.” 4.7 During his childhood PS experienced continuity in his education attending two mainstream schools (primary and secondary) despite multiple moves by the family. Both schools provided significant Special Educational Needs support for PS. However, as his home life began to unravel so did his behaviour in school. PS began having difficulties in the secondary school which came to a head when it is alleged that he attacked a staff member around the same time as the problems at home were escalating. Shortly afterwards he was placed in short-term respite care and had to manage a change in education; from then on PS did not return to his grandparents’ care. In 2017, with the oversight of the specialist virtual school provision, alternative education provision was sourced. PS initially had Official LCSPR -PS FOR PUBLICATION - March 2021 5 difficulties settling in as within two weeks PS was excluded for ‘throwing a chair’. In 2018, PS made an allegation that he was being bullied and in a few weeks was himself excluded. Despite these difficulties the specialist virtual school provision built a supportive and effective relationship with PS. It is also encouraging and significant to note that, despite being placed out of borough, PS continued to attend school, albeit less regularly. PS's continued engagement with the school is a significant testament to the strength of relationships, supervision, care and oversight provided by the school, especially given the level of disruption in his life. 4.8 As stated, PS’s behaviour at home had deteriorated in 2017 with aggression, threats, assaults of his grandparents and brother, self-harming and periods in which he was missing from home and damaging the home. The triggers for this deterioration can only be speculated upon but are not known to professionals at this point. It is known that PS was aware that his father had died of a heart condition a few years prior. Later he learned that an elder sibling had taken his own life in 2018. The impact of these events and the loss of his family could be assumed to have some significance, but they are not referred to within the records relating to PS and his treatment. 4.9 PS was referred to CAMHS following an attendance at A&E in 2017 due to further aggressive behaviour at home. He was assessed by CAMHS who felt that his behaviour was not the result of mental health issues and that the service the family were currently receiving (MST) was appropriate. It was also suggested that PS may be on the Autistic Spectrum. The grandparents describe the suggestion of possible Autism as particularly helpful as it helped them to understand PS’s behaviour and reframe it from his being ‘naughty’ to being a result of a known behavioural condition which could not be helped. At this appointment he was prescribed Risperidone for his impulsive behaviours. PS then attended five further appointments with CAMHS where his medication was increased and further medication prescribed to help him sleep. At this point psychotherapy was discussed because of his childhood trauma but no decision made. It is a concern that these contacts appear to have focussed on establishing a diagnosis and possible treatment plan solely. The Panel felt it would have served the interests of all concerned, but particularly the grandparents and PS, if alongside assessment, PS and his grandparents could also have been helped to manage his behaviour. Records suggests that Social Workers involved with PS spent too much time trying to meet the requirements laid down by CAMHS to access treatment. Time and attention focussed on this endeavour seems to have removed the focus and diluted the energy of the Social Workers to the point that no other type of intervention was considered or tried. It is significant that PS’s Social Worker had only just secured funding for him to be placed in a therapeutic placement and so able to receive the treatment CAMHS recommended when he was viciously assaulted. It is also ironic that due to his life-changing injuries from that assault, a further assessment will have to be made to secure CAMHS’ help in the future. 4.10 The crisis point came in the summer of 2017 when PS was taken to A&E due to his grandparents feeling unable to cope. It is said that the trigger for this decision was PS ‘barricading’ his sibling and cousin in a room following a row in the home. PS had not been taking his medication to control his impulsivity. CAMHS felt he was fit to be returned home as this behaviour was not thought to be due to mental health issues. On discharge from A&E, his grandparents refused to have him home with them. A two-week period of respite care was agreed with the grandparents and a temporary foster care placement was found for PS to allow time and space to develop a plan to enable PS’s return to his grandparents. However, at the end of this period, the grandparents did not feel able to cope with PS and did not allow him to return home. PS was found a foster placement – it was to be the first of Official LCSPR -PS FOR PUBLICATION - March 2021 6 four placements within a six-month period, three of them breaking down due to what were to become recurring issues – poor behaviour, aggression, self-harming, substance misuse and the influence of anti-social peers. 4.11 The foster care placement which began well broke down after less than four months due to concerns about PS’s behaviour which included assaults on staff in school and a resident at the placement, drug and alcohol misuse and increasing contact with anti-social peers. It was at this point, as the foster care placement was at the point of breaking down, that CAMHS began a psychotherapy assessment late in 2017. Six days after that appointment, PS was admitted to A&E after being found on the roadside unconscious due to alcohol misuse and was seen later the same day by CAMHS as part of the psychotherapy assessment with no reference to this incident. A further appointment took place a few days later in which “intensive assessments were undertaken” and he was warned that psychotherapy would be “a long and painful process”. This suggests that CAMHS were either unaware of the breakdown of the foster care placement and the admission into hospital, or that they continued their planned work despite these events. The CAMHS Information Report does not note these significant background events, only their appointments with PS. The Foster Carer gave notice to the LA of the placement end after the incident. 4.12 There was a LAC Review held late in 2017 in which it was agreed that the Care Plan now was not to return to the grandparents but to seek a long-term foster placement. It is not stated how this change was communicated to PS, nor how it was received. It is noted that throughout the first placement PS had stated his desire to return home and that he missed his grandparents. 4.13 Late in 2017, PS moved into a Residential Home where, after several serious incidents including him assaulting a member of staff in school resulting in another exclusion and a resident in the Residential Home, he was moved into an emergency foster placement early in 2018. Within two days of moving into this placement he was again admitted to A&E following a drugs overdose, and then ten days later was again admitted having self-harmed by drinking bleach and consuming washing powder tablets. He was seen by the hospital specialist support team who assessed him as having no mental health needs but did express concern for the safety of other children in the Residential Home. He remained in hospital for three days until a suitable alternative placement could be found. It is recorded that PS had self-harmed as he did not want to remain at his foster placement. PS was then accommodated in another Residential Unit in another area, stated to be “the only placement willing to take him”. He remained there until the assault. This was the fourth placement in six months. 4.14 PS’s behaviour remained challenging but able to be managed by the home, and CAMHS noted that PS was settling in and managing to focus on his exams. A professionals’ meeting was held at CAMHS in the summer of 2018 attended by a range of professionals. At that meeting there were concerns expressed by the Psychotherapy Team within CAMHS as to how psychotherapy would impact upon PS’s existing mental health and if he would be able to contain his emotions as the therapy intensified. The question of whether PS should be transferred to a more secure unit to enable this was considered but no decision taken. PS was admitted to A&E in late summer of 2018 following an incident of self-harming due to feeling low. It was noted that the carer from the Residential Home stayed with PS at the hospital overnight. 4.15 PS’s behaviour continued to be challenging, both at the home and at school, but records indicate there was positive partnership work between CAMHS and the Psychologist Official LCSPR -PS FOR PUBLICATION - March 2021 7 employed by the residential placement. PS was described as attending education, not thinking about self-harming and “managing better”. His medication was reported to have been reduced in consultation with CAMHS later in 2018 as a result. PS stated that he would like contact with his birth mother and a month later requested help with his mental health from his Social Worker. During the same period, CAMHS recommended that PS be moved to a placement that would offer enough support to enable the impact of psychotherapy sessions to be managed safely. This plan was reversed a month later – the decision was made instead for PS to remain at his current placement and for psychotherapy sessions to be carried out there, mainly due to PS’s positive engagement there. PS’s Social Worker reported him to be “happy, settled and secure” at the Residential Unit. 4.16 Late in 2018, PS’s funding arrangements for his education provider ended. At the end of 2018, PS was described as a child not in education, employment or training (NEET) and continued to be supported by specialist school provision with targeted employment support which enabled him to secure a number of GCSE passes despite the disruption caused by his frequent moves, exclusions and non-attendance. 4.17 The time of relative stability for PS that had existed in the new placement would begin to break down from the end of 2018 onwards. From 2019 there followed several significant incidents within a three-month period that were to have serious consequences for the plans being made for PS and his life. In 2019 PS deliberately ‘wound up’ another resident and caused damage to the home before storming out. The next day PS was assaulted by six men and hit with a crowbar outside a ‘car wash’ he was working in and he was robbed of £20. This assault was described as a ‘fight’ by the staff at the Residential Home, which seemed to underestimate the significance and likely impact on PS. 4.18 The report from the residential setting states that the assault on PS was discussed with a Police Officer but not recorded by them as a crime as PS did not wish to proceed. However, Police state that the matter was not reported to them and this is confirmed in the CSC Information Report. The residential setting report states further that in line with PS’s wishes, the staff at the Residential Unit and PS’s Social Worker agreed that they would not take any action. This decision was not in line with safeguarding practice. It is not known whether this was a random robbery or part of an ongoing dispute. A few days later due to having self-harmed, PS was admitted to A&E. He described having problems ‘where he was living’ and that he had been feeling suicidal but was now OK. A few days later PS disclosed to his Social Worker that he did not want to stay at the Residential Unit any longer. At his CAMHS Medication Review, the assault and robbery which occurred the month before was not addressed and the Social Worker from the Residential Home simply reported that “he had a good week; he had been out and about with staff. There was no further self-harm or thoughts of self-harming”. 4.19 There were further concerning incidents including cannabis being found in PS’s room and Police being called to an incident when PS repeatedly punched a male to the head as he left a McDonald’s site following an argument over a girlfriend, and in defiance of staff from the home insisting he return with them. This incident suggests both PS’s heightened anger and aggression but also the inability of external forces and sanctions to control him. A few weeks later a knife was found in PS’s room, and he stated he found it and kept it for protection. A week later PS assaulted a member of staff and was involved in a serious incident involving others from the home in which a car was damaged and staff threatened and assaulted, as a result of which PS was arrested. Shortly before PS was seriously assaulted (the incident which initiated this report) PS asked staff members if they would lend Official LCSPR -PS FOR PUBLICATION - March 2021 8 him money, returning later with new clothes. In a four-week period there were four incidents of PS either threatening or assaulting staff and residents at the home or damaging property. 4.20 The Special Guardianship arrangement remained in place for PS and his younger sibling and, following surgery, PS was cared for by his paternal grandparents at their home for seven weeks. PS then moved into a Residential Unit preparing him for independence. 5. The child and family views 5.1 In autumn 2019 the reviewer met with PS, his paternal grandfather, step grandmother and sibling at the family home, which was warm and welcoming. The reviewer’s view is that the family members communicated with each other in an open and supportive way. PS’s grandparents have provided stability and loving care for both grandchildren and, despite the trauma following PS’s removal into care and assault, still do so. The grandparents described to the reviewer the traumatic events that led to PS and his sibling being removed from their mother’s care and placed temporarily with them initially. At the time it was thought that the sibling was not their biological grandchild, but they could not bear to separate the two frightened and traumatised children. Together with his sibling, PS was eventually placed on a Special Guardianship Order (Adoption and Children Act 2002 came into operation in 2005). During the Special Guardianship Proceedings, the Judge ordered a paternity test which established they were full siblings. Grandparents believe that in order to help them care for the two children they should have received assistance both financially and to help them build resilience and coping strategies to help the traumatised siblings adjust to their new life. Instead of that, PS’s grandparents describe pawning jewellery to buy the children beds and clothes and feeling out of their depth and isolated with two such traumatised children to care for. They strongly believe that help at this point could have given them a greater understanding of the children’s individual needs and the strategies for meeting them and may have helped avoid the tragic events that they have all endured. 5.2 The grandparents believe PS was one of nine children born to his mother with one child being removed at birth. Prior to this crisis, his paternal grandparents had attempted to support PS’s mother and PS by taking them away on caravan holidays, buying toys and a computer and providing money for food to his mother. They believe these gifts were sold to fund her drug misuse. Nowadays PS has no face-to-face contact with his mother and only occasional Facebook Messenger contact. He has limited contact with a few of his half siblings, sadly the eldest of whom has taken his own life; PS’s grandparents understand that traumatic childhood experiences and their impact were the prime cause for the suicide. 5.3 Grandparents managed to cope with PS’s anger and distress and believe they needed but did not receive specialist professional help and guidance to manage. The exception to this was when PS was assessed by MST in 2017 as being on the ASD Spectrum. Grandparents describe this as a helpful service bringing them to understand at last that PS was not just being “naughty” but that the behaviour was related to physiological factors. This helped them to understand this behaviour and helped them to stop blaming PS and/or themselves when it happened. PS too benefitted from this insight and began to understand it was related to how his brain worked differently to others; this helped PS to recognise and sometimes prevent triggers that could lead him to lose control and also to stop seeing it as his fault for losing control. PS told the reviewer that he needed longer than others to process and understand instructions and that he can become obsessive over things and with people. During the interview he nodded confirmation constantly when spoken to, an example of a strategy learnt which others develop naturally to reassure that he understands what is being Official LCSPR -PS FOR PUBLICATION - March 2021 9 said. This was observed by the reviewer during conversations, when PS was nodding even when it was likely he did not truly understand. This was believed to be another learnt behaviour to avoid conflict, criticism and perhaps ridicule from others. It could be reasonable to surmise therefore that for PS, everyday engagement with others can be quite a taxing exercise. It is a measure of PS’s ability and determination and the support he received from family and education providers that, despite these difficulties, he was able to secure academic qualifications. 5.4 By early 2017 PS’s grandparents were feeling they could no longer cope with PS. The final trigger that led to this decision happened in the summer of 2017 when PS’s ‘barricaded’ his sibling and cousin in his room, following a row in the home. PS had not been taking his medication to control his impulsivity. The grandparents were particularly fearful of PS fire setting in his bedroom and the risks to him and the other children in his room. They told the reviewer that this decision was reached after much thought and they tried to pressurise services into providing a therapeutic environment for PS believing that the early experiences of neglect and abuse were the root cause of the current behaviour. PS has little memory of these earlier events but told the reviewer that he asked to be arrested by the Police as he did not want to cause any more upset to his family. At that time, he describes his behaviour being impulsive and destructive, fuelled by him feeling overwhelmed and angry. 5.5 These behaviours continued and caused the breakdown of the initial foster placement and then the first Residential Home where again he did not cope and continued to exhibit distress. From here he was placed in an emergency foster care placement where PS describes how his distressed behaviour caused an experienced Foster Carer to lock him in the garage as the only way to keep him safe. In spring 2018, PS moved to another Residential Unit where he remained a resident when assaulted. Initially PS described how he was one of two children placed in the unit with a small staff group. PS believed he settled in well and was receiving good support from his then Social Worker. The family believed they, with the Social Worker and CAMHS, were working towards obtaining the much-needed therapeutic support for PS. However, at this point, although CAMHS agreed that PS needed help, they were unwilling to undertake psychotherapy with him unless he was in a specialist residential placement that could ensure his and others’ safety during the therapeutic work. The grandparents believe funding was just being secured for this when PS was violently assaulted. 5.6 The final Residential Unit was described by PS as initially being a place where he felt safe but as the numbers of children and staff increased it became an unsafe environment where he could not manage his distress. PS described numerous incidents of internal door windows being broken, furniture damaged and rooms “trashed” by other distressed residents. PS felt staff had no control and that a member of staff was assaulted by a resident. PS believed staff did not like him, a view shared by PS’s grandmother, who described the staff member as being much less professional when making contact with her than other members of staff. On one occasion the staff member called in mid argument with PS and was unpleasant and derogatory about PS to her. It later emerged the staff member was the parent of the perpetrator who seriously assaulted PS. PS was told that he was known by the person who committed the assault, and PS later remembered a previous acquaintance with the perpetrator. 5.7 Following the assault in 2019 the staff member went to the hospital and stayed with PS’s grandmother at his bedside refusing to take a break. At the time PS’s Grandmother thought this was odd behaviour from a member of staff who she believed did not care for PS but was Official LCSPR -PS FOR PUBLICATION - March 2021 10 too upset to address this as she feared PS would die. At no point did the staff member reveal being related to the assailant. 5.8 Early in 2019, prior to the serious assault, PS was assaulted and robbed by a group of six males with a crowbar outside of the car wash where he was working on a ‘cash in hand’ basis. £20 from stolen from him, and PS stated that he was warned “not to speak to a staff member like that” by the boy with the crowbar but did not know who he was talking about. The same staff member had accompanied PS to work on a few occasions and knew where the car wash was. Following the sentencing of his assailant, his picture was printed in the local newspaper; PS recognised him immediately and rang his grandmother to tell her it was the boy who had threatened him in the earlier incident when he was robbed and threatened. PS had reported this robbery and the threats he received to staff at the Residential Unit, but they had not reported it to the Police nor supported him to do so. There is no evidence of the Regulator being informed. The family believe that had this been done and investigated then the later assault on PS could have been prevented. During the trial, CCTV was used to identify the assailant. As the robbery and attack occurred in the same place (just outside the car wash) his grandparents believe the same camera could have provided coverage of the earlier unreported attack and identified those responsible. It seems that both staff at the home and PS’s Social Worker were swayed by PS’s desire not to proceed nor contact the Police rather than follow safeguarding procedures. 5.9 The family believe that the Residential Unit was not fit for purpose, as following PS’s discharge from hospital after the attack various staff members visited PS at the grandparents’ home and behaved in an unprofessional manner. Some revealed they were not trained to manage the residents including the then Manager. It appears these concerns were shared by Ofsted who closed the Residential Unit after the assault. 5.10 At the time of writing PS is due to return to hospital for further surgery to insert a metal plate into his skull and he will require ongoing treatment and support following this terrible attack. His grandparents are fearful for PS’s future as they do not believe he will now be able to manage independently or is being equipped to do so given the impact of the injuries sustained. 6. Key Decisions 6.1The family feel they were not offered enough support or services when PS and his brother came to live with them. At no point did they feel they were given the knowledge, understanding and skills to enable them to support the children as part of the Special Guardianship Order. Foster Carers are given skills to foster, and other agencies supporting Foster Carers offer quick access to a Psychologist and a Social Worker for them as well as one for the child. There is little difference between the Foster Carer’s role and that of Special Guardianship other than the child and carers being related. The level of trauma experienced and being held by the children when they arrived to live at their grandparents’ home required a multi-faceted response containing practical, emotional and psychological support and advice over a period of years which the grandparents feel they did not receive. Given the level of trauma and the existence of a high number of Adverse Childhood Experiences (ACEs), which the Police report documents, breakdown of the SGO without additional support was likely. This is a national issue, particularly in relation to cases of a similar nature. 6.2 In late 2017 PS’s foster care placement was flagged by CSC as breaking down and it did so weeks later, prompting PS’s fourth care move to the Residential Home where he resided when the incidents occurred. During the same period, psychotherapy services became involved with PS and six days after an appointment PS was admitted to hospital having been Official LCSPR -PS FOR PUBLICATION - March 2021 11 found at the side of a road unconscious as result of drinking large amounts of alcohol. CAMHS appeared to continue this assessment and at a further appointment PS was warned that psychotherapy would be “a long and painful process”. This suggests that CAMHS were unaware of the breakdown of the foster care placement and potentially the admission into hospital or continued this intensive work despite that knowledge. The CAMHS Information Report does not note these significant events running alongside their interventions but refers to ‘good multi-agency working’. There is a note in the CAMHS report which indicates some knowledge of the unstable nature of PS’s accommodation status - “PS was also a little anxious as the placement was coming to an end and another was needed as stand bye (sic)”. This was a positive step from CAMHS in PS’s therapy journey. It is difficult to imagine a child, particularly one traumatised by past events and recently removed from their one known source of stability and security, being able to participate in such an intensive experience as a first session of psychotherapy. It would be disappointing if CAMHS were aware of the recent as well as the past traumatic events if they continued in their work with PS on these two occasions despite this. 6.3 During a scheduled psychotherapy appointment at CAMHS in which PS, a number of other professionals and PS’s grandparents attended (but not PS’s Social Worker, who had left the team, nor a representative from CSC) they discussed the risks of harm that PS could pose to others. According to CAMHS record, the psychotherapy team stated their concerns, along with PS’s grandparents, about the capacity of PS to harm others in the light of the information about the serious assault perpetrated by PS at a McDonald’s site where he banged a young person’s head against a wall. The representatives in the meeting appeared to agree (the notes are not explicit in this) that PS could be managed in the placement as advocated by the Residential Home’s representative at the meeting. It is of concern that such an assessment was made without the input of CSC who were the main agency responsible for PS and the only agency with access to all the information concerning PS’s behaviour and potential risks. There is no evidence of communication of this discussion to CSC. CSC were legally the Corporate Parents of PS and as such should have been involved in this meeting. The group were informed of the Social Worker having left the area and that a replacement was not available. Given the Corporate Parent role of CSC, good practice would have been to rearrange the meeting or at least defer the decision as to PS’s risk and suitability of placement to a date when a CSC representative could attend. As the Corporate Parent, CSC were carrying the responsibility for any such risks identified. 6.4 Early in 2019 PS was violently assaulted and robbed and days later contacted his Social Worker to say he was fearful about remaining in the area and that he did not feel safe. No record of any discussion with PS by the Social Worker, or any reassurance being offered to him concerning his fears, has been seen. Nor is there evidence of this being discussed in case supervision with the Social Worker’s Line Manager, which did occur and noted that: “The placement was settled.” PS’s concerns for his safety were not shared at his medication review at his CAMHS appointment which followed. If anything, a much more positive view was painted by the Residential Worker who described PS as “calmer”. The report from the Residential Unit refers to a “fight at work” and not a violent assault and robbery. This suggests the event was minimised by staff who may have become normalised and desensitised to such behaviours and their impact. Supervision, training, and management scrutiny are required to address the effects of these common dynamics or the dangers of unconscious bias in which such acts are seen as ‘the norm’ for such groups. This may also account for the fact that, despite the escalation in PS’s poor behaviour at the unit, residential staff did not flag these behaviours nor ask for a strategy meeting until months later. Other concerns are the lack of communication or possibly weight given to information provided by field workers to the CAMHS team concerning these events. It does not appear that they took Official LCSPR -PS FOR PUBLICATION - March 2021 12 any account of how the sessions with PS were to be managed. This could be a case recording issue in which such issues were addressed but not recorded. 6.5 The Residential Unit where PS lived prior to the assault was next door to an Unregulated Home for children of the same age, some of whom were placed from outside the area as well as an ex-resident of the Residential Unit. The Unregulated Home provided residents with greater freedom, had a much lower staff-to-resident ratio, gave residents a much higher living allowance (£57 compared to £10 per week where PS was placed) and a lower level of oversight cover. The co-location of two Residential Homes for disadvantaged and vulnerable young people in one local area caused both homes and the local neighbourhood significant problems in terms of anti-social behaviour and influence. The Panel were of the view, which was supported by practitioners and managers at the reflective learning events, that if possible, any ‘Change of Use’ Applications to the Local Authority for the establishment of an Unregulated Home near a Children’s Home should consider the likely effects and impact on the residents of the homes and the neighbourhood. The appropriate planning staff and councillors should receive appropriate safeguarding training with a focus on managing risks of this kind. As a result of learning from this event, it is a recommendation that current local planning regulations are explored to ensure that if the Local Authority has the power to restrict similar applications, it does so. The grounds of any restriction or refusal of a Change of Use application would be the impact it may have on environment, community and the welfare of the vulnerable children and young people residing in the units. 6.6 PS worked on a ‘cash in hand’ basis at a car wash – a fact which his Social Worker, Psychiatrist, employment advisor and residential staff (who sometimes dropped him off and picked him up from the car wash) were all aware of. Hand car washes are known ‘hot spots’ related to organised crime and exploitation. This placed a vulnerable Looked After Child in a potentially risky environment. PS was pleased to have found this work via a friend in the autumn of 2018 but became anxious about working there and left in early 2019. After that he began to express concerns about his safety in the area to his Social Worker and residential staff and was found with a knife in his room. In spring 2018 PS asked a staff member if he could borrow money then went missing and came back with new clothes, refusing to say where he had got them from. These are all recognised potential signs of exploitation. It would appear that at no point was Criminal or Sexual Exploitation considered by services despite him being in a high-risk group in terms of vulnerability. In addition to concerns regarding this, it was highly likely that his employment and renumeration were illegal in terms of revenue if not criminal law. This behaviour was being endorsed, at least implicitly, and is far removed from the example of leading a productive and law-abiding life that such services should be setting to its service users. 6.7 Early in 2019, PS was treated at A&E with bruising to the head and left hand following an alleged assault. PS stated he was "sitting in car with a friend after work" when he was approached by "six men in their 20s" who told him to get out "or they would attack him". PS told the A&E doctor that they "pulled the car door open" and then hit him on the left side of his head and left hand "with a crowbar”. The Doctor completed a MARF as this was seen as a safeguarding incident. However, the response by those with responsibility to care for PS following this assault is significant in its failure to protect PS and implicit acceptance of the harm that had been done to him. Records from the Residential Unit suggest that they informed PS’s Social Worker and spoke to the Police about the assault. They state it was agreed that no action would be taken regarding reporting this matter as a crime as PS did not wish to do so. However, the Police state they were not told of this assault and that it was described to them as a ‘fight at work’ – a significant minimisation. The Police state that had they been told of the assault they would have been required to record and treat it as a crime Official LCSPR -PS FOR PUBLICATION - March 2021 13 and proceed as such. It is likely that had the prosecution been pursued, evidence would have been available to have made a successful prosecution likely. We cannot predict the impact this would have had on PS, but it may have changed the escalating spiral of violent and anti-social events involving him and others known to him in the area. Clearly the issue of whether the Police were told and to what level they were consulted is important here in terms of an opportunity to intervene not being taken. It is accepted that both staff at the residential unit and PS’s Social Worker were aware of the assault and did agree to go along with PS’s wishes not to pursue the matter. This review has been unable to make a finding of fact related to these two versions of agency actions. Similarly, both staff at the Residential Unit and PS’s Social Worker knew that his behaviour had been deteriorating – he had been involved in acts of violence and damage to property and was known to carry a knife, and in view of this, the assault should have been seen as significant escalation in risk to him and possibly others. This acceptance suggests a tolerance of harm and risk for a Looked After Child and those around him that does not meet the standard expected. 6.8 The level of ACEs experienced by PS required a therapeutic response from the outset of Local Authority Services becoming involved with PS and his family. From the record it appears that the impact of such events on PS and his sibling were not considered, nor a plan made to ameliorate the impact when PS and sibling were removed from their mother’s care due to the abuse they had suffered. Indeed, the funding formed an important part of this plan: Psychotherapy by the CAMHS Team was not agreed until 2019 and even then could not be carried out as it was unclear whether such therapy required a different setting to the one in which PS resided at that time. On the contrary it seems that CSC did not consider these needs whilst all seemed well with the grandparents’ care of the children, despite all the known evidence concerning the impact of abuse on the emotional and physical wellbeing of children. It seems services only became involved in response to the grandparents’ request for help at crisis point in 2017. Had services been proactive and assumed that the family would need support taking on two vulnerable children at an earlier stage, the breakdown in 2017 may have been avoided and possibly the traumatic events that followed that breakdown also. It is a firmly held view of the Panel that CAMHS should have been more proactive at the time when PS was attending appointments, cooperating, relatively settled emotionally and engaging with services offered. The panel felt CAMHS could have worked with PS and his grandparents to address the difficulties they were all facing. The Psychotherapist had successfully established a working relationship with both PS and his grandparents. It is the Panel’s regret that this opportunity was not capitalised on during this period of active engagement by PS. 6.9 In the view of this reviewer, the failure by professionals not to override PS’s wishes and formally report the assault early in 2019 to the Police was misguided and ill judged. It breached safeguarding principles in every aspect alongside the impact on PS himself. It also prevented broader considerations, for instance whether the assault was part of a wider set of circumstances possibly involving organised crime, gangs or other elements of extortion for drugs or other debt. The CSC Information Report acknowledges a lack of information sharing with the Police by the Social Worker over this assault, all of which clearly indicates safeguarding concerns. What is evident is from that point on PS was fearful about remaining in the area and was found with a knife in his room. Ofsted reportable incidents in Schedule 5 include ‘a. Child involved in or subject to or is suspected of being involved in or subject to, sexual exploitation and b. Incident requiring police involvement has occurred in relation to a child which the registered person considers to be serious’. These events would have met these criteria and should have been reported irrespective of the wishes of the child. Official LCSPR -PS FOR PUBLICATION - March 2021 14 6.10 The key decision for a period of respite to determine what intervention was required for PS to return to the care of his grandparents in 2017 became a decision to obtain a long-term foster placement, possibly in response to the grandparents’ refusal for him to return to them. This is the pivotal decision that led to PS’s behaviour worsening and the inability of any placement to ‘hold’ him due to his anger, frustration and sadness at not being able to live with his family, which he knew to be due to his own behaviour. Such a decision may have been thought to be necessary on a pragmatic level. It does however raise two questions; i) Why weren’t the likely consequences of PS’s grandparents not feeling able to have him home discussed with them? Why was it not made it clear to the grandparents about the type of places and level of care he was likely to experience and the possible impact on him in terms of disruption? It is clear they did not know how the care system worked yet it seems their expectations were never checked out with them. ii) Assuming the grandparents would be willing to have PS home if they could manage him, why was a plan not formulated to provide the support they needed to enable this? There is no evidence in any of the documents of either actions being taken or considered to enable PS’s return. CSC recorded in 2017 that the grandparents felt PS’s return to be impossible unless they could move into a house with an additional bedroom to separate the siblings. I am aware that PS and his sibling sharing a bedroom was often the catalyst for arguments. Why was there no advocacy with the Housing provider to enable a move to a house with an additional bedroom? Or a discussion with the grandparents to plan to enable them physically, financially and emotionally to manage PS’s return? This may have helped the grandparents to feel they were being supported practically and to be more confident in taking the risk of PS returning to them. 6.11 The absence of supervision notes regarding these key issues suggests that supervision played little part in the decision making or guiding of the Social Worker concerned. I aware that PS had six different Social Workers allocated to him from the time of his becoming a ’Child in Need’ to his assault. I am assuming from turnover of staff that the allocated Social Workers involved would not have had much prior knowledge of PS or the case, and that case supervision would have been of help in terms of decision making and passing on knowledge and experience of the case. 7. Analysis of events 7.1 Before commenting on this it is important first to note that PS had six Social Workers working with him and his family over 18 months from 2017 to 2018. Given this degree of turnover of staff it is difficult to expect that they would be able to identify, connect with and engage with other agencies immediately. Equally the other agencies experiencing this degree of turnover in staff were likely to become a little disillusioned in working with personnel who were again starting from a low knowledge base of their role in PS’s care. 7.2 There is little evidence of CSC working with the grandparents once PS and sibling were removed from their mother and placed in their care. On a practical and emotional level, it appears the grandparents were entirely dependent on their own resources to accommodate the two children. The grandparents describe having to pawn goods in order to buy beds and continued to live in a house too small for two additional children. Implicit in these observations is the message that they were left to it by CSC. In the defence of CSC, there is no evidence that grandparents ever explicitly asked for help before early 2017. It is clear from the Child in Need meeting in the summer of 2017, which makes reference to the ‘tension’ between PS’s grandfather and the Social Worker, that working relations were poor and unlikely to be able to secure positive outcomes as things stood. Crucially there was no Official LCSPR -PS FOR PUBLICATION - March 2021 15 evidence that CSC engaged with PS’s grandparents in order to establish what they needed to be able to have PS return to their care and did not seem to discuss their decision and the implications of PS being made subject to a Care Order with the plan changing to long-term foster care. 7.3 Similarly the relationship between CSC and CAMHS was not effective. PS’s Social Worker spent a lot of time and energy trying to access help and support from CAMHS who then would stall any commitment on their part by requiring further assessments, reviews of PS’s emotional state or suitability of the accommodation to sustain the work planned. To the Social Worker’s credit, they persistently tried to access help, but this was at the cost of considering other more immediately accessible support. Information exchanges did not seem good either with significant events not seeming to be on CAMHS’s radar when working with PS. The Psychotherapist from CAMHS was a consistent professional who did engage and was an available point of contact with PS. However, there are no references to liaison with workers in the community or vice versa with CAMHS in relation to PS. 7.4 CSC met with other key professionals in PS’s care at the Looked After Children’s meeting to which Education Services generally sent a representative. From the notes shared of those meetings it seems that the various education providers generally managed PS on their own and used their own means of rewards and sanctions to manage his behaviour. There was not much evidence of worker to worker contact nor of the Social Worker maintaining oversight of his progress and behaviour. It would seem that the Social Worker was taken up with the task of keeping PS accommodated safely and responding to crises and did not have the space to consider educational matters. Clearly in the long-term this was unfortunate. Records available make little mention of supervision and none of reflective supervision in which the worker is helped to review how they responded to current situations as a tool for further learning. There are no entries in the records detailing advice being sought or given in terms of how to manage PS and whether his supervision was effective in reducing risks both to and from him, despite his known history both before and after his removal from his mother’s care. Management oversight is invisible in this case other than in terms of funding matters, responding to crises or other legal or practical matters. 7.5 It is noted that it does not seem that the Advocacy Service were ever engaged to help PS present his views in any of the many forums that were meeting to discuss his future, nor of any strategy meetings being called in response to the assault in early 2019 nor any of the other matters that PS was involved in. All such episodes appear to have been dealt with as individual incidents by the professionals involved, rather than being identified as a pattern of behaviour that required co-ordinated responses involving Police, Education, Substance Misuse, Youth and Diversion Services etc. 7.6 From the outset of PS being removed from his grandparents’ care all foster care placements were out of area. Although this was probably not by choice, the family have not identified this as an added barrier to their continuity of involvement. A Panel member from Health believed these frequent moves outside of the originating Local Authority meant that professionals did not get to know PS well and take ownership of his care. Moving GP surgeries meant he did not build up a therapeutic relationship with any one doctor. The Residential Unit is overseen by the Local Authority in which it is located, but they would not be privy to PS’s issues and needs, therefore they did not appreciate how inadequate the placement was. This may also have had an impact on the continuity of care and the ability of the Social Worker to obtain and co-ordinate services in an unfamiliar area. There are no documentary references to substantiate this. The placing authority (CSC) continued to provide the Social Work resource, however all other services (educational, fostering and Official LCSPR -PS FOR PUBLICATION - March 2021 16 residential) were and had to be provided from the area in which PS was resident. This may have caused communication and difficulties in succession planning on top of the disruption already experienced by PS. It is to PS’s credit and a testimony to him and the education providers that, despite the trauma and dislocation in his life at a critical time in his education, provision continued and he did secure GCSE qualifications – an amazing feat. 8. Wider significance 8.1. The Local Authority should be required to recognise the possible significance when considering a planning application for ‘Change of Use’ of the impact of the proposed change on existing facilities in close proximity, such as Children’s Homes or other establishments which accommodate vulnerable children or adults. Such co-locating could lead to increased risk both to the residents of the co-located units and the local community. This issue may be beyond the powers of the Local Authority to address. This in itself needs to be clarified and if it is the case then the possible impact of such ‘Change of Use’ applications should be taken to the appropriate national forum so that the issue of restricting risk near Children’s Homes in the future can be raised there. 8.2. Following the assault early in 2019 a Section 47 Enquiry should have been triggered and the Residential Unit should have reported the matter to Ofsted. The practice identified in this case suggests that neither the Social Worker nor Residential Staff worked in line with safeguarding principles in their failure to report PS’s assault by a group of males using a crowbar to the Police. At this point we do not know whether or to what degree Police were aware of the assault, as Police state they were not informed of it, which is confirmed by CSC. However, the report from the Residential Unit states that the matter was discussed with the Police. This failure meant that the Police, who may have used this information as intelligence in terms of issues such as organised crime or Child Criminal or Sexual Exploitation, could not do so. It also meant that the wider issue in terms of PS’s safety were not able to be explored. Was he targeted? If so why? Was there a continuing risk to his safety? Did he need to be moved for his own safety? These were all questions that did not appear to have been considered by the responsible professionals. 8.3 It is striking throughout the Information Report from CSC how few references were made to decisions or significant issues being discussed with managers, either in formal or informal supervision. This is concerning as PS had six changes of Social Worker in the 18 months leading to his assault in 2019. Changes of Social Workers are known times of heightened risk for the service user and the organisation. It is reasonable to surmise that maintaining grip and continuity with a case in which change and escalation could occur so quickly would be difficult for a new worker unless they were supported purposefully by a manager with some background knowledge of the case. The issue of the frequency, quality and nature of supervision and management oversight in general of such cases, particularly but not exclusively of new staff, should be reviewed with a view to identifying whether the current approach is adequate to support staff and keep children safe. 8.4 Inter-agency communication did not seem to work very well in this case, particularly concerning CAMHS, the CSC Social Workers and the residential workers. Significant events that involved PS – arrests, assaults, fights and A&E admissions – did not appear to figure in the sessions or meetings conducted by CAMHS and significant decisions, such as whether PS posed a risk to other residents, were made without the input of the Social Worker or CSC representatives. It is not clear from the evidence whether such failings were isolated or representative of a wider issue nor whether they were systemic or cultural in origin. However, failure to communicate could have a devastating impact on the lives of the children Official LCSPR -PS FOR PUBLICATION - March 2021 17 and their families being supervised by CSC and of the potential victims of those children. It is likely that these issues have existed for some time. The author is aware that there were significant changes in the provision of CSC services in the local authority area responsible for PS’s care following Ofsted inspections that found the Local Authority Children’s Services to have been ‘inadequate’ in performance for several years. 8.5 The ability of the Social Worker to access resources to respond to PS’s risk and needs and the deterioration in his circumstances after becoming a Looked After Child in 2017 is concerning on a wider level. Accessing the identified resource appeared complicated. Although CAMHS were readily available to offer support when needed – the Psychotherapist was particularly accessible in this regard – it was difficult for the case worker to access help on a more planned basis to enable PS to receive the psychotherapy sessions it was felt he needed. Referrals to secure access to psychotherapy sessions appear to have taken up much of the Social Worker’s time and from 2017 until PS’s assault in 2019 had still not secured the intervention, requiring the approval of the Resources Panel on two occasions. This was due to changes in PS’s circumstances and delays caused by the need for a ‘Forensic Examination’ which did not include PS or grandparents and for which a further funding application had to be made. It seems that once the CAMHS option had been identified, no other plans or strategies were considered. This had two effects, firstly, directing the Social Worker’s time, attention and resources to securing that resource, and secondly preventing any other more accessible options being considered. 9. Learning from events 9.1 SGOs on the whole offer positive and cost-effective placements for children keeping them close to extended family and safe. PS’s case was closed by CSC three months after the making of the SGO. For SGOs to work, family members are expected to deal with extraordinary presenting behaviours, stress and often financial outlay. Guardians need training, advice and support to be able to do this. Research has identified the factors that impact on the stability of SGO placements include the presence of emotional and behavioural difficulties of the child/ren placed, and the level of support the Special Guardians receive (Boyer et al, 2015)1, (Harwin et al. 2019)2, and (Wade et al, 2014)3. Therefore, it is critical that families involved in SGO placements receive information, advice and training at the start on ACEs and the strategies they need to adopt to maintain the placement and so provide stability for the child. Providing ongoing support for Special Guardians would reduce breakdowns and help to manage risk in a cost-effective way. PS and his grandparents believe that had they, as a family, been supported throughout, the placement may not have broken down, preventing the trauma and lifelong impact PS has experienced and will continue to have to live with. His grandfather stated that it was only when PS received his diagnosis in 2017 did any professional explain to him that PS’s behaviour was not ‘naughty’ i.e. within his control but a response to previous trauma. This is basic knowledge obvious to those in the social care system but not necessarily so to others. Additionally, the grandparents had only a rudimentary knowledge of how the care system worked and of how decisions were made within it. This lack of knowledge meant that their own decision not to allow PS to return to them was based on inadequate information. This was unfair to both 1https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/450252/RR478B_-_Family_justice_review_special_guardianship_orders.pdf.pdf 2 https://www.cfj-lancaster.org.uk/app/nuffield/files-module/local/documents/HARWIN%20summary%20report%20SO%20and%20SGOs%20_%204Mar2019.pdf 3 http://eprints.whiterose.ac.uk/82322/1/SpecialG2014.pdf Official LCSPR -PS FOR PUBLICATION - March 2021 18 them and PS, and tragic given the consequences of his move into the care system. There is no evidence of any conversation, information or advice being offered to the grandparents within the time from PS’s temporary ‘respite care’ to the assault. 9.2 The Residential Unit was not fit for purpose or equipped to care for a child such as PS, who as a vulnerable child was allowed to work for ‘cash in hand’ in a car wash, places that are known to be potentially risky environments related to Child Exploitation and Organised Crime. The Residential Unit Values as stated on their website were not translated into everyday practice. It would appear poorly trained and inexperienced staff were not supported or effectively supervised by management. Following the assault on PS in 2019 Ofsted closed the home; prior to closure the management would have been alerted to Ofsted’s concerns but failed to respond appropriately i.e. failure to provide evidence of key worker sessions. The Residential Unit’s Information report provided for this review was of poor quality and offered a generic response to specific concerns. In order to create a positive and safe environment in a children’s home the safeguarding culture must be completely embedded across all processes – recruitment, supervision, case management, training, key worker plans, external communication with other agencies and management oversight. The organisation which owns the Residential Unit should provide assurance to the commissioner evidencing that its services now meet the required standards. 9.3 Psychotherapy services commenced PS’s assessment for psychotherapy late in 2017 as the foster care placement was breaking down. Previously they had liaised with the Foster Carer and should have checked prior to commencing what they described to PS as “a long and painful process” to ensure his circumstances would allow such work to be carried out safely. At the appointment he was described as presenting as “a little anxious as his placement was coming to an end and another needed to be found as a stand bye(sic)”. He was found six days later drunk and unconscious at a roadside. This suggests that PS was going through something of a crisis in his life and yet it appears that both sessions continued without reference to these personal and environmental factors, other than acknowledging his ‘anxiety’ as to his accommodation. 9.4 Although PS did not wish to proceed with a complaint following his assault early in 2019 the agencies involved should have acted as responsible adults and asked for the assault to be investigated. Victims of crime often are fearful of retribution. PS had disclosed there was a witness who could have been interviewed. In their response Police stated they were not informed. If this was the case, then the culpability of both the Residential Unit and the Social Worker in this omission could be seen as greater. If, however the Police were informed in some capacity as described by the Unit and it was not recorded, this is a significant error. This was a key incident where information in terms of intelligence gathering could have informed a risk assessment. It is of note that there was no evidence of any strategy discussions by CSC with the Police in respect of PS’s missing episodes, the assault on PS and PS’s fears for his own safety. 9.5 The focus of all agencies’ attention from the temporary move into respite care onwards was on practical and necessary tasks – finding stable accommodation, continuing in education and responding to the numerous crises PS presented. The source of much of these difficulties – PS’s trauma, anger and frustration at his rejection by his family, his behaviour and moods that seemed to him beyond his control – were effectively outsourced to CAMHS. This meant that for months PS had to live with the effects of such thoughts and feelings in large part on his own. It is not a tenable strategy to leave the management of such discomfort and distress in a vulnerable person solely in the hands of a scarce resource with a stringent assessment policy that would require funding before it could be accessed. Official LCSPR -PS FOR PUBLICATION - March 2021 19 An interim plan should have been made that would have enabled some opportunity for PS to be able to express his feelings, hopes and fears with someone he could trust at the earliest opportunity after his expression of such feelings. Such an intervention would not have to be ‘therapeutic,’ just a listening response would have been supportive and valid good practice. 9.6 The Social Workers involved in PS’s case failed to respond and try to fix one of the key barriers to his grandparents being able to take PS back, which was the lack of a bedroom in their existing property to enable both PS and his sibling to have their own space. This practical solution does not appear to have been considered by any of the Social Workers, nor raised with a Manager, although PS’s grandparents had raised it with the LA. It raises the wider question of to what degree is co-operation and consultation is accepted practice and to what degree does becoming involved in environmental factors such as housing be recognised as a valid and essential part of casework. 9.7 It is difficult to judge the impact of PS being placed out of area as one cannot prove cause and effect; did the lack of consistency lead to PS being at increased risk? It is recognised that consistency of care in terms of health needs is key to a positive outcome and because of this the Psychotherapist from CAMHS made concerted efforts to remain a SPOC for PS and his family. I would also assume that the Social Worker’s task of identifying and coordinating services to support PS and trying to maintain continuity with his life prior to removal into foster care would be more difficult due to lack of familiarity with the area. For PS it would have added another level to the discomfort and disruption already experienced and with few internal or external resources to call on to help. 10. Good Practice 10.1 Although out of scope of this review, the endurance and commitment to the well-being of PS and his sibling by their grandparents throughout should be recognised as good practice. 10.2 The commitment and effort made by the Psychotherapist to become and remain a consistent figure within PS’s life from 2017 is considered good practice. He understood and acted on the importance of continuity of care for PS, to the point in which he changed role in CAMHS so he could remain a single point of contact for PS. The Psychotherapist was able to see PS at short notice at clinic when requested late in 2017. 10.3 The tenacity and flexibility of PS’s providers of Education in trying to manage and respond to PS’s difficulties in ways in which allowed his education to continue. In particular the secondary school provided continuity as well as the specialist virtual school provision and employment advisor who continued to support and prepare PS for GCSE exams even after he had been permanently removed from the school due to his violence and aggression. 10.4 The consultant on duty at A&E Unit early in 2019 recognised a safeguarding concern and made a referral (MARF) following his attendance due to his serious assault. It is unfortunate this referral did not trigger an appropriate response. 10.5 The Community Health Team flagged to the dedicated Safeguarding Nurse their concerns over a high number of A&E visits by PS. 10.6 The Social Worker’s persistence with CAMHS in relation to PS was recognised by his grandparents and is acknowledged by this Review. However, this is tempered by the limited impact this had due to the lack of management oversight. Official LCSPR -PS FOR PUBLICATION - March 2021 20 11. Recommendations for change 11.1 The Local Safeguarding Partnership (LSP) should undertake an audit within six months to gain assurance that the ‘voice of the child’ is routinely captured and taken into account during assessments, including Child in Need and Child Protection plans. That there is a mechanism in place to evidence how well agencies are incorporating the voice of a child during interventions. This should be a key performance measure within the LSP performance dataset. 11.2 The LSP request a review of the availability and role of Advocacy for the Looked After Children of the LA including the provider, the effectiveness of the service, and information of the accessibility to all children in care, to identify whether improvements can be made. 11.3 The LSP to seek assurance from Corporate Parenting of the measures used to determine suitability of residential settings used for placing children. This relates to children’s homes such as that in this case and must include the practices which are required, i.e. adequate maintenance of building, adequate staffing levels, appropriate selection and training of staff and that supervision of staff and day-to-day recording systems are fit for purpose. This level of detail to be then built into the commissioning framework used by CSC with all suppliers of residential homes for children and young people. 11.4 That LSP to share this report with the local authority area where the Residential Unit was located and to also share the report with the organisation responsible for the Residential Unit and seek assurance that the concerns raised in this review have been addressed. Confirmation to include that all residential staff receive face-to-face interactive training which includes awareness and understanding of the stages of child development, the impact of ACEs on development and behaviour and the issue of safeguarding young people with vulnerabilities, learning and other disabilities, in relation to both Child Criminal and Sexual Exploitation. This training reminds staff that all offences should be reported and that the young people they work with are more likely to be victims of crime and require support to report matters to the Police. Completion of training for all staff to be a condition of continuing employment and of this organisation’s continuing contract with CSC. 11.5 That the LSP seeks assurance from Health and CSC that the channels of communication between Social Workers and CAMHS are underpinned by a joint working protocol which emphasises the importance for information sharing and collaborative working. To help, a joint learning event with CAMHS and CSC be undertaken to improve understanding and communication between the two bodies, along with referral procedures and requirements to streamline the process. 11.6 That the LSP seeks assurance from each partner that cases are scrutinised in a formal process. This may be through formal case supervision. Specifically, that newly-qualified Social Workers and other practitioners working directly with children and families receive formal supervision on a monthly basis, irrespective of any ‘informal’ supervision that may have happened in the interim. That in the absence of any Manager through illness etc, supervision be explicitly made available by a stand-in Manager as an interim measure, particularly in the case of newly-qualified or Agency Social Workers. 11.7 That LSP establish an independent working group to review how effective the current support given to Special Guardians is and how it can be improved. This group to include at least one lay person and a special guardian. A report with recommendations to improve effectiveness to be submitted by April 2021. Official LCSPR -PS FOR PUBLICATION - March 2021 21 11.8 That all staff working with children such as PS including Social Workers and Managers be resourced and trained to spot the early signs of and apply swift response to exploitation and be able to provide Mental Health ‘First Aid’ to the children and young people they are supervising that are known to be vulnerable. That all staff working face-to-face with children including all Managers are aware of and can apply the principles of the ‘Trauma Informed Practice’. That the ongoing training to deliver this to all staff be completed as part of CSC’s training plan. 11.9 That LSP seek assurance that the Referral Pathway with CAMHS is effective and provides a therapeutic consultation with the referrer if it is known that CAMHS will be unable to offer any interventions themselves in the short term (i.e. within 3 months). Such interventions to be recognised as a ‘stop gap’ and not a replacement to CAMHS involvement. This to be an expectation that will be agreed by respective managers on a case-by-case basis. CAMHS then to signpost appropriate work and resources to enable the responsible worker to engage meaningfully and to prepare the child for their work with CAMHS both practically (e.g. housing) and emotionally. 11.10 That LSP are assured that all staff working with children and young people have an understanding of Child Criminal Exploitation and are able to identify the early indicators such as cash in hand work. |
NC047334 | Report of an independent review of the scope and conduct of Sir Ronald Waterhouse's inquiry into allegations of child abuse in care homes in Gwynedd and Clwyd since 1974. Key findings include: the conclusions made by the Tribunal were reasonable considering the evidence presented; reluctance to proceed with a public inquiry was due to a cautious approach rather than a protective attitude towards offenders. Recommendations include: ensuring that materials (including computer records) relating to an important public inquiry are correctly preserved and archived.
| An independent review of the Tribunal of Inquiry into the abuse of children in care in the former county council areas of Gwynedd and Clwyd in North Wales since 1974The Right Honourable Lady Justice Macur, DBEThe Report of theMacur Review(Revised Redacted Version)December 2017Return to an Address of the Honourable the House of Commons dated 5 December 2017 for The Report of the Macur Review An independent review of the Tribunal of Inquiry into the abuse of children in care in the former county council areas of Gwynedd and Clwyd in North Wales since 1974 (Revised Redacted Version) The Right Honourable Lady Justice Macur, DBE, Lady Justice of Appeal Ordered by the House of Commons to be printed on 5 December 2017 HC390 © Crown copyright 2017 This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. This publication is available at www.gov.uk/government/publications Any enquiries regarding this publication should be sent to us at [email protected] 978-1-5286-0022-4CCS0817897938 12/17 Printed on paper containing 75% recycled fibre content minimum Printed in the UK on behalf of the Controller of Her Majesty’s Stationery OfficeContentsForeword Summary Chapter 1: Introduction Chapter 2: Methodology Chapter 3: Background and Delay to the Establishment of a Tribunal of Inquiry Chapter 4: The Tribunal’s Constitution and PartiesChapter 5: The Scope of the TribunalChapter 6: Procedure Adopted in the course of the Inquiry by the TribunalChapter 7: FreemasonryChapter 8: Establishment NamesChapter 9: Paedophile RingChapter 10: Concluding Remarks and RecommendationsAppendicesAppendix 1: Lady Justice Macur DBE’s letter of appointment dated 14 January 2013 Appendix 2: The Macur Review TeamAppendix 3: Appendix 4 of the Tribunal Report ‘Lost in Care’: Note by the Chairman of the Tribunal on its proceduresAppendix 4: Blank pro forma detailing the universal process adopted by the ReviewAppendix 5: The Macur Review Issues Paper Appendix 6: Acronyms1315254175107135197207239249253255257259 271273285The Report of the Macur Review | 1ForewordIn conducting this Review I have adhered to the principles of thoroughness, independence and transparency throughout as I hope will be apparent herein.The length of this Report belies the thousands of hours spent in investigating documents relating to the Tribunal of Inquiry into “the abuse of children in care in the former county council areas of Gwynedd and Clwyd since 1974” and in considering the additional information obtained from ministerial papers, interviewees and other contributors. I am grateful to all who have contributed their views and information and for the co-operation of many in the production of documentation and in particular those I invited to meet with me. I have proceeded at all times on the basis that there was something to find rather than nothing to hide.I have been conscious of a public interest in the examination I have conducted into the integrity of the Tribunal of Inquiry, but have not underestimated the impact that the knowledge of this Review may have had upon those who gave evidence of childhood abuse and may have assumed that the publication of the Tribunal Report, “Lost in Care”, marked an end to a difficult life chapter for them. I have endeavoured to ensure that this Report addresses the terms of reference set to me in a straightforward fashion and with sufficient detail to demonstrate the conclusions I draw mindful, however, that its length should not deter the reader. I hope that this Report may bring a conclusion to the question mark raised against the Tribunal and achieve the finality that many participants in that process will desire.The Right Honourable Lady Justice Macur, DBEDecember 20152 | The Macur ReviewThe Report of the Macur Review | 3SummaryIntroduction1. The following is a summary of the main conclusions that I have reached and express at the end of each of the chapters in this Report. I do not reproduce them verbatim. I nevertheless hope that interested parties will be inclined and able to devote the time to read the report as a whole. My detailed conclusions and the narrative text in support of them are contained within the Report itself. My concluding remarks and specific recommendations are found at the end of this Report. 2. This Review was commissioned by government and announced on 8 November 2012 at a time of significant public concern about allegations of widespread historic child sexual abuse involving celebrities and establishment figures, said to have been protected from scrutiny by reason of their standing in society. Long standing disquiet re-emerged that the statutory inquiry into the abuse of children in care in the former county council areas of Gwynedd and Clwyd since 1974, announced on 17 June 1996 and chaired by Sir Ronald Waterhouse (“the Tribunal”), had failed to discover such individuals’ participation in the abuse or had otherwise concealed it. That is, the Tribunal’s Report, ‘Lost in Care’ published in February 2000, did not include the names of establishment figures as had been expected. 3. The terms of reference set to this Review require that I consider the scope of the Tribunal and whether or not it sufficiently investigated specific allegations of child abuse in North Wales care homes falling within its remit. I have been asked to make recommendations to the Secretary of State for Justice and the Secretary of State for Wales.4. Given the context in which this Review was commissioned and the, at least, implicit allegations of a government ‘cover up’, I have interpreted that part of the terms of reference which refers to “the scope” of the Tribunal to necessitate an examination of the actions of the Welsh Office (as it was then) and other government departments leading up to the establishment of the Tribunal. The second part of the terms of reference needs no further explanation. 5. My letter of appointment rightly anticipated that the Review envisaged would be predominantly document based, but did not preclude me seeking to interview those likely to be able to clarify issues arising. In addition, I have invited and considered contributions from interested parties; an ‘Issues Paper’ with suggestions of broad areas of interest has sought to prompt relevant written submissions. Individuals have been able to contact the Review by a variety of means. I held a public meeting in Wrexham, North Wales, with the aim of engaging local people in geographical proximity to the former Gwynedd and Clwyd county council boundaries and the Tribunal’s hearings. 4 | The Macur Review6. A significant delay to the start of this Review was caused by the failure of the Wales Office (as it became from 1 July 1999) to archive, properly or at all, the Tribunal documents. As a consequence, documents and materials were forwarded to me in a state of disarray. A preliminary inspection of materials received by the Review revealed that the Tribunal’s computer database was missing; later established to have been destroyed. 7. Every single document of the million plus pages of materials provided to the Review has been examined with a view to isolate those relevant to the Review and to ensure that nothing of relevance was concealed or contained in what appeared to be extraneous papers, or for leads to any materials or information which was excluded, concealed, overlooked or ignored. Manuscript comments on the documents have been scrutinised. This manual inspection took more than six months to complete. Materials were scanned on to an electronic document management system. The subsequent electronic search of the materials available to the Tribunal resulted in the identification of over 1,400 potential complainants of physical and sexual abuse for detailed analysis by the Review. 8. Interviews have been conducted with individuals closely involved with the Tribunal process and those who appeared to have information relevant to the Review on the basis of their written submissions. I have interviewed those involved in the police investigations and those who worked on the prosecution files of individuals accused of ill treatment, physical abuse, and/or sexual abuse of children in care in Gwynedd and Clwyd in the relevant period. 9. I am aware of other investigations and events that have arisen during the course of my Review and have sought information and made enquiries, as appropriate. In this regard, I have examined material and documents held by the Home Office relating to the loss or destruction of files, believed to relate to claims of child abuse and a dossier compiled by the late former MP, Mr Geoffrey Dickens. 10. I have provided a full account of my findings to the Secretary of State for Justice and the Secretary of State for Wales, but have advised that redaction of some parts of the report will be necessary to protect the integrity of pending and current criminal investigations and proceedings. Further, I have urged caution regarding the public identification by name of complainants, contributors to the Tribunal, and those individuals accused of abuse or speculated to be involved in abuse, who have not been subject to a police investigation, have not been convicted of a criminal offence and/or whose name is not in the public domain in the context of child abuse. In the case of the former, the Sexual Offences (Amendment) Act 1992 may apply in addition to their right to respect for their family and private life. In the latter cases, the allegations against them result from multiple hearsay or an unattributed and/or untested source and the individuals concerned have had no opportunity to address the allegations against them, although rumours continue to circulate. Some of these individuals may wish to be publicly exonerated in terms that this Review has found no reliable evidence whatsoever which implicates them. I have not considered it within my remit to seek their views in this regard. In any event, I do consider that it The Report of the Macur Review | 5is essential that the commissioning departments should be appraised of the nature and extent of the relevant information in accordance with the terms of reference set to me and for them to seek legal advice as to redaction of names. Establishing the Tribunal11. On 7 September 1992, Mr Gwilym Jones MP, the Parliamentary Under-Secretary of State for Wales, announced that a public inquiry was necessary into allegations of abuse of children in care in North Wales but that it would have to await the conclusion of police investigations and criminal prosecutions. On 17 June 1996, the Right Honourable William Hague, Secretary of State for Wales, announced the establishment of the Tribunal. The elapse of approximately four years has been adversely commented upon. My analysis suggests minimal delay following the conclusion of criminal proceedings, but marked reluctance to embark upon a public inquiry, although not with a view to protect politicians or other establishment figures. 12. Criminal investigation and proceedings continued between September 1992 and 9 February 1995. On 10 February 1995, Mr Rod Richards MP, the Parliamentary Under-Secretary of State for Wales, indicated that Leading Counsel would be appointed to advise the government as to whether a public inquiry was needed, and if so, what form it should take. I conclude this was a reasonable step, but question the selection of a Leading Counsel, eminent in her own field, but without experience in matters of statutory child protection, as opposed to either of two prominent female family law silks identified by the Welsh Office as possible for the role, but who the Treasury Solicitor’s Department said may have felt “obliged” to recommend an inquiry. 13. Miss Nicola Davies QC (now Mrs Justice Nicola Davies) was appointed in this role on 10 May 1995. She expressly made clear, and the Welsh Office knew, that she had no relevant expertise in the subject matter of statutory child protection and continually sought the appointment of a social services assessor to assist her examination. She also repeatedly raised concerns about the terms of her examination, which prevented her from seeking further documentary evidence, oral evidence or further representations. 14. Miss Nicola Davies QC advised against a public inquiry on the basis that, on the evidence available to her, there were no clear grounds to believe that the current systems operating in Clwyd and Gwynedd were failing children in care, but she recommended a detailed and independent expert examination of current practice and procedures of North Wales care agencies. This was reasonable advice in the circumstances known to her and was adopted. However, whilst officials had reported to ministers Miss Nicola Davies QC’s conclusions, they did not highlight at that time concerns raised by the Social Services Inspectorate Wales or other information subsequently received, and not available or known to Miss Nicola Davies QC, which contradicted her findings of a reduction in child abuse and improvements in child care practices. 6 | The Macur Review15. An investigation commissioned by Clwyd county council and chaired by Mr John Jillings was also being conducted into “what had gone wrong with childcare in Clwyd, why it had happened and why it had continued undetected for so long.” The ‘Jillings Report’, submitted in March 1996, was not published in the light of unequivocal legal advice that to do so would expose the local authority to significant and multiple claims for libel and the risk of losing its public insurance indemnity. The government unsuccessfully pressed for it to be made suitable for publication. It appears that the failure to publish the Jillings Report ultimately forced the hands of government in establishing the Tribunal. 16. I am satisfied that the government was right to consider the different options since a public inquiry pursuant to the 1921 Act was correctly understood to be a major undertaking. However, by August 1995, it was clear that Miss Nicola Davies QC’s examination of documents could not uncover the scale of abuse that had occurred in the past, or assess the possibility that it was continuing, and that the Jillings Report had been hampered in accessing relevant material and had been unable to conduct a full review.The Tribunal’s terms of reference 17. I consider the time period set for the Tribunal’s investigations to be reasonable. The starting point of 1974 aligned with the creation of Clwyd and Gwynedd county councils on 1 April 1974. Likewise, the geographical boundary of Clwyd and Gwynedd imposed upon the Tribunal was logical since it encompassed the centre of allegations of abuse. Initially, it seems that the Welsh Office was content to widen the inquiry into other areas of England, but there were good reasons not to do so because of police investigations underway in other counties. Undoubtedly, a nationwide public inquiry conducted with the same terms of reference would have been entirely unmanageable in scale and would have defeated its purpose. 18. Objectively, it was valid to exclude scrutiny of Crown Prosecution Service (CPS) decisions as to whether or not to prosecute named individuals. This exclusion reflects the convention that prosecution decisions, once taken, should not be subject to detailed public scrutiny. However, in my view, an exception to this rule was justified given that it was the small number of prosecutions, relative to the number of complaints of abuse, that had contributed to the establishment of the Tribunal and to allay any public perception of concealment. I found no evidence to support the view that CPS decisions were made with a view to protecting establishment figures or any other abuser. 19. The Tribunal heard evidence from former residents of Gwynfa clinic, a psychiatric residential facility for children and young people located in Clwyd, but was unable to make findings due to ongoing police investigations involving a member of staff and other, unspecified, reasons. In any event, it transpires that inaccurate information was provided to the Tribunal on behalf of the Clwydian Community Care NHS Trust with responsibility for Gwynfa. Counsel instructed by the Welsh Office to review materials concerning Gwynfa advised that the Tribunal had been seriously misled in significant respects and that a public inquiry into events at Gwynfa was necessary. The Report of the Macur Review | 7A copy of Counsel’s advice was sent to the Tribunal on 1 March 1999. In my view, these issues should have been recorded in the relevant part of the Tribunal Report, which remained unchanged by the Chairman despite him being alerted to discrepancies in the evidence that had been produced in relation to Gwynfa. 20. I am satisfied that the terms of reference were not framed to conceal the identity of any establishment figure, nor have they been interpreted by the Tribunal with the design to do so. The appointment of Tribunal members and staff 21. I consider Sir Ronald Waterhouse (now deceased) was eminently suited to the post of Chairman of the Tribunal by reason of his status and experience. It would be unlikely for any member of government or official to consider Sir Ronald Waterhouse amenable to outside influence or persuasion to protect the establishment. There is ample evidence of his independence from the Welsh Office and rebuff of their intervention. 22. The two other members of the Tribunal, Miss Margaret Clough and Mr Morris le Fleming, had relevant professional experience of the issues raised in the circumstances leading to the Tribunal and were unknown to each other or the Chairman prior to the Tribunal. It would be unlikely for any member of government or official to consider the appointment of a panel of three independent individuals if intending to manipulate process or outcome. 23. Counsel to the Tribunal were well qualified for appointment by reason of their expertise, experience and standing. However, two of the three Counsel to the Tribunal, namely Mr Gerard Elias QC and Mr Ernest Ryder (now Lord Justice Ryder) were, or had been, Freemasons at the time of their appointment. I have seen no documents which suggest that any part of the government’s legal services, that is, either the Treasury Solicitor’s Department or the Attorney General’s Office, investigated whether Counsel had links with freemasonry prior to their appointment, although it was, or should have been, apparent that the Tribunal would be called upon to investigate the influence of freemasonry in the protection of those accused of child abuse. Mr Gerard Elias QC recalls that the question of a conflict of interest was discussed and Lord Justice Ryder said that he completed a declaration of interest, but I have found no record of either. The lack of documented discussion and the absence of the declaration of interest indicates a lack of due diligence in a matter of clear public interest.24. The Chairman dismissed an application for a public register of interest requiring all Tribunal personnel to specify whether they were or had been a Freemason. I note that the Welsh Office did not support the application and that the Secretary of State for Wales rejected the criticism voiced by Mr Rhodri Morgan MP as to the appointment of Mr Gerard Elias QC on the basis of his connection with freemasonry. I consider the Chairman’s decision to have been made with inadequate, if any, consideration of public perception in this regard, nor the possible adverse implications upon the integrity of any findings made by the Tribunal in relation to freemasonry. 8 | The Macur Review25. The head of the Tribunal’s Witness Interviewing Team (WIT), Mr Reginald Briggs, was a retired Detective Chief Inspector who had served in the South Wales police force and was a Freemason. The employment of retired police officers to trace and conduct interviews with witnesses who wished to complain about the police raised a further potential conflict of interest. Competing arguments as to their employment are adequately documented. On balance, I consider the rationale for employing retired police officers was right. They were experienced in interviewing witnesses and delay would be inevitable in the selection and training of other personnel. However, the employment of retired police officers from South Wales would have been objectively insensitive to some of the complainants of abuse to the North Wales police force, by reason of the proximity of the two Welsh police forces.The Tribunal’s investigation of specific allegations of child abuse Procedure adopted by the Tribunal Documentation26. The Tribunal made a conscientious effort to obtain all existing relevant material. Some material of potential relevance was no longer available. There is no evidence to suggest deliberate destruction. 27. Concerns have been reported that a former employee of the successor authorities to Clwyd and Gwynedd county councils was involved in deliberately withholding potentially relevant files from the Tribunal. In May 1999, the Chairman was notified of these concerns. No further action resulted. I am not in a position to determine conclusively whether or not files were withheld from the Tribunal, however, the files collated were not the only source of allegations and it is unlikely that the relevant employee was in a position to protect alleged abusers. I do consider that the police should have been alerted by the Tribunal to the suggestion of a possible act of perverting the course of justice and that the Tribunal Report should have referred to the possibility that documents had been withheld. Witnesses28. The Tribunal was widely advertised and prospective witnesses were directed towards a dedicated telephone helpline. Generally speaking, those who contacted the helpline, and who appeared to have relevant information, were invited to be interviewed by the WIT. In addition, the WIT was instructed to trace witnesses who had previously given police statements. The WIT received a clear direction from Counsel to the Tribunal as to how to conduct the witness interviews at which statements were prepared. Witnesses were allowed to be accompanied when being interviewed by members of the WIT. The presence of a solicitor or third party during the interview protected the interests of the witness and the interviewer, and was sufficient guard against concealment or omission of complaints made. The documents reveal very few complaints made by those who had been approached and suggest that the WIT approached the task sensitively. The Report of the Macur Review | 929. It would be unrealistic for the WIT to trace all witnesses who had provided a police statement, in particular those who had made more minor allegations of abuse. The WIT worked efficiently and industriously to obtain last known addresses for hundreds of potential witnesses identified in the police statements, but there were prospective witnesses who the WIT did not attempt to trace without reason given, or apparent from the material. Some of these complainants appear to have made serious allegations of abuse relevant to the Tribunal’s terms of reference, but they are relatively few and, for the avoidance of doubt, did not concern establishment figures. 30. 600 other potential witnesses, who had not responded to the advertisements or otherwise made themselves known to the Tribunal, were selected randomly utilising an independently devised statistical formula. This was entirely reasonable in principle and could have provided corroboration or moderation of the scale of the abuse that was to be determined. The documents reveal that the WIT completed inquiries into 111 potential witnesses of the ‘Random 600’, as it was known, but relatively few of those seen provided a Tribunal statement detailing abuse suffered. In the circumstances, it was felt inappropriate to seek to interview the balance. It is unfortunate that the Tribunal Report does not reflect that this process was not followed through to conclusion, but the decision to abandon the process was proportionate in view of the level of response as against the time expended and the information available from other sources. 31. Legal representation was ensured for all living complainants who had made a statement to the Tribunal and those they accused. There was no representation for deceased complainants or accused. The Tribunal’s rulings on representation were reasonable and not designed to impede access to justice. I am satisfied that it was reasonable and proportionate in light of available resources and the anticipated length of the hearings for the deceased not to be represented. Management and presentation of evidence32. The Tribunal prepared a schedule containing all allegations of physical and sexual abuse as contained in police and Tribunal statements. Analysis of the schedule revealed it to be largely accurate, but identified a small number of omissions or incorrect categorisation of the abuse alleged. This Review did not rely on the Tribunal schedule. 33. The management of the disclosure process in relation to social services, medical and criminal records was well ordered and appropriate to guard against unnecessary ‘fishing expeditions’ and to protect confidentiality, whilst ensuring observance of due process.34. Oral and written evidence was adduced before the Tribunal. Arrangements made in this regard were satisfactory and the decisions made as to whether to call a witness to give oral evidence or whether to read their statement were, on the whole, reasonable. Such decisions were necessary in order to manage the huge volume of evidence before the Tribunal. 10 | The Macur Review35. In general, I consider Counsel to the Tribunal explored all matters of relevance with witnesses during the course of their oral evidence. On the relatively few occasions where matters contained in witness statements were not explored, there was generally good reason. On some occasions, allegations against unidentified police officers were omitted when reading statements to the Tribunal, but unredacted statements were available to the members of the Tribunal and all Counsel representing parties before the Tribunal. 36. There is no evidence that the Tribunal sought deliberately to avoid investigation of any specific allegation of abuse. I am satisfied that the process was not likely, nor designed, to protect any individual or institution implicated in the abuse.37. The Chairman explained in his note on procedure, at Appendix 4 of the Tribunal Report, why an adversarial approach was adopted. His reasoning was sound. It would have been difficult to devise a process that could have catered for every individual witness in light of the emotive subject matter under investigation. An adversarial approach, which involved so many legal representatives from independent practice, does not readily admit the prospect of undue influence or interference or concealment of relevant evidence. 38. The witness support service was independent and was introduced for the purpose of mitigating the impact of the traumatic process of making a statement alleging abuse and/or giving evidence before the Tribunal. It appears that the service was properly co-ordinated and well run, but it is inevitable that no service would be capable of alleviating all distress or anxiety. 39. Decisions made to withdraw Salmon letters and give assurances to those accused that they would not be named in the Tribunal Report were, in the main, justified in an effort to reduce the length of the hearings in the context of the other evidence available.40. The Tribunal’s ruling on anonymity was not designed to protect abusers, of whatever status, but rather to facilitate the giving of evidence. The Tribunal’s investigation of freemasonry41. Despite two of Counsel to the Tribunal and the head of the WIT’s association with freemasonry, there is nothing to call into question the adequacy of the Tribunal’s investigations into the issue of freemasonry at any stage of the process. The findings in relation to the known Freemasons, Gordon Anglesea and Lord Kenyon, were in accordance with the weight of the evidence before the Tribunal. Speculation and concerns as to the involvement of establishment names in child abuse in North Wales 42. Examination of available police documents relating to the period prior to the establishment of the Tribunal reveal that information provided by various sources to the police about establishment figures was unreliable or speculative and largely The Report of the Macur Review | 11based on hearsay. At least one journalist acted irresponsibly in conducting his own investigations into the involvement of establishment names. Notably, in the light of the circumstances leading or contributing to the establishment of this Review, Sir Peter Morrison’s name did not feature at all in the police material. 43. There is reference within the Welsh Office papers, prior to and during the course of the Tribunal, to the alleged involvement of establishment names in the abuse of children in care, but no names are identified, save for one and he in the context of concealment of the names of child abusers. There is no document I have seen which deals with the action taken in respect of this information. The Tribunal’s investigation of the alleged involvement of establishment names 44. Tribunal working papers reveal that the Chairman and Counsel to the Tribunal were alert to the expectation of finding evidence relating to ‘high profile names’ and recognised that, in the interests of the Tribunal’s credibility, they could not ignore rumours and speculation in respect of the involvement of such figures. I make clear again that I have seen NO evidence of child abuse by politicians or national establishment figures in the documents which were available to the Tribunal, save that which could be classed as unreliable speculation. 45. It was necessary for the Tribunal to make an evaluation as to the reliability of informants and the nature of their allegations when considering whether the matters should be investigated further. Where a source of information was identifiable and made a specific allegation of abuse, or where allegations reported in the media were supported by allegations contained in witness statements, the Tribunal made attempts to trace the witness and investigate the allegation. This approach was reasonable. 46. The name of “McAlpine” did arise during the course of the Tribunal hearings, but in circumstances where the actual identification of the individual was in obvious doubt. It was reasonable not to require Lord Alistair McAlpine to attend the hearings to answer allegations which did not appear to refer to him, and consequently, in light of the findings concerning allegations made against the name of “McAlpine”, there would be no reason to refer to any McAlpine in the Tribunal’s Report. The names of Sir Peter Morrison, other politicians of the day and now notorious celebrities did not feature in the evidence before the Tribunal. In these circumstances, there would be no reason for the Tribunal Report to refer to them. 47. There were allegations against one member of the clergy and unidentified police officers contained in statements available to the Tribunal that were not read out during the course of the hearings, and to which there is no reference in the Tribunal Report. In respect of the former, this is likely to be because he was under police investigation. However, it is arguable that the allegations against unidentified police officers falling within the Tribunal’s terms of reference should have at least been acknowledged in the Tribunal Report, given the sensitivities around the investigations conducted by North Wales Police. The assertion in the Tribunal 12 | The Macur ReviewReport that allegations of sexual abuse had been made against only three police officers, other than Gordon Anglesea, may not be strictly accurate, subject to the Tribunal’s definition of sexual abuse or their findings upon whether or not there was sufficient evidence as to whether a complainant was in care at the relevant time. 48. Allegations were made in police and Tribunal statements against a former police officer of the North Wales Police. No findings were made against him and he was not named in the Tribunal Report. Subsequently, he was convicted of a sexual assault against a young person not in care at the relevant time. It is arguable that the conviction, which became known during the drafting of the Tribunal Report, should have been referred to as a matter of public interest. The Tribunal’s investigation into the existence of a paedophile ring49. The Tribunal defined a paedophile ring as a group of individuals, known to each other, exploiting children for sexual gratification by passing victims and information between themselves. This definition was not unreasonable.50. Very few complainants alleged that they had been sexually abused by two men jointly participating or in the presence of others. There was evidence that two convicted abusers, involved in the running of North Wales children’s homes, had separately introduced residents to men outside of the residential care establishments for the purposes of sexual favours. These allegations were explored during the course of the complainants’ oral evidence. The Tribunal Report does not make specific reference to all of these allegations, but this is unsurprising given that they were isolated allegations, often involved unidentified participants, and would have added little to the more specific findings made against named individuals in the Tribunal Report. 51. The Tribunal Report recognised that the main complainant of a paedophile ring operating in North Wales was referred to in the Tribunal Report as Tribunal working papers reveal that the WIT attempted to trace and interview 15 possible victims of an alleged paedophile ring and all of alleged abusers. Several of the men accused by of abusing him were called to give evidence at his solicitor’s request. The Tribunal’s difficulties in making particular findings against named individuals on the basis of uncorroborated evidence are well referenced and cannot, in my view, be deemed perverse. 52. Witness statements before the Tribunal did reveal several allegations of sexual abuse made against different instructors in the army cadets, who were also serving or retired police officers. Whilst the Tribunal Report notes that allegations had been made against police officers at a time when they were working as army cadet instructors, the issue of whether or not this would suggest a paedophile ring was not fully explored. The Report of the Macur Review | 1353. Otherwise, on the direct evidence before them, it was not unreasonable for the Tribunal to conclude that there was no evidence of a further paedophile ring in existence. Conclusion54. I have found no reason to undermine the conclusions of the Tribunal in respect of the nature and the scale of abuse. Neither is there evidence of the involvement of nationally prominent individuals in the abuse of children in care in North Wales between 1974 and 1996. Consequently, I do not recommend the establishment of a further public or private inquiry or review.14 | The Macur ReviewThe Report of the Macur Review | 15Chapter 1: Introduction Background to the Review 1.1 This Review was established to examine the scope and conduct of the “Tribunal of Inquiry into the abuse of children in care in the former county council areas of Gwynedd and Clwyd in North Wales since 1974”, established under the chairmanship of Sir Ronald Waterhouse in 1996 (‘the Tribunal’). 1.2 The Review was announced on 8 November 2012 in the midst of the increasing number of allegations of sexual abuse made against the late Jimmy Savile and the implication of the BBC’s complicity in concealing and effectively countenancing the same. The extensive media interest that surrounded the affair created the context for allegations against other ‘establishment’ figures to be aired. It also resurrected the disquiet voiced after publication of the Report, ‘Lost in Care’ (‘the Tribunal Report’), in February 2000 by politicians of the day and journalists, that prominent public figures had been involved in the abuse of children in care in North Wales, but had escaped exposure and public censure by virtue of their standing in society. Many suspected the connivance of government, the police, masonic lodges and/or the Tribunal itself. A significant number have maintained this stance to date. 1.3 In November 2012, a witness to the Tribunal (referred to as in the Tribunal Report), alleged in the media that there had been a wider circle of abusers than those referred to in the Tribunal Report, including businessmen, police officers and a senior Conservative politician, who some believed to be Lord McAlpine. Lord McAlpine, the former Conservative party treasurer, released a statement describing the allegations as “wholly false and seriously defamatory”. He made clear his intention to institute defamation proceedings against those circulating rumours on Twitter and other social media. confirmed publicly, after seeing a photograph of Lord McAlpine, that this was not a man who had abused him. The majority of potential defendants to the libel proceedings apologised and agreed to make a charitable donation. Another was ruled to have defamed him. In those circumstances, many expected or called for this Review to be abandoned. 1.4 However, around this time, press reports also contained former ministers’ accusations that Sir Peter Morrison, Parliamentary Private Secretary to the late Prime Minister Margaret Thatcher, a former deputy chairman of the Conservative party and MP for Chester from 1974 to 1992, who died on 13 July 1995, had been involved in the abuse of children in North Wales. More significantly, the Right Honourable David Jones MP, the immediate past Secretary of State for Wales, informed Sir Jeremy Heywood, the Cabinet Secretary, of a telephone call he received, he believed in about 2000, said to be from a member of the Tribunal staff, which implicated the late Sir Peter Morrison and appears thereby, at least by reason of cumulative effect, to have triggered this Review.16 | The Macur ReviewTerms of Reference for the Review 1.5 On 8 November 2012, the Right Honourable Chris Grayling MP, Lord Chancellor and Secretary of State for Justice, made a Written Statement to the House of Commons in the following terms: “Following the Prime Minister’s statement on 5 November, I am announcing today a review of Sir Ronald Waterhouse’s Inquiry into the abuse of children in care in the Gwynedd and Clwyd council areas. The Review will be chaired by Mrs Justice Macur DBE, a High Court Judge of the Family Division. The Review’s terms of reference are: ‘To review the scope of the Waterhouse Inquiry, and whether any specific allegations of child abuse falling within the terms of reference were not investigated by the Inquiry, and to make recommendations to the Secretary of State for Justice and the Secretary of State for Wales.’ The arrangements for the Review will be a matter for Mrs Justice Macur. The Ministry of Justice and the Wales Office will provide support to her, and all relevant material will be made available to support the investigation.”1.6 The Right Honourable Lord McNally PC, Minister of State at the Ministry of Justice, made a similar statement in the House of Lords on the same day. Parameters of the Review 1.7 My letter of appointment (Appendix 1) is dated 14 January 2013. It makes clear that my Review is “a non-statutory document-based Review and not an Inquiry held under the Inquiries Act 2005”. I was not asked to conduct a fresh investigation into the allegations to establish civil or criminal liability or to order financial settlement. I did not have the power to hold oral hearings, but could conduct ‘meetings’ and invite, receive and consider written representations as I considered appropriate. A separate, but parallel police investigation, Operation Pallial, was announced by the Right Honourable Theresa May MP, Home Secretary, on 6 November 2012 to assess the allegations recently received, to review the handling of the allegations of physical and sexual abuse by the North Wales Police force (NWP) in the relevant period and to investigate any new allegations arising in this context. It is continuing. 1.8 A Memorandum of Understanding was agreed between the Review and Operation Pallial in January 2013 governing how the two teams would work in tandem. It was obviously necessary that the Review should give priority to Operation Pallial in respect of the inspection of documents and interviewing of witnesses and/or complainants, in order to protect the integrity of criminal investigations and prospective future prosecutions.The Report of the Macur Review | 171.9 During the course of this Review, a number of contributors have provided me with information including allegations that were not made during the currency of the Tribunal. I have recorded these allegations in my Report when relevant to the parameters of this Review, but have not been in a position to make any determination of their reliability.A brief overview of my approach 1.10 I have interpreted my terms of reference so as to investigate and address the concerns expressed or implied, which have suggested that the Tribunal was inherently unreliable by reason of the constraints imposed by its terms of reference, or its constitution, or in its process of investigating complaints and/or the conclusions it reached in the Tribunal Report. I provide a detailed account of my methodology in Chapter 2. Throughout this Report, I refer generically to prominent members of society, whether local or national, as ‘establishment names’ or ‘establishment figures’.1.11 I have interpreted my terms of reference relating to the ‘scope of the Waterhouse Inquiry’ to require an examination of events prior to the establishment of the Tribunal in the context of what has been expressed to be the suspected malign influence of freemasonry and/or government, and/or other public bodies.1.12 Consequently, I deal in this Report with:• The apparent delay in the establishment of the Tribunal, addressing the possibility that ministers and/or officials wished to avoid a public airing of allegations made against establishment names or figures (Chapter 3).• The Tribunal’s constitution and parties represented before the Tribunal, including the selection and recruitment processes leading to the appointment of the Tribunal members and its personnel, and the conduct of the Welsh Office in their role as a party to the Tribunal, examining whether any were involved in concealing evidence of child abuse (Chapter 4).• The formulation of the Tribunal’s terms of reference, analysing whether they were specifically devised or interpreted in order to exclude investigation of establishment names or figures, or any other alleged abusers (Chapter 5). • The procedure adopted by the Tribunal in the course of the inquiry, assessing whether the approach chosen was amenable to the investigation of the allegations made and was pursued in like manner regardless of the identity of those accused (Chapter 6).• Freemasonry, examining the adequacy of the Tribunal’s investigations into allegations against Freemasons accused of abuse or its concealment (Chapter 7).• Establishment names or figures, examining the adequacy of the Tribunal’s investigations into allegations against establishment names and whether the Tribunal Report wrongly omitted to refer to the identities of those implicated (Chapter 8).18 | The Macur Review• The existence of a paedophile ring, examining the adequacy of the Tribunal’s investigations into allegations, in general or specifically, as regards a paedophile network infiltrating the care system (Chapter 9); and• Concluding remarks and recommendations (Chapter 10). Inevitably, there is overlap of subject matter between the chapters.1.13 It would be impractical to make reference to every document I have seen, or every contribution made to the Review, or every interview I have conducted. For the most part, where I do make reference to documents, communications or contributions, I summarise the same, for to do otherwise would render this Report over long. However, I do reproduce text in full when it appears to me to be either particularly pertinent or incapable of adequate précis. Where there is information that runs contrary to my conclusions, I have reported upon it. 1.14 I have made reference to material that would otherwise be subject of legal professional privilege in so far as it concerns the Tribunal legal team and Welsh Office legal team, taking the view that privilege has been waived by ‘the client’ in each case for the purpose of this Review. When alerted to this, the Wales Office responded saying they had no objection to the material held by the Review being used in this way.1.15 A comprehensive list of the nature of the documents reviewed has been compiled, albeit not their individual components. All documents provided to the Review have been or will be returned to their source as requested, but will otherwise be retained with the Review documents for consideration of future archiving. Tape recorded interviews have been transcribed. The transcripts, and notes of interviews conducted but not recorded, have been produced and submitted for agreement by the interviewee. In addition, there is a computer database containing copies of all documents scanned and deemed potentially relevant to this Review’s analysis of the allegations of abuse. My sources of reference are therefore amply documented and should be preserved. 1.16 Where I have identified matters in the documents provided to me or arising from contributions to this Review which, if not revealed, could undermine public confidence in the integrity of this Review, I report upon them regardless that they do not impact upon my conclusions. 1.17 Chapter 6 of the Tribunal Report sets out the “Tribunal’s approach to the evidence”. Specifically, it indicates that it did not “undertake a detailed examination of each specific incident, bearing in mind the overall objectives of the Inquiry underlying our terms of reference.”1 This Review has considered the Tribunal’s handling of each of the documented complaints in the manner indicated in paragraphs 2.46 to 2.48 below. 1 See paragraph 6.02 of the Tribunal ReportThe Report of the Macur Review | 19Reporting of names1.18 I indicate in paragraph 2.48 the manner in which this Review has scrutinised each and every allegation contained within the materials made available to it. Where I have considered it to be relevant to refer to specific complainants and contributors to address, demonstrate or describe a particular topic, I do so by reference to their name in the Report that I deliver to the Secretaries of State for the commissioning departments. In the case of the complainants whom I identify and who are also specifically referred to in the Tribunal Report, I also specify the non-specific initial adopted by the Tribunal. However, I remind the readers of this Report (redacted or otherwise) that the Tribunal Report explicitly records that an individual is not identified by the same initial throughout.1.19 I have cautioned the Secretaries of State for the commissioning departments that the Sexual Offences (Amendment) Act 1992, sections 1(1) and 6 prohibits the inclusion in any publication addressed to the public at large of any matter relating to the identity of a victim of an alleged sexual offence if it is likely to lead members of the public to identify that person against whom the offence is alleged to have been committed. I advise that the public identification by name of complainants not protected by this statutory provision, or individuals who made representations to the Tribunal is unnecessary and to be avoided to guard against any adverse repercussions and in accordance with their right to respect for their private and family life. Nevertheless, I have thought it necessary to include the names of some complainants and contributors in order to fully inform the Secretaries of State of the commissioning departments of their identities, which maybe of interest to Operation Pallial or other reviews or inquiries.1.20 In Chapters 8 and 9 I refer to the names of individuals rumoured or speculated to be involved in child abuse and raised prior to and during the Tribunal investigation; some of these names continue to be featured in the media in this context. I have done so in order to address the source and reliability of the information, and with a view to considering whether the Tribunal’s approach to the available material was reasonable in this regard.1.21 The individuals concerned include those who have not been subject to police investigation or have not been convicted of a criminal offence. Consequently, I have cautioned the Secretaries of State of the commissioning departments that, quite apart from ‘Human Rights’ considerations, to identify publicly those who fall into these categories, many who have not otherwise been subject to media reporting in this regard, would be unfair in two respects and unwise in a third. First, the nature of the information against them sometimes derives from multiple hearsay; second, these individuals will have no proper opportunity to address the unattributed and, sometimes, unspecified allegations of disreputable conduct made against them; and third, police investigations may be compromised. 20 | The Macur Review1.22 I do not overlook the prospect that those individuals who continue to be the subject of unattributed allegations, rumours or speculation may wish to be publicly exonerated insofar as this Review is able to do so. Arguably, those individuals should be invited to make representations on this issue to the commissioning departments.1.23 Save for the prospect of police investigations, actual or prospective, the reasons not to identify these individuals are equally applicable to those now deceased; a similar argument as to the exoneration of the deceased could be proffered to their family. 1.24 I have written separately to the Secretaries of State of the commissioning departments indicating my firm view that, whilst it is essential that they should be informed of all relevant detail considered by this Review, certain parts of this Report must be redacted pending the conclusion of criminal investigations and resultant criminal proceedings. This accords with the usual requirements of reporting restrictions pending and during criminal trial. It is for the Secretaries of State to determine any further redaction of my Report weighing public interest with the caution and for the reasons I have advised above.Salmon letter process1.25 I sent ‘Salmon’ letters to two interviewees prior to my interview with them in order to alert them in advance to specific allegations of their misconduct made to me and which I might wish to discuss with them. Subsequently, I have sent letters to individuals and organisations who may be criticised within this Report, identifying the nature of the possible criticism and materials I have relied upon in reaching my preliminary conclusions and inviting their response. In any case where the conduct of an employee in the execution of their duties might attract critical comment, and it appeared to me to arise from the instructions given by their employer, I have notified the latter. I have written to the known next of kin of deceased individuals whom I might have criticised in the Report and afforded them the opportunity to comment upon my preliminary conclusions.1.26 When requested to do so, I have afforded those notified the opportunity to inspect the relevant materials identified, but have not provided them with copies of the materials to take away or permitted copies to be made. Inspections have been conducted in the presence of a trainee solicitor unconnected with the Review. The same arrangements for inspection have been applied throughout. I have considered the responses received to these letters before finalising my conclusions and make reference to them as relevant. 1.27 In addition, where appropriate, I have alerted surviving individuals of my intention to report certain details not otherwise in the public domain, but which do not constitute a criticism of their behaviour and invited their comments. I have not alerted the establishment or other figures whom I identify in accordance with paragraphs 1.20 to 1.23 above in the expectation that their names will be redacted.The Report of the Macur Review | 21Legal principles applied1.28 I have not conducted this Review in an appellate capacity to determine afresh the findings and conclusions of the Tribunal. To do so would have been contrary to my terms of reference. Rather, I have considered whether the methods of investigation utilised during the inquiry were reasonable and sufficient to ensure that the Tribunal had access to all the relevant evidence and based their findings upon it. In so far as I adjudge the findings and decisions made to be rational and reasonable, I indicate that they are ‘not perverse’ regardless of whether I would have made the same adjudication. Independence of the Review 1.29 My Review is independent of government. At no time have ministers or their officials attempted to influence me in the conduct of the Review or the conclusions I have drawn.1.30 I was not required by the commissioning departments to declare any conflict of interest at the time of my appointment, or subsequently, or to indicate any interest in the subject matter of the Review. However, for the avoidance of doubt, I record the following information. I played no role in the Tribunal, including its establishment, conduct or the implementation of any of its recommendations. I appeared as Junior Counsel before Sir Ronald Waterhouse when he sat as a judge of the Family Division, but never, to my knowledge, in relation to hearings that concerned children or young persons who were placed in residential care in North Wales during the relevant period. In 1996, I was prosecuting Counsel in unrelated criminal proceedings against a former police officer accused, in the course of the Tribunal’s hearing, of having sexually abused two children who may have been in care. I subsequently represented Flintshire county council, a ‘successor’ local authority, in unrelated childcare proceedings. I did not represent, nor participate in any criminal trials, for either the prosecution or defence of the North Wales care home staff implicated in the Tribunal hearings. I have come to know personally and/or professionally many of the Counsel who appeared on behalf of complainants, accused and other interested parties before the Tribunal, and others who represented the prosecution in associated criminal trials. Many now hold judicial office, have taken other positions or have been promoted in rank. To avoid confusion, where any individual has been promoted in rank, I refer to their present position on first mention of their name in this Report, but thereafter revert to their title at the time of the Tribunal. Save where identified as an interviewee, I have not sought their views, opinions or observations upon the Tribunal process. 1.31 I declare this interest, but do not consider that this caused a conflict of interest in regard to any issue arising during this Review. 1.32 I am solely responsible for the conclusions and opinions expressed in this Report, but have been ably assisted in the Review by a secretariat seconded from government, a solicitor from independent practice, a team of paralegals and my judicial clerk. The names of all Review personnel are to be found in Appendix 2. I am satisfied that all members of the Review team have consistently acted with all 22 | The Macur Reviewdue independence, discretion, diligence and with regard to the sensitivity of the subject matter at hand. No individual has declared or displayed any bias, prejudice, political affiliation or membership of, or association with, interested parties, pressure groups or freemasonry. I am assured and confident that members of my secretariat have maintained independence from their assigned departments in the conduct of their roles in this Review.Transparency of the Review 1.33 In the interests of transparency, I report two matters relating specifically to the conduct of this Review and one matter relating to the preparation of the final Report of the Review.1.34 As indicated at paragraph 1.4 above, the Right Honourable David Jones, MP, Secretary of State for Wales, met with Sir Jeremy Heywood, the Cabinet Secretary, on 5 November 2012. During the course of that meeting, Mr Jones voiced concern at the absence of any reference to Sir Peter Morrison in the Tribunal Report, despite what he assumed had been an authentic telephone call from a person who identified themselves as a member of the Tribunal staff. At the time of the telephone call, Mr Jones was a practising solicitor in North Wales and a Conservative prospective parliamentary candidate. The telephone call was said to be made to warn him that a once prominent member of the Conservative party, namely Sir Peter Morrison, had been named in one of the Tribunal’s sessions as an abuser, and that this was likely to be in the Tribunal Report. The caller said that he was a Conservative party supporter and wanted to tip off the party to this name being made public. Mr Jones said that if the caller had identified himself he could not recall the name given. He had discussed the call with his constituency chairman, but heard nothing further. He told me that he had not been aware of the names of other politicians as falling under similar suspicion. Mr Jones said he specifically requested the meeting of 5 November 2012 to be minuted. He gave me permission to obtain minutes of the meeting from the Cabinet Office. This was requested in December 2012. After repeated prompting, a first ‘note’ of the meeting was eventually produced to this Review by the Cabinet Office on 14 May 2013.1.35 The first ‘note’ records Mr Jones as saying “he recalled the general dissatisfaction of the way in which the Inquiry was conducted and a number of high profile names that continued to crop up in the context of child abuse allegations ...” The first ‘note’ went on to name three former MPs and Sir Peter Morrison. This is in stark contrast to the information Mr Jones supplied to me during interview. Accordingly, I asked for his observations. 1.36 It was then that I was informed that the former Secretary of State for Wales and the Cabinet Secretary had not been asked to approve the first ‘note’ before it was sent to me. Mr Jones emphatically disputed its accuracy. A second ‘note’ of the meeting was then produced by the Cabinet Office on 9 July 2013, which indicated that the named politicians, other than Sir Peter Morrison, were said to have been subject to The Report of the Macur Review | 23ongoing rumours and speculation on the internet subsequently. I confirm that the other politicians named in the ‘notes’ have been subject to rumours and speculation, as indicated later in this Report, however they were not named by any witness when giving evidence to the Tribunal.1.37 I am told by their offices that this second, amended, ‘note’ is approved by Mr Jones and the Cabinet Secretary. 1.38 In response to my request for an explanation of the manner in which the notes had been prepared, the Cabinet Secretary’s Principal Private Secretary responded, “... exceptionally, it may be agreed at a meeting that there will be a note which is to be agreed by all parties but this course of action is exceptional and was not the course of action agreed in this case.”1.39 I alerted the Cabinet Secretary of my intention to refer to this matter by letter dated 15 May 2015. He responded in terms that “it is not standard practice to share draft notes of meetings with those that attend a meeting. Nor is it standard practice to ask attendees to agree the content. My Principal Private Secretary (PPS) took a contemporaneous note of the meeting but I did not agree with the former Secretary of State for Wales, David Jones, that there would be a joint note produced of our conversation. If it had been agreed that a joint note would be produced, I can assure you that my PPS would have shown him the note in draft and secured his agreement to it.” He went on to deal with Mr Jones’s suggestion that the note was inaccurate, by indicating that he (the Cabinet Secretary) had “read the note again in the light of this. It is not a verbatim account of the meeting. Cabinet Office minutes are not intended to do more than cover the key points of the meeting. In that context, I am satisfied that it is an accurate account. Notes of the meeting were taken contemporaneously at the time and the formal note produced later, on request.”1.40 The letter does not specify which of the two notes has been read and verified as accurate by the Cabinet Secretary. Consequently, I wrote to him on 17 June 2015 inviting this clarification. I have received no response.1.41 In light of the timing of the production of the notes to this Review, I consider it likely that the discrepancy between the notes arises from an attempt to decipher or interpret the notes taken during the meeting on 5 November 2012 too long after the event. This incident does not undermine the conclusions I have reached in this Report. I report this discrepancy lest it be thought that an absence to reveal this information is evidence of a conspiracy to conceal. 1.42 The Right Honourable William Hague MP, Foreign Secretary (now The Right Honourable Lord Hague of Richmond), requested access to the Review’s papers immediately after the Review was established in November 2012. He was allowed access on 3 July 2013 to a restricted number of documents, which were likely to have been seen by him during his tenure as Secretary of State for Wales. I would not have permitted it, but for his reliance upon the 2010 Ministerial Code which 24 | The Macur Reviewallows ministers “reasonable access to the papers of the period when they were in Office.” He proceeded with the appointment to access the material in the knowledge that it would be reported and has not sought that I should conceal the same. I did not meet or communicate with him at any time during his review of the materials. 1.43 I subsequently wrote to the Right Honourable Mr Hague on 15 July 2014 seeking information as to any knowledge he may possess concerning missing dossiers said to contain allegations of child sexual abuse, then being reported contemporaneously in the press. Having received no response, I wrote again on 8 October 2014. In his letter to me of 13 October 2014, Mr Hague apologised for the delay in responding, but indicated that the earlier letter had not reached him. He said that he had no knowledge of the missing dossiers; his reason for reviewing relevant papers was to refresh his memory of decisions taken in light of the renewed interest in the Tribunal. I record these matters in the interest of transparency. 1.44 On 30 September 2015, I received an unsolicited letter from Mr Jonathan Jones, Permanent Secretary, HM Procurator General and Treasury Solicitor Government Legal Department based upon his understanding of the manner in which I proposed to deal in this Report with the inclusion of names of individuals subject to unsubstantiated allegations. Mr Jones requested a meeting to discuss the matter in person. I responded by letter dated 13 October 2015 declining a personal meeting, indicating my intention in this particular regard and explaining the rationale behind my decision. Nevertheless, I made clear that I would consider any further written observations he may make in this regard.1.45 On 27 October 2015 I received a letter dated 23 October 2015 from The Right Honourable Michael Gove MP, Lord Chancellor and Secretary of State for Justice, who had been shown the correspondence previously referred to. The Lord Chancellor and Secretary of State for Justice expressed the view that as a matter of principle it would be wholly unfair to name individuals who have been merely rumoured and speculated to be involved in child abuse, and ‘strongly urged’ that I consider whether there are ways of dealing in this Report with the manner in which the Tribunal dealt with such rumours and speculation without naming the people concerned. He suggested that I underestimated the unfairness and prejudice to such individuals of including their names in the Report submitted to the commissioning departments to determine redaction and that, in any event, redaction “is more properly a task for you.” He invited me to refer any allegations “about which you are not in a position to make a finding”, but which merited further investigation, to the police or otherwise to consider “providing Justice Goddard with the full unredacted text who would then be able to consider further disclosure in line with established processes under the Inquiries Act 2005.”1.46 I have given all due weight to the views of the Lord Chancellor and Secretary of State for Justice, but for the reasons I refer to in paragraphs 1.19 to 1.22 of this Report, I am not persuaded that I should take a different course.The Report of the Macur Review | 25Chapter 2: MethodologyIntroduction2.1 This Review has taken a significant time to report. At the time of my appointment it was impossible to know the scale of the task I had been set. I refused then, and subsequently, to indicate a date when this Report would be produced and presented. I did so in order that the thoroughness and integrity of my investigation should not be compromised. In particular, I did not feel bound by the political calendar to present my Report before the General Election. The substance of this Review has cross party implications, wider public interest and, more particularly, affects many individuals who participated in the Tribunal process. I believe that events have proved that I was justified in this stance. This chapter details the vast quantity of materials inspected, the methodology of the Review’s work and the difficulties encountered which have added to the timescales of the Review. A small delay has been occasioned by the necessity to abide by government recruitment and tendering protocols. During the course of the Review, I have contemplated increasing the number of personnel involved in the examination of material. However, the time that would have been expended in vetting, selection and training would have detracted from the progress of the examination of the papers.The Review2.2 Inevitably, my Review needed to obtain and consider the documents requisitioned or created by the Tribunal and those concerned with its establishment, procedure and outcomes. A press notice was issued on 28 November 2012 making clear that the Review wished to obtain all documents that would, or should, have been made available to the Tribunal. It asked that any person with information relating to the remit of the Review contact the Review team on designated telephone numbers or via a dedicated email address accessed only by members of the Review team.Call for documents relevant to the Review2.3 A call was made to all government departments, local authority chief executives and public bodies likely to hold information relevant to the Review. Consequently, I received documentation from the Wales Office, Welsh Government, Flintshire county council and Conwy borough council (two of the six successor authorities to Clwyd county council and Gwynedd county council), the Crown Prosecution Service (CPS), the Attorney General’s Office (AGO) and the Department for Education. As indicated at paragraph 2.17 and 2.18, I later requested access to pertinent information held by the Home Office and the Government Legal Department (GLD). 26 | The Macur ReviewNature of documents received 2.4 I have received materials that were obviously considered by the Tribunal, namely witness statements, medical and social services files, care home inspection reports, reports of internal inquiries into events in certain North Wales children’s homes commissioned by the Gwynedd and Clwyd county councils and court transcripts of some parts of relevant criminal trials and the civil proceedings initiated by Gordon Anglesea, a former Police Superintendent, in respect of what were determined to be libellous comments linking him to child abuse in North Wales children’s homes. Other materials obviously arose from the running of the Tribunal, including secretariat and administrative communications, Witness Interviewing Team memorandum, daily transcripts of evidence, procedural rulings of the Chairman, agenda for meetings and written communications between Counsel and Solicitor to the Tribunal and the Chairman, the Chairman’s correspondence, the working papers of Counsel to the Tribunal, the notes of evidence of the other two members of the Tribunal and minutes of meetings between the three members of the Tribunal to discuss their findings at the conclusion of the evidence.2.5 In addition, I have had access to documents relating to the inception, progress and outcome of the public inquiry and the participation of the Welsh Office (the Wales Office since 1 July 1999) as a party before the Tribunal. These materials consist of ministerial, local government and civil service internal communications, instructions to and written advices from Counsel on various inter related matters arising, the minutes of meetings of the ‘North Wales Working Group’ established to support the representation of the Welsh Office before the Tribunal and communications including notes of Counsel/Solicitor/Client communications, that would otherwise be privileged as indicated in paragraph 1.14 above. Presentation of documents2.6 Tranches of documents were received by the Review between 15 November 2012 and 7 January 2014, amounting to 523 boxes and five separate files. 2.7 398 boxes originating from the Wales Office, now stored by the Welsh Government, were accompanied by a ‘reference index’ referring to 718 boxes, 35 general files, and 11 personal files. A separate index provided by the Clerk to the Tribunal, Ms Fiona Walkingshaw, did not, in the main, accord with the contents of the boxes delivered. All but a small minority of the boxes were security tagged and double bagged. The contents of those that were not were unremarkable. 2.8 The Welsh Government continued to discover relevant documentation after the first delivery of its own materials to the Review in January 2013. In total, three further consignments were received. In April 2013, I received an apology on behalf of the Welsh Government that the further documents had not come to light sooner, and was informed that they had been discovered in a locked safe which had not been opened for a considerable length of time. As a result, a further physical search The Report of the Macur Review | 27for relevant files or documents was made, but no additional documents came to light. However, on 26 November 2015, I was advised that the Welsh Government had discovered further documentation potentially relevant to the Review. Two files were subsequently delivered on 1 December 2015. All consignments of documents belonging to the Welsh Government were delivered in boxes comprehensively and accurately indexed, as were those contained in the single box provided by the Department for Education. 2.9 Contents of 11 of the 20 boxes of documents provided by the North Wales successor authorities contained an index, which did not always reflect the box content. The remaining nine boxes consisted of materials emanating from an earlier investigation commissioned by Clwyd county council and chaired by Mr John Jillings (see paragraphs 3.7 and 3.21), which were sent to the successor authorities by the Tribunal for the purpose of storage and/or destruction. The material in these boxes was not indexed, but the contents were well ordered. 2.10 Boxes of CPS files, primarily comprising prosecution advice files, still existing were delivered and found to be correctly indexed. Additional documents and material received2.11 Subsequently, I requested and received from the CPS, documents relating to the criminal prosecution of Derek Brushett for sexual assaults upon residents in an approved school for young males in the 1970s, and from the Welsh Government, the report of an independent internal audit of his work as a Social Services Inspector when employed by the Welsh Office (see paragraphs 4.108 to 4.119). 2.12 Following my meeting with a former auditor of Flintshire county council, I considered it necessary to obtain documents relating to his claim for constructive dismissal, and which referred to local authority employees who had had significant input into the Tribunal process. With his permission, I requested and received seven boxes of material from the solicitors he had instructed. These documents were recovered from storage. As expected, they were not indexed, but were apparently complete. 2.13 There has been documentation submitted by individual contributors to the Review. This includes a list of names held by Mr Martyn Jones, former MP for Clwyd South/South West and referred to in Hansard reporting the debate on ‘Safeguards for Children’ on 17 March 2000, and his notes of a meeting with police officers concerning the same. An additional box file was provided by the Senior Crown Prosecutor who appeared before the Tribunal, containing his working papers. I have been supplied with copies of Mr Richard Webster’s book, ‘The Secret of Bryn Estyn’, and other publications by the organisation FACT (Falsely Accused Carers and Teachers).2.14 I have made explicit requests of certain individuals who have implied in their written responses to me, or else in the media, that they hold information about abusers who were not investigated by the police or Tribunal, but they have not supplied me with further information or documents. 28 | The Macur Review2.15 Following my interview with and with his authorisation, I made a request for materials said by him to be potentially relevant to my Review and stored by a solicitors’ firm he had previously instructed. The particular solicitor named by had left the practice some time before. Unfortunately, it seems that although the case files had been archived, they had since been destroyed in view of their age. However, the solicitor dealing with my query recalled that, prior to archiving and destruction of the files, the solicitor named by had visited the office and may have taken any documents he considered worthy of retention. I have written to the solicitor concerned, but he has not responded. 2.16 I have visited the Serious Organised Crime Agency (subsequently to become the National Crime Agency) North West Division offices in Warrington in order to access the HOLMES (Home Office Large Major Enquiry System) database created in respect of the police investigation commencing in North Wales in 1991. I have been provided with the downloaded entries and documents I requested. 2.17 More recently, I have requested information from the Home Office concerning the ‘missing dossiers’ said to have been compiled as a result of the late Mr Geoffrey Dickens MP’s submissions to a former Home Secretary. I attended at the Home Office and was allowed access to the unredacted copies of the reports and the associated annexes prepared following the “Independent Review of Two Home Office Commissioned Independent Reviews Looking at Information Held in Connection with Child Abuse from 1979-1999”, by Mr Peter Wanless CB and Mr Richard Whittam QC in 2014 (‘The Wanless and Whittam Review’). They contained no relevant information of which I was not already aware from the materials previously available to this Review. It was subsequently reported in the media that documents had been discovered in the Cabinet Office archive, which were not available to Mssrs. Wanless and Whittam at the time of their reviews, and which refer specifically to former Conservative MPs including Sir Peter Morrison and Sir Leon Brittan. I have not seen those documents.2.18 As a result of a letter sent to me by the Attorney General (AG), to which I make reference in paragraph 4.44, I became aware that the GLD may hold material relating to the Tribunal, which had not previously been disclosed to my Review. Consequently, the GLD was requested by letter dated 5 June 2015, to produce all relevant documents relating to the appointment of Counsel to the Tribunal. Documents were provided with an explanation for their prior non disclosure and an apology. It was said that the AGO is separate from the GLD and no appropriate liaison had occurred between the two prior to my letter addressed to the AG. Subsequently, as a result of the Treasury Solicitor’s response to a Salmon letter dated 28 October 2015, it became apparent that the GLD held additional files pertinent to the terms of reference of this Review. Two boxes of documents were provided on 4 November 2015.The Report of the Macur Review | 29Storage and access to Review documents2.19 All documents received by the Review have been stored in secure premises to maintain their integrity and by reason of their sensitivity. Save for the Right Honourable Mr William Hague’s inspection of ministerial papers relating to his tenure as Secretary of State for Wales, which I refer to at paragraph 1.42 above, and the inspection of relevant documents by the recipients of Salmon letters, which I refer to at paragraph 1.26 above, access to the materials has been strictly restricted to members of the Review team, all of whom have been ‘security vetted’. Prior storage of Tribunal documents and failure to archive2.20 I am satisfied that the Tribunal documents were properly stored in Gloucester during the compilation of the Tribunal Report, and for three months after its publication, and were appropriately identified and catalogued for onward transmission and ultimate storage in Cardiff. They were most likely handed over “in a fit state for archiving” as suggested was necessary in emails at the time, of which I give examples below.2.21 In a letter dated 19 May 1998, the Tribunal Deputy Chief Administrative Officer wrote to Welsh Office officials, “Attached are lists of documents being delivered on 19 May to Curran Embankment File Store. As requested earlier could you let the Gloucester Officer know in due course what your classification numbers are …” On 18 November 1998, he emailed a Welsh Office official reminding him to alert the Archive Registry that the documents already forwarded should be archived for 75 years, and that the Tribunal would require a list of the classification numbers when allocated. 2.22 On 1 March 2000, he notified Wales Office ‘recipients’ by email, “I shall be delivering to CP2 tomorrow … the first tranche of items from the Gloucester Office ... I will be returning 3 files that were borrowed from the archive when it was in Curran Road … from SOL 112. Also I will be returning a file to SOL 113 and another to SOL 153. In addition I will need to borrow SOL 92 and SOL 128. I also need to check whether SOL 87, 88 and 89 are in the Mezzanine ...” His ability to specify the precise destination of the files to be returned demonstrates the nature of the catalogue that had been created. I also note the similar ability of the Clerk to the Tribunal to direct, from long distance, a search of documents by reference to identified boxes in response to a request for disclosure in April 2001. 2.23 In March 2000, the Clerk to the Tribunal wrote to the Head of the Wales Office, “apart from the fact that, owing to their sensitivity, these documents should be placed in a secure and appropriate storage/archive as soon as possible ... we are under some pressure from the Valuation Office not to leave the papers in Gloucester any longer than necessary as major building works are planned for the suite of offices in which the papers are kept ... grateful if you could advise me … of the arrangements for storing the papers after 15 May 2000. In making these arrangements it should be remembered that part of the Tribunal archive is already in CP2 and will have to be removed and put with the papers from the Gloucester office at the new location ... it would be helpful to have access to expert legal advice about the desirability of retaining the database of information compiled by the Tribunal in the course of its proceedings.”30 | The Macur Review2.24 The methodical approach of the Tribunal administrative staff was not mirrored by the Welsh Office or subsequently by the Wales Office. In October 1998, a Welsh Office internal memorandum referred to the arrangements for storage of the papers produced by the Welsh Office Legal Team then currently held in CP2 (presumed to be Cathay Park Cardiff), “although the files have been allocated registered numbers they have not yet been formally registered although many do carry the registered number allocated to them ... the files can contain a number of different categories of document.” 2.25 In June 1999, a Welsh Office internal memorandum indicates that “a full set of Tribunal papers is, we understand, to be given over to the Secretary of State for archive purposes. It is not clear whether that material will be held by the Department (or in future the National Assembly), or whether arrangements need to be put in hand for the material to be placed in safekeeping elsewhere, perhaps in the Public Record Office.”2.26 Of particular note are the contents of an email dated 25 April 2000 from a Wales Office official to others in terms, “my concerns are essentially directed towards those records which would be deemed to be Welsh public records … we are still essentially in a paper document system and there still exists a need for the Tribunal material to be properly identified and catalogued. Welsh public records must be accessible and secure, this applies not only under the Public Records Act but also the revised Data Protection Act 1999. I have been raising this point for some time now and my concerns are that as we move further away from the date of the publication of the Report and its impact lessens as other priorities emerge, these papers will be left still unidentified and current knowledge of the value of the records lost as those with the knowledge move elsewhere. Someone needs to grasp this nettle once and for all.” 2.27 It appears that boxes of Tribunal papers were delivered for storage, initially to Curran Embankment file store in Cardiff, in and around May 2000. They have been moved, some apparently several times, subsequently. My examination of the exterior markings of the boxes suggests that the contents have been decanted from their original Tribunal packaging. There has been no attempt to archive them since 2000. Widespread disorder has replaced the apparently careful indexing of materials conducted by the administrative officers and Clerk to the Tribunal.2.28 It is possible that some relevant documentation has been destroyed in accordance with government policies which prescribe destruction, or review for the purposes of destruction, of documents at different ages according to the nature and substance of the contents. If so, it will have likely been on an uninformed basis in the absence of a comprehensive index. There is no record of any such process other than as relates to the documents belonging to, and supplied by, the Welsh Government. 2.29 I wrote to the Director of the Wales Office on 15 May 2015 to inform him, amongst other things which are referred to elsewhere in this Report, of the criticism I was minded to make of the inadequate archiving of the Tribunal materials. The Director responded explaining that no attempt had been made to re-organise the documents The Report of the Macur Review | 31following the announcement of the Review in order to ensure a rapid production of materials to the Review and to avoid any suggestion that any member of the Wales Office had sought to interfere with the contents of the boxes of documents.Absence of the Tribunal’s computer database 2.30 The absence of a reliable index may have been compensated by access to the Tribunal’s computer database. The Tribunal Report1 records the scanning and filing of “12,000 documents, some of which ran to many pages” onto the Tribunal’s computer. Two of the Counsel to the Tribunal, the Clerk, and one of the Solicitors to the Tribunal, all independently told me in interview that every document of note obtained for the Tribunal was logged and entered upon the bespoke computer database for use in what was intended to be a ‘paperless’ inquiry. It was said that the original documentation was not necessarily retained after being scanned into the computer database.2.31 An agenda for an administrative meeting held on 9 February 2000, following the delivery of the Tribunal Report, suggests “that the scanner should be wiped clean as the information already exists in hard copy. This would avoid the involvement of data registration ...” However, the Clerk to the Tribunal specifically recalls its retention, indexed the same and was able to identify the label of the relevant archive box in which she had seen it stored. It was not present in any of the boxes delivered to me. All possible agencies were approached in an attempt to locate it. 2.32 Correspondence in relation to missing files indicates that a secondary computerised database was compiled by the successor authorities (see paragraph 6.79). During her interview with me, the Clerk to the Tribunal thought it possible that Flintshire county council, one of the successor authorities, may have inadvertently retained a copy of the database since computer hardware was returned to the authority after the conclusion of the Tribunal hearings. However, Flintshire’s Head of Legal and Democratic Services notified the Review on 3 January 2013 that the “Head of ICT and our records officer both confirm that the databases were backed up to tape and the tapes given to the tribunal staff ... the servers were reformatted thereby wiping all the data so that they could be re-used within the council. It is our understanding therefore that the Welsh Office [sic] have those tapes ...” 2.33 The Wales Office conducted a search but found no trace. The tapes were found to have been transferred to the Welsh Government for storage and record management in either Cathay Park or Neptune Point, Cardiff, in accordance with a service level agreement that required the records of the ‘North Wales Child Abuse Tribunal’ to “be clearly identifiable and separately stored ... [with] no access to these records ... (except for records management purposes) without the express consent of the Wales Office.” Investigations were commenced with, and an extensive search obviously conducted by, the Welsh Government.1 See paragraph 1.11 of the Tribunal Report and paragraph 2 of Appendix 4 of the Tribunal Report (reproduced at Appendix 3 of this Report)32 | The Macur Review2.34 On 8 March 2013, my Secretariat was informed in terms, “with regards to the tapes holding back-up information relating to the Waterhouse Inquiry, I attach an email exchange from 2008 which states that the information held on the tapes was corrupted and unreadable. Also, attached is the formal documentation relating to the destruction of the tapes.” On 3 June 2013, it was confirmed that the Wales Office was not informed of the destruction at the time since, “there was no indication that the tapes belonged to the Wales Office. The labelling on the tapes were very scant and it was near impossible to tell what the tapes were about ... Furthermore the tapes were housed with other Welsh Government back-up tapes.”2.35 The email exchange in September and October 2008 indicates attempts made to read the tapes and retrieve the data. There is no doubt that the subject of this email traffic is the ‘North Wales Tribunal backup tape’. A ‘technical support specialist’ employed by Siemens IT Solutions and Services Ltd, reports “the catalogue held on the first tape is corrupt (along with the data on that tape) which renders the other media in the set unreadable.” The tapes were thereafter consigned for “secure shredding ... on the Child Abuse file.”2.36 I note a briefing paper prepared six months earlier in February 2008, dealing with the policy for “Storage and disposal of computer back up tapes and recovery data”, sought “agreement to proposed new procedures to reduce the time back-up tapes are kept to two years and to the disposal of back-up tapes older than two years.” It seems that this proposal was adopted and implemented in relation to approximately 4,500 tapes.2.37 I wrote to the Permanent Secretary of the Welsh Government on 15 May 2015 indicating my provisional views on the destruction of the computer database. The Permanent Secretary responded indicating that his research had shown that, whilst the ‘limited information’ on the labels to the tapes suggested that they referred to the Tribunal, it was necessary to identify what was actually on the tapes by reading them. The Welsh Government’s ICT contractors at the time were aware of possible encryption issues, “but when asked to retrieve the data they were unable to do so citing digital continuity, digital rot (degradation of the software programme over time) and data degradation (data decay) over the eight or more years since the tapes were created.”2.38 Unfortunately, if the computer database contained the cipher key to the initials utilised by the Tribunal to identify complainants in different chapters of the Tribunal Report, it too has been lost. It is not documented elsewhere. It has been necessary for the Review team to reconstruct the cipher key from base materials with consequent delay. 2.39 The failure to archive the Tribunal material, properly or at all, has increased the workload and extended the time scale of the Review considerably. In the absence of the Tribunal’s computer database and credible indices, it is impossible to confidently report that I have seen all relevant documentation that was before the Tribunal; although by process of analysis and cross referencing, I think it likely that I have obtained the majority, if not all, relevant documentation from various sources. The Report of the Macur Review | 33Preliminary examination of documents2.40 My preliminary examination of the first consignments of boxes of documents originating from the Wales Office was conducted without the benefit of a credible index. They contained materials obviously relevant to this Review, but also many duplicated documents together with ‘encyclopaedias’ of public legislation and circulars, fee notes, invoices and other associated papers concerned with the running of the Tribunal premises. Two boxes identified as arising from the Tribunal contained material relating to the University of Wales and a building development! 2.41 Consignments from other sources were better ordered. On devolution, the Welsh Government had inherited the relevant ministerial and Welsh Office papers relating to the Tribunal, created prior to 1 July 1999, and owned those created subsequently. It appears to have stored them appropriately in accordance with a service level agreement, albeit in several locations. The Department for Education had inherited relatively few relevant documents concerning the Tribunal, originally emanating from the Department of Health. The AGO produced four envelope files which referred to legal aspects of the process. There were some, but fewer, duplicated materials. Electronic Document Management System 2.42 Quite apart from their disarray, the sheer volume of potentially relevant documents, comprising more than one million pages, necessitated the Review to commission a bespoke electronic document management system. However, it was clear that the time and financial cost of scanning all materials supplied to the Review onto a secure computer database was disproportionate and would severely delay progress. 2.43 Therefore, I instructed the Review team to conduct a manual check of the boxes with a view to isolating all statements and other documents which contained reference, or were of relevance, to complaints of abuse or otherwise referred to the establishment or running of the Tribunal. Specifically, any duplicated documents with manuscript addition or annotation were to be retained and treated as creating a separate document from the original. All individual Review team members’ manual searches were randomly cross checked by another. I considered it was necessary to examine every document to ensure that nothing of relevance was concealed or contained within what appeared to be extraneous papers. 2.44 Ultimately, more than 200 boxes of documents were identified as of potential relevance and were scanned onto the electronic document management system between 19 March 2013 and 3 July 2013. Unfortunately, since many of the boxes of documents were unsorted at the point of delivery, they were necessarily scanned on to the system out of order and in a mixture of single documents and lengthy bundles. This meant that unrelated files were found together and single documents out of context. 34 | The Macur Review2.45 The database has been continuously refined by the deletion of duplicate materials to assist the efficient search of materials. Nevertheless, in the region of 434,500 pages remained available for search in the electronic document management system. Process of more detailed analysis2.46 The terms of reference set to this Review meant that it could not reasonably rely upon the accuracy of schedules of allegations of abuse prepared by the Tribunal. The Review’s independent electronic search commenced in July 2013. The scanned material was first examined to identify all allegations of physical or sexual abuse contained in the material available to the Tribunal, regardless of whether the complainants had provided evidence to the Tribunal. In this fashion, a list of over 1,400 potential complainants was created.2.47 The schedules prepared for this Review are more wide ranging than those prepared on behalf of the Tribunal, which recorded (i) an alphabetical list of children’s homes in which former resident individual complainants alleged abuse, and (ii) the names of the recipients of Salmon letters accused of abuse, or witnessing it without intervention (see Chapter 6 herein). The Tribunal schedules do not record the individual allegations made, but allocate a category of abuse to them, that is ‘physical’ or ‘sexual’. The Review schedules have been sourced from all materials made available to the Review and not restricted to police or Tribunal statements. They include allegations made by witnesses to, not necessarily victims of, the reported abuse. 2.48 Searches were then conducted to identify all documents relating to each allegation made by a complainant. All documents returned in the searches, in some cases several hundred, were categorised and reviewed. Information was collated as to the nature of the abuse alleged, date and, if revealed, name of the alleged abuser. Thereafter, in the case of each complainant, assessment was made as to whether the Tribunal had (a) considered the allegations; (b) made findings upon them; and, (c) pursued all reasonable inquiries. A blank pro forma is found at Appendix 4 to illustrate the universal process adopted by the Review team in respect of each of the complainants identified. The review of the materials was not restricted to a simple correlation of findings made in relation to explicit allegations and complaints, but analysed documentary evidence of links between abusers, introduction of residents to others, and identification of visitors and their ostensible purpose in visiting the home, to see if further lines of inquiry were overlooked by the Tribunal. 2.49 From the outset it was clear that a computer program (specifically, the optical character recognition function) could not be devised to recognise text in manuscript documents. Trial runs indicated difficulties in reliably and consistently identifying text upon poor quality paper, or when manuscript marks or annotations were made in the near vicinity of the typescript, for example, because it was underlined. Consequently, and recognising the potential limitations of generic search terms, a final examination was made of each page which had not been previously returned in relation to search terms, in accordance with the process indicated in paragraph 2.48 above. The Report of the Macur Review | 352.50 I have been personally responsible for analysing the relevant government departmental records for indications of concealment of information or undue influence upon the Tribunal. 2.51 At all times this Review proceeded on the basis that there was something to find, rather than there being nothing to hide. Searches have been conducted in the knowledge that it would be unlikely to uncover evidence which explicitly revealed concealment or bad faith, but alert to the fact that to be “hidden in plain sight” is an effective ploy.Other sources of information2.52 I have watched recordings of various past television documentaries and news items concerning the subject matter investigated by the Tribunal, and more recent interviews conducted before and following the announcement of this Review. I have read newspaper articles in which allegations against previously unidentified alleged abusers have been made.Issues Paper and written submissions2.53 An Issues Paper was published on 8 January 2013, in English and Welsh, requesting information relating to the remit of the Review (a copy is provided at Appendix 5). A press release about the Issues Paper was issued in English and Welsh on the same day. Hard copies were also distributed to parties who may legitimately be thought to have a particular interest in the Review, and to any individual who specifically requested it. Additionally, a copy of the Issues Paper has been available on the Review’s dedicated webpage at www.gov.uk/government/organisations/macur-review and also included on the Children’s Commissioner for Wales’ website. 2.54 Submissions to the Review were invited to be made by email, post or via a dedicated telephone line by 29 March 2013, although those who requested additional time to complete their submissions were accorded all appropriate leeway. Mindful of the potential of a caller’s embarrassment in speaking about childhood abuse to a member of the Review team, a free telephone line with recording facility was made available from the outset. A pre recorded message inviting callers to leave their message was given in both English and Welsh. 2.55 All resultant contributions were recorded and have been followed up as appropriate.Wrexham event2.56 Conscious that this London based Review might alienate potential contributors with relevant information to reveal, a public meeting was held in Wrexham on 18 June 2013. The aim was to engage local communities, previously part of the Gwynedd and Clwyd county council boundaries, and to provide residents with the opportunity to meet the Review team on their own home ground.36 | The Macur Review2.57 The event was publicised with good notice in English and Welsh in the press and on the Review’s website. The Children’s Commissioner for Wales advertised the meeting on his Twitter feed and website and alerted various individuals to it. The successor local authorities, Assembly Members, MPs and others were invited to promote attendance of all interested parties at the event. All recipients of the Issues Paper and those who had made contact with the Review were notified of the event. 2.58 Public sessions were held in the morning and afternoon with general discussion, questions and answers. I then conducted private meetings with any person indicating a wish to speak with me. Both the public and private meetings were well attended. A follow up meeting was arranged in one case. Further information or documents as necessary were sought from other contributors. Interviews and oral submissions2.59 I selected as prospective interviewees those individuals whom I thought might have relevant information that had not been available to the Tribunal or, otherwise, whose participation in the Tribunal process would provide evidence of their first hand experience of events ‘on the ground’. In addition, I met with several individuals who had requested a meeting with me and who appeared to have information relevant to the Review on the basis of their written submissions. Interviews have been conducted with a range of individuals as indicated below. Members of the Tribunal, Legal Team and Clerk to the Tribunal2.60 Sir Ronald Waterhouse died on 8 May 2011. I have conducted interviews with the two surviving members of the Tribunal, all three Counsel to the Tribunal, the successive Solicitors and the Clerk to the Tribunal. I have also interviewed the head of the Witness Interviewing Team (WIT). CPS and Police 2.61 I have met with the immediate past Director of Public Prosecutions (DPP) and, with his agreement, have interviewed the two CPS lawyers responsible for initially dealing with the prosecution files of those accused of the ill treatment, physical abuse and/or sexual abuse of children in the care of Gwynedd or Clwyd county councils. 2.62 I then interviewed the Senior Crown Prosecutor who appeared before the Tribunal and carried out his own review of the decisions of the two CPS lawyers referred to above. 2.63 I have interviewed the Senior Investigating Officer of the 1991 police investigation and have met with the head of the National Crime Agency and the senior police officers heading Operation Pallial. The Report of the Macur Review | 37Successor authority staff assigned to the Tribunal 2.64 I have interviewed a local authority administrative officer, designated as the co-ordinating liaison officer by the successor authorities, and responsible for the location of files originating from the former Gwynedd and Clwyd county councils for the use of the Tribunal. Complainants to the Tribunal 2.65 Relatively few complainants who had made witness statements to the Tribunal or during either of the police investigations contacted the Review or sought to speak to me. However, some of those who did attend the public meeting in Wrexham on 18 June 2013 spoke to me in private. On 26 August 2014, I interviewed a complainant to the Tribunal, who had criticised the Tribunal process in correspondence with the Chairman, and who has subsequently been predominant in criticising the Tribunal process publicly in the media. Another complainant witness, contacted me in August 2015 and was interviewed on 10 September 2015.Journalists 2.66 I have interviewed two journalists who have shown particular interest in the subject matter of the Tribunal and whose articles appeared to suggest potential sources of relevant information to the Review.MPs and local councillors2.67 Interviews have been conducted with a former Welsh MP and a local authority Councillor, in office at the time of the Tribunal; both of whom had indicated disquiet and perceived deficiencies in the outcome of the Tribunal by reason of information they held. Former auditor 2.68 A former auditor of Flintshire county council was interviewed as a result of his suggestion that a member of one of the successor authority’s staff may have withheld relevant local authority files from the Tribunal.Former union official2.69 A former union official contacted the Review after I wrote notifying her that reference would probably be made in my Report to a statement she had previously prepared for the purposes of Employment Tribunal proceedings. She indicated that there was additional information that she could provide to the Review and was interviewed in June 2015. 38 | The Macur ReviewFormer care home staff and social workers 2.70 I have questioned a previous children’s home worker who was a ‘whistle blower’. I have met with two other former care home members of staff. A member of my secretariat met with a former North Wales social worker. I have received representations from members of FACT. Other contributor2.71 The Review solicitor met with an individual who wishes to remain anonymous and who identified documentary evidence likely to be of use to the Review, which, in fact, had already been obtained.Government 2.72 I had a courtesy meeting with the immediate past Lord Chancellor and Secretary of State for Justice, and the immediate past Secretary of State for Wales, jointly, on 19 December 2012. Additionally, during a separate meeting on 30 January 2013 with the immediate past Secretary of State for Wales, David Jones MP, he provided information concerning a telephone call made to him from a person who identified themselves as a member of the Tribunal staff, as detailed at paragraphs 1.4 and 1.34 above. I have since met with the current Secretary of State for Wales on 12 September 2014. 2.73 Issues of social care and children’s services in Wales were devolved to the Welsh Government. I met with the First Minister in December 2012 to describe my role and how I intended to undertake my Review, and to request the co-operation of the Welsh Government in providing any historical information that was of relevance. 2.74 I have also met the Cabinet Secretary and the immediate past Permanent Secretary of the Ministry of Justice jointly on one occasion; and I met separately with the immediate past Permanent Secretary on one occasion. These meetings took place immediately after the announcement of this Review as a matter of courtesy. Children’s Commissioner for Wales2.75 I met with the immediate past Children’s Commissioner for Wales on 27 November 2012. He undertook to make individuals who had reported allegations, or said they held information about child abuse, aware of this Review and the parallel police investigation.Conduct of interviews2.76 I have not found the terms of my appointment which prevent me “to hold oral hearings” to be restrictive, and believe that, in the majority of cases, interviewees have displayed a genuine desire to co-operate and assist the Review, and have been straightforward in their responses. I did not appoint ‘Counsel to the Review’ but have conducted all but two interviews myself, in the presence of members of my secretariat and/or the solicitor to the Review.The Report of the Macur Review | 392.77 The interviews have been recorded in writing, when possible, as transcribed from audio tape. Interviewees were notified in advance that this would happen. A record of the interview has been supplied to the interviewee for their comments which have, where appropriate and seemingly accurate, been incorporated into the record.2.78 My questions were intended to be probing, but not adversarial. I did not invite interviewees to take an oath or make affirmation as to the truth of the information they provided, but assessed that all were aware of the import of full and frank response to my questions.2.79 I have conducted interviews with 38 individuals. Wherever possible, these have been conducted at locations convenient to the interviewee. Anyone who wished to be accompanied was permitted to be so given the nature of the subject matter. When this occurred, the person accompanying them was required to agree that they would respect the confidential nature of the interview, would not seek to intervene in the interview process and were not, or would not likely be, an actual or prospective contributor to the Review in their own right. I did, however, conduct a joint interview with the two surviving members of the Tribunal to accommodate the recent ill health of one of them. Two interviewees were notified in advance that I would be discussing concerns that had been raised about their conduct. Some interviewees were asked to clarify issues subsequently as appropriate.Conclusions2.80 This Review, as was the Tribunal, is dependent upon the integrity of the contributions it receives. Issues relating to the integrity of the documentation available to the Tribunal, and consequently to me, are dealt with in a separate chapter.2.81 I have made every effort to assimilate information relevant for this Review. Operation Pallial may yet discover further information, and is the best equipped to do so. Necessarily, my conclusions are based on the information available to me now.2.82 Whilst regrettable, I do not regard the late production of papers referred to in paragraphs 2.8 and 2.18 to be suspicious. The documents now produced are innocuous. However, a necessary delay has been occasioned by the necessity to thoroughly review the documents provided in November and December 2015 and raises the possibility that other government departments have made inadequate response to the call for all relevant materials to be provided to the Review. 2.83 The failure to adequately archive the materials associated with the Tribunal has undermined the integrity of the materials. The manner in which the Wales Office boxes of materials were filled suggests that the most likely explanations for missing or misplaced documentation are the result of: human error in the face of overwhelming volumes of materials; the contamination of a perfectly good indexing system with a view to reducing storage charges; re-organisation and re-location; and, possibly, deployment of ‘destruction policies’ with little thought of a Review such as this. The wholesale disorganisation of materials would militate against any thought of informed malign intervention or removal of documents.40 | The Macur Review2.84 I incline to regard the destruction of the Tribunal computer database as an unfortunate and innocent mistake, rather than a calculated ploy. Those who have admitted to its destruction would be unlikely to have a personal interest in deleting its contents nearly nine years after the presentation of the Tribunal Report and with no concept of a Review such as this, even if, contrary to the assertion of the Welsh Government’s ICT support, the tapes had been readable.2.85 This Review has been widely publicised and contributions positively encouraged and facilitated. That I have received relatively few contributions from complainants of abuse should be seen in the context of the painful subject matters investigated by the Tribunal, the distance of time, prospective changes in their own domestic circumstances and the ongoing current police investigation. I have not presumed that lack of participation necessarily indicates satisfaction with the Tribunal process. 2.86 Subject to the caveat I express in paragraph 2.39, I remain confident in the conclusions I reach in this Report in light of the numerous, varied and cumulative sources of information available to me. The Report of the Macur Review | 41Chapter 3: Background and Delay to the Establishment of a Tribunal of InquiryIntroduction3.1 Despite numerous and, increasingly, nationwide calls for a public inquiry into the events in North Wales children’s homes, there appeared to be significant delay in the announcement of the Tribunal. The delay has been interpreted by some to indicate that the government feared that establishment figures would be exposed as complicit in child abuse. This chapter reports upon the chronology and nature of events which preceded the establishment of the Tribunal of Inquiry so as to examine the extent and reasons for the delay. Events preceding the establishment of the TribunalPolice investigations and CPS action 3.2 Between 1970 and 1992 a significant number of allegations were made by children and young people about the physical and sexual abuse they suffered whilst in care in North Wales. A police investigation conducted in 1986/87 into such allegations arising in Gwynedd did not lead to any criminal prosecutions.3.3 In July 1991, the Chief Constable of the North Wales Police (NWP) was requested to investigate the “overwhelming number of links” between individuals convicted of serious sexual offences against young people in care and a former approved school, which later became a residential care home in Clwyd, by the Chief Executive of Clwyd county council who was concerned as to the “possible existence of a paedophile ring in North Wales.” The Chief Constable agreed, and at the end of 1991 merged this investigation with the similar one commenced in October 1991 in Gwynedd. Very few criminal prosecutions resulted. 3.4 The small number of prosecutions mounted by the CPS in North Wales led to speculation of its connivance with the NWP not to bring offenders to trial. In September 1992, designated special case worker, fearing that ongoing media coverage was likely to compromise the few pending criminal trials, wrote to the AG to inquire about the possibility of proceedings being initiated in relation to media articles, which would prejudice not only current prosecutions, but also ongoing investigations. 3.5 However, on 26 November 1992, the AG advised that since no court cases were immediately pending there was no possibility of contempt proceedings being started. Media reports about the situation in North Wales continued to appear. Gordon Anglesea, a former Police Superintendent in NWP was named, implicitly and explicitly, as involved in sexual abuse of boys in care. The resulting libel trial was heard at the end of 1994.42 | The Macur Review3.6 In these circumstances and the voiced suspicions that members of the NWP were either involved in the abuse of children in care, or else in the protection of those who were, the repeated and increasing demands for investigation by an outside force were unsurprising. The Chief Constable of the NWP resisted them on the grounds of his confidence in the new investigation and his belief that the costs of replacing the investigating team, in terms of confusion, delay and expense, could not be justified. 3.7 I report in paragraph 4.109 below the contents of a letter dated 22 February 1993, addressed to the Permanent Secretary of the Welsh Office from the Chief Constable of the NWP, relating to the alleged concealment of complaints by a Social Services Inspector which he said had prompted his call for a public inquiry. However, it is clear that the mounting speculation about the failure of Clwyd county council, the successor authorities or the Welsh Office to publish ‘the Jillings Report’ (a report from a Panel of Inquiry established at the direction of Clwyd county council in January 1994 and chaired by Mr John Jillings to investigate “what went wrong with child care in Clwyd … why did this happen and how this position could have continued undetected for so long”) and the consequent impact upon police morale, added to his concerns and his calls for a public inquiry. Complaints of Mrs Alison Taylor3.8 The Tribunal Report1 records that in September 1986 an article appeared in the Daily Mail referring to police investigations into allegations of the mistreatment of children in care. This newspaper article was mentioned in an anonymous letter addressed to the Prime Minister and forwarded to the Welsh Office for attention. Subsequently, in December 1986, Mrs Alison Taylor, a former Deputy Officer in Charge of Ty’r Felin, a children’s residential home in Gwynedd, wrote to the Welsh Office, copying her letter to the Prime Minister, Margaret Thatcher, and other government departments, referring to her own personal employment situation and making allegations against Nefyn Dodd, in respect of his management of Ty’r Felin and the ill treatment of children in residential care in general. 3.9 The Tribunal Report notes that at this time the Welsh Office declined to become involved in matters that were for local determination and in a letter dated 14 January 1987 suggested that Mrs Taylor consider what further action was necessary when the social services department had “reported on her case”. The Tribunal Report2 details the further letters and reports sent by Mrs Taylor to various government departments and the responses made.3.10 I report that in 1988 an internal Welsh Office memorandum considered whether “there is smoke” in the repeated allegations of Mrs Taylor, but it is clear from contemporaneous local authority communications to the Welsh Office at this time that her character was disparaged by reference to the institution of disciplinary proceedings against her. In mid 1991, ministers were reminded that she had first 1 See paragraph 49.58 of the Tribunal Report2 See paragraphs 49.63 to 49.66 of the Tribunal ReportThe Report of the Macur Review | 43written in 1986, but invited to note the advice that the Social Services Inspectorate Wales (SSIW) “… view is that it would be a mistake to interview Mrs Taylor. Her allegations have already been very fully investigated and remain unsubstantiated ...” 3.11 The advice was accepted. The Tribunal Report3 records that Mrs Taylor was advised in a letter dated 12 July 1991 from the Right Honourable Wyn Roberts MP, Minister of State for Wales (later Lord Roberts of Conwy), on behalf of all other government ministers and departments to whom her letter of June 1991 had been sent, that it must be concluded that all allegations made prior to the police investigation in 1986 and SSIW inspection in 1988 had been properly investigated. The letter stated that “the Social Services Inspectorate conducted an inspection of residential child care facilities in Gwynedd in September and November 1988. Their report was published ... [and it] makes clear that the inspectors did not find anything to substantiate your allegations ...” She was advised to consult with her solicitor on how to proceed and to inform Gwynedd county council of any new information.3.12 The Tribunal Report notes4 that Mrs Taylor’s solicitor wrote in March 1993 expressing concern about the Welsh Office inaction to the complaints and pointing out the shortcomings in the 1988 SSIW inspection, which made no reference to the police investigation. The response of the Secretary of State for Wales was that any complaint about the NWP should be referred to the Chief Constable and if necessary the Home Office, and that complaints concerning Gwynedd county council should be taken up as a formal complaint with that authority. It also described the method of the SSIW examination to have been to hold “discussions with the resident youngsters in private during which they were given the opportunity to raise and discuss any issue ... No reference to abuse emerged ...” 3.13 In her second statement to the Tribunal, Mrs Taylor suggested that the correspondence passing between herself and the various government departments and agencies demonstrated a “pattern of official inertia” and that “all roads appeared to lead back to the Welsh Office and to Sir Wyn Roberts, MP, both of whom were thoroughly disinclined to create an upheaval.” 3.14 In an undated and unsigned note prepared by a Welsh Office official in response, the author claims “that all correspondence received by the Welsh Office from Mrs Alison Taylor … was responded to appropriately and the issues raised treated seriously and pursued so far as it was possible so to do, having regard to the limitations upon the capacity of a government department to intervene in relation to the issues raised ...” However, the Secretary of State for Wales was notified by officials in October 1997 that Lord Roberts (as he had then become) was likely to be criticised by Mrs Taylor at the Tribunal for giving little or no support in her efforts to secure an investigation into the child abuse allegations.3 See paragraph 49.66 of the Tribunal Report4 See paragraph 49.69 of the Tribunal Report44 | The Macur Review3.15 The Tribunal found that the Welsh Office had been wrong to accept “so readily” that Mrs Taylor was a “troublemaker” without an independent investigation of the background or circumstances, and that it was wrong to suggest to her that the 1988 SSIW inspection “embraced” the allegations she put forward. The Welsh Office response to her complaints was described as “inappropriately negative and inadequate”.5Support of Mr Geoffrey Dickens MP3.16 On 24 September 1991, Mr Geoffrey Dickens MP wrote to the AG (Sir Patrick Mayhew QC MP) “Your files will reveal that I raised concern with your office regarding the Ty’r Felin children’s home in 1986. My informant at the time, Mrs A Taylor, was dismissed ... I have assisted in the production of a documentary report for HTV which was broadcast 26 September. In your replies to me in 1986 you place reliance on the police enquiries. Having viewed the entire documentary ... (indecipherable) ... from witnesses who were named but not interviewed during the police enquiries, I hope you will agree to call for a proper enquiry. Your office may find it helpful to call for the TV film ... I am deeply concerned ...” Local authority investigations and government response3.17 The Tribunal found that the Welsh Office advice to the Director of Social Services for Clwyd about the nature of the inquiry needed into the allegations of abuse emanating from Cartrefle children’s home had been “confused and mistaken” leading to a “cumbersome, long drawn out and repetitive” investigation.6 The Tribunal commended the subsequent analysis and recommendations in the report of the local inquiry that was established, although finding them of limited value since the report could not be published; a file note (see paragraph 4.111) indicates that the results were reported to SSIW who notified Welsh Office officials of the nature of the allegations and recommendations made. However, both Clwyd and Gwynedd county council had previously commissioned several investigations and inquiries into particular children’s homes or individual events of abuse, many of which the Tribunal found had not been fit for purpose or had been misrepresented to local social service sub-committees, and which were not notified to the Welsh Office. 3.18 On 2 December 1991, an internal Welsh Office memorandum records, “PUSS [Parliamentary Under-Secretary of State] asks ... that officials should contact Clwyd CC tomorrow morning to point out to them the Ministerial as well as public concern about the latest allegations, to suggest that they carry out some form of inquiry if they are not already doing so ...” 3.19 On 7 September 1992, Mr Gwilym Jones MP, the Parliamentary Under-Secretary of State for Wales, indicated in a Welsh Office news release that “in view of the great public disquiet and on current information” and “the call by the North Wales 5 See paragraphs 49.68 and 55.10 (73) of the Tribunal Report6 See paragraph 49.86 of the Tribunal ReportThe Report of the Macur Review | 45Police for a public inquiry,” he had concluded that a public inquiry was necessary to consider “the nature and scope of the allegations which have been made about child abuse in North Wales ...” This was to await the conclusion of police investigations and criminal prosecutions. 3.20 Councillor Dennis Parry, who became leader of Clwyd county council in 1991 wrote to Sir Wyn Roberts MP on 29 January 1993 seeking that he establish a “major and vitally necessary Inquiry” without delay since it would otherwise be “materially compromised by the anticipated delays ... [by reason of] organisational upheavals or the displacement of personnel.” 3.21 Clwyd county council commissioned the internal ‘Jillings Inquiry’ in 1994 (see paragraph 3.7 and below). Shortly before its dissolution in March 1996, Clwyd county council received the Jillings Report (see paragraph 3.26). The Jillings Report was not published by Clwyd county council or by the successor authorities in the light of unequivocal legal advice from Leading and Junior Counsel that to do so would expose the local authority to significant and multiple civil claims for libel and the risk of losing its public indemnity insurance. Nevertheless, the Jillings Report was ‘leaked’ and quoted in parts by the media suggesting its non-publication was a cover up. 3.22 The successor authorities urged the Secretary of State for Wales to establish a public inquiry to put an end to allegations of a cover up. 3.23 The last relevant criminal prosecution concluded on 9 February 1995. On 10 February 1995, Mr Rod Richards MP, the Parliamentary Under-Secretary of State for Wales, announced that a Queen’s Counsel would be appointed, pursuant to section 81 of the Children’s Act 1989, to undertake an investigation of papers and to advise the government whether a further inquiry into matters of child abuse in children’s homes in North Wales was needed and, if so, the form it should take. Thereafter, on 10 May 1995, the Secretary of State for Wales appointed Miss Nicola Davies QC (now Mrs Justice Nicola Davies) in this role. 3.24 Miss Nicola Davies QC reported on 22 November 1995. Her conclusions and recommendations only were published at her request, as she had given an undertaking to parties co-operating in the production of documents that they would be assured of absolute confidentiality. She advised against a public inquiry, but recommended that there should be a detailed and independent expert examination of the implementation of practice and procedures of the North Wales child care agencies.3.25 Consequently, in a Parliamentary Written Answer on 11 December 1995, Mr Rod Richards MP, the Parliamentary Under-Secretary of State for Wales, announced the appointment of Ms Adrianne Jones, former Director of Social Services in Birmingham and former Head of the Department of Residential Child Care Support Force, to head such an examination. Her terms of reference required examination of documents held by Gwynedd county council and Clwyd county council and by all private agencies in those counties who provided residential care for children from 1991 to date with a view to scrutinise child care procedures, their adequacy and effectiveness and including management and personnel procedures, and make recommendations. 46 | The Macur Review3.26 The Jillings Report was submitted by the successor authorities to the Welsh Office at the end of March 1996. Following a meeting with the successor authorities on 6 June 1996, during which the Right Honourable Mr William Hague, Secretary of State for Wales, requested that they publish the Jillings Report, he made a statement to the House that “The successor authorities have subsequently informed me that they are unable to meet that request. In their view, the report is likely to contain evidence that was given in confidence to the inquiry team, and is in any case so seriously and extensively defamatory that an acceptable version of it cannot be produced. In the light of my own legal advice, I have considered whether I could make the report as it stands available to the House. I have concluded that, in view of the nature of the defamation it contains, it would not be a proper use of parliamentary privilege to do so. I find this a deeply unsatisfactory outcome, and one that reflects badly on the former Clwyd county council. It devoted two years and a substantial amount of public money to an inquiry, the report of which cannot safely be published. When public authorities establish investigations, they should do so in a way which, at the very least, permits the principal findings and recommendations to be made public.”3.27 Ms Adrianne Jones reported formally in June 1996. She identified “significant gaps” in “operational, management and personnel procedures” in management practices in the field of child care and made 41 recommendations directed at the successor authorities to Gwynedd county council and Clwyd county council. 3.28 On 17 June 1996, the Secretary of State for Wales, Mr Hague, announced as “further [Government] initiatives” the commission of a judicial inquiry into the abuse of children in care in the former county council areas of Gwynedd and Clwyd since 1974. The statement was welcomed by members of the Opposition, but described as ‘belated’ since “his Department promised a public inquiry nearly four years ago” and in the interim had repulsed a sustained campaign by local politicians, senior police officers, the public and the media “to honour their promise.”Review of government deliberations and advice to ministers leading to the public inquiry 3.29 As indicated above, the Tribunal was critical of the failure of the Welsh Office or other government departments to deal with the persistent efforts of Mrs Taylor to obtain any external or further inquiry into the care system in North Wales between 1986 and 1991. The Tribunal Report noted7 continuing public interest in the subject and questions being asked in the House of Commons on a number of occasions. In addition, the Welsh Office was criticised in the Tribunal Report for its overall lack of leadership and failure to inform itself adequately of what was happening on the ground.8 The Tribunal Report refers to Mr Gwilym Jones MP, Parliamentary Under-Secretary of State’s announcement that a public inquiry into the allegations would take place, noting that there was no indication of the “form that the inquiry would or 7 See paragraph 2.36 of the Tribunal Report8 See paragraph 47.63 of the Tribunal ReportThe Report of the Macur Review | 47 might take and it was clear that the police investigation would continue for a substantial period because new allegations of abuse were continuing to be made.”9 However, the terms of reference set to the Tribunal did not specifically require it to consider whether or not the Welsh Office should have established a public inquiry sooner.3.30 As indicated above, I have interpreted the terms of reference set to this Review to require that I do consider the timing and nature of the government’s response. 3.31 I can confirm that there is nothing in the documentation seen by this Review which undermines the statement in the Tribunal Report that “prior to the Cartrefle disclosure in June 1990, Alison Taylor was the only source of information to the Welsh Office about allegations of child abuse in local authority community homes in North Wales on any significant scale” and that these allegations from December 1986 were restricted to Gwynedd “until a much later stage”.10 In these circumstances, set in the context of the Tribunal’s other critical findings of the Welsh Office’s “lack of initiative” and failure to take the opportunity to inform itself of what was happening, it is not surprising that the Welsh Office did not consider the necessity to announce a public inquiry sooner. However, the periods of time following the announcement of Mr Gwilym Jones MP on 7 September 1992 and before the conclusion of the criminal proceedings in February 1995, and thereafter and leading up to the announcement that a public inquiry would take place, call for more detailed report. Deliberations and advice prior to the conclusion of the criminal proceedings 3.32 The Director of the Wales Office has informed me that officials provide ministers with briefing and advice orally, as well as in writing. Unless recorded, such oral communications are lost to any future review. However, documentation prior to the conclusion of the criminal proceedings in February 1995 reveals longstanding debate about the necessity for a public inquiry and consideration given to other options available to the department. The Director of the Wales Office has informed me that officials provide ministers with briefing and advice orally, as well as in writing. 3.33 Members of the Welsh Office Legal Group obviously interpreted Mr Gwilym Jones MP’s announcement literally, as indicated by the preparation of a detailed ‘minute’ dated 30 September 1993 commenting on the practical arrangements that would need to be put in hand for a public inquiry. This was not understood to be the case by other officials in the department. It was brought to the attention of a senior Welsh Office official with a manuscript annotation, “[Mr J] I think you should take a stiff drink before reading this!” The senior Welsh Office official responded on 6 October 1993 expressing surprise and concern, “Are we not getting ahead of ourselves? We have no Ministerial decision on the nature or scope of an inquiry ...” 9 See paragraph 2.36 of the Tribunal Report10 See paragraph 49.84 of the Tribunal Report48 | The Macur Review3.34 On 8 October 1993, a note records that a public inquiry looked to be a “fiersomely [sic] expensive exercise”. 3.35 A ‘Note for the Record’ marked ‘CONFIDENTIAL’ dated 18 October 1993 summarises a meeting held on 13 October 1993 between Welsh Office officials and the Chief Executive and County Solicitor of Clwyd county council intended to discuss how arrangements for the inquiry indicated by Mr Gwilym Jones MP should be taken forward. 3.36 It appears that, at that meeting, officials discussed the two options for taking forward the announcement in terms of a Secretary of State public inquiry under the powers in the Children Act or a Secretary of State directed local authority independent inquiry. It was agreed that one difficulty with a local authority inquiry was that it would have no powers to compel evidence or witnesses, but officials made the point that “… if a local authority inquiry found itself without sufficient powers to pursue matters which required investigation it could report on the work it had been able to do and recommend that the Secretary of State should set up a further inquiry with powers to compel …” They noted that the Chief Executive “was firmly of the view that it would be wrong to set up a local authority inquiry with the expectation that it would be followed by a Secretary of State inquiry [and] we accepted this point ...” (It is worthy of note that shortly after this meeting, in January 1994, the Chief Inspector of SSIW notified Welsh Office officials that Clwyd county council had decided to commission its own internal inquiry of the social services department which became the Jillings Inquiry. He indicated that he had “mentioned this informally” but “would not wish to comment on whether such a step was appropriate at this time ...”) 3.37 On 10 November 1993, a senior Welsh Office official, who had sought advice from a Department of Health official with greater experience of child abuse inquiries, reported two suggestions made by the Department of Health officials: a local authority inquiry set up using Secretary of State powers to compel witnesses and evidence; or, the appointment of a senior barrister to examine any documentary evidence and advise as to what further investigation was appropriate. The senior Welsh Office official commented that the second option “would be a less costly way of proceeding at least initially and might enable us to avoid a public inquiry altogether”. On 11 November 1993, a ‘Confidential’ message in SSIW documents reads, “glad to see that [Welsh Office Official] has been to see [Department of Health official]. The advice he has had may help to avoid a full blown S-o-S [Secretary of State] inquiry with all the nightmare of the terms of reference and, of course, costs ...” Subsequent legal advice made clear that a local authority could only be compelled to conduct a non statutory inquiry.3.38 In September 1994, a draft submission circulated to officials in the Welsh Office and the SSIW questioned whether there need be an inquiry at all. A SSIW inspector responded pointing out the limitations of the Jillings Inquiry, which had neither the authority to compel the attendance of witnesses nor the production of documents. She referred to her meeting on 29 September 1994 with the Jillings Panel members in stark terms to the effect that, “Reviews and enquiries in Clwyd The Report of the Macur Review | 49to date have not established the full extent of the abuse nor the nature of the management and practice which allowed abuse to flourish undetected. Reports of reviews and inquiries into incidents in children’s homes in Clwyd have not been published, nor have they been made available to county council members. There is confusion about accountability, terms of reference, the authority and duties of panel members. The Independent Panel of Inquiry has been denied appropriate access to information. Only the chairman of the panel is to be allowed to see relevant social services department files, all of which are held by the police. The panel has been told that it may not advertise in the press for individuals to come forward to give information. SSIW’s advice about the terms of reference for the Independent Panel of Inquiry was not taken by Clwyd County Council ... In view of the difficulties experienced by previous panels in Clwyd it is clear that to achieve these objectives an inquiry panel would need the authority to compel the attendance of witnesses and the production of written information including individual case files, logs, policy documents. Its commissioners would need to be totally independent of Clwyd County Council and other local agencies and of interference by them. The inquiry would need the authority to explore the role played by the police at various stages. I conclude that only a judicial inquiry … would meet these criteria.” 3.39 The SSIW inspector’s views were endorsed by the Chief Inspector of SSIW in a minute to Welsh Office officials, which cautioned against placing reliance on the ability of the county councils to commission an inquiry which could only conduct voluntary investigations. He made reference to the inability of previous inquiries, and the Jillings Inquiry, to measure the extent of the abuse or the possible collusion by the management regime, and expressed his view that “an inquiry with anything less than powers to compel witnesses and obtain full access to all relevant information and documentation would, I believe, be unsafe.” 3.40 Noting this advice from SSIW, a senior Welsh Office official indicated to a junior official that the comments should be incorporated into the draft submission to ministers. Whilst describing the content of the advice as “worrying of course,” it did not persuade him to move to an inquiry without considering other options first, including a private inquiry as had been recently conducted by Sir Cecil Clothier into the murders committed by nurse Beverly Allitt. Advice to ministers on options for an inquiry3.41 The resultant written submission to the Secretary of State for Wales and Mr Rod Richards MP, Parliamentary Under-Secretary for Wales, is dated 16 November 1994 and is annotated “as discussed on 20 December 1994”. It sets out the scope and types of inquiry, including the option of whether an inquiry was needed at all.3.42 Under the heading “Need there be an inquiry at all”, the author of the submission notes the closure of one of the children’s homes at the centre of the allegations in 1984, the radical change in the pattern of Clwyd county council services and the fact the council had also decided to establish their own inquiry under Mr Jillings. It notes that previous inquiries in Clwyd “including the present one” had run into 50 | The Macur Review“considerable difficulty,” had been unable to measure the extent of abuse to children or the extent of possible collusion by the management regimes, and that there could be no reliance on the “willingness or the ability of the County Council(s) to undertake an inquiry which would get to the heart of the matter”. In any event, legal advice was that such an inquiry would have no power to compel witnesses and that “a county council could only meet the costs of such an inquiry at the expense of services which are already hard pressed.” 3.43 In considering the option of a non-statutory private inquiry, such as that recently commissioned by the Department of Health and chaired by Sir Cecil Clothier, the advice noted that this type of inquiry did not have the power to compel witnesses, “but we could ensure, when establishing the inquiry that such powers would be provided if the chairman and his team subsequently felt in need of them.” There had been limited legal representation and all of the witnesses that the inquiry wished to see had appeared voluntarily. The costs would be substantially less. 3.44 Another option of a “prior investigation of the papers by (probably) a QC” noted that this would “enable an independent person to examine files and to make recommendations to the Secretary of State about the scale of the problems and accordingly the scope and powers of any inquiry.” The submission identifies the “weakness in this procedure” to be that if the report suggested no inquiry be held then it would “do nothing to dispel local concerns and fears or overcome accusations of a cover up”. 3.45 Recognising that “Given the Parliamentary Secretary’s statement of September 1992 (notwithstanding the phrase ‘under present circumstances’) any decision not to proceed with an inquiry now would be severely criticised” and there would be many who pressed for a “full” independent inquiry and accusations of a cover up, it was apparent that such an inquiry “will be expensive, might not find anything new, and indeed might end up disappointing many because it will not have been able to look in detail at Police actions …” The clear advice was that “on the face of it, [there were] no grounds for a full scale statutory inquiry under s81 of the Children Act 1981 ... an inquiry of this kind would be lengthy and costly and would almost certainly not report before April 1996 when the new unitary authorities come into being.” Mr Rod Richards MP was advised to agree the establishment of a non-statutory private inquiry.3.46 The same senior Welsh Office official referred to in paragraph 3.40 above supported the advice given. In a separate note to ministers, he referred to the possibility that a full public inquiry would be intimidating for victims of abuse and may deter them from coming forward. Similarly, those “with something to hide” would be inclined to say as little as possible. He went on to say that “cost must be a secondary consideration but it is nonetheless a significant one.” The cost of a public inquiry would be “formidable”; starting with a private inquiry, however, would minimise costs and if it led to a public inquiry “at least this would be because there was evidence of matters so grave that the additional burden would seem justified.” The Report of the Macur Review | 513.47 On 6 December 1994, in a note to the Secretary of State for Wales, headed ‘NORTH WALES CHILD ABUSE ALLEGATIONS’, Mr Rod Richards MP, Parliamentary Under-Secretary of State for Wales advised, “The very serious allegations in North Wales have involved various individuals and court cases are still proceeding ... All the court cases are expected to be completed by next Spring, and I have discussed with officials what our next step should then be ... Gwilym [Jones] concluded in 1992 that a public inquiry would be needed into all of this ... A full public inquiry … would be very expensive … [a] private inquiry actually being a much better way of getting at more of the truth. There is however a real likelihood of an outcry if we are seen arbitrarily to announce a private rather than a public inquiry. I would therefore propose that we first ask an eminent lawyer (certainly a woman – perhaps Ms Butler Sloss?) to consider the evidence and recommend to us what form of inquiry would be appropriate. My feeling for this is that such a person would be much more likely to veer towards a private inquiry, which advice we could then accept.”3.48 The Secretary of State for Wales requested officials to consult with the Chief Constable of the NWP on the option of there being no inquiry at all. A meeting took place between officials and the Chief Constable on 24 January 1995. A submission to ministers dated 27 January 1995 prepared by a senior Welsh Office official records that officials “conveyed the Secretary of State feeling that an inquiry would need to be fully justified in view of its likely cost (the money might be better spent on improving services), the further trauma it would cause for many of those who would appear before it and the disruption it would cause for all those involved.” However, the Chief Constable was noted to have raised concerns that whilst no clear evidence of organised paedophile activity had emerged from the police investigations or proceedings, there remained concern about whether paedophiles were still employed in children’s homes. The police referred to concerns that many of the allegations that had been made in police statements were still outstanding and that there might be information in possession of Clwyd county council that had not been disclosed to the police. The Chief Constable indicated that if the Secretary of State’s decision was not to have an inquiry, he would have to express his reservations. 3.49 Ministers were advised that the meeting with the Chief Constable produced no further argument against the option of ‘do nothing’. The submission suggested that police concerns about the suitability of individuals who may still be in contact with children could be notified to social services departments so that they could “keep a discreet eye” on them, saying this was “a matter of commonsense [sic] ... which can be pursued without involving the expense of even the minimal option [of a prior examination of papers by a QC]”. Whilst noting that it was “a matter for Ministers’ political judgement”, the author offered his own view that “the choice is very finely balanced.” He stated, “If our resources were not so constrained my advice would be to play safe and [seek QC’s opinion]. As it is, they are severely constrained and even that minimal option would be a most unwelcome call on them. Since, increasingly, it seems likely that an investigation of papers would do no more than confirm that an inquiry is not needed, the game seems not worth the opportunity cost candle. On fine balance, therefore, I favour [doing nothing].”52 | The Macur Review3.50 The comments of Mr Rod Richards MP were annotated on the side of the note in manuscript and dated 2 February 1995. He did not favour the “keeping an eye” on suspects suggested. His view was that witness statements needed to be examined by “someone who is (a) impartial and (b) understands what he is looking for”.3.51 In any event, on 3 February 1995, the same senior Welsh Office official reported “further developments which Ministers will wish to take into account” when considering the issue. This included the fact that officials had just learned that the Chairman of the Jillings Inquiry had produced an interim report, which was understood to assert “… that there are still flaws in Clwyd County Council’s management and operation of children’s services; that relevant information has been withheld from the Panel by Clwyd County Council and others; and that the former Director of Social Services for Clwyd has refused to meet the panel, apparently on legal advice.” The advice given to ministers was that the developments “alter the balance of argument overall” and that to “do nothing further” was no longer sustainable. Government actions after the conclusion of criminal proceedings 3.52 The Secretary of State for Wales decided to appoint a QC to examine the evidence and to report to him on what further action should be taken. Terms of reference for the examination of papers by a QC3.53 Draft terms of reference for the examination were circulated by a junior official in the Child and Family Division to SSIW and other officials at the conclusion of the known relevant criminal prosecutions on 9 February 1995. The difficulties that the Jillings Inquiry had encountered in obtaining access to local authority papers were highlighted with advice that the investigation would need to ensure the cooperation of all the agencies concerned. In these circumstances, he queried whether the draft terms of reference should refer to the Secretary of State’s powers under statute to establish a further, more large-scale, inquiry. 3.54 The draft terms of reference were discussed with Miss Nicola Davies QC on 15 March 1995. It was noted as “agreed that the appropriate way forward was to treat this matter as a case of senior counsel being asked to advise the Secretary of State as to whether or not a full inquiry was needed ... Counsel’s task would not therefore have any statutory basis and everyone was aware of and accepted the fact that it would accordingly not have any statutory powers to compel witnesses or documents …” Selection of Miss Nicola Davies QC3.55 The Welsh Office sought the advice of Treasury Solicitors on the appointment of one of three named prominent female Queen’s Counsel to advise the government in relation to the need for a public inquiry. The Deputy Treasury Solicitor responded on 2 March 1995 noting that one was still involved in another inquiry, and the other two had not previously been briefed by the department but could be approached, however, “it does occur to us that because of their close involvement in the field of The Report of the Macur Review | 53child protection they might feel under pressure to advise that an Inquiry should be held.” He went on to say that “in the circumstances I offer for your consideration the name of Nicola Davies QC …” Miss Nicola Davies QC was said to have a “close family connection with Wales” and to have been frequently instructed by the department. It was noted that she was involved in the Cleveland Inquiry, but it was stated that “her practice is mainly in the field of medical negligence and associated medical litigation.” 3.56 The Deputy Treasury Solicitor’s advice was accepted and Miss Nicola Davies QC subsequently appointed. The Director of the Wales Office responded to the provisional criticisms I notified to the Wales Office in my letter dated 15 May 2015 on the matter of Miss Nicola Davies QC’s apparent lack of relevant expertise in matters of statutory child protection. He relied on the fact that (i) the two female QC’s with “close involvement” in the field of child protection had not previously been briefed by the Treasury Solicitor; and, (ii) in being described as more likely to advise that an inquiry should be held, they may therefore be thought of as partial and not independent. In any event, he considered that the selection of Counsel was akin to the situation where “there is nothing improper in Government consulting on policy options, while having a preference for one of them.” 3.57 Junior Counsel was briefed to assist Miss Nicola Davies QC in her examination, but notably following her appointment, at the meeting on 15 March 1995, Miss Nicola Davies QC indicated that “she would probably need a social services assessor to advise her on specific aspects of the practice of social services departments and other matters.” On 25 July 1995, Miss Nicola Davies QC’s instructing solicitor referred to the appointment of a social services expert in terms “[a Treasury Department official] suggested that this might be the case when he first met her and now that Nicola is well into her investigation she agrees.” On 2 August 1995 an attendance note records that “Nicola Davies phoned. Clwyd have come up with the documents and there will need to be a lot of input from social services … will need social services input but this may cause delay.” On 4 August 1995, her instructing solicitor indicated to Mr David Lambert, Legal Adviser to the Welsh Office, that Miss Nicola Davies QC would like to have a meeting with a social services assessor to discuss various issues. In a minute dated 4 August 1995, the solicitor referred to a named individual as social services assessor “who is due to be appointed today.” This individual is referred to in Treasury Solicitor documents of the same date. Specifically, a letter from Miss Nicola Davies QC’s instructing solicitor to Mr Lambert referred again to a social services expert who, by the time of a Consultation arranged on 31 August 1995, “should have had an opportunity to do some reading. I think that he, too, should attend the Consultation.” 3.58 A file note of a discussion between two members of the Welsh Office staff on 7 August 1995 obviously anticipated that the social services assessor would be in post by the time of the Consultation and “would enable us to take true stock of the position.” However, on 18 August 1995 there is reference to “last minute failure of earlier candidates” for this role. On the same date there is indication that Miss Nicola Davies QC rang Welsh Office officials to “explain in more detail the nature 54 | The Macur Reviewof the professional social services assistance she required” and it is noted that “we have now agreed that she, irrespective of the consultation, would still value a social services assessor and I have confirmed with her that Adrianne Jones will be contracted by the Department for this purpose.”3.59 On 29 August 1995, the record of a conversation between a Welsh Office official and Miss Nicola Davies QC noted that she was “unimpressed with both Social Services Departments particularly Gwynedd, (which she described to me as a law unto themselves) their quality of documentation and record keeping, and their procedures generally” and that “in the light of her findings” in this regard, “she was seeking the appointment of a Social Services Adviser.” The author of the note indicates that he queried whether these issues may affect her conclusion that “on the basis of [the documentary evidence] (the North Wales police evidence ends in the mid-1980s) she will not be recommending a public enquiry” and was told that this would not be the case. It went on to record, “I suspect from Miss Davies’ comments that she will not now seek such an appointment but that her report will draw the Secretary of State’s attention” to her findings relating to her views about the social services departments.3.60 In the event, neither Ms Adrianne Jones nor any other social services assessor was appointed to assist Counsel in her examination. In a subsequent letter written to me in clarification and amplification of points previously made as indicated in paragraph 3.56 above, the Director of the Wales Office wrongly noted that Miss Nicola Davies QC “was assisted by a social services expert and, with that additional input, must have felt able to undertake the task despite the absence of that expertise.” Limitations on Miss Nicola Davies QC’s examination 3.61 As indicated in paragraph 3.54 above, it was known that Miss Nicola Davies QC would not have the ability to compel witnesses or documents. At the meeting on 15 March 1995, it was decided that members of the public would not be invited to make representations, nor would any specific additional evidence be invited. A senior Welsh Office official put it in terms that the department was “not looking for a ‘certificate of seaworthiness’ in respect of any of the Agencies.” The note of the meeting records, “Everyone agreed on the need to focus and limit the scope of this examination and to limit the ‘risk of it burgeoning into an inquiry’.” It is noted that the Treasury Solicitor “emphasised that it would be fatal to go anywhere near opening up the process to further evidence.” Miss Nicola Davies QC expressed her unease at her inability to seek further documentary evidence necessary to supply any missing detail, which she felt “could be closed with one brief letter from the body concerned”. The Treasury Solicitor suggested, however, that such bodies could make direct representations to the Secretary of State for Wales and that, in reaching his decision as to whether to hold an inquiry, he should take into account all relevant considerations, including the advice from the QC and any such representations. This suggestion was dismissed by a senior Welsh Office official, who emphasised that “the Secretary of State was not keen to become involved in a detailed consideration of issues in addition to counsel’s advice and wanted to place most The Report of the Macur Review | 55reliance on that advice. The QC’s independence was important in political terms.” It was agreed that “there were a number of delicate and difficult issues many of which could not be resolved until much further down the line and many would have to be left to the judgment of Counsel and Instructing Solicitor.”3.62 Amongst other materials, Miss Nicola Davies QC sought access to documents held by the NWP. On 3 May 1995, ministers were advised that the NWP wished to seek legal advice regarding “the ownership of papers held by the force” before permitting Miss Nicola Davies QC access to them. It was said to be possible that “Miss Davies will be prevented from examining some or all of the papers.” 3.63 Mr Rod Richards MP, Parliamentary Under-Secretary of State, responded and advised the Secretary of State for Wales the following day, on 4 May 1995, that the department should exert pressure on NWP to release all their papers, since “if the QC is denied access to police papers, it seems to me that she may well conclude at an early stage that a fuller inquiry is necessary.” He set out his view that, if the NWP continued to deny access, the alternatives would be “to decide that an investigation of papers is not now possible and proceed to hold no inquiry at all (not tenable), or a full public inquiry (not desirable) …”3.64 On 26 May 1995, Miss Nicola Davies QC’s instructing solicitor wrote to Mr Lambert reporting the NWP’s misunderstanding of the nature of Miss Nicola Davies QC’s investigation. The letter explains that the solicitor for the NWP had anticipated that Miss Nicola Davies QC would seek a court order for disclosure of certain force documents that could not be voluntarily disclosed. Miss Nicola Davies QC’s instructing solicitor had pointed out the lack of statutory power or standing of the examination to do so. She informed the NWP that it would probably not be necessary to see every single document, but they “needed to see sufficient to identify where the problems lay and what action had been taken since these problems had been identified, and what the system was now.” 3.65 Thereafter, in a progress report to ministers on 7 June 1995, a Welsh Office official advised that Clwyd and Gwynedd county councils and the NWP were “co-operating fully and promise complete support.” It is noted that the NWP did wish to withhold case summaries and opinions forwarded to the CPS, but that “this should prove of no practical significance as Miss Davies has said that she wishes to see only primary documents such as witnesses statements.” 3.66 However, on 4 August 1995, Miss Nicola Davies QC’s instructing solicitor wrote again to Mr Lambert and reported that “the material held by the police contains a mass of evidence up to the mid-80s but limited information thereafter” and that it is apparent from the documentation available from Clwyd county council that it was not until the late 1980s and 1990s that there was considerable development in the systems and procedures in place. She states that “what concerns [Miss Nicola Davies QC] is that, given the absence of primary evidence, she is unable to ascertain from the documents any real … picture of what the current position is. It is not possible to see whether abuse is still occurring and whether the monitoring 56 | The Macur Reviewprocedures are effective. She feels that, on the available information in the documents, her report is unlikely to be as helpful as was hoped.” She suggested a consultation to “discuss the problems, as perceived by Nicola, and to decide whether her investigation should continue,” and proposed this take place on 31 August 1995.3.67 A file note dated 7 August 1995, referring to a discussion between two members of the Welsh Office legal staff, concluded that “on balance it was probably better to have the consultation late in August since by then her task will be three quarters complete and abandoning the project at that stage would seem a less attractive proposition. Also of course it would enable us to take true stock of the position including getting feedback from the social services assessor who by that stage would have been able to read into many of the documents.” The file note went on to record, “we considered what Nicola might be able to say in her report and we felt that it would be possible for her to conclude, for example, that provided she had had access to documentary evidence of what the current systems and procedures are she could conclude that on the basis of that information her view was that perhaps there should be a Social Services inspection on behalf of the Secretary of State and that depending on the outcome of that inspection and assuming its conclusions were satisfactory that no inquiry was needed. We certainly did not need a public inquiry to tell us what was happening now.” 3.68 On 18 August 1995, a junior Welsh Office official made a progress report to senior officials. He reported that Miss Nicola Davies QC felt that she had gone as far as she could in examining written material and could not make any further progress without taking primary evidence and would be making her position clear at the “meeting of all interested parties” on 31 August 1995. He noted that “at this stage it is uncertain, if she was not permitted to take primary evidence, whether Miss Davies would be prepared to make a report and/or make a recommendation to the Secretary of State on whether a public inquiry was necessary,” but that following a brief meeting with other officials it was “decided that it would not be worthwhile to put advice to Ministers at the present time.” 3.69 On the same day, a note to the same officials confirmed that “Nicola Davies appears to have developed a concern that given the absence of primary evidence she may be unable to ascertain from the documents any real picture of what the current position is and considers it would be sensible to have a consultation to discuss these problems and to decide whether her examination should continue.”3.70 An official obviously spoke to Miss Nicola Davies QC prior to the Consultation arranged for 31 August 1995. A further note for officials was prepared on 29 August 1995 reporting on his two conversations with her. It stated that she had completed her examination of all the documentary evidence and, on the basis of that evidence, noting that the police evidence did not go beyond the mid 1980s, she did not conclude that there was a sound evidential basis to recommend a public inquiry. He recorded that she was “uneasy” about the arrangements in respect of fostering and private care. The Report of the Macur Review | 57Consultation between Welsh Office officials and Miss Nicola Davies QC3.71 The Consultation between Miss Nicola Davies QC and senior Welsh Office officials took place on 31 August 1995. Ms Adrianne Jones was invited and did attend the Consultation, but could only have done so in the role of observer. A note of that Consultation was prepared. It records that Miss Nicola Davies QC had come to the conclusion that “the answers which the Secretary of State had wanted would not be forthcoming from the exercise she had carried out.” It had not been envisaged that the police evidence would come to an end in the mid 1980s as was found to be the case. She expressed her view that whilst a purely paper exercise could work in some circumstances it would not provide the full answers here. She felt there was a need to interview people about putting procedures into effect and that had not been within the scope of her instruction. Therefore, there was no “hard factual evidence” post the 1980s to indicate that a public inquiry was needed. She would prepare her advice to the Secretary of State that a public inquiry was not needed. In her view, there needed to be good evidence to justify a public inquiry and she could not draw that conclusion as matters presently stood. If she had found evidence that a large number of people had had serious allegations made against them fairly recently and those allegations had been left unresolved then her conclusions would have been different. However, the allegations were old and the number of individuals, probably half a dozen, was not great. I note that in a paragraph in the note dealing with Miss Nicola Davies QC’s conclusions regarding foster care and social services management, it is recorded that she had “stressed also that one had to remember when looking at the documentation that some people who were guilty of misconduct were obviously good at covering their tracks in the documentation”. It was agreed at the Consultation that Miss Nicola Davies QC would complete her work as soon as possible and submit her advice.3.72 On 14 September 1995, an official wrote to Miss Nicola Davies QC stating “I have now been able to reflect further in the light of our meeting and feel sure that, for the reasons we discussed, it is right to draw a line under your examination at this stage.” 3.73 The note of the Consultation was circulated. On 15 September 1995, Miss Nicola Davies QC’s instructing solicitor wrote to the Welsh Office official who had prepared the note, which she confirmed “seems to be a detailed and accurate record of what was said”, but made a “few comments”. She clarified her understanding that she did not believe that Counsel had concluded their examination of all the documents held by Gwynedd because of the “disorganised state in which they found them” but, as she understood the position, “feel that they have seen sufficient of this documentation to conclude that no useful purpose would be served by their continuing their examination of it since this would not serve to demonstrate whether the systems and procedures are now being implemented satisfactorily.” Further, she recalled that Miss Nicola Davies QC had said that in order to hold a public inquiry “there had got to be very good evidence that there were things going on.” Miss Nicola Davies QC’s instructing solicitor thought that the note of the Consultation should record that this part of Counsel’s advice was given specifically in response to the senior Welsh Office official’s query and that Counsel had said that she could not say that children were at risk. 58 | The Macur ReviewConsideration of Miss Nicola Davies QC’s report and subsequent action3.74 Miss Nicola Davies QC reported in writing thereafter. Whilst she advised against a public inquiry - although noting that she “would not hesitate to recommend” one if there was evidence of abuse continuing to the extent it existed in the past - her full report sets out plainly the limitations of her investigations in several places and also her anxieties. I recognise that the references that follow are drawn from different paragraphs in her report and are not in chronological order but, in my view, they give clear warning signs of the difficulties. 3.75 Miss Nicola Davies QC’s report indicates that she had not had power to compel people or organisations to disclose documents, although she believed that in the main they had co-operated. The majority of police evidence she had seen related to those who had been in care up to, but no later than, 1987/88 but a 10% sample of residents in the Bryn Alyn community between 1985 and 1993 revealed a higher number of complainants in the late 1980s and early 1990s. The majority of children in care in the late 1980s and 1990s had not been interviewed. As to evaluation of the social services records, she was “conscious of the fact that I am a lawyer without the skills necessary to fully appreciate the quality of any assessments and the nature of the record. An informed view can only be provided by a person trained in social work”. She reported, “The difficulty which I face is that the terms of this investigation preclude the taking of oral evidence. As a result I do not know if other children have complained or wish to complain. This could only be discovered by interviewing children or associated persons ...” She had seen the reports of four internal inquiries from Clwyd and two from Gwynedd and urged that they should be read in full. She found that the conclusions of two of the reports of independent investigations carried out in the 1990s following complaints made at the Bryn Alyn Community “reflect the unease that I have felt throughout this investigation. Even when paper procedures appear to be adequate ... there are still real difficulties at ground level. It takes an incident or a complaint deemed serious enough to warrant an investigation to unearth facts ... It is an example of the difficulty of my own investigation, namely the reliance on documents and the absence of any oral evidence. It highlights my fear that an investigation such as mine will not uncover the true facts.” 3.76 She noted that, in 1996, local government reorganisation meant that departments would be disbanded, “but many of the same people will continue to work for the new authorities and thus one’s reservations remain.” She noted that documentation provided by Clwyd county council and Gwynedd county council relevant to the period 1980 to 1990 was “of limited evidential value” and that “the record to be found in children’s files, staff files and the books kept at the various homes frequently lacked both form and detail.” She concluded that “in deciding whether to recommend a public inquiry I have asked myself the following question: do clear grounds exist for a reasonable belief that the systems presently operated in Clwyd and Gwynedd ... are or may be failing children in care? On the evidence I have seen I cannot say such grounds exist.” She noted that “in compiling this report I have relied solely upon documentary evidence ...”The Report of the Macur Review | 593.77 Pending consideration of the report, on 8 November 1995, an official advised ministers that Councillor Dennis Parry, the leader of Clwyd county council, asked that the Jillings Report be considered by the Secretary of State for Wales before making a decision about whether there should be a public inquiry. Councillor Parry suggested that the Secretary of State should not make any announcement on the basis of Miss Nicola Davies QC’s report alone, unless the decision was that there should be a public inquiry. The official notes that Miss Nicola Davies QC had no contact with the Jillings Panel and that a view had been taken that she should restrict her work to an examination of the documents held by various agencies. He states, “Our view has been that Miss Nicola Davies’ report would be sufficient for the Secretary of State to decide on whether there should be a public inquiry or not. However, it is difficult to reject Councillor Parry’s proposals outright and for the Secretary of State to refuse to see the Jillings report. As anticipated, Miss Davies is recommending that there should not be a public inquiry. A decision of the Secretary of State to endorse that recommendation could be severely undermined if subsequently the Jillings report, on the basis of evidence and for reasons not known to the Department, recommended otherwise ...” The official notes that “we could find ourselves quite possibly back at square one in terms of the pressure upon us to hold a public inquiry ...” 3.78 On 9 November 1995, a senior inspector of SSIW wrote to senior Welsh Office officials after examining the conclusions of Miss Nicola Davies QC’s report. He perceived the conclusions to rely heavily on changes in practices and procedures made by social service departments since 1989, the age of the complaints investigated by the police and the small amount of material about complaints in the period 1989 to 1995. The inspector advised that the expressed limitations within the report made the “final judgment finely balanced” and that there would not be “strong ground to hold onto this position [of no public inquiry] in the light of this report, particularly if the Jillings Report reveals more concern.”3.79 This advice was questioned by a junior official who advised that “only if Jillings points to people still in post who ... continue to pose a threat to children in care would I think a judicial inquiry was justified.” At the same time, he referred to the report of Miss Nicola Davies QC lamenting that the government were only able to publish the conclusions. He indicates that it would have been better if it had been possible to publish a statement about the reasons why the publication was to be restricted. He noted, however, that the introduction to the report, which explains the reasons for the restriction, could not be published in its present form since it “unhelpfully refers to the consultation that we had in August and it reads as if the Welsh Office decided to draw the examination to a close at that stage. That of course wasn’t the case ... its publication will lead to a lot of questioning and criticism of the Department.” He went on to question whether the report was a final version or a draft “on which we can still comment and on which Nicola Davies is prepared to make some amendments? If the latter, then obviously I would like to see the introduction amended so that it makes the point about confidentiality but in a form that we can publish along with the conclusions and recommendations.” 60 | The Macur Review3.80 On 13 November 1995, Welsh Office officials and legal advisers and members of SSIW met to “discuss Nicola Davies’ advice”. The consensus was that the advice “was acceptable” and was something on which officials could properly base a recommendation to ministers that there was insufficient evidence to enable her to conclude that a public inquiry was necessary. There was slight disappointment on the subject of presentation, “for example it did not assist ... that the central conclusion that a Public Inquiry was not required was hidden away ... it was felt that this could usefully be highlighted and perhaps given a sub-heading of its own.” Also, it was felt that there were a number of ambiguities in relation to the recommendations and it was “regrettable that the text used such terms as “investigation” and “evidence” in the context of the proposed steps that should be taken by the Department in order to meet Nicola Davies’ concerns.” It was noted that it would be important to clarify precisely what she meant to ensure that her concerns could be addressed. A further Consultation was to be sought to address the points. 3.81 An official from the Social Services Policy Division of the Welsh Office, who had not attended the meeting but had seen the report, wrote to a Welsh Office official on 15 November 1995 indicating her disappointment in the report and wondering if there was “still some scope to firm up the drafting?” She went on to comment, “It is obviously Nicola Davies’s view that the documentation is insufficient to make a firm decision (p36 [referring to her fear that her investigation would not uncover the true facts] in particular is absolutely damning) since she seems to be saying that the paper evidence is inadequate for her to make a firm conclusion. I am also concerned that the police appear to have been a little less than wholehearted in pursuing the investigation.” She states that “to me, this evidence suggests that there probably were real causes for concern and that we can only establish their full extent by a much wider exercise.” She did, however, agree that it was only if there was enough evidence that there were people still in post, who continue to pose a threat to children in care, that a judicial inquiry was necessary. She thought an inspection, rather than an investigation, was necessary to confirm the adequacy of present arrangements.3.82 Welsh Office officials sought to arrange a further Consultation with Miss Nicola Davies QC. On 16 November 1995, a member of the Welsh Office legal team wrote to Miss Nicola Davies QC’s instructing solicitor setting out “the thinking here”, which had prompted them to suggest the Consultation. He referred to her recommendation that a further examination should be made of policies and practices, and the uncertainty created by the use of the terms “investigation” and “evidence”. He said that it would be helpful before submitting the report to the Secretary of State for Wales “to have a clear and mutually agreed understanding on this matter.” 3.83 The note of the Consultation, which took place on 20 November 1995, indicated its essential “purpose” to be clarification of a number of points arising in the body of Miss Nicola Davies QC’s report. It was thought “particularly important that terminology used in [the] published part of the Report corresponded with the nature The Report of the Macur Review | 61of those next steps.” The note states “in that regard Miss Davies was happy to substitute the term “examination” for “investigation” in the Recommendations since she accepted that the terms presently used were probably a little too judicial in nature.” Miss Nicola Davies QC also agreed to “look again” at those places in her report where she had referred to the constraints which followed as a consequence of the terms of reference since “those constraints were well known and … whether they needed to be repeated.”3.84 In relation to publication of her report, the note of the Consultation records that Miss Nicola Davies QC would provide a covering letter, which “would make additional reference to the original terms of reference [that had indicated an intention to publish her recommendations and reasons for them, and explained that there may be some matters that it might not be possible to publish] and she would seek to indicate their appropriateness in view of the confidential nature of a large number of the documents concerned.” It was in this context it appears that she “stated specifically that she entirely accepted the constraints imposed in the terms of reference and did not think that they were so fundamental as to make the whole exercise appear flawed”. Miss Nicola Davies QC was of the view that a public inquiry was not the appropriate mechanism to redress the “massive wrong” that had been done to children in the past, but rather that it would be necessary if “children were currently at risk”. She clarified that she did not seek to criticise the police in her report, but had some reservations about the way in which the CPS had “applied their normal criteria in deciding whether or not prosecutions would go ahead.” She did not accept that her proposed examination of child care management practices should be undertaken by SSIW, as she considered SSIW to be “tainted” by reason of their prior involvement. She did, however, accept that “this would cause the Department some considerable difficulties, particularly in view of the short time scale involved.” 3.85 Following the Consultation, a note dated 23 November 1995 between legal advisers to the Welsh Office, discusses the statutory basis of the inspection of the social service departments that Miss Nicola Davies QC advocated. Administrators were said to be working on the basis that “if Ministers are to avoid potential embarrassment arising from Miss Davies’ failure to endorse the remedial steps being taken” as regards SSIW inspections, that a team of independent social workers needed to be set up. The matter was said to continue to be a “highly sensitive matter which, once again, is due to enter the public arena.” The note refers to the progress of the Jillings Inquiry noting that the report was believed to be finalised. It indicates that Leading Counsel who was advising the Jillings Inquiry had offered to release a copy of the report to Miss Nicola Davies QC, but the offer was not taken up. 3.86 Significantly, in light of Miss Nicola Davies QC’s conclusions, a ‘file note for information’ within the Welsh Office files dated 23 November 1995 sent by a SSIW inspector to senior Welsh Office officials, the legal adviser who had attended the Consultation with Miss Nicola Davies QC and another SSIW inspector, reports a telephone call received from a former principal officer (not Mrs Taylor) of children’s services for Clwyd county council on 22 November 1995. She said she had worked 62 | The Macur Reviewfor Clwyd from December 1991 until March 1994. She had been on sick leave until her retirement on health grounds in March 1995. She had been told of the child abuse on her first day. In her view, there was “a reluctance to acknowledge difficulties or deal with problems reported at grass roots. Allegations against the department were not dealt with.” She said she had a dossier of evidence about this, which she was willing to make available. The situation was such that she believed “that the circumstances that were reflected in the Cartrefle report [a previously commissioned local authority investigation into a children’s home] still prevailed which might allow continuation of abuse.” The note of the telephone call concludes that it is for “information at this stage”, and that further advice would be tendered “assuming we receive the documentation”. I have found no further reference to the steps taken in response to this information in the documents that have been provided to this Review. 3.87 Miss Nicola Davies QC submitted a second version of her report, described by SSIW in a note to Welsh Office officials dated 28 November 1995 as having “little amendment in the body of the report,” but that the conclusions provided a clearer, better argued summary and explanation of her views. However, in the same note, the officials were alerted to omissions in the annexes to Miss Nicola Davies QC’s report, which did not refer to some internal reviews of more recent times. In responding to these concerns on 6 December 1995, a senior Welsh Office official confirmed that this arose from the fact that Miss Nicola Davies QC “only examined those papers held by the Police relating to investigations triggered by the letters from Gwynedd and Clwyd County Councils. It was not part of her brief to go on an extended fishing expedition.” He stated that “if you have outstanding concerns … it is for SSIW to pursue” Advice to ministers on Miss Nicola Davies QC’s report3.88 In November 1995, the Secretary of State for Wales was advised that “Miss Davies expresses concern on a number of matters. She also points to the limitations of the procedures involved in this examination particularly in terms of her inability to hear any oral evidence and to question professional social work practice and procedures. However, at our most recent consultation with her on 20 November, she expressed confidence in the soundness of this process.” The official summarised the position as “a complex issue, not least because of the complications generated by the Jillings report and the uncertainties that is creating. Nevertheless, Miss Davies has now reported upon her examination and we know of no reason why her recommendations should not be accepted in full ...” 3.89 On 29 November 1995, a senior official advised the Secretary of State for Wales and Mr Rod Richards MP in writing on Miss Nicola Davies QC’s advice. He indicated that he had “thought long and hard about whether there should be a public inquiry, and have questioned Nicola Davies closely about it on two occasions.” He thought that there were two sets of circumstances in which such an inquiry could be held: where it was clear that a group of children had been seriously failed in the past; or, “where there is clear evidence that the cohort of children currently in care The Report of the Macur Review | 63is not receiving the protection from abusers to which they are entitled”. In respect of the latter, he noted, “In this case, Nicola Davies’ report is clear: all the evidence in recent years points to a significant improvement in procedures and a substantial reduction in abuse. I am thus satisfied that she is correct to recommend that there should be no public inquiry.” 3.90 This written advice did not refer to the limitations upon Miss Nicola Davies QC’s ‘examination’, which had obvious implications to the advice she tendered against holding a public inquiry; namely, she had not had access to all documents, the shortcomings in the documents that she had inspected and her anxiety that she could not discover the present situation from looking at documents alone. Neither did it refer to the detail of the discussion with Miss Nicola Davies QC in either Consultation regarding those constraints, nor the telephone call from the principal children’s officer received on 22 November 1995, nor the concerns that had been raised by SSIW regarding the omissions in the annexes to Miss Nicola Davies QC’s report that suggested she had not had access to some internal reviews of more recent times. 3.91 Nevertheless, consequent upon Miss Nicola Davies QC’s recommendations, Ms Adrianne Jones was appointed to conduct an examination of documents held by Gwynedd county council, Clwyd county council and by all private agencies in those counties who provided residential care for children. Advice to ministers on further developments3.92 Chronologically, the independent panel chaired by Mr Jillings had been convened prior to Miss Nicola Davies QC’s appointment. In a letter to Mr Ron Davies MP from the Secretary of State for Wales dated 12 July 1996, it was confirmed that “a copy of the terms of reference for the Jillings Inquiry was passed to the Social Services Inspectorate for Wales who offered comments on them. However, they were not agreed in any sense and Clwyd County Council acted entirely independently in establishing the Jillings panel of enquiry [sic] and its terms of reference.”3.93 The Jillings Report was submitted to Clwyd county council in late February 1996. A copy was provided to the Welsh Office. On 22 March 1996, a senior official briefed the Secretary of State for Wales on his assessment of the Jillings Report. He stated “I found nothing in the report to indicate that such widespread and systematic abuse is continuing to the present day … The Panel ... argue that because they did not have sufficiently extensive powers of investigation they were unable to assess in detail the role of certain players - notably the Police. But their analysis of the role of Clwyd County Council is damning.” He suggests, in relation to sections dealing with the Welsh Office, that “if you have not already done so, I think you should read this material for yourself.” He notes that, “The Panel were not invited in their terms of reference to consider whether there should be a Public Inquiry. They nonetheless call for one ... To my mind this is the least persuasive part of their report ... [they do not] provide new evidence of continuing abuse or serious inter-agency failures. Had they done so an inquiry, focused on the specific problems of North Wales, might have 64 | The Macur Reviewbeen appropriate ... Instead they are seeking a very general inquiry [not focused on the specific problems of North Wales] ... I have considered these matters carefully. In my judgment the report does not sustain the case for an Inquiry of this nature. On the key issue of providing assurance for the future, the work we have commissioned from Adrienne Jones (who has had access to the Jillings’ report) should achieve this objective (in North Wales) much more quickly and effectively than a public inquiry.” Advice was tendered as to handling issues since it was known that Clwyd county council had been advised not to publish the report. It was predicted that the “reaction to the failure to publish may well lead to allegations of a ‘cover-up’ and further fuel calls for a Public Inquiry. These will inevitably be directed at the Department.” 3.94 However, there is no reminder in this note to the Secretary of State for Wales of the matters referred to in paragraphs 3.38 and 3.51 above in terms of the difficulties faced by the Jillings Inquiry in seeking access to documents and obtaining evidence. There is also no reference to the recent telephone call referred to in paragraph 3.86 above in which concerns were raised about current practices. 3.95 In a minute dated 17 April 1996, a junior official reported to a senior official a conversation held with Ms Adrianne Jones, who together with “the examining team are increasingly concerned about Conwy County Borough’s child care and more specifically child protection arrangements ... It was Adrienne’s [sic] view that we should be alerted to this matter now so that steps can be taken prior to our receiving her report towards the end of May.” I find no reference to this information being forwarded on to ministers at the time. 3.96 On the same day, the Permanent Secretary advised the Secretary of State for Wales that “the first question we will be asked is whether, having perused this version of the Jillings Report for two weeks, we now think there should be a public inquiry into these matters. Our present position is that, following receipt of Miss Nicola Davies’ report, we think there should be no public inquiry. If we answer now that we are considering whether the Jillings Report provides new material which demands a public inquiry we shall be seen to be on the run. I think that we should therefore reach a conclusion now on whether or not the Jillings document causes us to revise our November view. [A senior official] who has considered the Report in detail believes that nothing in it should cause us to change our view. Others may hold a different view. I suggest that before you make your Parliamentary Answer tomorrow you decide where you stand on this ... We will fan the flames if we seem to be conspiring with others to suppress the report so I suggest that we go on to the front foot against the local authorities and urge them to get themselves and their report into a state in which it is publishable.”3.97 This appears to accord with Mr Rod Richards MP’s response to a letter that I sent to him on 15 May 2015, and to which further reference is made later in this Report. That is, Mr Richards recalled that the officials’ advice changed not as a direct result of the contents of the Jillings Report, but as a result of Clwyd county council’s decision not to publish it, and the consequential pressure of public and political opinion on the Welsh Office.The Report of the Macur Review | 653.98 In a note prepared and addressed, amongst others, to the Secretary of State for Wales, dated 16 May 1996 a number of ‘pros & cons’ of a public inquiry were articulated for consideration in terms worth repeating here: “PROS: a) A number of the alleged victims of abuse have pressed for a public inquiry for some time. They argue, amongst other things, that society has a duty to investigate thoroughly and to expose the full level of abuse. That process may be of therapeutic value to them. b) It would meet public demand for detailed account of what happened in Clwyd and who might be to blame. It gets over the problem that Jillings is not publishable. c) It would lead to authoritative recommendations for minimising the risk of repetition and ensuring safe and appropriate care arrangements. d) It would address suspicions of a paedophile ring with high-placed protectors. It might expose such a ring if one existed or still exists. An inquiry would go some way to re-assure the public if it found no evidence of such a ring. e) It would - eventually - clear the air in respect of present North Wales staff and officials. It would overcome suspicions of a cover-up because of a failure to publish Jillings f) It would examine Jillings’ comments on the Welsh Office and provide opportunity to answer those criticisms in our evidence to the Inquiry. g) It would give the appearance of the maximum possible commitment to ensuring the safety of children in care. CONS: a) A large number of former residents who may be victims have remained silent. A public inquiry might be harmful to them many of whom have families of their own who might be unaware of this background. Two suicides of witnesses have occurred one connected with the Chief Superintendent Anglesea libel case and one following the Ty-Mawr inquiry in Gwent. b) The issues have already been addressed with the reports of Nicola Davies, Jillings and Adrianne Jones. The first and last to be published in part and it may yet be possible - notwithstanding latest local authority statement - to publish Jillings in some form and to some degree. c) It is virtually certain that some of those giving evidence to an inquiry would take the opportunity to make unsubstantiated allegations both of former and existing officials and other persons, including many prominent in public life. In all probability 66 | The Macur Reviewthese would be very extensively reported in a way that would be profoundly damaging to the people concerned. If the allegations were unfounded and this was eventually confirmed by the inquiry, a great deal of injustice would have been suffered in the possibly lengthy interim period. d) It would be enormously costly financially and would divert resources and effort from local authorities and other agencies who would be directly involved. It is difficult to believe there would be much added value from such a process given recent comprehensive reports (Warner: “Choosing with Care) and Adrianne Jones. There is a need to get on with implementing recommendations of these reports in the new authorities. e) It isn’t at all likely that an inquiry would be able to find evidence of such a paedophile ring if this has eluded the police. Even if the inquiry’s conclusions were negative on this point it is very likely that some proponents of the theory would remain unconvinced. This raises possible difficulties over the scope of the inquiry in terms of pursuing witnesses from further afield e.g. Cheshire. f) Difficulty over scope of the Inquiry in respect of the police. g) There might be a considerably greater delay before we would be able to respond effectively to the Jillings criticism of the Welsh Office.”3.99 Notably, the listed “Pros” do not include the limitations of the ‘examinations’ conducted by Miss Nicola Davies QC or the Jillings Panel or subsequently reported concerns, including those expressed by Ms Adrianne Jones about present day child care and child protection in Conwy borough council.The decision to have an inquiry 3.100 On 19 May 1996, the Secretary of State for Health wrote to the Secretary of State for Wales agreeing “that, in the Welsh context, it is sensible to hold back further comment until the end of the month when you expect to receive Adrienne [sic] Jones’ report on measures to improve children’s home management in North Wales.” In the meantime, suggesting that officials be instructed to work up more fully an account of the measures taken and those in prospect to address the wider issues, and to “consider further and quickly at a meeting of the Ministers most closely concerned, whether any further action or review is justified and if so what its purpose and scope should be.”3.101 A memorandum issued on behalf of the Secretary of State for Wales on 7 June 1996, distributed to the Lord Chancellor, the Solicitor General, the Home Secretary, the Chancellor of the Duchy of Lancaster and the Secretaries of State for Health, Environment, Scotland and Northern Ireland, sought a collective view on how to proceed. It stated that the Secretary of State for Wales had “reluctantly” come to the view that “we should seriously consider adopting one of the public inquiry options.”The Report of the Macur Review | 673.102 A draft of a note by the Secretary of State for Health submitted on 6 June 1996 argued against “a major statutory inquiry in Clywd [sic]”, but “[if] ... a 1921 Act inquiry is inescapable its terms of reference should be as narrowly tied to local issues as possible.” It stated that “the most powerful argument against a major ‘wider issues’ public inquiry is the delaying and diversionary effect that it would have on progress in implementing the measures already taken or in preparation. It might, for example, be difficult for the Home Office to proceed with its plans for legislation on criminal records and more effective supervision of released sex offenders. It would also make it more difficult for the Health Departments to force local authorities and others to implement properly the safeguards already in place … We shall be handicapped if, by the establishing further inquiry, we move the focus from local action and responsibility to one of national analysis and debate.”3.103 A letter dated 11 June 1996 from the Home Secretary argued that an inquiry would not “shed any fresh light on current issues” and could “cause additional distress to those whom it was supposed to help.” It suggested “there is surely widespread disquiet about what might be contained in the Jilling [sic] Report. I am convinced that the most effective way to counter the rumours and speculation would be to publish, if not the whole report, at least a revised version of it. I hope that this possibility can be fully examined before you decide to embark upon any other course.”3.104 On 11 June 1996, a meeting of interested ministers was called and chaired by the Lord President (‘the Lord President’s Meeting’). A letter dated 12 June 1996, sent to the Principal Private Secretary for the Secretary of State for Wales appears to stand as the minutes of the meeting. There is no indication as to whether the minutes are approved by those who attended the meeting, but there is no other reason to question their accuracy or provenance. Noting those present to be The Lord President, Secretaries of States for Wales, Health, Environment, the Lord Chancellor, Ministers of State for Home Office, Scottish Office, the Solicitor General, the Paymaster General and Assistant Whip and two officials from the Cabinet Office, it noted that “in discussion the following points were made: a) there were advantages in establishing the inquiry under the 1921 Act. It would be an inquiry of high authority. It would have powers to compel the attendance of individuals and the production of documents [and]…powers relating to contempt … [it would] also allow the role of the police to be investigated and was preferable to other options such as a Police Complaints Authority review. b) The Inquiry should be confined as narrowly as possible into the past events in North Wales, although the emergence of problems in other areas, notably Cheshire, and the structure of inquiries set up under the 1921 Act would not make that task any easier. A UK-wide investigative inquiry into past events would not be sensible. There would be problems with examining criminal cases, a number of which were still outstanding.68 | The Macur Review c) The Inquiry’s terms of reference would, therefore, need careful consideration. In particular, it would be highly unusual for such an inquiry to examine decisions on whether or not to prosecute in particular cases. That could lead to people being convicted by public opinion, even where they had not been prosecuted or had been acquitted. On the other hand, it would be difficult to avoid consideration of the role of the Crown Prosecution Service (CPS), particularly as the inquiry would consider the role of the police in events in North Wales. Furthermore, the police had in the past, when they had the responsibility for prosecution decisions, had such decisions scrutinised at inquiries. It would be odd to exclude the CPS from similar treatment. The low number of Prosecutions by the CPS was striking. The terms of reference should also avoid the inquiry considering general child care policy. Your Secretary of State [for Wales] would circulate draft terms of reference to colleagues for comment. d) … the Jillings report to be made available to the chairman of the inquiry (who would, in any event, be able to call for the report if he wished, under the 1921 Act powers), who would then be able to consider it and offer any comments he wished upon it in his report. e) It seemed highly likely that the inquiry would need to be chaired either by a judge or by a senior member of the bar … f) The cost of the Inquiry … Secretary of State [for Wales] would be able to absorb this cost within … existing resources g) The 1921 Act allowed legal representation to be refused … in a case of this sort it was highly likely that such representation would be necessary ... might add to the estimated costs of the Inquiry h) … an announcement [to be made] within the next fortnight …”Conclusions3.105 In the circumstances I have previously outlined, I consider it was inevitable that the government would be ultimately driven to conclude that only a public inquiry would suffice to allay growing concern. I do consider there was unwarranted, albeit marginal, delay in doing so. Specifically, by August 1995 at the latest, it should have been apparent to officials that neither the Jillings Inquiry nor Miss Nicola Davies QC’s examination of the documents would uncover the scale of the abuse that had occurred in the past, or the possibility that it was still continuing, or likely to recur if substandard child protection practice continued. Ministers should have been so advised immediately. It was unlikely that the position would change prior to Miss Nicola Davies QC’s final report.3.106 The Tribunal concluded that, but for Mrs Taylor’s complaints about Nefyn Dodd, there would not have been any public inquiry into the alleged abuse of children in care in Gwynedd. Her allegations required investigation. It was wrong to suggest that a SSIW inspection in 1988 had been a sufficient investigation of her concerns. The Report of the Macur Review | 69Although it was suggested that she take her solicitor’s advice on the further steps to be taken, the Tribunal Report records the inadequacy of the Welsh Office response to the detailed and reasoned solicitor’s letter sent in 1993.11 I agree with the Tribunal conclusions that further investigation was amply merited, but consider that the government was reasonable not to establish a public inquiry immediately on the allegations as they stood. There are no documents to suggest that Sir Wyn Roberts MP attempted to influence decisions concerning the establishment of the public inquiry.3.107 The contact directed to be made with Clwyd county council in December 1991 was apparently made without full knowledge of the facts, nor of the previous inquiries conducted by the local authority which had failed to avert or address widespread deficiencies in children’s services. It was not a constructive intervention. 3.108 The statement of Mr Gwilym Jones MP, the Parliamentary Under-Secretary of State for Wales, in September 1992 made reference to the necessity to await the outcome of criminal proceedings before proceeding with an inquiry. The government would be justifiably subject to criticism in creating any situation that compromised ongoing criminal investigation or prospective trials of accused abusers, which continued until February 1995. There is nothing in the court transcripts or CPS documentation which suggests inordinate and intentional delay. 3.109 My reading of the note of the meeting between Welsh Office officials and officers of Clwyd county council in October 1993 leads me to the view that the Welsh Office officials’ primary agenda was not to discuss practical arrangements for a government inquiry, but rather to encourage the establishment of a local authority inquiry. There is nothing in the documents to suggest that the officials were any better informed in 1993 as to the deficiencies with previous local authority inquiries than they had been in 1991. The notification by Clwyd county council of the local authority inquiry in January 1994 was likely to have been influenced, at least in part, by the meeting in October 1993. 3.110 The significant difficulties encountered by the Jillings Panel could not have been more comprehensively detailed than in the SSIW report of September 1994. The reasoning and unequivocal conclusions of the inspector were soundly based. There is reference to “considerable difficulty”, including the lack of co-operation of local authorities and the police, being encountered by the Jillings Panel in the advice to ministers at the time but, in my view, it did not convey the extent of the problems identified in the detail of the SSIW report. The inability to place reliance on the outcome of the Jillings Inquiry in these circumstances should have been obvious and explicitly drawn to the ministers’ attention, at the time and subsequently. 3.111 It was entirely reasonable for the Welsh Office to ‘take stock’ of the situation at the conclusion of the criminal proceedings and not move immediately to the establishment of an inquiry, whether public or private. It was reasonable to seek the representations of the Chief Constable and other interested parties. The necessity 11 See Chapter 49 of the Tribunal Report70 | The Macur Reviewto consider all options included the informed assessment of the relative advantages and disadvantages of a local internal inquiry, government directed private inquiry and public statutory inquiry. 3.112 The appointment of a Leading Counsel to advise the Secretary of State for Wales on future action was justified. Miss Nicola Davies QC was eminent in her field, but she expressly made clear, and the Welsh Office knew, that she had no relevant expertise in the matter of statutory child protection. In these circumstances, I consider that the identification of Miss Nicola Davies QC for the role, as compared with the two female QCs with ‘close involvement’ in the field of child protection, was questionable. For the avoidance of doubt, I make clear that I make no explicit or implicit criticism of Miss Nicola Davies QC in accepting the instructions on the basis that she made clear from the outset her need for, and repeatedly sought the assistance of, a social services assessor. I am satisfied that she acted independently and in good faith throughout. 3.113 The restrictions placed upon Miss Nicola Davies QC seeking oral evidence or further representations were prima facie valid in the context of the task which had been set. I do not consider that it was improper to direct the nature of her investigation in this fashion. However, the corresponding need for expertise in the subject matter of the documents she was expected to research should have been more readily apparent to the commissioning department. That is, Miss Nicola Davies QC was not instructed to advise the Secretary of State for Wales on the relative merits of a private as opposed to a public inquiry, and, even if her instructions had been so restricted, it is difficult to see how she could have done so in the absence of expertise in the subject matter. Her analytical skills and obvious experience of appearing in public inquiries could not compensate for her lack of expert knowledge in the field of child protection. A social services assessor was likely to have been able to supplement the deficiency, but, in the event, was not briefed. There is no evidence that Junior Counsel briefed had expertise in this field. 3.114 In the light of what I regard to be the distinct sense of reluctance to embark upon a full inquiry, as is apparent to me in the documents to which I have previously referred, l come to the view that, unknown to her, Miss Nicola Davies QC was appointed in the hope and anticipation that she would be less likely to advise an inquiry than would Counsel experienced in child protection matters, which advice the government was likely to accept. Obviously, a difficulty would arise if the government were seen to reject independent advice given. 3.115 Miss Nicola Davies QC repeatedly raised concerns that the constraints imposed by her terms of reference impacted upon her ability to properly advise the Secretary of State. At one stage, it was thought possible that she would withdraw from the process. Understanding that Welsh Office officials would obviously wish to see the examination completed by Miss Nicola Davies QC, it seems clear to me that officials were also concerned that for Miss Nicola Davies QC to publicly abandon the investigation before completion could only result in one outcome; the government would be forced to establish a more wide ranging inquiry. The Report of the Macur Review | 713.116 I consider it entirely appropriate that Welsh Office officials should challenge the opinions of Miss Nicola Davies QC in Consultation and to seek to ensure that the part of her report that was to be published should contain sufficient detail and analysis to explain the conclusion she reached. I think it a more questionable practice that the Welsh Office representatives should have suggested that Miss Nicola Davies QC remove or relegate the reference to the constraints upon the investigation she conducted. Miss Nicola Davies QC’s conclusions were reasonably drawn from the documents and information made available to her.3.117 Welsh Office officials did accurately report Miss Nicola Davies QC’s conclusions to ministers. However, in doing so, it does not appear to me that the obvious caveat she expressed about the limitations of her investigations and her restricted access to documentation was placed into proper context or given sufficient weight. There is no reference to the deficiencies notified by SSIW to officials concerning information she had not seen or referred to in reaching her conclusions, and the extrinsic evidence of ongoing concerns, of which she would not be aware. 3.118 Miss Nicola Davies QC’s recommendations as to the necessity for an expert examination of relevant social work/residential care systems in Gwynedd and Clwyd were adopted. The appointment of Ms Adrianne Jones as that expert was swift and well informed. I consider her credentials were impeccable and well suited her to the task. However, this was obviously no substitute for a wider inquiry into the abuse that had occurred with full access available to all materials and additional information.3.119 The publication of the Jillings Report proved controversial. I am entirely satisfied that the Secretary of State for Wales and the officials in his department were assiduous in their efforts to affect publication of the Jillings Report in a non libellous form which would nevertheless allay public suspicion of a cover up, and no doubt be seen as the best prospect to avoid the increasingly looming prospect of a public inquiry. 3.120 However, the inherent difficulties in the Jillings Panel procedure were, I find, effectively and unhelpfully ignored when advising ministers at the time. That is, it should have been obvious to officials that the Jillings Panel had been unable to conduct a thorough review. The issue of whether the Jillings Report would be published in full or redacted form did not address the actual underlying problem. 3.121 The Secretary of State for Wales’ obvious frustration with the successor authorities’ failures in relation to the Jillings Report, as indicated in paragraph 3.26 herein and as appears in the ministerial documentation, seems misplaced in the circumstances indicated in paragraphs 3.36 and 3.38. The Secretary of State appears oblivious to the problems clearly notified to officials at a much earlier stage. 3.122 A redacted version of the Jillings Report was actually published in July 2013. The fact of its later publication may well prompt questions of why it could not have been published in similar fashion before. However, I consider that the successor authorities and government were surely right to heed the clear advice of eminent and independent legal practitioners. I have read the unredacted Jillings Report 72 | The Macur Reviewboth in draft and its final form. It did not identify establishment figures alleged to have committed abuse. Its publication in 1996 in redacted form would not, in my judgment, have appeased the public concern about institutional child abuse in North Wales and its concealment, because there would have continued to be speculation as to what had been redacted. 3.123 The subsequent telephone calls to officials from a previous principal officer of children’s services and Ms Adrianne Jones, the expert appointed by the government to review child care management of the successor authorities, warning of continuing deficiencies were cogent indicators that the situation was not resolved. These communications should have immediately been reported to ministers and in the context that the conclusions of Miss Nicola Davies QC were subverted. 3.124 Noting that the documents available to the Review, or at all, may not reveal all advice tendered to ministers at the time, I consider that it would be reasonable to anticipate that if oral advice was given which contradicted the written advice provided, this should be minuted, as should be any significant amplification of the advice or additional information provided. The construction of the individual briefing notes do not suggest that they were accompanied by previously submitted briefing notes and written advices. If the documents I have seen are a complete and accurate record of the advice tendered to ministers, it appears compartmentalised; that is, not placed in the context of preceding and accumulative events and/or all available information. There is nothing to alert successive Secretaries of State to the deficiencies in the previous process and therefore it may be said that they did not receive comprehensive and timely advice on all relevant matters relating to a decision whether to recommend the establishment of a public inquiry. Whilst I do not conclude that this was a deliberate ploy with an intent to deceive or knowingly mislead ministers, I do consider that if piecemeal information and advice was tendered by officials, it did obscure the decision making process and contributed to delay in the establishment of the Tribunal. 3.125 It is right that a public inquiry pursuant to the 1921 Act was correctly understood to be a major undertaking. Many valid reasons not to embark upon a public inquiry were identified and discussed by government ministers, including the vast emotional and financial cost. However, I note in the officials’ correspondence a repeated reference to the prospective significant financial cost involved to an extent which suggests to me that this was a factor they weighed heavily in the balance. 3.126 Issues that delay would compromise the Tribunal’s investigation, as raised by Councillor Parry, are addressed in the following chapters in the context of other issues. Whilst an important consideration, I do not consider in the prevailing circumstances that time delay should have been viewed as a determinative factor in the decision whether or not to establish a Tribunal. However, there would have been a valid reason to ensure the preservation of all materials that may be relevant for the purpose of an inquiry of whatever type deemed necessary.The Report of the Macur Review | 733.127 The delay in establishing the Tribunal will inevitably have contributed to continued suspicions of a ‘cover up’. As indicated within this Report, there were undoubtedly rumours, and what have transpired to be unsubstantiated allegations, of the involvement of politicians and establishment figures in the sexual abuse and exploitation of children in care in North Wales. I note from the documentation that officials of several departments were “aware of many rumours ... [and] could never be sure what an inquiry of the kind we were proposing would discover.” However, whilst I am critical of some aspects of the background to the establishment of the Tribunal, I make clear I have found no indication in any document of a government ‘cover-up’.74 | The Macur ReviewThe Report of the Macur Review | 75Chapter 4: The Tribunal’s Constitution and Parties Introduction4.1 The constitution of a Tribunal of Inquiry and the personnel and parties involved in its process will dictate the reliability of outcome. Any real or perceived conflict of interest of any person or party with influence over process will tend to undermine the procedure and results, however objectively sound they are. This chapter examines not only the individuals, groups and parties who had the potential to manipulate the proceedings, but also whether their selection was with that view in mind.Tribunal composition 4.2 The members of the Tribunal were appointed by warrant on 30 August 1996. Sir Ronald Waterhouse had been identified previously as Chairman by the Right Honourable William Hague MP, the Secretary of State for Wales. The other two members of the Tribunal were selected from a list compiled with a view to expertise, experience and availability. Sir Ronald Waterhouse defined the qualities he sought in his colleagues and was consulted as to names of prospective appointments, but did not otherwise identify or select them. He thought it desirable that at least one member of the panel should be a female and that both his fellow members should have no prior connection with Wales. Chairman4.3 Sir Ronald Waterhouse was an experienced and respected member of the judiciary of long standing. He retired from the High Court bench in 1996. He was a Judge with experience of family and criminal law. He had no known political affiliations to the Conservative party and it has been suggested to me by Miss Margaret Clough, a fellow member of the Tribunal, that his ‘political leaning’ was toward the Labour Party. He was not a Freemason (see paragraph 4.37).4.4 Sir Ronald Waterhouse had been Leader of the Wales and Chester Circuit in 1978, very briefly before his appointment to the High Court bench. An anonymous undated manuscript note sent to the Chairman and found within the Tribunal papers reads: “Sir Ronald Waterhouse. You have been put in charge of the enquiry [sic] because you are local and will make sure that certain persons are cleared or kept out of the enquiry. Shame on you.”4.5 I wrote to the Right Honourable Mr William Hague on 18 May 2015 concerning his early discussions with Sir Ronald Waterhouse prior to his appointment as Chairman of the Tribunal. He responded on 1 June 2015 and supplied information concerning the appointment of Sir Ronald Waterhouse as Chairman of the Tribunal, which is not contained within the documents that I have seen. Namely, that Mr Hague recalls that he telephoned Sir Ronald Waterhouse on 13 or 14 June 1996 in the hope of persuading him to take the role. Sir Ronald Waterhouse had been reluctant to do so in view of his recent retirement from the bench. Mr Hague was satisfied that Sir 76 | The Macur ReviewRonald Waterhouse “with his experience in Wales and in the relevant areas of law, was the right man to take on the task.” Discussions took place as to the nature of the inquiry and that it would be “fully independent ... Much of our discussion was about the possible length of the work ... From the very beginning therefore, Sir Ronald would have been clear of my and the Government’s view of his complete independence ...” Mr Hague said he was relieved when Sir Ronald Waterhouse, having reflected on their conversation during the telephone call, then “agreed to do the job.”Meeting between the Secretary of State for Wales and Sir Ronald Waterhouse prior to his appointment4.6 The Right Honourable Mr Hague MP, Secretary of State for Wales, had dinner with the Chairman elect on 17 July 1996 in the presence of Mr David Lambert, Legal Adviser to the Welsh Office, and another Welsh Office official. On 11 July 1996, the Secretary of State for Wales had received a “briefing for your dinner … Establishing the Tribunal is proving to be something of a tortuous process not least because, as parties to the tribunal, our access to Sir Ronald is necessarily very limited ... attached … is a note of the points we should like you to raise and of the ones we expect Sir Ronald to mention to you … up to now David Lambert has provided our only channel of communication with him, and I am sure he will want to have the opportunity to brief you about his impressions in advance of your dinner … [Sir Ronald was expected to] … share his thinking about the extent to which he should use the Tribunal to test the truth of evidence and reach conclusions about allegations against individuals. (This is difficult territory and not something upon which you should express a firm view …) [and] draw your attention to the fact that he expects the Inquiry to result in public expression being given to the allegations that have persisted for some time about the involvement of public figures in abuse that occurred.”4.7 The combined recollections of the two officials led to a note of discussions during dinner, the relevant parts of which I reproduce in full herewith since the note is capable of adverse interpretation. I make clear at the outset that such notes were not said to be contemporaneous and do not appear to have been submitted to Sir Ronald Waterhouse and/or the Secretary of State for Wales for their approval or comments. 4.8 The relevant parts of the notes are as follows: “a) … it was agreed to proceed on the basis that the Tribunal’s aim would be to complete the hearing of oral evidence by the end of the calendar year 1997 … The Secretary of State said that he would answer an arranged Parliamentary Question on the last day of the session to indicate the target … Sir Ronald concurred, and agreed that it would strengthen his hand in resisting pressures for endless ramifications of evidence, etc, to be pursued that a definite target date would have been publicly specified.The Report of the Macur Review | 77 e) Everyone who wanted to give written evidence would have to be allowed to do so. Sir Ronald indicated, though, that he hoped thereafter to be very selective in deciding who should be required or indeed permitted to give oral evidence. ... h) Sir Ronald indicated that it would be necessary to take fresh statements even from those who had already made statements to the police. The statements made to the police had been prepared with a specific, and limited purpose in mind; the Tribunal’s concerns would be wider. ... j) All the Tribunal’s papers would be made available to the police in due course. However Sir Ronald did not contemplate making any other kind of communications to the police bearing on the conduct of individuals. He did envisage, though, that the Tribunal’s report might need to record, where appropriate, the conclusion that specified individuals were indeed abused as they claimed. This would tend to carry the inference that the Tribunal considered that some or all of the persons whom they accused of having abused them must indeed be guilty of having done so … k) It would be the Tribunal’s aim to avoid private sessions in so far as possible. The Tribunal would however seek to suppress names where appropriate and hope to persuade the press to respect this. l) The Secretary of State expressed concern at the extent of the general attacks upon the characters of those involved that were occurring in the current actions involving Ian Botham and Imran Khan. He hoped that this would not be a prominent feature of the Tribunal’s proceedings. Sir Ronald, however, indicated that he did not think that it could be prevented. Those accused of misconduct had to be free to question the credibility of those making the allegations by attacking their general characters and reputations.”4.9 The note is open to an interpretation of attempts at, or actual connivance at, a ‘cover up’ which is why I produce it here; see, for example, the words ‘very selective’ and ‘suppress’ attributed to Sir Ronald Waterhouse at paragraphs (e) and (k). I note that the record shows that the Secretary of State for Wales’ apparent reference to ‘general attacks’ on character was interpreted by Sir Ronald Waterhouse to refer to prospective complainants.4.10 In his letter to me dated 1 June 2015, the Right Honourable Mr Hague recalled the dinner, but understandably, had no detailed memory of the conversation. He was unable to be “certain of the context for Sir Ronald reportedly referring to being ‘very selective’ about oral witnesses and hoping to ‘suppress names’...”, but thought this related to the need for an “efficient and timely inquiry” and for a report that could be published without the risk of defamation. So far as the comments attributed to him at the dinner were concerned, he referred me to statements he had made 78 | The Macur Reviewin Parliament to the effect that he hoped that Tribunal witnesses’ privacy could be maintained commensurate with the public interest. This, he said, was the context for his reference to the “celebrated libel trial of that time ... which had seen attacks on the character of all participants.” In conclusion, on this point, he was certain that “no one present at the dinner or any other discussion about the inquiry could reasonably be in any doubt” of his intentions as Secretary of State that there should be no ‘cover-up’ and a fully independent Chairman.4.11 I wrote to Lady Waterhouse on 19 May 2015 as a matter of courtesy notifying her of issues that I was then minded to include in my Report, which might result in criticisms being made about the actions or decisions of her late husband, Sir Ronald Waterhouse. Leading Counsel, who had not previously been concerned with the Tribunal, responded on her behalf. On this matter, he recognised the potential for an adverse interpretation of the comments. He suggests that the word ‘selective’ should be considered in the light of the size of the inquiry and the necessary management of the evidence, and the reference to ‘suppress names’ to be with a view to avoid private sessions and still to ensure the confidentiality of witnesses.4.12 In the light of the meeting as reported, I have scrutinised the daily transcripts and other Tribunal documents for any sign of the Chairman’s reluctance to investigate allegations against any person or establishment figure, or those which may implicate them. I refer in paragraph 4.122 to my conclusion overall in this respect, as detailed more fully in Chapters 7 to 9. In short, I did not detect any reluctance to investigate any issues raised by admissible evidence, whether it implicated establishment figures or not. The other members of the Tribunal 4.13 Miss Margaret Clough had been a senior official of the Social Services Inspectorate of the Department of Health with responsibility including children’s services. Mr Morris le Fleming was former Chief Executive of Hertfordshire county council and had served as an assessor in the ‘Beck Inquiry’ into the abuse of children in care in Leicestershire conducted by Andrew Kirkwood QC (subsequently to become Mr Justice Kirkwood, now deceased). 4.14 Neither of them was known to each other or the Chairman prior to their appointment. Neither of them declared a conflict in interest with any individual or local authority, nor suggested that they were affiliated to the Conservative party. Mr le Fleming has confirmed in writing to me that he has never been a Freemason and has no recollection of any enquiry to that effect prior to his appointment (see paragraph 4.37).4.15 I have had access to the notes of evidence prepared by Miss Clough and Mr le Fleming and have seen the Clerk to the Tribunal’s notes of discussions held during, and the minutes prepared and schedules drawn of their discussions with the Chairman after, the hearings. All findings made by the Tribunal were seemingly discussed and ultimately agreed. The Report of the Macur Review | 794.16 As previously indicated in paragraph 2.79, I interviewed Miss Clough and Mr le Fleming jointly. I was informed by both that they had not felt subject to outside interference or undue pressure and were certain of the Tribunal’s independence. However, Mr le Fleming considered that his participation in the Beck Inquiry was greater because he had “a very good relationship with [Counsel to the Beck Inquiry].” Miss Clough felt that her position as “the only non-lawyer in about 60 lawyers … [meant that] even though attempts were made to make it non-adversarial, it is still a very adversarial process.” Both were undoubtedly aware of the scale and importance of the public inquiry. Each commented on the close working relationship between the Chairman and Leading Counsel to the Tribunal. However, Miss Clough did say that she did not feel “the slightest sense that I was being stopped from pursuing anything I wanted to pursue.” 4.17 The Tribunal’s documents support her perception of them playing nothing other than a full part in the proceedings. For example, the contemporaneous annotation of a document by the Clerk to the Tribunal relating to a request for an informal confidential indication to be given to a social worker, against whom allegations had been made, that he would not be criticised in the Tribunal Report reads, “Ch content to agree to this. Members concerned about the practice of giving indications of whatever nature however informal/confidential – Ch asked counsel to inform his Counsel (AP) that whilst the Trib were sympathetic to his position it is unable at this stage to consent to this request.” That is, the Chairman’s initial views did not prevail. 4.18 On 24 September 1996, Miss Clough is noted to have “delivered a list of documents that she felt would be of assistance to the investigation. The list was similar to that prepared by Mr le Fleming.” Miss Clough is noted to have asked for a briefing on the terms of reference so as to inform her reading of background materials (but rightly told that it would be inappropriate for Counsel to ‘brief’ tribunal members). Each of them prepared notes on the evidence, and in relation to their specialist fields, in relation to topics covered by the Tribunal’s investigation for the information of the Chairman throughout the hearings. 4.19 Miss Clough contacted my Secretariat on 10 July 2014. She wished to report that on unspecified dates she attended some of and on one occasion had lunch with him. He had provided her with a leaflet about the Paedophile Information Exchange, although he did not tell her he was a member or try to promote the organisation. She said they had engaged in a “purely academic discussion” about it.4.20 I wrote to Miss Clough on 15 May 2015 alerting her to the fact that I was minded to refer in this Report to her contact with prior to her appointment as a member of the Tribunal and the information that she had provided during the telephone call. In her response, she explained that the purpose of her call was to inform the Review that, in light of recent media reports concerning a list of establishment figures connected with child sexual abuse allegations involving Elm Guest House, and having reminded herself of my question as to whether she had seen a list of establishment figures said to have been 80 | The Macur Review involved with a paedophile ring in North Wales, she was able to categorically state that if the latter included name, she had not seen it. He had produced a leaflet about the Paedophile Information Exchange at a lunch which she and other students had attended, but had not admitted any personal involvement in the organisation or advocated its cause to her. She had no other contact with him subsequently and did not feel that the nature of her contact with him caused her any conflict of interest.Assessor4.21 Sir Ronald Hadfield, a former Chief Constable of Nottinghamshire and then the West Midlands, was appointed as an assessor to advise on police matters. He was independent of the NWP and was subsequently explicitly critical of the 1986 police investigation led by Detective Chief Superintendent David Owen. The Chairman had not identified or selected him personally, but had required “an eminent former chief constable … as a special adviser on police matters.”4.22 The Chairman had suggested in a meeting on 16 July 1996 with Mr Lambert, then acting as de facto solicitor/secretary to the prospective Tribunal, that Sir Ronald Hadfield should not be considered as assessor to the Tribunal by virtue of his leadership of the West Midlands police at a time when that force had been subject to heavy criticism. I have not found any further reference to this advice and it was obviously discounted.4.23 The Chairman made clear in his opening statement on 10 September 1996 that “… such advice as Sir Ronald [Hadfield] may tender from time to time will be in written form and will be circulated at least to Counsel and solicitors appearing before the Tribunal …” and was capable of challenge in cross examination. Sir Ronald Hadfield’s statement to the Tribunal is reproduced in full in the Tribunal Report.1 4.24 Sir Ronald Hadfield died on 31 January 2013 shortly after this Review was established.Counsel to the Tribunal Selection of Counsel4.25 Counsel to the Tribunal were nominated by the AG after consultation with the Chairman. 4.26 All three Counsel were in independent practice. Mr Gerard Elias QC, who was former Leader of the Wales and Chester Circuit, was Leading Counsel. Mr Gregory Treverton-Jones (since appointed a Queen’s Counsel), who was a member of Mr Gerard Elias QC’s chambers, and Mr Ernest Ryder (now Lord Justice Ryder) who 1 See Appendix 11 of the Tribunal ReportThe Report of the Macur Review | 81 was from Manchester chambers, were Junior Counsel. The Chairman made clear in his opening statement on 10 September 1996 that whilst their duty was “to advise the Tribunal on both legal and evidential matters and to present the evidence to the Tribunal in oral and documentary form… it will be for the Tribunal to decide ultimately what evidence it is necessary and appropriate to hear.” 4.27 The Chairman knew of and positively endorsed Mr Gerard Elias QC. The Clerk to the Tribunal informed me in interview that the Chairman had known Mr Gerard Elias QC for a long time and, she thought, he had once been his pupil master. A note of a meeting between the Chairman, the AG and Solicitor General on 29 July 1996 records, “Against this background, counsel of the highest calibre would be required. The preference of the judge is for Gerard Elias QC - formerly the Leader of the Wales and Chester Circuit … The judge certainly favoured a common lawyer reflecting the extent to which the handling of the complaints and the conduct of the local authorities would be in issue … Reverting to the question of counsel, it was noted that the inquiry would be sitting in Ewloe, Flintshire. There would be merit in having counsel who lived in reasonable proximity. The preferred option of the judge is Gerard Elias QC.” 4.28 One contributor to the Review, Mr Gareth Taylor, previously known as Michael Hassan Ullah, thought it significant that the Chairman and Leading Counsel had “met” on “the Pembrokeshire case … trial of child sexual abuse …” but did not explain in what way. However, I note that the comment should be seen in the context that, during the course of the Tribunal and to this Review, this contributor expressed himself as critical of the Tribunal process and did not accept all of the findings of abuse ultimately made.4.29 Mr Gerard Elias QC recommended Mr Treverton-Jones. Mr Treverton-Jones was a member of the AG’s panel on the customs and excise list. Mr Gerard Elias QC’s recommendation was approved and Mr Treverton-Jones was instructed as first Junior Counsel to the Tribunal.4.30 On 13 August 1996, a message to the Deputy Treasury Solicitor from Mr Lambert reads, “I saw the Judge yesterday and he would very much like to have a second Junior Counsel … who has some considerable experience of family law matters and wonders … whether it might be possible to send him a list of possible appointees ... to consider and make a recommendation to you.” Mr Justice Douglas Brown, a recent Family Division Liaison Judge of the Northern Circuit, was approached for recommendations. He provided a list of several names including the name of Mr Ryder, then a Junior Counsel based in Manchester, who was subsequently appointed.Conflict of interest4.31 Prior to the appointment of Mr Gerard Elias QC, consideration was given to the potential conflict of interest arising by reason of his wife’s employment. This issue had been raised by the Chairman in the meeting on 29 July 1996 attended by Law Officers and Mr Brian McHenry, Solicitor to the Tribunal. Mr Lambert was asked 82 | The Macur Reviewto make further enquiries. In his letter dated 31 July 1996 to the Deputy Treasury Solicitor, Mr Lambert reports, “we have discussed the interests of Mrs Elias ... She is a non-executive member of the board of WHCSA [Welsh Health Common Services Authority]. This is a central servicing authority which gives technical and legal advice to … health authorities and National Health Trusts in Wales ... It has no involvement in the provision of hospital or other medical or dental services in Wales. There has been no criticism, to my knowledge, of the provision of medical or other services with regard to the persons who have been allegedly abused and who will form part of this Tribunal of Inquiry. Administrative colleagues cannot see any conflict of interest were her husband to be appointed as the Leading Counsel to the Tribunal team.”4.32 There are no documents I have seen which indicate that the same consideration was given to the possibility that any of Counsel to the Tribunal were, had been or may be a Freemason. The first indication of this potential conflict of interest being raised appears in a letter dated 6 September 1996 written by Mr Rhodri Morgan, MP for Cardiff West, to the Secretary of State for Wales “to express the strongest possible objections” to the appointment of Mr Gerard Elias QC as Leading Counsel. The letter related that: “While in no way reflecting on Mr Elias’s legal qualities and capabilities, the fact that he is a prominent freemason and an officer or past officer of the same masonic lodge as your Parliamentary Under Secretary of State and so many other Conservative Party ‘heavies’ makes this an incredibly insensitive appointment. You must surely be aware that freemasonry will be an issue in the Waterhouse Inquiry, since freemasonry within the North Wales Police has always been pointed to as a possible factor in the long delays in exposing and solving the child abuse problem in Clwyd and Gwynedd. Furthermore any possible critical examination of the role of and possible failures of the Social Services inspectorate of your Department may well be perceived to be more difficult given the fellow freemason links between Mr Elias and Gwilym Jones in the Dinas Llandaf Lodge … I should be grateful, therefore, if you would consider this matter and its possible impact on the willingness of previous victims or witnesses of child abuse in North Wales to come forward and for the Inquiry to follow its course to a full conclusion.” 4.33 The letter was disclosed to the Chairman and Mr Gerard Elias QC. In a fax communication dated 17 September 1996 with suggested drafts of the letter in response, the Solicitor to the Tribunal reported that, “both Sir Ronald and Mr Elias would prefer the ‘full frontal’ approach, as it is the stance which the Chairman would take were the matter raised in open hearing.”4.34 The Secretary of State for Wales responded to Mr Morgan MP in a letter dated 20 September 1996 to the effect that Mr Gerard Elias QC was “appointed by the Attorney General following consultation with the Tribunal Chairman, Sir Ronald The Report of the Macur Review | 83Waterhouse.” He went on to say that Mr Gerard Elias QC was judged to be the most suitably qualified person in terms of legal skills, range of experience, judgement and personal qualities to undertake the important task. He concludes that: “Whether or not Mr Elias happened to be a freemason was not a consideration nor was there any reason to regard it as relevant. There is no basis whatsoever for any suggestion that he will be influenced in the discharge of his duties as leading counsel by virtue of his membership of a lodge.”Application for a register of interests4.35 Independently of the concerns expressed by Mr Morgan MP, on 16 January 1997, Pannone & Partners, solicitors representing a number of the complainants wrote to the Chairman “concerning a sensitive issue … namely the involvement in the Inquiry of members of the Freemasons. You will be aware that allegations of Masonic connections with the abuse of children in care in North Wales have been raised in the media over the past five years. These have focused on the Police but also extend to those running homes and in Social Services. These concerns are bound to be voiced again before the Tribunal. It would be most regrettable if the effectiveness of the Inquiry were to be in any way undermined by suggestions (however baseless) that Masonic influence ‘behind the scenes’ had compromised it in its task. We are therefore writing to suggest that a public register be kept of Masonic membership amongst Tribunal members, staff, advisers and witnesses … Accordingly, we are instructed to make a formal application to the Tribunal in due course for a direction that membership of the Freemasons and other similar organisations should be disclosed.” 4.36 An attendance note from the Deputy Treasury Solicitor dated 17 January 1997, made aware of Pannone & Partners’ proposed application by Mr Lambert states, “It did not help that one of the two junior counsel assisting the Inquiry was a Mason (Mr Ryder had been the Judge’s appointment, taken from a list furnished by the Attorney’s office and which had the agreement of Mr Elias). The other junior Counsel was appointed at the request of leading Counsel.”4.37 On 20 January 1997, a Welsh Office official advised the Secretary of State for Wales, “There have been, almost from the outset, allegations about a Freemasonry connection with the North Wales Child Abuse scandal ... In the Permanent Secretary’s absence on Friday I hastily convened a meeting ... to discuss the Judge’s approach ... After consulting the Acting Treasury Solicitor and the Attorney General’s Department, we advised the Judge that, in the main, these were issues for him to determine as they were directly concerned with Tribunal proceedings ... we did however advise him of the Department’s rules and procedures ... the need for Welsh Office personnel to declare any conflict of interest that may arise during the course of their work. We understand that the Judge is now likely to deal with this on the following basis: With regard to the Tribunal members themselves ... take the matter up with Secretary of State (We know that the Judge himself is not a 84 | The Macur ReviewFreemason ... but we did not ask Mr Le Fleming whether he was a Freemason, and do not know whether he is one or not) ... With regard to … Welsh Office staff ... he will refer to the departmental procedures about conflict of interest. It is likely that the Judge will extend this to cover Counsel to the Tribunal (we know that Mr Elias ... and Mr Ryder … are Freemasons); and also the team of former policemen who are engaged in taking statements from witnesses (we know that at least one of them is a Freemason). As regards witnesses, the Judge intends to say that he will allow Counsel to ask witnesses about their membership of this organisation if he judges it to be relevant in the context of proceedings and of the witnesses’ evidence.” The note continues, “Should there by [sic] a media approach I would suggest … ‘These appointments were made on the basis of the individuals’ qualifications and qualities. They were not asked whether they were Freemasons because there was no reason to regard this as relevant’.”4.38 The papers do not indicate the source of the Welsh Office’s stated knowledge that Mr Gerard Elias QC or Mr Ryder were, or had been, a Freemason or when it became known to them. I have found no document which records any conversations with Counsel to the Tribunal prior to their appointment about their affiliations or association with freemasonry and/or any consequent debate as to whether, if so, this constituted or would be perceived as a conflict of interest. I do note that the suggested response to any media approach about appointments does not seek to distance the Welsh Office from the process. It does, however, contrast with the concerns expressed by the same official to the Secretary of State for Wales during a video link on 7 October 1996 in relation to, “the freemasonry issue especially with respect to the appointment of the former Detective Chief Inspector from South Wales and the rumours that were apparent within the South Wales Police Force regarding the reason for this appointment.” 4.39 The notified application was made on the first day of the hearing, 21 January 1997, by Counsel instructed by Pannone & Partners. Whilst noting the “very strong and impressive opening” of Leading Counsel, Mr Gerard Elias QC, which would have “greatly strengthened” the confidence of the complainants in the Tribunal, he nevertheless made the application for a register of Freemason membership. The application was supported by an advocate representing another complainant. Counsel for the Welsh Office made no representations.4.40 The Chairman’s approach was not entirely that envisaged by the Welsh Office. The Tribunal dismissed the application; the Chairman making clear from his comments that he was not a Freemason, and directing criticism of any appointments of Tribunal members to the Secretary of State for Wales and of Counsel to the AG. The Chairman did not refer to Welsh Office procedures regarding declaration of any conflict of interest arising.4.41 A member of the public writing to the Prime Minister after the reporting of the Tribunal’s ruling on a register of Freemason membership reflected the distrust of many at the ‘infiltration’ of Freemasons and their perceived desire to protect their own, and other establishment figures, at all costs. A response was made in similar terms to that written to Mr Morgan MP.The Report of the Macur Review | 854.42 The response did not refer to the information contained in a letter copied to the Secretary of State for Wales dated 25 September 1996 and addressed to Mr Morgan MP from the Grand Secretary of the United Grand Lodge of England. Attached to that letter was an extract from the Grand Lodge’s leaflets “Freemasonry & Society” which includes the following, “… The Charge to the new Initiate calls on him to be exemplary in the discharge of his civil duties; this duty extends throughout his private, public, business or professional life … there is no conflict of interest between a Freemason’s obligation and his public duty … A Freemason’s duty as a citizen must always prevail over any obligation to other Freemasons …” Within the same extract is included, “If an actual or potential conflict of duties or interest is known to exist or is foreseen, a declaration to that effect should be made. It may on occasions be prudent to disclose membership to avoid what others mistakenly imagine to be a potential conflict or bias, but this must be a matter for individual judgement.”4.43 Journalists have continued to highlight the issue of freemasonry and clearly perceive a conflict of interest given the long rumoured protection offered to establishment figures by virtue of their masonic connections.My further enquiries4.44 In response to my letter to him dated 15 May 2015, the AG notes that the Tribunal Report refers to all three Counsel being “nominated by the Attorney General to act as Counsel to the Tribunal”, but explained that whilst the Law Officers maintain a panel of Counsel to undertake work for government departments after a recruitment process based on merit and experience, it is not a requirement that Counsel to inquiries are selected from the Panels or that a nomination for an ‘off Panel’ Counsel to be appointed to an inquiry is approved by Law Officers. He asserts in his letter to me that the AG did not appoint Counsel to the Tribunal and would not have a role in terms of assessing Counsel for any conflicts of interest. This, he considered, remained a matter for the Tribunal itself and the professional considerations of Counsel themselves. 4.45 The Welsh Government suggested in a letter to me that while Counsel to the Tribunal were “formally instructed” by Treasury Solicitor in their capacity as Solicitor to the Tribunal, the AG had been involved in discussions with the Chairman as to the identification of Counsel to be nominated. 4.46 In response to my letter to him relating to the appointment of Counsel to the Tribunal, the Treasury Solicitor indicates that he has not felt it appropriate to make enquiries of the officials involved at the time and refers to the view expressed in the letter to Mr Morgan MP, as indicated in paragraph 4.34. He indicates that this “was clearly the considered view at the time and [he did] not consider it appropriate for [him] to go behind that conclusion.”4.47 I interviewed all three Counsel to the Tribunal separately. None raised any anxiety about external political interference which could have undermined the independence of the Tribunal process. I did not raise the issue of freemasonry with them at that time since I had not then seen the documents to which I refer above.86 | The Macur Review4.48 I wrote to Mr Gerard Elias QC and Lord Justice Ryder separately on 13 April 2015 seeking that they confirm: (i) whether, at the time of their appointment they were or had been a Freemason; (ii) if so, whether they had been asked to declare any conflict of interest, including whether they were a Freemason, by the Welsh Office, the AGO, Sir Ronald Waterhouse, or any others, prior to their appointment; and, (iii) whether they had otherwise volunteered that information.4.49 Mr Gerard Elias QC confirmed that at the time of his appointment as Leading Counsel to the Tribunal he was a Freemason, which “… at that time was generally known. The fact was known to the Welsh Office and to Sir Ronald and the question of any possible conflict of interest was raised in discussion with both. Both were satisfied - as was I - that no conflict existed or was likely to exist.” He dismissed the suggestion that he had ever been a ‘prominent’ Freemason. He had indicated that he would not “participate in freemasonry in any capacity whilst the Tribunal operated” and had not been active since that time. He said that “had matters ever developed such that there could have been any perception of conflict [he would] doubtless have reconsidered the position. [He knew] that Sir Ronald would have also been alert to canvass any issue which he believed might raise the spectre of conflict of interest. No such issue arose.”4.50 Lord Justice Ryder confirmed that he had been a Freemason prior to his appointment as Counsel to the Tribunal, but could not recall whether or not he was still a Freemason at the time of his appointment; however, he was not an “active member” of the Freemasons at that time. He had tendered his resignation from the organisation soon after joining its ranks, but the formality of the procedures then involved some delay. No one from the Welsh Office or AGO had spoken to him about the subject. He recollected that after his appointment he was asked to complete a piece of paper declaring any possible conflicts of interest. He had declared his past or present status as a Freemason, but has no recall of the origin of the document or its destination. He had been asked by Sir Ronald Waterhouse about conflicts of interest at the time of delegation of Counsel’s duties. He had confirmed his past or present membership to the Chairman and had also discussed with him, during several conversations, other potential conflicts that his prior professional contact with local authorities under investigation may create. He said that, “As allegations began to be received by the Tribunal the issue of Freemasonry became more concrete”. He then agreed with Sir Ronald Waterhouse that it was inappropriate for him to be “party to any decisions or to handle any evidence relating to the same.” He said that at no stage did he take part in decisions relating to the “investigations, the calling of evidence or its analysis” in relation to freemasonry issues.4.51 I have seen no document containing any declaration of interest. Upon receipt of Lord Justice Ryder’s reply, I requested the Wales Office and AGO to make a further search for any such documents relating to the Tribunal. Neither were able to locate the same. The AG did, however, indicate that the GLD held files relating to the appointment of Counsel to the Tribunal, which had not been previously disclosed to the Review. I have previously referred to this matter in paragraph 2.18. The files subsequently disclosed did not contain any declaration of interest made by Counsel.The Report of the Macur Review | 874.52 Mr Treverton-Jones has confirmed in writing to me that he is not now, nor has he been a Freemason.4.53 I was alive to the fact that two of the three Counsel to the Tribunal were, or had been, a Freemason when I examined the documents created or annotated by them. I have had access to a large quantity of manuscript and typed notes produced by them throughout the Tribunal process, although obviously by reason of the number that must have been created during this time, not all of them. I have read manuscript annotations upon witness statements and other documentation, whether in their own hand or indicating their presence at meetings at which matters of procedure and practice were discussed. I have seen records of planning / strategy meetings between Counsel to the Tribunal and with other Counsel and advocates representing interested parties, members of the Tribunal and the Solicitor to the Tribunal, and have seen notes passing between them. I have seen instructions issued to the WIT and other Tribunal staff or assistants. In addition, I have had recourse to the daily transcripts of proceedings and seen the nature of Counsel’s questioning on behalf of the Tribunal and the lines of inquiry made by them or on their behalf by the Solicitor to the Tribunal. I record that there is nothing within the documents that have been disclosed to me that indicates any knowledge of available evidence relating to Freemasons and/or establishment figures that they suppressed, or decision taken which may suggest intent to do so if such evidence became available. 4.54 In this regard, it is pertinent to report the contents of a letter dated 3 February 1998, sent to the Solicitor to the Tribunal on behalf of the Masonic Province of North Wales complaining of the perceived “disparagement [of freemasonry] at the proceedings of the Tribunal” and “gratuitous involvement of the Craft and its late Provincial Grand Master (Lord Kenyon)”. This does not suggest that the Tribunal was minimising the issue. The letter was placed before the Tribunal and discussed between them and Mr Gerard Elias QC. Thereafter, Mr Stuart Howard, then Solicitor to the Tribunal, responded on 12 February 1998, “you must surely be aware that one of the matters that the Tribunal must investigate is the alleged influence of Freemasons on the investigation by the police and by social services into the abuse of children in care in North Wales between 1974 and 1996.” Solicitors and Clerk to the Tribunal 4.55 The Solicitors to the Tribunal were Mr Brian McHenry (now Reverend McHenry) from mid July 1996 until December 1997, and subsequently Mr Stuart Howard. They were seconded from the Treasury Solicitor’s Department as was the Clerk to the Tribunal, Miss Fiona Walkingshaw. They were interviewed and obviously approved by the Chairman, but had not been identified by or known to him previously. Mr McHenry was known to have had previous experience of public inquiries.4.56 I have interviewed the successive Solicitors to the Tribunal. Neither was concerned as to any lack of integrity in the Tribunal process, save that in interview with me, Reverend McHenry expressed that on occasions he felt that he was excluded from meetings between Counsel and/or Counsel and the Chairman, and remarked upon the frequent visits of Mr Lambert to the Tribunal. 88 | The Macur Review4.57 I wrote to Mr Gerard Elias QC on 15 May 2015, concerning Reverend McHenry’s perceptions, amongst other things, and invited his comments. Mr Gerard Elias QC responded that he remained on friendly terms with Reverend McHenry, but that Counsel to the Tribunal and Solicitor to the Tribunal had different functions. In his experience, Solicitors to Tribunals often wished to be more involved in ‘the action’. He said the Solicitor to the Tribunal had never been deliberately excluded.4.58 The second concern raised by Reverend McHenry relating to the early involvement of Mr Lambert, by reason of his employment with the Welsh Office and therefore his potential conflict in his role, is discussed at paragraphs 4.94 to 4.98.Administrative staff4.59 Administrative staff were seconded from the Welsh Office. Their letters of secondment required them to be independent of the Welsh Office and to behave at all times in order that their loyalty to the Tribunal must never be questioned. They were instructed not to engage in any activity which could be interpreted as political and to avoid behaviour which called into question their political neutrality.4.60 All personnel employed on Tribunal business were to be security vetted. There are letters which refer to security questionnaires still to be completed and which needed to be returned and for the provision of documents to make identification checks. Follow up communications included the necessity to take up matters with individual’s home departments. The Witness Interviewing Team 4.61 The Tribunal’s Witness Interviewing Team (WIT) comprised retired police officers; the initial appointees having served in the South Wales police force. Retired officers from forces outside Wales joined subsequently. The WIT was employed to trace and interview potential witnesses at the direction of the Tribunal. 4.62 Mr Reginald Briggs was the head of the WIT. He was a retired Detective Chief Inspector having served in the South Wales police force. He told me in interview that he had been recommended for appointment by Mr Gerard Elias QC. Mr Briggs also informed me that he knew Mr Gerard Elias QC professionally having been involved in a number of cases prosecuted by him. He unhesitatingly volunteered to me that he was a Freemason. He said that he had been interviewed on two occasions before being appointed to the role and had been asked if he was a Freemason. He had confirmed that he was, but was happy to ‘pack it in’ if it had been necessary to do so. He did not consider it had affected his performance in any way.4.63 Mr Gerard Elias QC, in his response to my letter of 15 May 2015, makes the following points: (i) he did not appoint Mr Briggs; (ii) he did recommend Mr Briggs since he knew him as “highly efficient, a good manager of staff, capable of organising and running a team, and that he had recently retired” and there was “an acute need to recruit those who already had the skills and experience for the task and could almost immediately set to work”; (iii) he did not know that Mr Briggs was a Freemason.The Report of the Macur Review | 894.64 The appointment of previously serving police officers from the South Wales force appears to have been controversial in more than one respect. 4.65 On 11 September 1996, Mr McHenry wrote to the Deputy Treasury Solicitor stating that he had taxed Mr Gerard Elias QC on the use of retired South Wales’ detectives for taking witness statements, acknowledging that “[public] confidence could be undermined if word got out that former detectives from South Wales were being used in the preparatory work. The North Wales Police were in the frame. Public opinion would not distinguish between the North and South Wales police forces. The police were being implicated in the emerging Belgian scandal ... [creating] considerable risks for the integrity of the process.” He said Mr Gerard Elias QC had responded that the Tribunal was not involved in a police investigation. The former detectives were not serving officers. They were the most efficient statement takers. Given the size of the task and the short time frame, nobody else could undertake the work which required skilled and experienced handling. 4.66 Subsequently, in a note dated 23 September 1996, Mr McHenry was “anxious not to lose the services of these former officers [that is Briggs et al] because time is valuable and further delay in gathering evidence and statement taking will hinder the presentation of evidence to the Tribunal.” 4.67 In a note dated 8 October 1996, the Tribunal Chief Administrative Officer records that in a meeting held on 2 October 1996, Mr Gerard Elias QC had reported that five former police officers from South Wales had started to work tracing and interviewing potential witnesses. The note goes on to say that Mr Gerard Elias QC “estimated that 5 more will be required as soon as the present five are organised and up to speed, [however] the Chairman has decided that these should come from outside Wales and not be recruited by the same person, Mr Briggs who recruited the original members … At least one or two of the additional interviewers should be female. Originally Mr Briggs had spoken to an ex lady officer from South Glamorgan but this was put on holds [sic] when it was decided not to employ any more people from that area.” A retired female police officer from an outside force was subsequently appointed. 4.68 On 9 October 1996, a trainee solicitor wrote to Mr Lambert quoting as his source “an informal contact I have with the South Wales Police ... In essence the former officers who have been appointed are highly experienced in organising and conducting police investigations, but they have little or no experience of conducting interviews of this kind using modern methods.”4.69 Mr Gerard Elias QC was obviously made aware of the note. He responded to what he saw to be rumours which undermined the confidence of the public and the Welsh Office in the operation of the Tribunal. In a note intended to be seen by Welsh Office officials, he sought to “disabuse” the informant who was “seriously in error”. He wrote, “The facts are as follows: 1. Former police officers from Wales & outside will be employed on the Tribunal’s behalf … 2. No former police officer will be called upon … to ‘assess the way in which the NW police conducted their recent investigation’ or ‘the methods of interviewing they used’ ... 3. No former police 90 | The Macur Reviewofficers are being used to ‘extract information’ from anyone ... 6. Those who are to come into contact with adults who may have been the subject of … abuse have had the benefit of … discussions on the proper approaches both with myself … and Ernest Ryder. 7. No former officer will undertake any Meeting … with a complainant without that person having acquainted him/herself with the essence of the interviewing Guidelines laid down … in the Cleveland Inquiry and with the ‘REPENT’ (The Structured Interview) format as taught at the Harrogate Police College ... written Guidelines given to each of our Tribunal representatives [state], ‘Please bear in mind at all times that you are not seeking to produce any particular outcome from your meeting - you are not encouraging or discouraging complaints or allegations; you are recording whatever the witness wishes to tell you. It is imperative that you do not ask the witness leading questions on contentious matters.’ The difference between this approach and that involved in carrying out a criminal investigation will be obvious ... 8 … Counselling facilities have been put in hand & the Tribunal representatives are well aware - and armed with written details to hand to a complainant.”4.70 The Welsh Office concern as to the recruitment of the first members of the WIT is indicated in paragraph 4.88. A note dated October 1996, from one official to another, indicates that independent research was conducted into the character of the WIT. It reads, “This somewhat cryptic note concerns the investigation by the Midlands into the actions of the South Wales Force concerning the apparent failure to investigate allegations of abuse at the Cardiff children’s home ‘Taff Vale’. I wanted to make sure that the ex-officers recruited by the Tribunal were not part of that investigation and this note clears them.” 4.71 On 23 October 1996, the Tribunal Chief Administrative Officer recorded the recruitment of three retired officers from external forces “best suited to this work because of their background in criminal work and they have all undertaken a considerable amount of interviewing over the last few years. They all knew about the existence of the Home Office Code of Practice and more importantly they were the three with the best inter-personal skills.” On 20 November 1996, he reported to the personnel department of the Welsh Office, “over the last two months I have been able to observe [the first five interviewers] working and I have no problem in recommending an extension to their contacts … Mr Briggs has worked extremely hard in setting up a system for tracing and interviewing witnesses. He has been successful in developing a team spirit, bringing together ex-officers from several Police Authorities. He also has the confidence of the legal team working here.” He went on to describe the work of the other four members of the team in complimentary fashion and concluded, “the whole team has settled down well and criticism has only been minor and has not been about individuals but about the concept of employing ex-police officers.”4.72 Concerns continued however as to the deployment of the retired police officers. On 4 November 1996 an Assistant Solicitor to the Tribunal wrote to Mr McHenry accepting that the WIT were “the best persons available to do the necessary chasing, finding and locating witnesses to the Tribunal, and were the most experienced to obtain the type of statements required ... [however] the WIT The Report of the Macur Review | 91members do look like former officers and behave as such ... difficult for them to disguise. The witnesses to the Tribunal would not take long to spot them. Due to the allegations that are likely to be levelled at the NWP, I endorse the point mooted ... that it would be a good idea to send one WIT and one graduate out to interview … Now that there have been a few complaints about the WIT members, and that there have been noises made ... I wonder to what extent the recommendation … may be taken forward?” Apparently this suggestion was not adopted in many cases, if at all. 4.73 A letter addressed to the Solicitor to the Tribunal from on 4 November 1996 complains, “to use ex police officers is an insult. You said they have got a clean record on file, so as the former superintendent, Yet in the high court he admitted to fiddling his expenses, Yet his record is clean ... This Tribunal is a Joke NO ONE listens, the only thing you and the chairman seem to listen too is bad advise ... let me assure you I will not allow this very important job to be done in a sloppy way ... There is no one more determined than me to make sure this tribunal is a success, yet you lot seem to be determined for it to flop. Mind you what’s knew? [sic]” 4.74 On 12 November 1996, the Tribunal Chief Administrative Officer wrote to solicitor, “ makes a comment on the use of ex-police officers as interviewers. The Chairman decided in view of the difficulties being experienced in tracing witnesses for interviews that the most experienced people to work in this field would be ex-police officers. The Tribunal has been very careful in their selection, making sure that they were previously employed by Police Authorities which have had no contact in any form with child abuse matters in North Wales. Every ex-officer employed has been carefully vetted on a personal basis and only those with exemplary records and good inter-personal skills have been employed.” 4.75 At the commencement of the Tribunal hearings, the contracts of several members of the WIT were extended to include “the work of warning witnesses required to attend hearings, their care whilst at the Tribunal and, as and when required, the conveyance of witnesses to and from the Tribunal of Inquiry”. I have found no complaints about their conduct in this role. Some witnesses declined the service. During interview with me, Mr Briggs produced a letter of thanks sent from a solicitor on behalf of one of his clients who had been escorted to the Tribunal by him.4.76 On 6 March 1997, solicitors wrote to complain about Mr Brigg’s conduct that morning. It was alleged that, during a conversation between Mr Briggs and the former had said to others nearby ”Look how easy it is to wind this lad up, look how he bites.” An argument ensued. Mr Briggs, when asked for his response, acknowledged that there had “been words” concerning loud vocal assertion that “this Tribunal is a total sham”, but that soon afterwards had assisted in locating a witness and had told Mr Briggs “I’m OK now”. had no recollection of the incident when asked by me in interview, but acknowledged continued antipathy towards members of the police forces in Wales. 92 | The Macur Review4.77 The incidence of complaints against the members of the WIT is very small. Those complaints may be categorised almost exclusively as being by reason of their determined approach in tracing witnesses and seeking to interview them. I have found none to suggest that prospective witnesses were deterred from reporting complaints, save in the case of one contributor who suggested that the WIT were only interested in allegations of sexual abuse. 4.78 The continued use of members of the WIT as chauffeurs ensured and facilitated the attendance of witnesses at the Tribunal. There is nothing in the daily transcripts or other documents to suggest that any witness complained of undue influence being brought to bear by any member of the WIT involved in the transportation of witnesses. Witness statements were already in existence and laid before the Tribunal, many prepared by members of the WIT. The successor authorities’ staff assigned to the Tribunal4.79 On 24 July 1996, the Chief Executive of Wrexham county council indicated in a meeting with Mr Lambert that the approach of the successor local authorities was to establish ‘an informal advisory group’. A joint enquiry office was to be headed by Mr Andrew Loveridge, Director of Legal and Administration of Flintshire county council. Each successor authority would ‘lose’ two members of staff to this group. 4.80 Ms Sian Griffiths was assigned by Mr Loveridge, effectively as a co-ordinating liaison officer to the Tribunal. Her conduct in this role has been called into question in two distinct respects, as detailed in Chapter 6.Telephone call4.81 If the telephone call referred to in paragraphs 1.4 and 1.34 was made by a member of the Tribunal staff, this obviously raises an issue of their propriety and impartiality. Ultimately, for reasons given later in this Report, I conclude that it was a hoax call. Parties to the Tribunal4.82 20 complainants were represented by a Leading Counsel and two Junior Counsel, a further 39 complainants were represented by a separate Junior Counsel. A separate Leading Counsel and solicitor advocate represented the organisation ‘Voices from Care’. A Leading and Junior Counsel represented over 100 residential care staff, including those against whom serious allegations were made. Others accused or implicated were separately represented. The Welsh Office, NWP, successor authorities and insurance companies were each represented by Leading and Junior Counsel. The CPS was represented by a solicitor advocate. Councillors Malcolm King and Dennis Parry and the North Wales Health Authority were represented by Junior Counsel. The Report of the Macur Review | 934.83 Notes of meetings between the Clerk to the Tribunal and the Chairman at the time of the preliminary hearings indicate his positive assessment of Leading Counsel likely to be briefed on behalf of the complainants and Voices from Care, but he was not responsible for their instruction. Other Counsel were briefed independently by the interested parties. Counsel for the Welsh Office was instructed with the approval of the AG. The Welsh Office 4.84 The Welsh Office was the commissioning department for the Tribunal, but was also subject to investigation in the public inquiry. There was an inevitable tension in the dual nature of its interest. Examples of early communications which follow demonstrate that the Welsh Office did not adequately recognise, and/or observe, appropriate boundaries as a party to the Tribunal. Equally, the response of the Chairman demonstrates he would not accord the department special status or permit its intervention. This message became clearly understood as is shown in later communications.4.85 In September 1996, Mr Lambert, then acting as Legal Adviser to the Welsh Office, wrote to the Solicitor to the Tribunal indicating that following the first preliminary hearing of the Tribunal, a number of matters were beginning to cause the Welsh Office concern. In particular, “we had always assumed that the former residents of children’s homes in North Wales who had allegations to make would, in the first instance, be witnesses of the Tribunal … There would appear to be a risk ... that the granting of legal representation to groups of such people at this stage may tend to undermine this approach. It is understood for example that … the firm of solicitors in Leicester that requested representation at the preliminary hearing, is currently advertising for clients … It seems to us that if this happens on any significant scale the existence of large numbers of former residents who would have their evidence prepared with the help of a single legal team (which might subsequently be acting for these same clients in compensation claims) could risk prejudicing the work of the Tribunal as a whole … The number of different groups, in some cases within single classes of organisation, who it would appear are likely to be granted representation will almost certainly have an impact upon the cost and duration of the Inquiry. This will certainly be the case if extensive cross examination is allowed - which in turn could lead to the Inquiry taking on an adversarial, as opposed to inquisitorial, character …” 4.86 A file note dated 27 September 1996 made by the Solicitor to the Tribunal reads, “I read over the letter to Sir Ronald and he said he was deeply offended by its contents. This grandmother can suck eggs!”4.87 A meeting which subsequently took place on a “Saturday afternoon” between Sir Ronald Waterhouse and Mr Lambert appears to have been subject to a manuscript undated report. Matters discussed included that, “Sir Ronald wishes to see all contracts relating to Tribunal matters before they are issued by the Department … Mr S [a Welsh Office official] is not to take part in any financial discussions with the Secretariat or Tribunal staff. He is a witness and must be seen to be independent … 94 | The Macur ReviewWhile it is acceptable for the Department to write and meet with the Tribunal staff and Secretariat about financial matters, it is not acceptable for representations to be made about matters which are within the sole purview of the Tribunal. Thus: no further action will be taken by the Tribunal about the letter recently sent by me about the granting of legal representation by the Tribunal to various individuals; and the letter … about the police investigators should not be sent. Their method of appointment and their code of conduct in carrying out their investigations are matters solely for the Tribunal.” 4.88 In a note to “PS/SS” dated 4 October 1996, a Welsh Office official recorded, “we spoke earlier today about the difficulties we are experiencing with the Tribunal mainly because of the recruitment practices it is adopting [with reference amongst others to police investigators] … if not stopped - the Tribunal’s approach would give rise to serious public, and possibly Parliamentary, criticism. On the other hand, we are equally aware that any attempt on our part to make the Tribunal change its ways leaves us open to the charge that we are undermining its independence and frustrating its efforts. This is a pretty uncomfortable position in which to be, and it is important that the Secretary of State is made aware of the possible implications. In an attempt to resolve matters, Mr Lambert will be having an informal word with Sir Ronald Waterhouse this afternoon.” 4.89 There is a note made on 16 October 1996, recording that “The Permanent Secretary said that it was vital that the Department’s interests should be represented as forcibly as necessary, and that … [the Tribunal Chief Administrative Officer] should insist on access to meetings between the Judge and the legal team. [A senior Welsh Office official’s] regular trips to Ewloe would help reinforce the message. The Permanent Secretary stressed the need to keep the Treasury Solicitors informed of developments, particularly in view of the likely need for assistance in reinforcing tough messages …” The note indicates that the Permanent Secretary misunderstood the nature of the Chief Administrative Officer’s secondment and the independence of the Tribunal. However, I have found nothing in the documents to suggest that any such direction was given. 4.90 On 21 November 1996, departmental correspondence notes a Welsh Office official’s difficult relationship with the Chairman in relation to costs. In December 1996, an official briefed the Secretary of State for Wales, “our relationship with the Tribunal continues to have its problems ... One thing we are doing immediately is to transfer responsibility for the administration of the Tribunal from me to Finance Group. This will mean that I personally will no longer have to wrestle with the conflict created by our dual role in relation to the Tribunal ...” 4.91 In June 1998, a Welsh Office official writing to Mr Lambert, at a time when Sir Ronald Waterhouse was known to be drafting the Tribunal Report, suggested that the “door [is] slightly open for one of us to speak to Sir Ronald about the tone and content of the report.” He was quickly informed that “Mr Lambert has advised that we should not try to give the Tribunal a steer.” The Report of the Macur Review | 954.92 In March 1999, a submission to the Secretary of State for Wales from the Child and Family Division identified insignificant “factual errors” in the draft of the first 27 chapters of the Tribunal Report. It states, “We have a dilemma. On the one hand we do not believe we should check the report for accuracy ... it is not our report. We would put ourselves at grave risk of accusations that we had influenced the report should it become known that we were checking it in any way. On the other hand the errors might discredit the report.”4.93 The response of the Secretary of State for Wales is noted in manuscript. It directs that the Clerk to the Tribunal should be told, but “it should be recorded in a note that makes it explicit that the WO [Welsh Office] is providing information and is not seeking to influence the Tribunal’s views.” I confirm there is nothing that I have seen in any document that could be interpreted as an attempt to influence the findings or views of the Tribunal. Legal Adviser to the Welsh Office 4.94 Mr Lambert was Legal Adviser to the Welsh Office. Prior to the appointment of Mr McHenry and Miss Walkingshaw, he effectively acted as the Chairman’s Solicitor and Clerk. He was not previously known to the Chairman. 4.95 In a letter dated 28 November 1996, Mr Lambert wrote to the Treasury Solicitor explaining the “involvement which I have had with ... Sir Ronald Waterhouse from the Tribunal’s inception ... arose because for 2 ½ months from the time that the Tribunal was established ... there were no Tribunal staff. It was therefore necessary for me to liaise on a very regular basis with the Chairman to explain the activities I was undertaking at the Department’s request, to begin to set up the Tribunal machinery. The result was a very efficient channel of communication between myself and the Judge ... Liaison with the Judge has continued to this day because he has requested that he is kept abreast of all matters relating to the Department’s control over the costs and other financial matters … A list of the particular matters [largely of administrative concerns] is attached ... In a perfect world I am sure that these are matters which would be dealt with by the Tribunal Secretariat and its Solicitors ... however … The magnitude of the work in which they are involved means that there are significant administrative areas which have to continue to be the direct responsibility of the Welsh Office ... I do expect that, by the time the Tribunal begins its sittings ... the involvement of the Department … will have been considerably reduced and that, therefore, it will no longer be necessary for there to be this continued liaison between myself and the Chairman. However, until this occurs, it is evident that he very much appreciates this link.”4.96 During this time, Mr Lambert continued to advise the Welsh Office in relation to Tribunal matters.96 | The Macur Review4.97 Correspondence passing between Mr Lambert and a senior Welsh Office official in December 1996 and January 1997 recognises the perception of the conflict of interest in his dual roles. Mr Lambert wrote in favour of his continuing the “line of contact, provided that there are no discussions which could in any way compromise the Department’s case. While ... for important matters, Mr McHenry should be persuaded to put his statements in writing... there are other matters which both he and I have found to be very helpful to discuss. I would like your agreement for such conversations to continue at my discretion.” A senior official agreed that he should have discretion to speak to the Solicitor to the Tribunal, but “the underlying principle to be observed here is ... that now that the Tribunal hearings are about to start, your main commitment will have to be to the preparation of the Department’s evidence and the defence of its position; so that any contacts with Mr McHenry must not compromise this or be incompatible with it.”4.98 I am satisfied that Mr Lambert had given appropriate advice to Welsh Office senior officials prior to the announcement of the Tribunal regarding the necessity of maintaining ‘Chinese Walls’ and the consequent cost and disruption to the department. However, the senior officials did not appear to recognise that his own reports back to the Welsh Office at this time did not entirely sit within the concept of the professional distance he had advocated, nor the direction they had given as indicated above. That said, I note from the records that he was punctilious in fully recording all his meetings with the Chairman. They can be described as largely attempting to placate the difficult relationship between commissioning department and independent Tribunal. His advice to the department during this time was largely anodyne. Counsel for the Welsh Office4.99 Miss Patricia Scotland QC (now Baroness Scotland of Asthal QC) was Leading Counsel for the Welsh Office. Her junior, Mr Dermot Main Thompson had been briefed independently of her. It is clear from other documents that Miss Patricia Scotland QC had previously advised the Jillings Panel, and was stated by a local councillor when writing to the Secretary of State for Wales to be advising the Jillings Panel on the need to add to the contents of their report. This previous instruction was known to the Welsh Office. In the main, it appears any initial antipathy to her appointment by Welsh Office officials was overcome after their initial Consultation with her. 4.100 I do not perceive that Miss Patricia Scotland QC’s advice to the Jillings Panel created a conflict of interest in her appearing on behalf of the Welsh Office before the Tribunal. The unredacted Jillings Report and associated materials were available to the Tribunal. Any advice she tendered to the Jillings Panel would be subject to legal professional privilege, but would be irrelevant to the Tribunal’s investigation.4.101 The process of representing the Welsh Office was obviously not straightforward. Instructions to Counsel were unequivocal on the face of them, “The Welsh Office will seek at all times to assist the Tribunal in the carrying out of its objectives as set out in the Terms of Reference …” However, I do note the comments in a number of documents which appear to contradict that assertion, as I indicate below. The Report of the Macur Review | 974.102 In a Consultation with Leading Counsel on 11 October 1996, a senior Welsh Office official was recorded to have said “that he would not wish the Welsh Office to accept the blame for anything it did not have to accept because of the concern about compensation claims.” The report of a meeting, which had taken place on 17 December 1996 involving the Permanent Secretary and the Chief Inspector of SSIW, revealed that “[the Chief Inspector of SSIW] was highly critical of the legal team who were working with him in the preparation of his evidence, accusing them of imposing impossible deadlines and promising the Inquiry material which, in his view, should not be produced. As a result of this, [the Permanent Secretary] wants to know why we are providing so much material to the Inquiry ... I [Instructing Solicitor to Counsel for the Welsh Office] heard this morning that, during a meeting with David Lambert, [the Permanent Secretary] enquired whether I was working for the Inquiry or for the Welsh Office, the implication being that I was co-operating to too great an extent with the Inquiry in agreeing to provide evidence.” 4.103 Leading Counsel for the Welsh Office advised Welsh Office officials, in Consultation on 17 December 1996, that “one of the Jillings criticisms was non co-operation by WO [Welsh Office] ... In practice Inquiries depend upon all parties co-operating with the spirit behind the setting up of such an Inquiry, i.e. to ascertain what happened, why [and] what went wrong. [Therefore the] usual adversarial approach becomes more muted and has to be more subservient to main purpose of Inquiry. To do otherwise would defeat aim of Inquiry ... [Counsel] would be very unhappy if at this stage proposing to disclose information [which was] (a) highly sensitive and speculative; (b) ... not in public domain; (c) … confidential ... Although we shouldn’t be giving confidential information, we need to be addressing with vigour areas of potential concern so that when and if we are questioned we have a cogent and well researched response ready ... [therefore] we have to deal with current situation as delicately as we can giving the I.T. [Tribunal] all the information we have in that it is a consolidation of what is or should be in the public domain ... If we prepare our material we have the advantage of ‘packaging’ it but we must do it in the most full and frank [way] ... Don’t want to say anything which is a hostage to fortune but don’t want to refuse to give material we shall be obliged to give in due course.”4.104 In minutes of a meeting held on 21 July 1997, it is indicated that the Permanent Secretary was “worried about compensation claims to date and that is why she has been very cautious about disclosing any department information; the Welsh Office nevertheless has a duty to furnish the Tribunal with all the evidence it requires to fulfil its function.” 4.105 In a ‘Note from Leading Counsel regarding the Tribunal request for further evidence and recommendations’ dated 22 January 1998, she records, “the WO [Welsh Office] are placed in the difficult position of being a party to and the commissioner of the Inquiry. As such there is an inherent conflict of interest. It is in the WO’s interest, as a party, for as little criticism as possible to attach to the manner in which the duties and powers invested in the Secretary of State were exercised in the past. 98 | The Macur ReviewHowever, as the commissioner of the report, it is of the utmost importance that the structure currently in place be rigorously reviewed so as to ensure that the mistakes of the past, if any, are not repeated ... Having invested millions of pounds in this exercise it would be a tragedy if the recommendations arising from this Inquiry were based on perceptions which were insufficiently well informed to make all or any of them amenable to implementation. The fact that the Inquiry may, if only in part, be pilloried for any such failing would be of little comfort as the judgment of the WO who were responsible for commissioning, instructing and assisting the Tribunal to undertake this task might likewise be questioned.” 4.106 Some of Leading Counsel’s notes to her solicitor and recorded oral advice to Welsh Office officials demonstrate the fine line between correcting what are perceived to be the misconceptions of Counsel to the Tribunal whilst defending the position of the Welsh Office. However, the advice tendered and apparently followed indicates that the Welsh Office was well aware, not only of its duties and responsibilities to the Tribunal, but recognised that any subsequent perceived deficiencies, which were in its power to correct, would discredit the Tribunal process and subsequent Tribunal Report, and thereby defeat the object of the exercise.4.107 I report these exchanges for obvious reasons of transparency. I confirm that, alerted to the possibility by the matters raised in paragraph 4.102 above, I have scrutinised the papers to see if the Welsh Office deliberately concealed evidence from, or misled, the Tribunal. I have found nothing to indicate this was the case, however, I do indicate in paragraphs 8.39 and 8.41 that I did not discover any documents in the Tribunal materials which related to a matter of potential relevance to the Tribunal and had been produced by the Welsh Office. Derek Brushett4.108 Derek Brushett was a senior inspector in the SSIW, part of the Welsh Office. He had taken part in meetings in which advice to ministers had been formulated prior to the establishment of the Tribunal and in others afterwards in which the evidence of the Welsh Office had been discussed.4.109 His actions in relation to an allegation of abuse had previously received adverse attention. On 22 February 1993, Mr David Owen, Chief Constable of the NWP, wrote to the Permanent Secretary at the Welsh Office headed ‘PERSONAL AND CONFIDENTIAL - Gwynedd/Clwyd Child Abuse Inquiry’, “I called for a public enquiry into the above some several weeks ago and this call was prompted by clear evidence of the concealment of complaints and a complete absence of observance of rules and supervision … My particular concern regarding the Welsh Office stems from the contact that Derek Anthony Brushett, a Social Services Inspector employed in the Welsh Office, has had with a during the course of his professional career. I understand that in fact Brushett is godfather to one of children. During September 1992, the ‘Wales This Week’ programme … levied allegations against … contacted Brushett and told him that he had been indecently assaulted by and also by another man named The Report of the Macur Review | 99 Howarth. The timing of this allegation could well prove to be important in the future. The matter was not reported to the police, though I understand that Brushett did inform his seniors in the Welsh Office. Following enquiries, was interviewed and indicated the report that he had made to Brushett. We were eventually provided with a note of the matters that Brushett had reported to his seniors. The question obviously arises as to why no action was taken by Brushett or the senior personnel in the Welsh Office? I am sure you will be aware of the background allegations that range from masonic involvement to downright neglect … it appears the substance of the reason as to why the matters were not reported to the police was that Brushett had been told in his capacity as a private citizen … suffice it to say the reaction at these headquarters is one of total and absolute incredulity.”4.110 I can find no record that this letter was disclosed to the Secretary of State for Wales. The response from the Permanent Secretary dated 6 March 1993 contained a fulsome apology, but no indication that ministers had been informed of the details of the incident. There is a note of a meeting between Detective Superintendent (DSU) Peter Ackerley and a senior inspector of SSIW dated 20 February 1993, prepared by DSU Ackerley, at which this issue was discussed and in which he indicates that he was assured that ministers had been “briefed” and legal advice may have been taken. This note of the meeting is incongruent with the file note prepared by the Acting Chief Inspector on 22 February 1993, which suggests that it was not thought necessary to inform the police of what Derek Brushett had told his manager since the police had already interviewed the complainant involved. In those circumstances, I am uncertain as to what issue ministers had been “briefed” upon in relation to Derek Brushett’s failure to inform the police of the allegation. I have found no indication that SSIW independently brought this issue to the attention of senior officials in the Welsh Office prior to the visit of DSU Ackerley, or any documents briefing ministers on this point.4.111 In a ‘note to file’ dated February 1995, a Welsh Office official records, “it is unfortunate to have learnt in the context of this PQ [Parliamentary Question] that information has been withheld from this Branch by SSIW. In particular, we have not been shown a copy of the Cartrefle overview report by the independent panel, or the individual agency reports, nor have we seen before now the letter ... dated 24 October 1991 ... [which] points, for the first time to my understanding, to allegations of widespread abuse in children’s homes in North Wales.” On the face of it, this note implicates the SSIW (of which Derek Brushett was a senior inspector) of concealment of significant information concerning the situation in the former county council areas of Clwyd and Gwynedd. However, I have found another ‘note for file’ copied to officials by SSIW dated 3 December 1991 referring to allegations of child abuse in North Wales, and note that a background note was submitted to the Parliamentary Under-Secretary of State for Wales on 2 December 1991 referring to the recommendations of an independent review of the Cartrefle children’s home. The combination of the two notes quite clearly points to lack of communication, rather than concealment, as was apparent in the situation leading up to the establishment of the Tribunal.100 | The Macur Review4.112 A file note dated 24 April 1996 reveals that Derek Brushett informed the Chief Inspector of SSIW that he had “become aware, through media coverage, that a Mr Peter Harley has been convicted of sexual abuse of children, at a home ... Mr Harley was employed ... at Bryn-y-Don [a former approved school], where I was head, for a period from about 1975 onwards.”4.113 In a ‘solicitors’ advice dated 29 April 1997, Mr Lambert’s trainee solicitor recorded that on 17 May 1997 it had come to “our attention … that the evidence of a witness, to be heard that day by the [Tribunal] referred to an incident at Bryn-y-Don school ... involving a current Welsh Office Social Services Inspector … Mr Derek Brushett ... It transpired that the incident … was not referred to in the actual oral evidence ... On the morning of the 17 May, Mr Lambert, [the trainee solicitor], Mr Mooney (Deputy Chief Inspector of SSIW) and Mr Brushett met to discuss the issue ... Mr Brushett categorically denied the incident and further stated that he had not heard the allegation prior to this day ... Mr Brushett had received no Salmon letter from the Tribunal - this coupled with the fact that the allegation was not raised in the examination of the witness confirmed our view that the allegation was outside the terms of reference of the said Tribunal.” 4.114 In May 1997 the Welsh Office was informed that police investigations were being conducted into further allegations of child sexual abuse and other offences against Derek Brushett, subject to a strict prohibition against alerting him to the same. In October 1997 a senior investigating officer reported that Derek Brushett was unlikely to be seen by police until January. He was arrested in August 1998. He was convicted in November 1999.4.115 For completeness, I record that in a letter dated 30 June 1997 to the Solicitor to the Tribunal, SSIW conceded that it had misplaced an inspection report in relation to Bryn Alyn, “Mr Brushett has also been unable to find the report in his personal records.” Also, I have seen correspondence between Derek Brushett and a manager of the Bryn Alyn Community following their attendance at a conference together and referring to a forthcoming prospective visit to the Community. The letters are genial in tone, but not professionally inappropriate. I do not suggest improper interest by Derek Brushett in the Bryn Alyn Community or that the missing inspection report was likely to have contained incriminating detail, but nevertheless consider that this missing report should be reported as a matter of transparency.4.116 A note dated 3 March 1998 was prepared for the Tribunal concerning Derek Brushett’s employment history and current status. He had joined SSIW in 1988, “Allegations against Mr Brushett, whilst at Bryn-y-Don came to light during the course of the ongoing South Wales Police investigation into abuse of children in south Wales. The Welsh Office was advised in 1997... of the fact that allegations had been made against this member of staff. The police investigation has been extended and has … many months to run. Mr Brushett has not been arrested, but in view of the fact that he is under investigation … he has been redeployed to special duties within the inspectorate which involve no contact outside the Department … You will appreciate that since there is an ongoing police investigation, the information contained in this letter is provided in strict confidence and is only to be shared with the Tribunal members.”The Report of the Macur Review | 1014.117 Councillor King wrote to the Secretary of State for Wales on 27 November 1998 suggesting that, in light of the many allegations, “his [Derek Brushett’s] previous involvement in inspecting Children’s Services in North Wales… needs to be very carefully investigated and reviewed ... I have no idea what influence he may have had over the way the Welsh Office approached the Waterhouse Inquiry or how it gathered and gave its evidence, but as Derek Brushett was one of probably only two people with very substantial experience of direct work with children, it seems inconceivable that he did not play a major role in these processes ... [there was] very considerable and long running resistance ... shown by the Welsh Office to having a Judicial Inquiry. How much of this was actually instigated by Welsh Office Ministers at the time and how much were they advised by their expert officials?” Mr Martyn Jones MP (see paragraph 2.13) asked similar questions in Parliament (Hansard: 17 March 2000, Column 660). 4.118 Briefing the Secretary of State for Wales in response to the letter, on 23 December 1998 an official advised that once the department became aware that there was an allegation of physical abuse against Derek Brushett, his work was immediately constrained; he had no access or involvement to work with children or “a direct involvement with the development of evidence then being prepared for the Tribunal. In September 1997 [he] was further constrained to a narrow range of duties ... with limited access to colleagues.” 4.119 An independent audit of Derek Brushett’s work was commissioned and undertaken by Dr Kevin McCoythe, Chief Inspector of Social Services in Northern Ireland, and Professor Roger Clough of Lancaster University. Copies of the report were placed in the library of the House of Commons and can be accessed via the Welsh Assembly website. The Audit Team concluded that Derek Brushett “played virtually no part in handling concerns about Bryn Alyn Schools nor was he other than a peripheral figure in considerations of the nature of an inquiry concerning abuse in North Wales. This was handled at a high level in the Welsh Office.”Conclusions4.120 In my view, the selection of a recently retired High Court judge indicates the importance attached to the Tribunal of Inquiry and the intention that there should be an expert and discerning appraisal of the ‘child care’ situation appertaining in North Wales in the relevant period, in contradistinction to other inquiries conducted and panels convened in the preceding years by the local authorities. It was eminently appropriate to make such an appointment bearing in mind the skills, expertise and experience required to manage the scale of the task apparent from the outset. I do not consider that Sir Ronald Waterhouse’s connection with Wales disqualified him as Chairman of the Tribunal, particularly so in light of his specific request that his fellow members be appointed from outside Wales.102 | The Macur Review4.121 There is no note of the fact of a telephone conversation between the Right Honourable Mr Hague MP, Secretary of State for Wales and Sir Ronald Waterhouse in the material made available to the Review. Whilst this Review could not have been contemplated at the time, the surrounding events which led to the establishment of the Tribunal already indicated the sensitivity which would surround the appointment of the Chairman of the Tribunal. I consider the conversation should have been logged. If it was, it is regrettable that the record has been misplaced.4.122 The note of the conversation between Sir Ronald Waterhouse and the Right Honourable Mr Hague at dinner should be rightly subject to scrutiny. As a stand alone document, it lacks the context now provided by Mr Hague. In any event, the terminology attributed to Sir Ronald Waterhouse, as indicated in paragraph 4.8, is unfortunate and open to adverse interpretation by those suspicious of the Tribunal process. Following my review of the vast number of documents which base my conclusions in relation to the Tribunal process as a whole, as reported in Chapter 6, I do not consider that such an unfavourable interpretation is warranted. Objectively, I consider the reference to ‘general attacks on character’ linked to a celebrity libel trial to be incongruous to the issue of attacks upon a complainant’s character within Tribunal proceedings. On the basis of the document seen alone, it appears more likely to refer to attacks on the characters of establishment figures rumoured to be involved with the scandal. Mr Hague’s explanation provides the background and suggests a more detailed conversation than annotated. Therefore, whilst I regard the comparison he used to be inappropriate, I do not conclude that he was seeking to influence Sir Ronald Waterhouse in the investigation of establishment figures.4.123 The note could not possibly be a verbatim record of the conversation. I question why it was not submitted to Sir Ronald Waterhouse for his approval, if not merely as a matter of courtesy. However, it would be concerning if the Secretary of State for Wales and the Chairman elect had dined together without a note being taken of their conversation. It was obviously intended to be ‘witnessed’ by officials. Mr Lambert expresses surprise that he was invited to attend the dinner at all.4.124 I consider it unlikely that any official or member of Government would consider Sir Ronald Waterhouse amenable to outside influence or persuasion to ‘protect the establishment’. If there had been any thought of this at the outset, it was quickly dispelled.4.125 Equally, despite the comments I report in paragraph 4.16 which may suggest otherwise, I am satisfied that the other two members of the Tribunal were not excluded from discussions, demonstrated their independence and were not inhibited in their participation in the Tribunal nor intimidated by the status of its Chairman. The calibre, experience and expertise of the Tribunal panel is self evident. In volunteering the information about I consider Miss Clough to have demonstrated conscientiousness and integrity. The Report of the Macur Review | 1034.126 Assuming any individual or organisation to be intent on manipulating outcome, it would be far easier to be assured of being able to influence one individual, failing that a group with a common characteristic. The fact that a panel of three individuals was appointed, all established experts in their own fields and previously unknown to each other, runs counter to any belief that the Tribunal was selected on the basis that it would be susceptible to any influence or pressure to protect ‘the establishment’. 4.127 I find there is nothing in the documents to suggest that Sir Ronald Hadfield was compromised in his role. Any bias that he may have been perceived to hold was capable of exploration in cross examination.4.128 I consider that Counsel to the Tribunal did have a professional duty to disclose any actual or perceived conflict of interest and the Tribunal was responsible for dealing with any application made in that regard. Quite apart from their responses to me, the documents to which I refer in paragraphs 4.36 and 4.37 suggest that Counsel did so. I do not consider that these individual duties and responsibilities abrogated the responsibility of those involved in the instruction of Counsel from making relevant inquiries in the light of the “long standing” issues concerning freemasonry that would necessarily have to be investigated by the Tribunal. A failure to record discussions concerning two of the Counsel to the Tribunal’s association with freemasonry, or to lodge securely the written declaration of interest which Lord Justice Ryder recalls he made, is poor practice and indicative of a disregard, or misunderstanding, of the importance of the process being recorded. There is no document in the papers delivered to me, and none can be located, which resembles either a note of discussions or declarations of interest. (I have previously made criticism of the archiving and safekeeping of Tribunal documents). 4.129 The Welsh Office, as commissioning department, had an interest in ensuring the Tribunal process was seen as above reproach. I note that a different approach appears to have applied in the proposed defence of the instruction of Counsel to the Tribunal in the event of media approach and the concerns voiced about the appointment of a Freemason as the head of the WIT. I note that the Welsh Office did not join in the application made for a register of interests or make any representations on this issue via Mr Lambert to the Chairman. 4.130 It is difficult to reconcile the difference in the Chairman’s approach, reported to me by Mr Gerard Elias QC and Lord Justice Ryder, as regards their respective involvement in matters to do with freemasonry. I am unsure whether this reflects a lack of clear recollection of Mr Gerard Elias QC and/or Lord Justice Ryder, or the Chairman’s acknowledgment of the personal sensitivities of each Counsel at the time. Whatever the reason, I am satisfied that there would have been, and will remain, a perception of a conflict of interest in the Tribunal investigation into the influence of freemasonry in matters relating to child sexual abuse in North Wales, regardless that the Tribunal ultimately concluded that there was none. The answer will beg the question of whether this conclusion was reached because Freemasons, present or former, had been involved in the investigation. Suspicions of a ‘cover up’ of the role played by freemasonry in the concealment of child abuse will be little helped by the inherent distrust created by a secretive organisation. 104 | The Macur Review4.131 Members of the judiciary are required to indicate a personal interest in the subject matter of litigation they are called upon to try. It has been suggested that Mr Justice Drake, the High Court Judge who had presided over Gordon Anglesea’s libel trial, had done so at the start of the trial in terms which suggested that he was, or had been, a Freemason and invited the parties to make any submissions they thought appropriate. None did. I perceive that Sir Ronald Waterhouse was convinced in his positive view of the character and integrity, standing and proficiency of his nominated choice of Leading Counsel in particular. He had prior experience of his work and would have clear knowledge of his reputation and standing in the field. He appears to have overlooked the fact that this would not have been common knowledge in the wider public domain. Objectively, his stance on the issue of the proposed register of interests reflects the Chairman and the Tribunal’s strength of character, independence and resistance to outside opinion, but in my view, it was an over protective and probably unnecessary stand. This stance will likely fuel a continued distrust in the process. Whilst it would not necessarily alter public perception of there being a conflict of interest, I conclude that a register of interests, or declaration of interest by those concerned, may have reduced public disquiet on this point. 4.132 Nevertheless, following my examination of the documents, I consider that Counsel to the Tribunal executed their instructions conscientiously in all aspects of investigation into this, and other, topics. Further reference is made to the Tribunal’s examination of the links of freemasonry to child abuse and the protection of those alleged to have been involved in Chapter 7. All Counsel to the Tribunal undoubtedly had the appropriate specialist knowledge, advocacy skills and standing to justify their appointment.4.133 Documents clearly record the Chairman’s high regard for Mr Gerard Elias QC. I do not consider their previous professional association to contra indicate the appointment of Mr Gerard Elias QC as Leading Counsel to the Tribunal.4.134 I am satisfied that records demonstrate Mr McHenry’s frequent attendance and participation in meetings held by the Tribunal members and Counsel. The topics discussed when he is noted to be absent do not support any suggestion that he was deliberately excluded from meetings. I detect that Leading Counsel, Mr Gerard Elias QC, in particular, may have found the working style of Mr McHenry to be less attuned to his own than that of the second Solicitor to the Tribunal.4.135 In the absence of any documentation or transcript of evidence containing any allegation concerning Sir Peter Morrison before the Tribunal, I conclude that the telephone call to Mr David Jones was a hoax call. There is no other reason to question the Tribunal staff’s loyalty to the Tribunal.4.136 I do not consider that Mr Briggs’ association with freemasonry affected his performance in the role of head of the WIT. However, his interest would have been publicly registered if a register of interests had existed and may have reduced any public disquiet. There was a delicate balance to be drawn in using former police officers to conduct witness interviews. On the one hand, the necessity to ensure the The Report of the Macur Review | 105efficiency and viability of the Tribunal process in a short time scale. On the other, the sensitivity of complainants who believed they had not received an adequate police response to their complaints. Nevertheless, overwhelmingly, I consider the rationale for employing retired police officers in the tracing and interviewing of witnesses was right.4.137 Objectively viewed, it was wrong to permit Mr Briggs any influence in the appointment of the first members of the WIT, all from South Wales. By doing so, he effectively decided the character of the team, the members of which may reasonably be suspected by disgruntled participants to have especial loyalty to him, if not to police officers subject to investigation. I regard this aspect to have been addressed, at least in part, by the recruitment of retired officers from outside forces and the direction of Counsel to the Tribunal. Any possible adverse influence brought to bear upon witnesses transported to the Tribunal by former members of the WIT was capable of detection in the light of the adversarial nature of the Tribunal proceedings.4.138 Nevertheless, and taking all matters into account and overall, I find there is nothing in the documents that could legitimately undermine the credibility of the Tribunal panel or personnel.4.139 Counsel and legal representatives representing individuals, groups and organisations before the Tribunal were independent of the Tribunal and engaged in an adversarial process. The number and the nature of the respective interests represented before the Tribunal renders any possible external undue influence ineffectual.4.140 I have found no detail in the Welsh Office documents which suggest that it withheld evidence or information concerning allegations of abuse, save as referred to in paragraphs 8.39 to 8.41. The conduct of the Welsh Office in exposing the deficiencies of disclosure of the Clwydian Community Care NHS Trust (see paragraph 5.92) supports their integrity in the Tribunal process, despite other initial responses referred herein which could suggest otherwise by reason of their fear of exposure to compensation claims. 4.141 Mr Lambert’s position as de facto solicitor/secretary to the prospective Tribunal was necessary in the circumstances, but I do consider that he should not have continued with his role of Legal Adviser to the Welsh Office at the same time. However, I have not found any indication in the documents that the early decisions of the practical arrangements for the Tribunal were compromised or adversely influenced by his involvement. 4.142 In my independent research of the documents, I have found no indication that Derek Brushett had any influence in the Welsh Office decisions relating to the establishment of the Tribunal or the evidence that was to be led on its behalf. He was not sufficiently senior to do so. However, it should have been recognised that his position was potentially compromised by the events described in the letter referred to in paragraph 4.109 above. His self report of the incident to his manager should have been notified immediately to Welsh Office officials. The police 106 | The Macur Reviewcomplaint should have been notified to ministers. His future participation in meetings concerning the Tribunal should have been fully discussed against the background of the complaint made in 1993. Failure to make such a report or hold such a discussion, or to make a note of the same, indicates a failure to have regard to likely public perception if the circumstances of the police complaint became known.4.143 The substance of the notes that I refer to in paragraphs 4.85 to 4.93 corroborates the independence of the Tribunal. The Chairman obviously repelled any incursion into the Tribunal’s domain. The Welsh Office was left in no doubt as to this, much to their apparent initial chagrin, and it was obviously a sufficient rebuff to endure throughout the life of the Tribunal. My analysis of the documentation, as indicated above and elsewhere in this report, reveals the Chairman’s fierce protection of the independence of the Tribunal from the Welsh Office and other parties. The Report of the Macur Review | 107Chapter 5: The Scope of the Tribunal Introduction5.1 The framing of the terms of reference is crucial to the extent and nature of any Tribunal’s investigations. This chapter examines the terms of reference set to the Tribunal, the basis of their formulation and whether the effect was to impede the Tribunal from investigating any matters which could have led to the exposure of establishment figures or public bodies or wider paedophile activity.The Tribunal’s terms of reference 5.2 On 17 June 1996, the Secretary of State for Wales announced the terms of reference of the Tribunal of Inquiry to be:a) To inquire into the abuse of children in care in the former county council areas of Gwynedd and Clwyd since 1974;b) To examine whether the agencies and authorities responsible for such care, through the placement of the children or through the regulation or management of the facilities, could have prevented the abuse or detected its occurrence at an earlier stage;c) To examine the response of the relevant authorities and agencies to allegations and complaints of abuse made either by children in care, children formerly in care or any other persons, excluding scrutiny of decisions whether to prosecute named individuals; d) In the light of this examination, to consider whether the relevant caring and investigative agencies discharged their functions appropriately and, in the case of the caring agencies, whether they are doing so now; and to report its findings and make recommendations to him [the Secretary of State for Wales].Construction of the Tribunal’s terms of reference 5.3 The terms of reference at (a) impose a time span and geographical limit upon the Tribunal; at (b) direct an examination of the actions of ‘care agencies’; at (c) direct a wider examination of the response of ‘relevant authorities and agencies’ to allegations and complaints of abuse ‘excluding scrutiny of decisions to prosecute named individuals’; and, at (d) require the Tribunal to assess past conduct of the relevant caring and investigative agencies, and the present discharge of duties by the caring agencies. 5.4 I have not uncovered and would not expect to detect any controversy attaching to terms of reference (b) and (d), save as indicated in paragraph 5.101 below.108 | The Macur ReviewTime span5.5 The start date of 1974 provided by the terms of reference was apparently aligned to the creation of the new Clwyd county council and Gwynedd county council, which replaced five former county areas on 1 April 1974 under the provisions of the Local Government Act 1972. 5.6 In briefing the Secretary of State for Wales on the terms of reference in preparation for his dinner with Sir Ronald Waterhouse (see paragraph 4.6), an official advised that “we would have liked to have selected a later date than 1974 as the starting point of the Inquiry - especially given concerns about the reliability of evidence relating to events of over 20 years ago. But the establishment of the Clwyd and Gwynedd County Councils provides a natural starting point. [We are] aware that some would like the Inquiry to go back even further. But would hope that it would only consider pre-1974 evidence where it is directly relevant to the post-1974 period.” 5.7 A letter dated 8 July 1996 to the Secretary of State for Wales, written on behalf of the successor authorities, supported the selection of an earlier starting date on the basis that a number of individuals had been convicted of offences involving activities in children’s homes in the very early 1970s and there should be no cover up. Tribunal approach5.8 A note dated 10 July 1996 of a meeting between Mr David Lambert and Sir Ronald Waterhouse reports that “the Judge has informally indicated … The commencement date of 1974 is not absolute. The Judge is prepared to consider matters which started before this date and which continued afterwards ... particularly the case with Bryn Estyn [one of the residential children’s home investigated by the Tribunal] when it was an approved school.” Subsequently, in his opening statement on 10 September 1996, the Chairman made clear that “evidence relating to alleged abuse outside that period [1974 - to date] will not necessarily be excluded but its admissibility will be assessed by the normal criterion of relevance.” 5.9 Allegations of older abuse did emerge at the Tribunal. In accordance with the Chairman’s prior indications, evidence was heard where it appeared relevant to a pattern of offending on the part of a particular abuser, or might have demonstrated a particular ethos in a residential care establishment, or provided an illustration of the response to a complaint which was not otherwise available. Accordingly, although the Tribunal declined to make findings on the particular allegations falling “outside the period of our review”, it did consider the complaints made before the time span imposed and took them into account in the overall picture. For the avoidance of doubt, I make clear that none of these allegations earlier in time concerned establishment figures, or suggested their involvement in or protection of any paedophile ring, or were indicative of a wider paedophile ring than that found by the Tribunal to be in existence. The Report of the Macur Review | 109Geographical limits Government views5.10 The geographical area prescribed by the Tribunal’s terms of reference was limited to the former county council areas of Gwynedd and Clwyd. It is clear from ministerial documentation that this geographical limit was the source of some disagreement between government departments. There was a debate as to whether the Tribunal’s inquiries should be restricted to North Wales, the whole of Wales or should include neighbouring counties of England and beyond, as indicated in paragraph 3.102 and below.5.11 An official, briefing the Secretary of State for Health, wrote, “The Welsh Office preference has so far been to avoid further inquiry into the local Welsh issues; and to try and widen matters into a debate or inquiry into national issues about the adequacy of safeguards around children’s residential homes, foster care and other placements away from home. We are resisting this ... The dissatisfaction in Wales originated in allegations that the Clwyd abuse was not, or not at first, properly investigated because some members of the local police were implicated in it.”5.12 A subsequent note from the Secretary of State for Health dated 6 June 1996 acknowledged that, “no part of the UK has been without cases of this kind ...” However, he considered that “there has already been a substantial Government response” and safeguards introduced, referring to the Children Act 1989 and associated regulation, and concluded that, “if, in the Welsh Secretary’s view, a 1921 Act inquiry is inescapable its terms of reference should be as narrowly tied to local issues as possible.” That is, his view was that it should not extend beyond North Wales. 5.13 Inter departmental communications reveal further reasons were advanced in support of restricting the geographical limits. These included: i) minimising “the potential for overlap” with the Review of Safeguards against the abuse of children living away from home in England and Wales, also announced on 17 June 1996, to be conducted by Sir William Utting and commissioned by the Secretary of State for Health; and ii) the fact that a substantial number of criminal investigations surrounding children’s homes in Cheshire were still pending. Other views expressed5.14 I am aware that two contributors to this Review regarded the prescribed geographical limits to exclude consideration of the full range and scale of abuse committed by John Allen, a convicted abuser named in the Tribunal Report, particularly in relation to Cotsbrook Hall in Shropshire. Another contributor has suggested that John Allen holds the key to a wider network of paedophiles and an inability to investigate his geographically diverse activities precluded a proper appreciation of the number and social standing of its participants. 110 | The Macur Review5.15 Another contributor to my Review noted that the boundaries between North Wales and neighbouring counties in England were ‘fluid’ and it was artificial to restrict consideration to the two county councils in North Wales. In this respect, it is right to note that Sir Peter Morrison was MP for Chester from 1974 to 1992 and was a prominent public figure alleged in the press to have been implicated in abuse of children in care in North Wales (as indicated in paragraph 1.4). In addition, it is apparent that convicted abusers and others investigated by the Tribunal had worked in residential homes in counties outside Wales. Tribunal approach5.16 Analysis of the materials indicates that several inquiries were made beyond the geographical boundaries of Clwyd and Gwynedd county councils as indicated below.5.17 A letter dated 18 April 1997 from the Solicitor to the Tribunal to the Chief Constable of Cheshire explained the reason for a request made for an informal meeting with the Deputy Chief Constable to be “to permit the Cheshire Police to provide information and assistance to the Tribunal in an informal setting ... to discuss (1) common links between child abuse in Cheshire and the former counties of Clwyd and Gwynedd ... among the important issues which the Tribunal has to consider in seeking to determine the nature and extent of the abuse of children in care by those in positions of responsibility, is whether there was any form of paedophile ring, or infiltration by paedophiles into the residential care system ... you will doubtless be aware that ... other abusers, employed in the former counties of Clwyd and Gwynedd, were also employed in Cheshire during the period covered by the Tribunal’s terms of reference.” The Cheshire Police Authority assured full co-operation with the Tribunal, but stated, “there is a very limited amount of factual information concerning common links between child abuse in Cheshire and in the former counties of Clwyd and Gwynedd, all of which has previously been disclosed to the North Wales Police.” On 15 October 1997, Mr Treverton-Jones, Counsel to the Tribunal, met with the Solicitor to the Cheshire Police Authority to discuss the availability of any evidence which may relate to a paedophile ring extending into Cheshire. 5.18 Inquiries were also made on behalf of the Tribunal into the progress of other current ongoing police investigations into large scale child abuse in other parts of the United Kingdom at least in part, it appears, in relation to establishing possible links with alleged abusers in North Wales. On 2 May 1997, the Chief Constable of Gloucester wrote to Sir Ronald Hadfield, “I have now established that there are 12 investigations being undertaken in England, Wales & Scotland where allegations relating to child abuse which may have taken place in institutional settings … I have agreed that I will forward to you a summary of each individual investigation in a anonymised format, that is, without direct identification of the police force concerned.” On 15 August 1997, an Assistant Solicitor to the Tribunal wrote to a senior North Wales police officer confirming a list of alleged abusers to provide the basis of research with other forces. The Report of the Macur Review | 1115.19 It is perfectly clear from the daily transcripts and discussion in the Tribunal Report1 that the terms of reference did not inhibit the Tribunal from investigating the complaints of paedophile ring activity in Cheshire in so far as it concerned children in care in North Wales. In paragraphs 9.8 and 9.10 of this Report, I refer to material which concerns abuse alleged or suspected to have been committed in other geographical areas, but with connections to North Wales. Specifically, enquiries were made on behalf of the Tribunal in relation to residential institutions in County Durham and Cheshire. I have found no indication that the Tribunal did, or would have, declined to investigate explicit allegations made by children in care in North Wales concerning abuse committed against them when in care, even if outside the geographical boundaries prescribed by the terms of reference. 5.20 Documents reveal that the Tribunal was aware of John Allen’s wider connections, including with residential schools in Shropshire and Cheshire, as is clear from the Tribunal Report,2 but did not investigate allegations arising from them. The Tribunal was notified of police inquiries into some of these allegations by a letter dated 31 January 1997, which indicated that enquiries were being conducted into alleged sexual abuse that had occurred at Cotsbrook Hall in Shropshire. 5.21 The Tribunal did hear evidence, including in closed session (see paragraphs 6.222 and 9.16), relating to the activities of John Allen in London and Brighton, and acknowledged in the Tribunal Report that it gave rise to “some cause for concern …” However, the Tribunal determined it “…has not been within the scope of our terms of reference to investigate …” and “such evidence as has been given ... has been largely hearsay ... and it would be inappropriate to make any findings about them …”3 Miss Margaret Clough indicated to me in interview that she remained unhappy about “all the Brighton stuff” and that, in discussion with Sir Ronald Waterhouse after the Tribunal, she expressed the view that, if there was a wider paedophile network than that exposed during the Tribunal, it would have centred around John Allen. Further government consideration5.22 On 3 July 1997, the Secretary of State for Wales was briefed on ‘South Wales child abuse’. An official informed him of a police press conference to be held on 8 July 1997 and “our intention to alert the North Wales Tribunal to these developments”. The note went on to suggest that the media “are likely to seek to link these matters to events in North Wales … such comment is likely to lead to demands for a further inquiry or for the current North Wales Tribunal to have its remit extended to cover the whole of Wales.” 5.23 The advice given was that the lack of “hard information about these allegations, the nature or extent [of them]” rendered it “premature” to do so and that the police should be allowed to continue with their investigations and the question of any future 1 See Chapter 52 of the Tribunal Report2 See paragraphs 21.06 and 21.31 of the Tribunal Report3 See paragraph 21.46 of the Tribunal Report112 | The Macur Reviewinquiry, or presumably the extension of the existing one underway by the Tribunal, should await completion of inquiries and subsequent prosecutions. In this regard, I am aware that one caller to the Tribunal helpline, who represented a client alleging abuse in Ty Mawr, was referred to the South Wales police inquiry. 5.24 In the event, the Tribunal’s remit was not extended. However, in the course of my Review I have been alive to the possible links between the abuse of children in care in North Wales and South Wales residential children’s homes, not only by reason of the employment of several former police officers of the South Wales police force as members of the WIT (see paragraph 4.61) and Derek Brushett’s previous employment, but also the geographical proximity of the areas and the movement of residential care staff between homes.5.25 The conviction of Derek Brushett, a Social Services Inspector in Wales (see paragraph 4.114) in relation to child abuse in South Wales, necessitated this Review researching the voluminous CPS materials concerning his prosecution for indications of his participation in abuse in North Wales, or other than professional association with those against whom allegations had been made. None were found. Relevant authorities and agencies covered by the Tribunal’s terms of reference5.26 The terms of reference extended beyond those authorities and agencies responsible for providing statutory care to children to those public bodies recipient of allegations of abuse or responsible for their investigation. The explicit exclusion of scrutiny of decisions whether to prosecute named individuals did not exclude an examination of the role of the CPS in North Wales in the course of police investigations. The Police5.27 In a letter dated 11 June 1996 to the Secretary of State for Wales, the Right Honourable Michael Howard MP, Home Secretary, (now Lord Howard of Lympne CH, QC) indicated that he did “not believe an inquiry would shed any fresh light on current issues …” in the light of Miss Nicola Davies QC’s report. He went on, “You mention that there has been underlying concern about the action of the North Wales Police; I do not believe that concern is limited to policing issues. There is surely widespread disquiet about what may be contained in the Jilling [sic] report. I am convinced that the most effective way to counter the rumours and speculation would be to publish, if not the whole report, at least a revised version of it. I hope that this possibility can be fully examined before you decide to embark on any other course. I am aware that one of Jillings’ recommendations … is that the Police Complaints Authority should be invited to conduct an inquiry into the handling of the allegations of abuse by the North Wales Police, in a similar manner ... following the conviction of Frank Beck ... I do not believe that this would provide a practicable way of allaying public disquiet … The decision to invite a fresh PCA supervised investigation would be for the Chief Constable of North Wales and there has been no indication that he is thinking of taking this course of action. The PCA have also indicated to us that there The Report of the Macur Review | 113would be very real problems in conducting an inquiry into events which occurred so many years ago. The PCA can only examine issues relating to the police and even then the report of their investigations cannot be published. I cannot see, therefore, that such an inquiry would help to reassure wider public concern about the affair, nor do I believe it is necessary. Miss Davies ... had access to all material held by the police in connection with the criminal investigation. In her report she confirmed that ‘the North Wales Police carried out a thorough and extensive investigation into allegations of abuse of children in care homes in Clwyd and Gwynedd’.”5.28 I report upon documents in paragraphs 3.62 to 3.66 which indicate that Miss Nicola Davies QC did not have access to all material held by the police, and subsequently, in paragraph 3.117, the fact that I conclude that Welsh Office officials apparently did not adequately draw this and other information to the attention of ministers. I am not aware of the advice tendered to the Home Secretary by his officials in relation to the materials made available to Miss Nicola Davies QC or else the degree of participation of the NWP in the inquiry conducted by the Jillings Panel. As previously indicated, both the provision of documents held by the NWP to Miss Nicola Davies QC and the NWP participation in the Jillings Inquiry appears to have been restricted. Quite apart from these matters, the context in which the Tribunal was established, see for example the comments in paragraph 5.11, implicates the police. 5.29 In those circumstances, I refer to and quote from the Home Secretary’s letter at some length since, in my view, objectively appraised, some of the passages within and read without knowledge of his and other ministerial communications on this topic, may suggest that the Home Secretary was resistant to an investigation into the actions of the NWP, for whatever reason, under the guise of general opposition to the concept of a public inquiry. However, contrary to such a view, I report that I have seen no other correspondence which advances the same points and there is no suggestion in any subsequent documents that the NWP claimed it was not a ‘relevant authority’ falling within the Tribunal’s remit. The NWP was represented at, and participated fully in, the Tribunal proceedings. Materials were disclosed by the police. Senior officers gave evidence and were subjected to cross examination.5.30 I wrote to the Right Honourable Lord Howard of Lympne CH, QC on 15 May 2015 alerting him to the fact that I intended to refer to the terms of the letter and acknowledge the adverse interpretation that some may draw of various passages within it, even though I intended to indicate that no objection was raised to an investigation of the NWP response to complaints during the Tribunal process. In his response, Lord Howard made clear that the letter as a whole indicates the context of his reservations and that he was following the advice of Miss Nicola Davies QC and Home Office officials. He emphasised that any suggestion that his response was to avoid an investigation into the NWP would be entirely wrong and he did not agree that his letter of 11 June 1996 could, or should, be interpreted to indicate his general opposition to the concept of a public inquiry.114 | The Macur ReviewThe CPSDisquiet concerning CPS decisions and response prior to the establishment of the Tribunal 5.31 Disquiet about CPS decisions had been quite long standing and referred to ministers. In a letter to Mr Geoffrey Dickens MP, dated 29 January 1985 [sic] (but referring to correspondence in late 1986) the AG, Mr Michael Havers QC, apologises for the long delay in replying due to the necessity to “request information from the Crown Prosecution Service in North Wales.” The subject of the correspondence concerned the “ill treatment of residents at the Ty’r Felin Assessment Centre”. The letter indicates that a file had been sent to the North Wales Branch of the CPS in September 1986, “studied by senior members of staff, and certain advice was forwarded to the police ... they did not at that stage have sufficient evidence to institute criminal proceedings ... I have been informed, however, that certain further enquiries are now in hand, and no doubt when they are complete a new file will be sent to the Crown Prosecution Service for consideration.” 5.32 In answering an associated letter from Mr Wyn Roberts MP, complaining on behalf of his constituent, Nefyn Dodd (see paragraph 8.13), about Mr Dickens MP’s involvement, on 29 January 1987 the AG expanded “although I am quite satisfied that there was no evidence to support the majority of the complaints ... there were one or two matters which seemed to me not to have been fully investigated. These matters are now being dealt with as are certain further complaints...” A letter from the AGO to CPS headquarters dated 30 January 1987 identified the matters concerned and asked to be kept informed. 5.33 There were no criminal prosecutions arising from the 1986/7 police investigation, including against Nefyn Dodd, at this time. Subsequently, as previously indicated, a further police investigation commenced in July 1991. Very few criminal prosecutions resulted. Disquiet concerning CPS decisions relating to allegations against (former) policemen prior to the establishment of the Tribunal 5.34 On 26 March 1993, Dr John Marek MP wrote to the DPP, “I am alarmed at your statement of 24th March regarding the North Wales sex abuse inquiry that there are to be no prosecutions because of insufficient evidence or that it would not be in the public interest ... I have to tell you that there is great public interest in North Wales ... [television programmes] clearly showed a victim stating that the police were not interested in accusations against certain ex-policemen. I hope you will think again about this as justice must be seen to be done ... we are all at a loss to understand why you have made your decision. Either the numerous allegations are untrue or there has been a stitch up.” 5.35 The DPP wrote in response on 20 April 1993. Indicating that she had called for a full report on decisions relating to former police officers, she went on to say, “the evidence against each police officer, or former police officer, … was carefully reviewed ... the decision not to prosecute was taken purely upon evidential grounds. The Report of the Macur Review | 115In other words, the reviewing lawyer concluded that there was insufficient substantial, admissible and reliable evidence to provide a realistic prospect of convicting ... so far as ... the former Special Constable was concerned ... There was sufficient evidence ... However, we concluded that it was not in the public interest to prosecute ... I appreciate that this explanation gives only a broad indication of the reasoning which lay behind our decisions ... However, I am unable to go further and provide details of decisions in such individual cases ... [which] could amount to a trial of the suspect without the safeguards which criminal proceedings are designed to provide.” 5.36 I have seen the briefing note provided by the CPS designated special case worker responsible for initial advice in cases involving allegations against police officers in North Wales including former Superintendent Gordon Anglesea, to the DPP’s office in ‘mid April’ regarding his advice not to prosecute. It refers to inconsistencies between witnesses, lack of corroboration, consideration of the facts and that “after careful consideration, therefore, the decision was taken that there was insufficient evidence to prosecute either Anglesea, Jones or Sharman …” In the case of separate allegations against a fourth man, Special Constable Michael Hayward, he had made admissions of indecency with a 15 year old, but it was decided not to be in the public interest to proceed, having regard to his age at the time, the age of the incidents, that there had been no further allegations of improper conduct, his subsequent marriage and the fact “that the negative effects of a prosecution upon him and members of his family would far outweigh any possible public benefit that might result.” It was further noted that the prospective complainant had himself been subject of similar allegations by another and now lived out of the jurisdiction. 5.37 Unaware of the details of this note, Dr Marek MP responded on 10 May 1993 attaching statements of complainants and inquiring, “were you aware of the existence of these documents?”, obviously incredulous and concluding, “finally, I must say that there are many, probably wild, stories about very important and influential people mixed up in child sex abuse here in North Wales. The situation has arisen simply because no prosecutions have been brought against anyone then in authority and the fact that the North Wales Police have been investigating these matters for years and years without apparently achieving any success.”5.38 In discussing the situation, and following sight of a further letter from Dr Marek MP to the DPP, officials were concerned about “handling” issues. They were aware that “the DPP’s assertion that there is insufficient evidence must seem to [be] incredible to a layman who has seen a victim on TV saying in plain terms that a particular individual has buggered him. Clearly the public is unaware of ... subsequent inconsistencies and inaccuracies ... the nature of the Director’s reply to this latest letter [is] very important. She could easily appear to be coldly ignoring evidence which, to Dr Marek and others, is as plain as the nose on his face.” 5.39 I have seen the further faxed memorandum from to the Legal Secretariat’s officials on 10 May 1993 dealing at greater length with issues of discrepancy and credibility. It concludes, “although not directly relevant, enquiries have also been made concerning Anglesea’s behaviour in other areas of his 116 | The Macur Review life. One or two minor items of gossip concerning him have been reported to the investigating officers. For example … seen him at a local homosexual club … not been confirmed … [enquiries into his] domestic life have also failed to reveal any indications at all of any homosexual inclinations on his part ...” A background note briefing the AG subsequently in July 1993 assessed Gordon Anglesea to be of heterosexual orientation. 5.40 A letter was accordingly sent to the DPP’s Private Secretary on 14 May 1993, and the AG briefed on 18 May 1993, suggesting a discussion about the handling and form of her reply as soon as possible, “there is a real need to reassure the public that the case has been considered thoroughly and seriously and to prevent the understandable concerns of Dr Marek escalating to the point of public criticisms being made of the CPS … She will need to address the suggestion that the public are now listening to wild rumours about child abuse in high places in NW [North Wales] and do not understand how the police could investigate the allegations for so long without any apparent success.”5.41 On 9 June 1993, the DPP wrote to Dr Marek MP giving further explanation, referring to inconsistencies in account, and adding that “in cases of this nature which involve sexual allegations, a jury must always be directed by the judge that it is dangerous to convict in the absence of corroboration.” (The requirement for a Judge to warn a jury of the danger of convicting upon uncorroborated evidence of sexual abuse was abolished from 3 February 1995). 5.42 A meeting took place between Dr Marek MP and the AG on 7 July 1993, during which time attention was drawn to a letter from a BBC News reporter/researcher to the Police Complaints Authority dated 17 June 1993, which asked: how DSU Peter Ackerley could be capable of investigating Gordon Anglesea, when “for several years he worked beneath him?”; why the North Wales Police press officer told a BBC Wales reporter “rather gleefully” that the file on Gordon Anglesea was more or less complete and that he wasn’t going to be prosecuted despite the fact that a third person was reluctantly persuaded to give a statement because he was convinced that “the police would get him [Gordon Anglesea]”; and other general criticisms. The AG undertook to have the evidence looked at again. was summoned to a meeting with the AG, and although challenged, maintained his views and advice that there was insufficient reliable evidence to secure a conviction in the case of Gordon Anglesea.5.43 A letter dated 7 September 1993 was sent by the AG to Dr Marek MP. The AG’s files made available to me disclose numerous previous drafts and reflect the considerable care taken to ensure accuracy of factual content and what was considered to be the appropriate ‘general tone’. The letter reported that “the Director has considered this matter personally and remains satisfied that that decision [not to prosecute Gordon Anglesea] is the correct one ... As for the outcome of the investigation as a whole it is correct to say that a large number of allegations ... have been made and that relatively few prosecutions have been instituted. It may however help if I put this into context. Each matter put before the CPS has The Report of the Macur Review | 117 been looked at carefully on its own merits ... I have sought to address the specific points you raised with me in this letter; but I can also add that I am satisfied that the experienced lawyers in the Crown Prosecution Service who have considered each one of these many cases have done so with the thoroughness and care which the seriousness of the complaints required and which the public has a right to expect.” Exclusion of scrutiny of CPS decisions 5.44 The Tribunal’s terms of reference specifically excluded “scrutiny of decisions whether to prosecute named individuals”. The reason for this is traced to a letter from the AGO to the Secretary of State for Wales’s Private Secretary dated 14 June 1996, in which it is said, “as the Solicitor General explained at Tuesday’s meeting, it is a point of fundamental importance that prosecution decisions once taken are not subject to detailed public scrutiny or second guessing. The rationale is the importance of finality and fairness to the potential defendant, victim(s) and witnesses. The convention is not intended to protect prosecuting authorities. It has been endorsed by the Philips Royal Commission on Criminal Procedure and is reflected in the fact that prosecution decisions fall outside the scope of scrutiny by the Parliamentary Ombudsman and are also specifically excluded from scrutiny by the Home Affairs Select Committee. The Solicitor General considers it essential that prosecution decisions are specifically excluded …” 5.45 The relevant passage in the Philips Report reads: “The decision to prosecute or not of its very nature can involve the interests and reputations of witnesses, of the victim and of the accused or suspect. Publicly calling into question a decision not to prosecute could amount to a trial of the suspect without the safeguards which criminal proceedings are designed to provide. Similarly, questioning the original decision to prosecute when a person has been acquitted could amount to a retrial.” 5.46 A member of the Legal Secretariat expanded upon the reasons to exclude scrutiny of decisions whether or not to prosecute in a letter to Mr Lambert in terms, “a further reason why successive Law Officers and DPPs have sought to avoid providing material which can be used to second guess and criticise a prosecution decision is the very important principle that the prosecution process should not be subject to political pressure. You refer to the possibility that members of the CPS may be required to give evidence to the Tribunal. The Law Officers and DPP would certainly not want to impede the Tribunal’s work and have from the outset accepted that the Tribunal might wish to examine whether the working arrangements between the CPS and police were satisfactory and therefore to call members of the CPS to give relevant evidence. But, if this evidence were, for example, to extend to cover the view taken by a CPS member of the adequacy of information provided by the police to found a specific prosecution, the Tribunal would be seen as entering the area which the Law Officers are concerned to protect.” 118 | The Macur Review5.47 However, in providing a draft of this letter to the Solicitor General, the same correspondent in a note dated 29 August 1996 informed him, “I have cleared with the DPP and [it] incorporates her comments. We both believe that the Inquiry is ... almost bound to end up scrutinising the prosecution decision making process. But the exclusion from the terms of reference reflects an important principle ... I should add that the DPP says that she will be having a series of internal meetings about all this to ensure that all proper inquiries have been made both internally and externally and that relevant material is available to the Inquiry.”5.48 The explanation given on behalf of the AG for the exclusion was not challenged by ministers. CPS approach at the Tribunal5.49 The CPS was not represented before the Tribunal from the outset, but Senior Crown Prosecutor, attended the Tribunal as an observer in the public gallery. He prepared regular briefing notes for the Law Officers. 5.50 In a briefing note dated 9 October 1996, recorded that the “police acknowledge that a public interest immunity [PII] claim could be raised in relation to material such as police reports and CPS advice but feel that the balance of public interest may lie with disclosure ... Notwithstanding the terms of reference it is difficult to argue that advice provided by the CPS, including advice in individual cases, has no relevance to the Inquiry. The quality of the investigation and the relationship with the CPS are within the terms of reference and the police will maintain that their investigation was shaped, in part, by advice provided by the CPS … It is recommended that the CPS raise no objection to the course of action proposed by the police but that, in relation to any material determined by the Inquiry to be relevant, it is made clear that PII arguments may be put forward at a later stage and before any material comes into the public domain.”5.51 In his note dated 30 January 1997, reported that, “In his opening statement Counsel for the Tribunal did not introduce evidence of major failures on the part of the North Wales Police. At this stage, therefore, it appears that the Tribunal team itself is unlikely to suggest that the CPS has participated in assisting the North Wales Police in any form of ‘cover up’. There may, however, be others represented before the Tribunal who take a different view. The focus upon the low number of prosecutions; the number of allegations against one individual in cases such as Dodd; the possible application of the case of DPP v P on the probative value of allowing evidence of similar allegations; indicates that it may be suggested that the CPS was too cautious in its approach to review…”5.52 succeeded following his untimely death on was formerly Senior Inspector and Assistant Chief Crown Prosecutor, CPS London. During the course of the Tribunal’s hearings, the CPS made an application for representation at the hearings, which was granted by the Tribunal on 3 February 1998. No member of the CPS was called as a witness before the Tribunal. cross examined witnesses and made closing submissions to the Tribunal as referred to below. The Report of the Macur Review | 1195.53 indicated in interview with me that, in relation to provision of CPS material, he adopted a position which protected the constitutional basis for the exclusion of scrutiny of CPS decisions whether to prosecute rather than protecting the individuals concerned, but otherwise afforded appropriate access to materials as necessary. That is, his brief was not to obstruct any relevant investigation. In his briefing note dated 27 March 1998 to the AG, he reported that “one advocate sought much wider disclosure of CPS advices when police defended the extent of their investigations because of CPS advice. The CPS formally objected to the disclosure and there was some debate with the Chairman as to the extent of the exclusion within the terms of reference … In the event the specific advices as to decisions made upon the credibility of were referred to, but there was no wholesale disclosure.” He continued, “Police made the point that they had recommended the prosecution of former Superintendent Anglesea and former Special Constable Heyward [sic] … This could not be dealt with fully without transgressing the terms of reference.” It appears that the CPS notes of the relevant conference between and the AG were provided to the Tribunal. Tribunal approach5.54 Not surprisingly, in the light of the clear public disquiet voiced concerning the low number of criminal prosecutions prior to the establishment of the Tribunal as indicated above, the decision to exclude CPS decisions gave rise to strong objections at the time. In a letter dated 10 August 1996 addressed to the Secretary of State for Wales, complained vociferously about the exclusion saying, “there are many questions for the C.P.S. to answer … we want everything to come out. Including the corruption in the C.P.S. in North Wales …” 5.55 Clearly, the decision to exclude CPS decisions raised questions not only as to whether the CPS would escape critical examination as a body, but whether the Tribunal would be deflected from its own investigations into, and making findings in relation to, those cases where the CPS had decided not to prosecute. 5.56 I find no indication in the transcripts of the daily proceedings, or other documentation that I have examined, to suggest that the Tribunal felt the exclusion frustrated a full examination of the evidence into the alleged abuse of children in care, nor do I see how it can be reasonably construed to have done so. In the case of Gordon Anglesea, the Chairman made clear that if additional relevant information was available to the Tribunal, which had not been presented to the civil jury considering the libel proceedings, he would make findings as appropriate; this regardless of the CPS decision not to prosecute him. A submission made on behalf of another alleged abuser that the refusal of the CPS to prosecute effectively prohibited the Tribunal from making findings against him was roundly dismissed on the basis that the Tribunal’s remit was to evaluate the evidence with a view to make findings in accordance with the terms of reference, not to reach a decision as to the merits of a criminal prosecution. 120 | The Macur Review5.57 As a non appellate body, the Tribunal was bound to respect the verdicts of a criminal trial. In the Tribunal Report4 this is said to have caused no practical difficulty since in those cases where defendants had been acquitted, there was no fresh evidence adduced. There are several paragraphs in the Tribunal Report where reference is made to the specific exclusion which prevented scrutiny of individual prosecution decisions, but otherwise the Tribunal merely notes the refusal of the CPS to initiate criminal proceedings, and sums up the situation in terms that the decisions not to prosecute made by the police themselves or the CPS were “for a variety of reasons, usually encompassed within an explanation that there was insufficient evidence to justify a prosecution.”5 The Chairman did ask questions of CPS general policy including as to prosecution, notification of decision to the complainant, cautions, consultation with complainants, the absence of a complainant at the plea and directions hearing, the need to ensure the charges on the indictment reflected the seriousness of the offending, delay and abuse of process. 5.58 In their closing submissions, a number of the advocates for victims of abuse and Councillors Malcolm King and Dennis Parry were critical of the decisions made by the CPS. Submissions made on behalf of Councillors King and Parry urged the Tribunal to refer them to the AG to “undertake a separate investigation into the decision making process ... The prosecution rate and the conviction rate from other inquiries of a much smaller scope seems to have been much higher than that achieved in North Wales ...” It was suggested that there was considerable disquiet in the North Wales police as to the CPS special case worker’s, views on individual cases.5.59 Sir Ronald Hadfield considered that the CPS had shown a lack of objectivity in their response to the 1986/87 police reports. He thought that the deficiencies in the files, presumably both as to evidence gathered and opinion expressed, should have been apparent to an experienced Crown Prosecutor.5.60 In closing submissions on behalf of the CPS, reminded the Tribunal that it had not heard evidence from any member of the CPS. He highlighted the different functions of the CPS, created in 1986, in assessing sufficiency of evidence and ’public interest’, as compared with the Tribunal’s inquisitorial process. However, he recognised that “In applying the public interest test, there was the clear statement in the second edition of the [CPS] code that sexual assaults upon children should always be regarded seriously. And in such cases, where the Crown Prosecutor was satisfied as to the sufficiency of the evidence, it would seldom be any doubt the prosecution would be in the public interest.” CPS documents 5.61 Although prosecution decisions were explicitly excluded from examination by the Tribunal’s terms of reference, I nevertheless considered it necessary in order to address my terms of reference to examine those CPS documents which still exist in 4 See paragraph 6.11 of the Tribunal Report5 See paragraph 30.20 of the Tribunal ReportThe Report of the Macur Review | 121relation to the NWP investigation into abuse of children in care in order to establish whether, in excluding scrutiny of such decisions by the Tribunal, protection was thereby directly or indirectly afforded to establishment figures or any other individual. In doing so, I was assured of and received full co-operation from the immediate past DPP, and had the benefit of reading the briefing notes prepared by and the AG files provided. 5.62 By far the greater number of relevant prosecution files provided to the Review by the CPS were compiled by since was only responsible for those allegations concerning serving or retired police officers, of which there were comparatively few. In a note from to the DPP’s Private Office dated 5 July 1993, he indicated that he had “to date opened a total of 174 files ranging from sexual and physical assaults to attempts to pervert the course of justice. The figure includes a PACE application as part of the Anglesea Investigation and some of the matters dealt with by ... The files that are now being submitted are arriving for initial advice to identify the nature of the complaint actually made. Many of the allegations have been definable as nothing more than time barred common assault and the Police are concerned that they do not arrest or try to interview where it is clear that no proceedings would be possible in any event. As such the current advice files merely have statements of complaint and other witness statements. They do not have records of interview ... In addition, I have been sent two files where various nationally prominent persons have been named by a solicitor in Clwyd County Council and by a local councillor as being persons who are rumoured to have been involved in child abuse. Neither of these files has contained anything that could be described as evidence and the police have been advised accordingly. The existence of the files has been drawn to the attention of my [Chief Crown Prosecutor] and [Assistant Chief Crown Prosecutor] (Casework). These files are held at Colwyn Bay.” Informal review of CPS decisions5.63 In a series of notes dated between November 1997 and April 1998 (during the time when the Tribunal was sitting), conducted his own review of the relevant decisions of the CPS arising from the 1986 and 1991 police investigations at some length. He found, of a total of 280 relevant prosecution files on a Schedule compiled by arising predominately from the 1991 police investigations and including those sent to 12 files, which had not resulted in prosecution, had not been traced; a total of eight defendants were prosecuted; a further three defendants received a police caution; 12 files were ’for information only’; six files were for general advice, not relating to prosecution; four potential defendants had died; and, 13 alleged offenders had not been identified. 5.64 He recorded that in 193 cases the police had made the recommendation or observation that there should be no further action taken or that no prosecution should follow, for the most part as a result of there being insufficient evidence. In 28 files, the police gave no view as to whether the case merited prosecution. In three 122 | The Macur Reviewcases, the police recommended that the individual be cautioned. The CPS agreed with this course of action in two cases, but in one case, advised against a caution on the basis that there was insufficient evidence to provide a realistic prospect of conviction. The police recommended prosecution in relation to 20 files concerning 25 defendants, the comparative small number influenced, they said, by the early advices of the CPS not to prosecute other individuals in similar situations.5.65 In the main, considered that the decisions not to prosecute were “justifiable”, and that overall most of the CPS decision making was straightforward and clearly right, but identified a small number of cases where criminal proceedings would have been amply justified and considered that there “were a significant number of questionable decisions.” Necessarily, these mostly concerned the proportionately greater number of files compiled by . exposed a number of inadequacies and deficiencies in some advice files, which may be summarised as follows: erroneous application of the ‘evidential sufficiency test’; inadequate advice on missing evidence; uncertainty of case handling and decision making; incorrect analysis of evidence and consequently erroneous subsequent charge; attributing undue weight to matters other than the evidence and, applying a test higher than that within the Code for Crown Prosecutors; a failure to consider all allegations against an individual together in terms that one series of similar offences possibly afforded cross corroboration of evidence; the wholesale dismissal of the evidence of involved in several cases without separate consideration in each case; and, a ready acceptance of prospective but untested ‘abuse of process’ arguments. He concluded that, “In the light of the analysis, it is not surprising if the Tribunal is of the view that there may have been a lack of inclination on the part of the CPS to prosecute.” My review of CPS documents5.66 Most of the files appearing on master schedule were still available for my examination. I had previously conducted my own analysis of the file in relation to the ‘high profile’ decision relating to Gordon Anglesea and a further random sample of prosecution files. Some of those happened to include the files referred to in schedule as questionable decisions. Those which apparently dealt with named establishment figures were absent. This is not surprising. I suspect the file, so called, contained little other than the correspondence relating to them and to which I refer in Chapter 8. I have discovered no witness statement which contains any allegation of abuse in relation to the same. The files would have been obviously and rightly assessed by as lacking any evidence, as indicated in paragraph 5.62 above. 5.67 I agree with views in relation to those files I did happen to inspect before I became aware that they had been previously reviewed by . In relation to those cases I reviewed which had been advised upon by I found examples of all of the inadequacies and deficiencies identified by and which are referred to in paragraph 5.65. In relation to the few cases I reviewed which had The Report of the Macur Review | 123 been advised upon by I considered that in one case, he had erred in recommending no prosecution against former Special Constable Michael Hayward by reason of what I would regard as an objectively over generous interpretation of the public interest test.5.68 In one file, involving allegations against police officers, had reached a view that “evidence supplied by should not be relied upon to support any allegation of sexual or physical abuse against anyone.” He prepared a file note to that effect in February 1993. has indicated to me that he intended this annotation to apply to the prosecution files for which he was responsible. It is clear that and were in contact during this time about their respective cases. Thereafter, it appears that advised that counts in at least one indictment which named as the complainant should be withdrawn, and his evidence in general was not relied upon in subsequent criminal trials.5.69 In a briefing note to the AG dated 30 July 1997, suggested that “one consequence of these decisions [relating to allegations against police officers] was that counts on the indictment against Peter Howarth which were based on the evidence of any of the witnesses [concerned] … were not pursued. A second consequence was that Michael Taylor (Bersham Hall staff member) who admitted some offences of indecent assault was not prosecuted ... police were advised to caution because to prosecute would be inconsistent with the decision about [the special police constable].” 5.70 During the public meeting in Wrexham, an individual made clear to me that he was deterred from participating in the Tribunal by virtue of a CPS failure to prosecute his complaint of ill treatment against a member of staff.5.71 I interviewed and separately and before I interviewed I did not have access to schedule or internal review at the time of my interviews with either of them and therefore did not ask them to address any specific concerns raised by . I did, however, raise general points concerning their decisions and approach arising from my own reading of the files. Each of them volunteered in interview with me that he was not a Freemason.5.72 I wrote to and on 18 May 2015 inviting their response to my preliminary conclusions on issues relating to their decisions. I informed both that I had returned the relevant prosecution advice files to the CPS on 10 March 2014 should they wish to access the same in order to formulate their responses to my letter. 5.73 In their written responses to me, and indicate that they were not interviewed by in the course of his review, did not see his conclusions and have not been given the opportunity to challenge them. In fact, documents that I have seen show that responded in writing to a ‘handwritten minute of 10 September 1997’ prepared by referring to several issues arising from the 124 | The Macur Review files reviewed by and referred therein to a conversation he had had with on 10 September 1997. Reasonably, both and refer to the passage of time and the difficulty in recalling specific cases in detail; both have now retired. Each make the point that since their last involvement in these cases there have been significant changes in law, practice and policy and that some of their decisions may have been different in the recent climate.5.74 describes the management structure of the CPS and stresses the fact that he was responsible for initial review of the files, but was not a final decision maker, which rested with his CPS line managers of higher grades. In respect of he makes the point that he had given full written reasons for his view concerning his reliability and credibility of this witness and the fact that there was no corroboration for his individual complaints. He refers to the fact that his views on the particular cases, which give rise to the matters mentioned above, were discussed with senior police officers at the time in the presence of his line manager. He rejected any notion that he had the ability to influence the decisions made by other CPS lawyers, specifically in the context of who, or what offences, should be prosecuted. 5.75 specifically makes the point that it is possible for a range of different professional views to exist on a particular file, all of which fall within a band of reasonableness and none of which are therefore necessarily perverse. However, he accepts, with hindsight, that he “may have taken a cautious approach to a number of the charging decisions that [he] made.” His caseload in relation to these matters was large.5.76 I wrote to the present DPP on 18 May 2015 as a matter of courtesy to inform her of my provisional view relating to some of the decisions made by the prosecution during the relevant period and the absence of any published overarching review. The DPP confirmed that “the CPS has accepted that review represents a fair and balanced assessment of the decision making in these cases.” She accepts that it would have been possible for the DPP to have “published report or alternatively commissioned a new review from, for example, a retired judge, both of which the CPS has done recently in respect of other cases.” However, she draws my attention to the fact that the former DPP did already have the benefit of the authoritative reports of a former inspector, and this may have informed her past predecessor’s decision not to do so.Health authorities 5.77 A literal interpretation of the terms of reference set to the Tribunal would permit investigations into the circumstances of children not only in local authority care, but also the de facto care of other institutions or bodies, including NHS establishments in the former county council areas of Gwynedd and Clwyd. That is, the terms of reference at (a) require the Tribunal to “inquire into the abuse of children in care in the former County Council areas of Gwynedd and Clwyd…”, rather than those children in the care of the former Gwynedd and Clwyd county councils. The Report of the Macur Review | 1255.78 It is clear from the Tribunal’s working documents and the framing of the Tribunal Report that the Tribunal did not give this wide interpretation to the terms of reference. However, it did not interpret the terms of reference restrictively in so far as evidence was concerned. The Chairman regarded the pertinent filter for admissibility of evidence to be its relevance to the terms of reference not its source; for example, in respect of a witness who had not been a child in local authority care, he stated, “we are dealing with the treatment of children in care at Gwynfa and she [the witness] was there at a material time … I find it difficult to see how her evidence is irrelevant.” Gwynfa clinic 5.79 Gwynfa clinic was a psychiatric residential, assessment and treatment facility for children and young people administered by the Clwyd Area Health Authority from 1974, the Clwyd Health Authority between 1982 and 1993 and the Clwydian Community Care NHS Trust (‘the Trust’) thereafter. This facility housed, but was not restricted to, children ‘in the care’ of a local authority. The Tribunal heard evidence from 14 of its former patients and found that of the “total of 23 former patients [who] made complaints relating to the period 1974 to 1987… [it was] reasonably clear that 13 of these were in care at the time ...”6 5.80 The Tribunal Report noted the “vulnerability of young children when they are living in a residential clinic ... whether or not they are formally in care at the time”.7 However, the Tribunal felt hampered in making specific findings since “The picture that we have received of conditions at Gwynfa has been incomplete for a variety of reasons but most notably because we have not been able to investigate the activities of Z [a member of staff who was under police investigation] …”8 The Tribunal Report does not detail what the “variety of reasons” were, but in any event, it now seems clear that the Tribunal had been provided with inaccurate or incomplete information as indicated below. Concerns about evidence provided to the Tribunal relating to Gwynfa 5.81 A Welsh Office Health Advisory Group (‘the Health Group’) was established with specific responsibility for advising on health issues arising from and during the Tribunal investigations and hearings. The documents provided to me by the Wales Office, including numerous emails and letters between the Health Group and the Trust, briefing notes and records of various meetings, indicate the Health Group’s growing distrust of the accuracy of information provided by the Trust to the Tribunal, and concern at the response of Mr Laurie Wood, formerly General Manager of the Clwyd Health Authority responsible for Gwynfa before becoming the Trust’s Chief Executive in 1993, when informed of the apparent discrepancies and/or omissions. Subsequently, in a briefing note dated 9 March 1999, a senior Welsh Office official 6 See paragraph 20.17 of the Tribunal Report7 See paragraph 20.28 of the Tribunal Report8 See paragraph 20.28 of the Tribunal Report126 | The Macur Reviewadvised the Secretary of State for Wales that he considered himself deliberately misled by Mr Wood about “the allegations arising from Gwynfa and what the management response had been. This would have been particularly important to me in 1996 when the terms of reference of the North Wales Child Abuse Inquiry were being agreed. The first written advice I received on this matter in December 1996 and this has proved to be misleading on a number of issues ...” 5.82 A report had been prepared by Mrs Irene Train in 1992 for the Authority when she was Divisional General Manager (North) of the Community and Mental Health Unit of Clwyd Health Authority. In 1996, when working as a consultant for the Trust, she was instructed to prepare a further report. Both reports were submitted to the Tribunal. They asserted that she had been informed by the police that “the type of allegations made by these young people would constitute common assault and none alleged that any form of sexual abuse took place.” This information appears to be directly contradicted by a meeting note produced by the NWP to the Welsh Office, which records the police as having told Mr Brian Jones, Chief Executive of the Clwyd Health Authority between 1992 and 1996, in August 1992 that “further allegations of buggery USI and assaults” had been received in respect of a member of staff. A memorandum dated 24 March 1998 from a member of the Health Group to Mr Lambert suggests that this report deliberately mis-stated the true nature of the complaints since, “by describing the Gwynfa allegations as common assaults board members (of both the Trust and the Health Authorities), who were also members of the criminal justice system (JP’s, an ex-CPS lawyer and a solicitor who had worked for Child-line) [sic], would have no expectation of there being criminal proceedings.” I presume that she was referring to the fact that prosecution of common assaults must commence within six months or else will become time barred.5.83 I wrote to Mrs Train on 15 May 2015 inviting her comments on certain issues arising from the reports she prepared. She responded that she had no recollection of meeting with DSU Ackerley when he met with the Chief Executive of the Clwyd Health Authority in August 1992, but did remember meeting him in the February of that year, when he had asked for access to patient records at Gwynfa, which she initially refused pending the advice of the Welsh Office. She did recall “at some later date” that she went to Colwyn Bay Police Station with a non executive director of the Trust and a solicitor, where they were allowed to read statements and make notes. She recalled that, “we noted allegations of common assault, but none of sexual abuse.”5.84 Mrs Train retired many years ago. She said that until she received my letter she had not been aware of the Welsh Office concerns expressed in relation to her reports. She had no recollection of the specific details contained in her reports and believed that, although the reports “would have reflected the information provided to me”, it was possible that there were mistakes not apparent at the time. However, she is “certain that there was no intention on my part to mislead or obstruct the Inquiry in anyway.”5.85 On 28 May 2015, I wrote to Mr Brian Jones inquiring about his knowledge of the inaccuracies contained within the reports prepared by Mrs Train, particularly in light of the meeting he held with DSU Ackerley in August 1992, referred to above. I re-sent the letter on 11 June 2015.The Report of the Macur Review | 1275.86 Mr Jones responded. He noted the comments, but had “no files or records” to which he could refer. He went on to say: “...if the Welsh Office were troubled about conflicting evidence at that time it would have been far easier to have dealt with that matter if they had raised it at the time ...”5.87 I wrote in similar terms to Mr Wood on 28 May 2015. He indicated in his written response that he now resides abroad and said he could not access the files and documents involved. He said his recollection was that the Health Group’s concerns, referred to above, were only referred to him in early 1999 and that he was “totally unaware that the Welsh Office Health Department had any involvement in the matter of the Tribunal’s Terms of Reference” or that they were being agreed in 1996. He was certain that his then colleagues at the Health Authority “made every effort to present an accurate picture at the time and that no attempt was being made to minimise the seriousness of the allegations.” He said the report that the Trust submitted to the Tribunal “was prepared after exhaustive investigation and with full input from our legal advisors: it represented the facts as we were able to ascertain them ...” He concluded “... with the benefit of hindsight it is clear that we did not get things 100% right but we did try to deal with the allegations as thoroughly as we could and bearing in mind the absence of prosecutions in such a way as was consistent with employment law at the time. The evidence that was presented to the Tribunal was carefully drafted, fully sifted by our legal team and was as complete as we felt we could achieve: certainly not, to my mind evidence of any conspiracy.”Subsequent action by the Welsh Office and the Tribunal’s response 5.88 There obviously had been an expectation that the nature of management responses to allegations of abuse would be investigated by the Tribunal. The Solicitor for the Welsh Office informed the Health Group in a letter dated 17 December 1997 that “the Tribunal will not wish to investigate the merits of individual cases of abuse but, if you are able to identify for the Tribunal those cases in which either no action was taken, or inappropriate action was taken, by the Clwydian NHS Trust following a complaint brought to their attention, the Tribunal will hear evidence of the systems and procedures in operation at the time of the complaint, and the manner in which these were not complied with ...” In the event, the Tribunal did not investigate these issues. The Tribunal was assured by the Welsh Office during the Tribunal hearings that the allegations of abuse in Gwynfa would be investigated appropriately. The Tribunal may reasonably have anticipated that the management response to the allegations would form part of that investigation.5.89 I have seen Instructions to Counsel, Mr Adrian Hopkins (since appointed Queen’s Counsel), in November / December 1998 (after the conclusion of the Tribunal hearings) from the Welsh Office seeking advice in relation to the Trust’s management response to allegations of abuse arising in Gwynfa and its interaction with the Tribunal. The instructions state that “the Department is now aware of 82 complaints of abuse made by 40 former patients of Gwynfa”. They went on to list 13 specific concerns. Of particular interest in the context of my Review were those 128 | The Macur Reviewlisted as follows: “c) The Chief Executive of the North Wales Health Authority [then Mr Brian Jones] appears to have been informed by the police of serious allegations of abuse by Gwynfa staff on 6 February, 1992 and allegations of serious sexual abuse on 7 August, 1992 ... This matter does not appear to have been reported accurately or at the appropriate time to … the Welsh Office or the Tribunal … e) The Briefing for Board members of Clwyd Health Authority and Clwydian Community Care NHS Trust, [the report prepared by Mrs Train] which was later sent to the Welsh Office and submitted in evidence to the Tribunal contains statements that are contrary to what was actually happening and which the police dispute … g) ... The police were refused access to all records when many, such as staff records, were not subject to the issue of patient confidentiality … j) Important meetings with the police on child abuse [including with Mrs Train and the unit’s resident psychiatrist and Mr Jones] were not documented and correspondence not retained by Clwyd Health Authority officials … m) Serious conflicts remain within the chronology of events [as repeatedly reported to Mr Wood].” I have inserted the explanatory detail supplied elsewhere in the papers sent to Counsel in the square brackets above for ease of reference.5.90 Contrary to the responses of Mrs Train and Mr Wood, which I refer to earlier in this chapter, my own review of the core documents relating to this issue confirms the factual content included in the Instructions to Counsel that I reproduce in paragraph 5.89 above, save that the police were eventually allowed access to some of Gwynfa’s records in July 1993. It appears that the attempts by the Health Group to have the factual inaccuracies indicated above corrected in chronologies and the report produced by the Trust to the Tribunal were resisted on behalf of the Trust. Despite several invitations by the Health Group, Mr Wood in response rejected the necessity to do so. The majority of these documents that I have seen, comprising internal briefing notes and correspondence between the Health Group and the Trust, were not available to the Tribunal. 5.91 Counsel’s written advice considered that there were serious deficiencies in the management of, and care provided by, Gwynfa and indicated that he was of the opinion that the Tribunal had been misled in significant respects. He advised that a public inquiry was necessary. 5.92 On 16 December 1998, a member of the Welsh Office Legal Group wrote to the Clerk to the Tribunal, “as sanctioned by the Tribunal, at the behest of the Welsh Office, a process to review all the allegations of abuse arising from Gwynfa was initiated ... The [Trust] Corporate Group’s Report was received by the Department at the end of May. It has since been the subject of careful analysis. Our initial conclusion was that it contained serious omissions and that serious conflicts with the police evidence remained. The Department ... [briefed] Counsel with a view to him advising the Department on the scale and seriousness of the abuse; the management response; and options for the way forward. Counsel’s conclusion is that the Gwynfa allegations and the NHS Management response are sufficiently grave to justify independent inquiry.”The Report of the Macur Review | 1295.93 On 20 January 1999, a member of the Health Group wrote to Welsh Office lawyers “translating” the manuscript comments written by the Secretary of State for Wales on their briefing note advising him on the way they suggested he should deal with Counsel’s advice. The annotation was confirmed to read, “I am NOT content with the advice. This report [that is, Counsel’s advice] needs to be dealt with quickly, openly and effectively. I cannot understand the advice, which appears inclined to hide the report and the conclusions. Surely I should (a) ask police and CPS to decide urgently whether to pursue/prosecute and not to dither (b) agree to set up judicial inquiry and announce it NOW (even tho’ (a) may involve some delay) and (c) to provide the whole report NOW to Sir Ronald.” 5.94 A copy of Counsel’s advice was sent to the Tribunal under cover of letter dated 1 March 1999. Having inspected the original manuscript proofs prepared by the Chairman and first typed versions of the same, and compared them with the final Report, it is clear that he did not revise the content of Chapter 20, dealing with Gwynfa, in any respect upon receipt of the advice. 5.95 For the sake of completeness, I record that a public inquiry into the events at Gwynfa was not established by the Welsh Office. Following the UK government’s devolution of health policy, the National Assembly for Wales commissioned a review of the safeguards for children and young people treated and cared for by the NHS in Wales, led by Lord Carlile. The terms of reference are reported to “include provision for a further retrospective consideration of matters relating to Gwynfa”, but “not to mount a retrospective inquiry into what took place at Gwynfa” and make clear that it will not “seek to attribute blame or criticism to individuals”. The review reported in March 2002 and the resultant report, “Too serious a thing”, devotes two chapters to Gwynfa. Concerns about the Tribunal’s approach to health issues 5.96 Lord Kenyon had been a member of the Clwyd Area Health Authority and the Family Practitioner Committee in the 1970s. A briefing note prepared by Counsel for the Welsh Office in May 1997 suggests that there had been “anxiety [in the Health Group] … that the Inquiry is failing to pursue issues which may become politically sensitive as a result of the involvement, if only indirectly, of Lord Kenyon …” However, a Health Group note prepared on 2 October 1997 recorded that it was thought that the Tribunal “did not know” of the connection of Lord Kenyon. Mr Hopkins’ written advice does not refer to it. I have found no reference in materials available to me that this information was otherwise placed before the Tribunal.5.97 An anonymous contributor to my Review, introduced by the Children’s Commissioner for Wales, voiced lingering concerns that the obstructions created by the inaccurate portrayal of the circumstances appertaining to Gwynfa may well have concealed associations between Lord Kenyon and Gary Cooke (see Chapter 9) and other members of the NHS accused of paedophile activity with boys. 130 | The Macur Review5.98 Other concerns were raised at the time and in submissions to this Review, not specific to Gwynfa, revolving around relevant expertise in the interpretation of health records, and also the connection between mental health issues and the survivors of child abuse.5.99 In regard to health records, a letter was sent to the Solicitor to the Tribunal from the Solicitor for the Welsh Office to the effect “... on 13 February I passed on the concerns which had been expressed by the Health Department in connection with paragraph 2(g) of the document entitled ‘Complainants’ Files Proforma’ ... Is there any record of, or reference to, psychiatric, psychological or medical treatment or examination whilst in care? If so, what and when ... [the] Health Department’s concern is that it appears that medical information of this nature is being extracted from medical records held on Local Authority files by those who may have no medical training and may therefore have difficulty in fully assessing their significance ...” 5.100 An aspect of ‘health issues’ that was excluded by the Chairman was that which Voices from Care wished to raise in relation to the “mental health of any of the survivors of child abuse witnesses” on the basis that “it is well known in mental health circles that there has been, and remains a lacuna between Mental Health Legislation and the Children Act 1989 in relation to mental health problems of children.” In a letter dated 6 November 1997, the Solicitor to the Tribunal wrote at the direction of the Chairman, “your comments on mental health appear to show a misunderstanding of the concerns of the Tribunal. The provision of mental health services to children in care is part of the general inquiry but the Terms of Reference make it clear that the major purpose of the inquiry is to prevent the occurrence of abuse to children rather than the arrangements for providing treatment when such abuse occurs.”5.101 The solicitor for Voices from Care disagreed, asserting that the second of the terms of reference allowed the Tribunal to investigate whether the agencies or authorities responsible for the care of children could have prevented the abuse, or detected it at an earlier stage, and that disturbances in the mental health of children should have been recognised as evidence of distress or anxiety which may have been linked to abuse. The Tribunal’s view was unchanged. The Chairman’s views on his terms of reference 5.102 The magnitude of scale imposed by the terms of reference set to the Tribunal is revealed in the Chairman’s correspondence in the period after the conclusion of the hearings. In a letter to the Secretary of State for Wales dated 16 November 1998, he wrote, “the task imposed by our terms of reference has been extremely wide-ranging and the volume of evidence to be distilled is enormous ... I have been working full time since the Tribunal’s hearings ended ... the task is very onerous because the reputations of many are at stake and accuracy of detail, as far as it can be achieved after the lapse of time since events occurred, is essential.”The Report of the Macur Review | 1315.103 To on 8 February 1999, who had complained of the delay in producing the Tribunal Report, he wrote in similar fashion, “like you ... I am very concerned that the report is taking so long to write but that is not because of any lack of effort to complete it as soon as possible ... The range of matters to be covered is enormous and the time scale of nearly a quarter of a century obviously increases the size of the task ... Summary conclusions would not satisfy anyone and detail cannot be avoided.” Conclusions5.104 I consider the rationale in the selection of 1974 as the starting date, and the definition of the geographical boundaries, to be sound and proportionate. The circumstances which triggered the inquiry reasonably prescribed it. The date chosen reflected the creation of the new Clwyd and Gwynedd county councils; the boundary encompassed the centre of the allegations of abuse and mismanagement. 5.105 Initially, the Welsh Office would seemingly happily have widened the public inquiry into other areas of England (see paragraph 5.11). There was good reason not to do so into counties where criminal investigations were still underway, such as Cheshire and South Wales. 5.106 Neither time nor geographical limit restricted the Tribunal in its investigations. Evidence was heard which fell outside the parameters of time or location if deemed relevant to a pattern of behaviour or course of conduct. The geographical limitations apparently did not interfere with the Tribunal’s consideration of the relevant employment history of convicted or alleged abusers in the care system beyond North Wales. The Tribunal was obviously alert to the possibility of a cross boundary paedophile network (see Chapter 9). Whilst it is arguable that a wider investigation of out of area activities and links, for example, in the case of John Allen, may have led to ‘bigger fish’, I have uncovered no evidence to suggest that this would be so. 5.107 I have no reason to conclude from the documentation seen by the Review that Lord Howard was seeking to avoid an investigation into the NWP. The full participation of the NWP in the Tribunal process demonstrates their co-operation with the process.5.108 I am satisfied that the co-operation of the Law Officers and the NWP with the Tribunal process ensured that, but for information concerning Gordon Anglesea referred to in paragraph 7.18, all information informing relevant CPS process was placed before the Tribunal. Inevitably, any restriction placed upon the Tribunal would and will be viewed with suspicion. The decision to exclude CPS decisions to prosecute from the Tribunal’s investigation was, and is, objectively valid on a constitutional basis. However, I consider there will be circumstances where intrepid investigation of the criminal justice process in this regard will be necessary to safeguard other constitutional and human rights and to assuage genuine public concern. I note the DPP’s response suggesting a possible reason why her past predecessor did not regard it necessary to establish an independent published review of prosecution decisions. However, in the circumstances, I consider there 132 | The Macur Review was sufficient criticism and speculation to trigger at least an overarching internal and independent review of all, or a random selection of, charging/process decisions made by the relevant CPS lawyers, and for the publication of general findings and indication of any remedial action considered necessary. 5.109 I considered to be an impressive and straightforward interviewee. His written reports were balanced in that they fairly acknowledged the difficult circumstances created by the scale and nature of the abuse, yet were unhesitatingly critical of the basic errors of approach, which in my view on the basis of the sample I inspected independently, he accurately identified.5.110 I am satisfied that both and in some cases were responsible for errors of judgment in varying degree. Taking into account all the circumstances, the documents and my interviews with each of them, I assessed to be overwhelmed by the scale of the 1991 police investigation and only responsible for advising in relation to prosecution files submitted in respect of police officers, as necessarily unaware of the possible interplay between other cases considered by and those concerning police officers.5.111 It is clear from their written responses to me that neither should be viewed as an independent agent with sole responsibility for the decisions reached. The size of caseload is remarkable. Today, it would be inconceivable that he would be assigned all cases arising from a similar sized police investigation. knew his initial views would be subject to review by his superiors. If erroneous, they were accepted and compounded by them.5.112 I record that there is no evidence to suggest that either or acted with anything other than professional integrity and in good faith. There is nothing to suggest that took decisions with a view to the protection of any abusers, and specifically, not in order to protect any establishment figure or other individual. Equally, and specifically in relation to the high profile case involving Gordon Anglesea, there is nothing to suggest that was unreasonable in the exercise of his judgment on the basis of the information then available to him. I do not consider that either of them were complicit in a ’cover up’. I accept that they operated in a different climate surrounding the prosecution of child abuse allegations, current or historic, to that which exists today.5.113 However, in my opinion, in light of the information provided to me by the contributor who attended the Review’s public event in Wrexham, one consequence of the CPS decisions not to prosecute is that complainants may have been deterred from participating in the Tribunal.5.114 The ongoing police investigations into lately revealed allegations of serious sexual abuse involving Gwynfa staff would have prevented the completion of the Tribunal’s investigation into allegations of abuse at Gwynfa. In the absence of any indication of the unreliability of the Trust’s evidence as subsequently revealed, and in view of the Welsh Office assurance as to future intent, it was reasonable for The Report of the Macur Review | 133the Tribunal not to proceed to determine inadequate or inappropriate managerial response. It is regrettable that the question raised subsequently as to whether the Trust was complicit in a cover up of the allegations was not resolved by the Tribunal, but I regard this issue to have surfaced too long after the hearings had concluded to then reconvene. 5.115 However, I find the lack of any amendment to the draft Tribunal Report following the Chairman’s receipt of Counsel’s written advice to be surprising. I have not found anything to suggest that the advice was circulated to the other members of the Tribunal. It was unnecessary for an amendment to be made in relation to the generic finding that abuse was likely to have occurred within Gwynfa. However, since Counsel’s advice specifically challenged the veracity and integrity of evidence laid before the Tribunal as to managerial response to allegations of abuse, I would have expected the Tribunal Report to explicitly refer to the possibility, at least, of tainted evidence which had been submitted by the Trust. The reliance that appears to be placed upon the evidence of Mrs Train, either in respect of findings made in the Tribunal Report,9 or at all, is now questionable.5.116 I have no reason to reject Mrs Train’s assertions of her good faith in preparing the reports, however inaccurate they transpired to be. Nevertheless, I regard the discrepancy between the nature of the assaults reported by her, and those to which Mr Brian Jones was said to have been alerted in August 1992, to be remarkable. The communications between the Health Group and Mr Wood that I have seen do not accord with his recollection to the effect that he was unaware of a problem prior to 1999, or that Mr Jones was unaware of the problem sooner.5.117 An absence of a specific term of reference in relation to children resident within NHS units was unsurprising given the preceding events leading to the establishment of the Tribunal. However, I have considered whether the framing of the terms of reference, or the Tribunal’s decision not to reach detailed conclusions regarding Gwynfa, or else to question the integrity of the evidence placed before it, could support any suggestion of a ‘cover up’. I conclude it does not. The terms of reference were drafted in ignorance of what later transpired. The reaction of the Welsh Office in briefing Counsel in respect of the Gwynfa allegations in the terms it did reveals no attempt to conceal this aspect. The graphic reaction of the Secretary of State for Wales to a briefing concerning the handling of Counsel’s advice revealed his wish for transparency. The Tribunal was able to consider the regime in Gwynfa and made generic findings of abuse.5.118 I am not in a position to adjudicate upon the degree and reason why misinformation was promulgated by the Clwyd Health Authority or the Trust concerning the Gwynfa allegations. It would be difficult to do so at this distance of time in the course of a non adversarial procedure such as this Review. It is at least probable that if the concerns referred to above had been explicitly drawn to the Tribunal’s attention during the hearings, a decision would have been made to require the attendance 9 See paragraphs 20.15 and 20.30 of the Tribunal Report134 | The Macur Reviewto give evidence of one or more member of Clwyd Health Authority or the Trust. The reality is that too much water has passed under the bridge to contemplate any meaningful inquiry into managerial inadequacy in the relevant period and would likely have little influence in present day practice. In my view, the appropriate investigation will be whether there is evidence of a previous conspiracy to pervert the course of justice, and, if so, whether criminal prosecution is merited. This is more a matter for a police investigation.5.119 The Tribunal showed no reticence in investigating and reporting upon the role of Lord Kenyon and his influence upon the criminal justice system in relation to Gary Cooke, or as Grand Master of a masonic lodge seeking to influence the Chief Constable of North Wales who had spoken out against police officers being Freemasons, or to advance the career of Gordon Anglesea (see Chapter 7). In those circumstances, the Tribunal was unlikely to deviate from investigation of any suggested influence he may have brought to bear to subdue Gwynfa complaints, by virtue of his connection with the Clwyd Area Health Authority and the Clwyd Family Practitioners Committee. 5.120 The refusal of the Tribunal to investigate mental health issues in general is understandable. The decision not to seek expert advice on the interpretation of medical notes was within the compass of reasonable Tribunal management decisions when seen in the light of the abundance of express evidence of abuse. The exploration of the possible warning signs of abuse, as exhibited by disturbed behaviour, was arguably encompassed by the terms of reference, but would have meant a significant incursion into the hearings’ timetable, and possibly at the expense of other topics. Time was clearly at a premium, as indicated in Chapter 6 herein. In the circumstances of the other factual topics that clearly called for detailed inquiry, and bearing in mind the comparative paucity of any factual evidential basis upon which to embark upon an investigation of mental health issues with care workers and other witnesses, I am satisfied that the Tribunal’s decision not to do so cannot be deemed unreasonable. There is certainly no basis to presume that this decision meant that abusers were thereby concealed from detection.5.121 The Tribunal’s consistent and demonstrated application of a “filter of relevance” for the evidence it received in relation to the terms of reference indicated its flexibility and was entirely reasonable. I find no basis in any of the Tribunal working papers or daily transcripts of proceedings for suggesting that a rigid, restrictive or formulistic approach was adopted for the benefit of any individual, establishment or organisation. 5.122 Having analysed the papers, I agree with the Chairman’s assessment of the breadth of the Tribunal’s terms of reference. The length and detail of the Tribunal Report substantiates those reflections. I have no doubt that to have increased the scope of the Tribunal in any respect would have been to render it unworkable and unfit for purpose. That is, due process must necessarily be observed and sufficient evidence must be considered to elicit meaningful findings. Those findings must be capable of being reported within a reasonable time span of the events in question to render them of more than historical significance. In order to do so, some limit must be prescribed and focus maintained. The Report of the Macur Review | 135Chapter 6: Procedure Adopted by the Tribunal in the course of the Inquiry Introduction6.1 The Tribunal was responsible for devising its own procedure. The ‘Note by the Chairman of the Tribunal on its procedures’1 justifies reading in full and is appended to this Report (at Appendix 3) for ease of reference. The procedure appears comprehensive and designed to facilitate a thorough investigation of the issues before the Tribunal. However, its implementation has been called into question generally for the reasons why this Review was established, that is, an accusation that the Tribunal was prevented from or failed to investigate and/or discover and/or report upon the extent of, and reason for, the abuse of children in care in North Wales. More specifically, Contributors to this Review have complained about, or criticised, aspects of the Tribunal procedure which they believe discouraged or prevented witnesses from giving evidence and which consequently, they say, undermined the validity of its reported conclusions. 6.2 Therefore, it was essential for this Review to examine the procedure adopted by the Tribunal and its implementation in some detail. This chapter reports upon the various stages of the procedure in terms of the effectiveness of the procedure in identifying and accessing the evidence, and the diligence and consistency with which it was applied, focusing particularly upon those areas which have drawn criticism or adverse comment. Part 1: Documents6.3 There is no doubt that the Tribunal could not begin to comprehend the scale of its task, or begin to commence its investigations, or conduct its hearings in any meaningful sense, without reference to all existing likely relevant documents. The possible sources were wide ranging. The extent of their availability unknown. Some documents, such as police statements, would obviously contain allegations of abuse. Those which did not, for example social services records, may otherwise corroborate or undermine significant parts of factual accounts. Others would assist in the identification of potential witnesses to give evidence relevant to the terms of reference. The weight to be given to the substance of any document would be able to be determined by its provenance and detail. The Tribunal had obviously anticipated that, in the circumstances, “any documentary or other supporting evidence of incidents to which [the complainants] referred was likely to be difficult to trace and patchy at best.”2 The Tribunal also formed the view that, particularly in relation to Clwyd county council, documents which did exist may be unreliable. Incidents were found to have been recorded “so that an uninformed reader would not surmise that an alleged assault had occurred” and, on some occasions, “would be distorted in order to nullify it.”3 1 See Appendix 4 of the Tribunal Report 2 See paragraph 6.01.of the Tribunal Report3 See paragraphs 30.15, 30.31 and 30.32 of the Tribunal Report136 | The Macur Review6.4 However, documents which might reasonably be expected to exist, but which were notably absent, inevitably raise questions now, as they could have been expected to have done then, as to the reason for their loss or destruction. 6.5 The nature and extent of the documentation obtained by the Tribunal is indicated in a letter from the Chairman in response to information requested by Liverpool John Moore’s University on 29 April 1998. He indicated that “all potential Tribunal Witnesses made Tribunal Statements prior to appearing to give evidence before the Tribunal … Over 12,000 documents have been scanned into the Tribunal data base. Identification of the various sources of the documents drawn together … Clwyd County Council, Gwynedd County Council, Gwynedd and Clwyd NHS, North Wales Police, Welsh Office; Private & Voluntary Children’s Homes; Various outside Counties children’s files; Crown Prosecution Service; Court records; Boys & Girls Welfare Society; Care Concern; Local and National media coverage; Independent Inquiries e.g. Jillings, Insurers ... the figures may not be exact ...”6.6 However, the letter did not refer to those documents sought by the Tribunal, but no longer available, although there is reference to missing documentation at various parts of the Tribunal Report. This part of the chapter reports upon the Review’s examination of the steps taken by the Tribunal to obtain documents, the difficulties encountered, and the reasons why, if known, documents were no longer available or not made available to the Tribunal.Issues relating to the availability and integrity of documents sourced by the Tribunal The successor authorities6.7 A written summary of a meeting between Mr Andrew Loveridge, (Director of Legal and Administration of Flintshire county council and assigned lead for the successor authorities in relation to the Tribunal) and Mr David Lambert, on 9 July 1996 records that “successor authorities to Clywd [sic] know the whereabouts of virtually all their files. Mostly they are held centrally in Flintshire. Copies are with the Insurer’s solicitors. Further to this all files are summarised and held on a database. Also available are the assessments which range from crude methods of linkage through to more sophisticated ones of plotting the movement of those convicted … In relation to Gwynedd, it is believed that the files were disaggregated between the three successor authorities with the exception to those involved in current claims - these were despatched wholesale to the Insurer’s solicitors. Further to this most of the files in Gwynedd are believed to be in Welsh and unorganised.”6.8 This appeared to accord with an earlier report of Miss Nicola Davies QC’s instructing solicitor that, “Gwynedd’s documents which were stored in two attics and were not easily accessible and which are poorly identified ...” whilst Miss Nicola Davies QC in 1995 had described Clwyd’s documents as “readily accessible and ... meticulously identified, indexed and stored, and cross- referenced on a computer ... All the documents which were made available to the police ... have recently been returned by them ...” The Report of the Macur Review | 1376.9 However, on 8 October 1996, the Tribunal Chief Administrative Officer informed Welsh Office officials of the difficulty “acquiring the files which have since the re-organisation of Local Authorities been distributed to several locations and have not yet been catalogued or filed ...” As it transpired, the problem did not wholly relate to re-organisation. On 13 November 1997, it was recorded that the audit of children’s social service files of Gwynedd and Clwyd county councils by the independent social worker, who had been commissioned by the Tribunal for this purpose, was taking time as the logs were in disorder lacking information or clarity as to what they referred to. 6.10 By fax dated 22 October 1996, Mr Loveridge informed the Solicitor to the Tribunal that he had very grave doubts as to whether the majority of legal files (that is, those referring to cases taken to court), certainly for Clwyd, had been retained and those which had been located had very little in them, apart from duplicates of the children’s files and the advocate’s note when attending court to obtain revocation of the Care Order. He went on to suggest ”the logistical implications entailed in continuing the trawl for legal files, which may prove fruitless, are tremendous and it may be, in view of the prioritisation attached to the other requests that this is something that Counsel may wish to reconsider.”6.11 An initial indication had been given that there were approximately 12,000 local authority children’s files. It turned out that the number was significantly less. An explanation was sought by the Solicitor to the Tribunal. In response, Mr Loveridge wrote, “you obtained your own estimates from the Welsh Office and relied upon them ... the estimates we have been [sic] provided you with ... have always been just that, estimates. Caution was urged upon you as to the estimate of 12,000 in the first place ...”6.12 Documentation was supplied piecemeal. On 11 November 1996, the Solicitor to the Tribunal wrote to Mr Loveridge, “on 7th November, Ms Griffiths gave to our team in Mold a file of case conference minutes relating to alleged abuse by Local Authority staff. This is a most useful document the existence of which we were previously unaware ... I would also ask you to clarify the position of the Successor Authorities in relation to the production of evidence: how is it that only on 7 November 1996 a collated and prepared file of case conference minutes comes to light, that it is produced informally to a member of our paralegal team rather than under cover of explanation between ourselves?” In answer it was said that the file had been returned from Miss Nicola Davies QC and its “usefulness was not immediately appreciated and it was therefore filed.” 6.13 On 1 July 1997, the Solicitor to the Tribunal informed Counsel to the Tribunal that he intended to speak to Mr Loveridge about the reasons why boxes of material continued to be produced in Mold in response to applications for discovery. He indicated that he had asked how much more material was yet to be passed to the Tribunal. He noted that the boxes that had been produced from the archives were in response to what Ms Sian Griffiths called the “modern records list”. This was said to list all files sent down to archives by the council departments. 138 | The Macur Review6.14 On 11 September 1997, the Solicitor to the Tribunal wrote to Mr Loveridge again, “as you may be aware [a local authority employee] visited the Tribunal office at Mold earlier today to inspect various documents in connection with Phase II of the Inquiry. During the course of his visit [he] was able to identify a number of policy and management files which were not available for inspection. [He] informed the Tribunal team that he had recently seen some of these files in the Social Services offices at Wrexham, and I understand that it has now been confirmed that these files are still at Wrexham. It is of some concern to the Tribunal team that the files in question have not hitherto been made available to it ...”6.15 On 18 September 1997, a fax was sent from the Director of Personal Services at Wrexham County Borough to Mr Loveridge indicating that, as a result of a Tribunal inquiry on 11 September 1997, “we conducted a search of Grosvenor Road offices and discovered a substantial number of files in a locked filing cabinet. They should have been submitted to the Joint Successor’s Inquiry Office at the time of the original request. We are currently investigating how they were missed in our initial trawl ... I can only apologise ... I am sure you will recognise the difficulties that we face in identifying every single file that should be submitted.”6.16 There is no indication of difficulties in obtaining the relevant files of children in care of local authorities outside North Wales.The Jillings Panel material 6.17 On 15 July 1996, Mr Lambert informed Mr Loveridge that “Mr Jillings has been in contact with me and he would prefer that his documentation is deposited directly with the Secretariat with access for the Police to consider the documents. For my part, I am very willing to arrange for this and to meet his request that help be given by the Secretariat staff to collate the documents before they are passed to the Secretariat.”6.18 However, it is not clear that all statements or records of interviews of those witnesses who attended before the Jillings Panel were released. In a letter dated 18 November 1996, from a firm of solicitors to the Solicitor to the Tribunal regarding the request for “...consent from specified clients for the release of statements given to the Jillings Panel” it was said that, “ ...[one client] does agree to this ... [another] is not prepared to give his consent ...” 6.19 On 12 November 1996, the Solicitor to the Tribunal wrote to Mr Loveridge indicating that Counsel to the Tribunal had annotated a computer printout of the documents provided to Miss Nicola Davies QC. He went on to refer to the fact that the missing documents may be in the Jillings material which were still in the process of inspection, but requested copies of the documents to be provided nonetheless. Bryn Alyn Community and other private residential homes6.20 Children in the care of local authorities would also be housed in private institutions. The Tribunal therefore sought relevant files and documentation from these establishments. The Report of the Macur Review | 139Bryn Alyn Community: The fire at Pickfords 6.21 On 25 October 1996, a fire occurred in Pickford’s storage depot in Chester, which destroyed many Bryn Alyn Community files that had been stored there. There is no evidence I have seen to suggest a targeted arsonist attack. A note of a telephone call made by the company secretary of the Bryn Alyn Community to the Tribunal that day refers to “the second set of files i.e. those not looked at by the police …not the current files, were stored in Pickfords which burnt down today ... Will be gaps as no way of knowing what was lost in fire.” The note continues that later that day “Sian [Griffiths] rang. Was sorting out Bryn Alyn files and conveniently (for Bryn Alyn) there are over 80 files of the key players missing …” She recorded that of the “victims who alleged abuse by John Allen in court, 3 are available, all others missing; From the children mentioned in passing, 9 files available and 51 missing; In relation to staff files, majority missing, Inquiry into Ken Taylor [presumed to be referring to Kenneth Taylor, Child Care Officer with the Bryn Alyn Community] and other abusers from 1991, 34 staff files connected with that inquiry missing.”6.22 A note to Counsel to the Tribunal from Ms Griffiths dated 30 October 1996 indicates “following our telephone conversation regarding Bryn Alyn files I can confirm that I have cross referenced the list of files which we have received from Bryn Alyn against (a) the staff and children who were mentioned … during the course of the John Allen Trial … (b) other staff who have worked for Bryn Alyn and who have also been employed by Clwyd … (c) other children who have been placed at Bryn Alyn and also in Clwyd and/or Gwynedd Homes … (d) John Allens offences relate to the period 1972 – 1985, there are no log books or other documents prior to 1988 … As you will see from the lists there is a substantial amount of documentation which is missing. During the course of John Allens Trial it was mentioned that he had a number of files at his house relating to Bryn Alyn and in particular the files of [three former residents] which he took to the Office in London. Greg Treverton Jones currently has all the documents relating to John Allen - the file contains a variety of documents ...” On 4 November 1996, Ms Griffiths was reported as “… currently holding all logs for Bryn Alyn Homes [from] 1988 to date (others burnt); and all child complaint files and the majority of staff files for Tanllwyfan (all log books destroyed). [Ms Griffiths] reported that after Care Concern shut down all homes [were] sold off but log books should be arriving from other homes in due course.”6.23 On 4 November 1996, the Bryn Alyn Community company secretary wrote to the Solicitor to the Tribunal “enclosing the list of files which I have available for inspection ... The ones that are still intact have come from the residential units which are still operational ... You will note that virtually no files exist from the list of discharges for young people who were resident at Gatewen Hall, this is because the Unit had been closed for some length of time and therefore all the files were in storage.” On 11 November 1996, he sent to the Tribunal a list of staff files, but indicated that, “Unfortunately the only files available for inspection are [two boxes] plus of course all current employees.” On 18 December 1996, he made a declaration that “the attached list of files, which were held in storage at Pickfords in Hoole Chester were, to the best of our knowledge, completely destroyed by fire on the 25 October 1996.” The lists attached appear to me to relate to staff files in the light of the P45 and National Insurance numbers provided. 140 | The Macur Review6.24 Other Bryn Alyn Community documentation came to light subsequently. A note from the Solicitor to the Tribunal to Counsel to the Tribunal dated 4 March 1997 records “I have spoken to ... solicitors to the Community ... [he] told me that he had taken into custody some 15 boxes of paper which consist of log books, personnel files and children’s files ... to ensure that the papers do not find their way into the custody of the Insolvency Practitioners ... I then spoke to [the company secretary of the Bryn Alyn Community] … In respect of the documentation, [he] said that the material which he had placed with [the solicitors] consist of all the material which he had kept aside for our purposes. He told me that there was no other relevant material in his hands ... Following my discussion with [Counsel to the Tribunal], I spoke again to [the solicitor] and asked if we could take custody of the boxes of papers ... He thought that this would be very sensible ... will take urgent instructions and revert.” Clwyd Hall6.25 In a file marked “Old Welsh Office Legal Documents” there is an undated memorandum reading, “Clwyd Hall for Child Welfare. Privately Run & Owned Independent School ... closed on 27th July 1984 … Only 1 file on Clwyd Hall. [Office of Her Majesty’s Chief Inspector] confirmed via telephone that they have no files on this establishment - they’ve all been destroyed.” However, the absence of documentation did not preclude police investigation or the fact that abuse had occurred. On 20 March 1997, a Welsh Office official informed Mr Lambert “about Clwyd Hall School … The Police had fresh allegations of abuse of pupils at the school, which they were investigating outside the North Wales Tribunal ... The Police have now re-arrested a former member of staff who has confessed to some offences ...” Other private establishments6.26 There is nothing in the documents to suggest that other private establishments, which housed or had housed children in the care of local authorities, were unable to produce their records. The Police6.27 The NWP indicated early on that they were willing to disclose all documents and materials relevant to complaints “where they are legally able to do so”. Save as indicated in paragraph 6.31 and 7.17, all prospective relevant statements made to the police were apparently made available to the Tribunal. In the case of other police documents, agreement was reached between Counsel to the Tribunal and Counsel for the NWP that some documents could be copied by the other parties, and other documents inspected but not copied. 6.28 However, an attendance note dated 8 July 1996 recorded that the NWP Solicitor was aware that some items were no longer in possession of the police. She said that the police did have a list of all files removed from social services departments of relevant councils signed on their return and an assurance had been obtained that they would be retained pending any judicial inquiry that may be announced. However, the The Report of the Macur Review | 141police did not have much documentary evidence covering the period 1974 to 1989. The force’s destruction policy imposed a three year limit on most files, a six year destruction policy on files where civil proceedings had been indicated and ten year destruction policy on police officer note books. Some categories of documents, such as working copies of taped interviews, were destroyed after twelve months. 6.29 That which was known to be available was discussed in a meeting held between Mr Lambert, the NWP Solicitor and investigating officers on 19 July 1996. The summary prepared indicated that “1. The Police statements from the 1990’s investigation are available … 2. There is an issue of claims of PII on many of the Police files - such as informants documents and legal advice ... will need to be presented to the Judge for his consideration. 3. The PCA will need to be approached for files ... 6. The extent of the investigation into each of the suicides would be limited to the Sudden Death File prepared by the Police for and held by, the Coroner … [The police] have a substantial library of press cuttings and videos of the TV coverage in relation to the 1990’s Investigation ... The Police are willing to provide the Judge with a list of suspects from previous inquiries to help him prepare for the possible categories of accused.”6.30 On 17 September 1996, DSU Peter Ackerley wrote to the Solicitor to the Tribunal, confirming that, “In addition to the documentation already supplied to you the following is a summary in respect of the situation concerning further material that has been requested; I): Request for two copies of all material held with the Major Incident Room system concerning the Gwynedd/Clwyd Major Police Investigation. All other documents; messages; actions; officer’s reports and telex messages have been researched, extracted, compiled and copied ... we are currently receiving legal advice about P.I.I. II): Request for a list of files in the Ownership/Possession of Clwyd County Council Gwynedd County Council Privately maintained Children’s Homes viewed by police during the course of the major investigation. The list has been compiled … awaiting legal advice … III): Request to produce copies of all files in respect of an allegation or complaint of abuse made either by children in care, children formerly in care or any other person since the 1st January 1974. The North Wales Police destruction policy meant that we were unable to fully comply with the request. However, [the NWP Solicitor] has written to you to set out the position and indicate other avenues which you may wish to explore. In respect of the period outside our destruction policy there are two avenues through which we may be able to comply with the request.142 | The Macur Review Firstly our Crime Recording System has been researched … second avenue … detailed manual search of some 12,000 Police reports ... Once any such allegations/complaints are identified then we will seek to marry up the reports with any other relevant documents ...”6.31 During the course of the Tribunal hearings, Counsel to the Tribunal were made aware of a criminal investigation into allegations of indecent assault made by a female adult family acquaintance against Gordon Anglesea. Subsequently, they were informed that no proceedings were to be taken against him. A request for the police/CPS file was made and refused as irrelevant to the Tribunal’s terms of reference. This is discussed further in Chapter 7. Medical records6.32 There is nothing in the documentation to indicate that the Tribunal, Welsh Office or any other government department had notified all relevant institutions or Community Health Trusts of the necessity to retain records that would otherwise be destroyed in line with routine destruction policies for the purpose of the Tribunal or other review. 6.33 In a note to Counsel dated 11 November 1996, a member of the Tribunal’s legal team reported, “There is a slight problem in relation to [Gwynfa] staff files. Namely, that they are destroyed after six years, so few exist. [The Trust] have provided a list as far as they can but are unsure as to its accuracy or completeness.”6.34 Some Gwynfa records were obviously made available; however, as indicated in paragraphs 6.77 to 6.79 below, it appears that some of the files that were provided were subsequently misplaced by the Tribunal. Unfortunately, the number and contents are difficult to discern. 6.35 As regards other health records, a letter dated 10 January 1997 from the Clinical Director of Gwynedd Community Health Trust to the Solicitor to the Tribunal, asked whether the Tribunal “needs any health records kept by the Community Child Health Directorate in the old county of Gwynedd. These records are destroyed routinely when the person reaches the age of 26 years. If you wish any or all of these records to be retained … let me know soon - otherwise the records will be lost.”6.36 An email dated 8 December 1997 between Welsh Office officials indicates that other records may have been destroyed. It reads “my secretary has tried to obtain files on Clwyd & Child and Adolescent Psychiatric services and although your department had a record of the numbers, she was told they no longer existed.” A response on the same day indicates, “I can confirm that according to our records the files quoted below have been destroyed. I can also confirm that at no time prior to the commencement of the Tribunal was any adict [sic] issued on which subject files should be retained. In fact during the reviewing exercise I and my colleagues have been identifying files and forwarding them to the relevant section.”The Report of the Macur Review | 1436.37 It follows that the Tribunal would not have accessed all medical records, whether by reason of destruction policies or otherwise.Welsh Office6.38 The Welsh Office provided the Tribunal with policy documents, statutes and statutory instruments. It appears from a response made by SSIW on 14 February 1995 to a question from the Jillings Panel about inspections, that many files containing old regional planning information had been destroyed. 6.39 The Record Management Systems presently operated by government departments appears to be based on the “Grigg system” of retention and disposal, which entails the review of documents after a five year period for identification of those which may be destroyed immediately or after an additional designated period without further review, or after an additional designated period with further review, and those which should be reviewed after 25 years. The National Archives are reputed to operate a “model retention schedule”. I am not aware which system was in force during the relevant time frame of 1974 to 1996, but would expect some such policy to have been operated. An efficient system would require a file listing dates of destruction of identified documents as a record of review. I have not discovered any within the Tribunal papers. 6.40 In an agenda titled, “Fourth meeting of North Wales Working Group” on 18 March 1997, reference was made to submission of other documents to the Tribunal. The note of the meeting records that insofar as the papers relating to Mrs Alison Taylor were concerned that internal minutes relating to the answering of Parliamentary Questions need not be included and neither need a letter to the AG. As to documents originating from third parties, these parties were to be alerted to the imminent disclosure of their documents. In the case of MPs, it was intended that the Private Office should notify them. The note records that “it was agreed that the Home Office should see all the Department’s evidence before it was finally submitted, particularly since it retains responsibility for vetting.”6.41 I note that Mrs Taylor appears to have submitted to the Tribunal copies of all documents that she had written, including letters to ministers and others and her own reports. These would have included those which had not been produced by the Welsh Office. Destruction policies other than indicated above6.42 One of the witnesses appearing before the Tribunal, referred to photographs seized by the police, which he said revealed sexual activity between males, some who could be clearly identified as establishment figures, and young males, some obviously below the age of consent and whom he identified as being in care, including himself. He believed these photographs had been destroyed by the police to conceal evidence and protect the abusers. He stated that the majority of the photographs were not deployed during a criminal trial and depicted the illegal sexual activity of two police officers, Gordon Anglesea and Peter Sharman.144 | The Macur Review6.43 There was evidence before the Tribunal that photographs had been secreted and were located with the assistance of and removed by police from the premises in which Thomas Kenyon, son of Lord Kenyon, resided. The Tribunal cross examined a police officer about the photographs, who acknowledged their existence at the time and that the contents of the photographs showed homosexual activity, but denied that the faces of participants, other than were revealed.6.44 In his interview with me, Mr Ackerley doubted the deliberate destruction of materials other than in accordance with force policy or as a result of court order at the conclusion of criminal trial if the imagery was classed as pornographic. This process is illustrated in a photocopied manuscript memorandum dated 18 November 1991 contained within the Tribunal papers, sent from a Detective Constable in Llandudno to the Chief Superintendant, indicating that a video cassette tape seized on 15 November 1990 from the Ambulance Station, Old Colwyn and containing “various scenes of child pornography” was housed in the Superintendant’s safe at Colwyn Bay Police Station. David Hughes (see paragraphs 7.11 and 8.84) and another had been convicted of offences in relation to the tape and a destruction order had been made by Flintshire Magistrates Court. David Hughes’ appeal against sentence had been rejected and the officer therefore requested that the tape should “now be destroyed”. The request was approved and the document annotated “Destroyed by burning” is signed and date stamped 4 December 1991.Deliberate withholding of documents from the TribunalFormer auditor of Flintshire county council’s allegations6.45 In response to my call for information relevant to my Review, I was contacted by Mr Andrew Sutton, a former auditor at Flintshire county council and subsequently met with him on 6 February 2013. 6.46 Mr Sutton explained that one of the reasons he had left his employment at Flintshire county council was as a result of difficulties created, he perceived, by his repeated yet frustrated call for explanations of payments made to Ms Griffiths sanctioned by Mr Loveridge. Mr Sutton’s principal concern was that information had been deliberately withheld from the Tribunal by Ms Griffiths.6.47 His consequent claim for constructive unfair dismissal succeeded and was upheld on appeal. He consented to the disclosure to the Review of all Employment Tribunal papers relating to his case. They were considerable in number.6.48 It is evident from these papers that Ms Griffiths was claiming a significant amount of money in overtime in relation to her role assisting the Tribunal. The documents record that Mr Sutton, as auditor, was asked by the Director of Finance for Flintshire county council to investigate and obtain documents to substantiate the payments. The Tribunal’s accountant, Mr Roger Parry, also sought a detailed breakdown of the overtime claimed. Apparently, despite repeated requests from both Mr Sutton and Mr Parry, Mr Loveridge did not provide the information requested. It seems that The Report of the Macur Review | 145ultimately the overtime was paid on the basis of assurances given by the Director of Finance to Mr Parry to the effect that Mr Loveridge had justified to her the level of overtime worked and that the claims were correct. 6.49 During his interview with me, alleged that he had received “threats” from police officers during his audit of these payments. He referred to who was who told him to “back off” and “Beware of the Brotherhood”, which he believed to refer to masonic influences. In a letter written by in 2001, found within the papers received from his solicitors, it appears that at that time he considered these warnings to have been said in a “supporting manner” and in respect of a number of investigations that he was conducting into the council at that time. Apparently, his view had changed by the time of the interview with me and he appeared to regard them as sinister. 6.50 Mr Sutton thought that the overtime payments may have been made to Ms Griffiths because she had threatened to expose the deliberate withholding of documents from the Tribunal. This Review has been provided with a copy of an audit report by Audit Services of Flintshire county council dated June 2002, which found no documentary evidence of hours worked and recommended more stringent controls of overtime. However, the report made clear that there was no evidence that overtime had not been worked. 6.51 The statement of and a witness to the Employment Tribunal convened to hear Mr Sutton’s claim, refers to her conversation with Mr Howard Marshall, who was acting as Ms Griffiths’ union representative. Part of the statement recording the detail of the conversation is tippexed out and is replaced by a manuscript sentence. The relevant extract with the handwritten amendment reads: “On this particular occasion, Howard Marshall told me that he had just spent the morning with Sian Griffiths in his office and that she was very angry and said that if she did not get the settlement she wanted, she would start to make allegations about what she and had done in the past in the course of work.”6.52 The original text still visible beneath the tippex reads: “On this particular occasion, Howard Marshall told me that he had just spent the morning with Sian Griffiths in his office and that she had been very angry and said that if she did not get the settlement she wanted, she would start to tell people how much information she had assisted in holding back from the Waterhouse Tribunal.”6.53 I wrote to on 21 May 2015 alerting her that I intended to refer to her witness statement provided for the purpose of Employment Tribunal proceedings, and specifically in relation to the amended paragraph as indicated above. sought a meeting with me in response to that letter. I interviewed her on 22 June 2015. 146 | The Macur Review6.54 told me that she was a staff development and training officer for Flintshire county council and had been a union official at the relevant time. She said that she was not responsible for the amendments to her statement. She pointed out that she had not signed the amendment as acknowledgment of the change and that the handwriting which overlaid the tippex was not hers. The author of the manuscript was unknown to her. She said that she had not been aware prior to our meeting that such a change had been made. She confirmed the accuracy of the original wording in the statement and went on to re-iterate the fear that Ms Griffiths had withheld materials from the Tribunal. She was aware that Mr Christopher Clode, a former Child Services Manager of Flintshire county council (see paragraph 6.59) had subsequently contacted the Tribunal to this effect, but had been told that it was “too late”.6.55 Consequently, and with the support of the local authority’s pensions officer who, despite an independent local government pension arbitration service upholding Ms Griffith’s claim, thought it remarkable that Ms Griffiths was “earning more than the Chief Executive” over the period during which the Tribunal was sitting, alerted the police to her fears that evidence had been suppressed. had visited subsequently and later told her that Mr Marshall had denied her account. She said that the police officer had not taken notes during his meeting with her or taken possession of the documents photocopied by the local authority’s pensions officer, which related to Ms Griffith’s overtime claims. To her knowledge, the matter was taken no further. 6.56 told me that she believed she had been under the surveillance of undercover police officers around this time, although she could not be sure whether it was before or after her conversation with Mr Marshall. She believed her telephone had been tapped. She knew that had received threats. She had suffered work related stress and had moved home.6.57 also indicated that she had been told, four years ago, of a former local authority official destroying documents, but said that it was difficult to “tease out what was gossip and speculation”. 6.58 I note that Mr Loveridge did not give evidence before the Tribunal, although he was the recipient of a Salmon letter. A “Note to advocates” distributed during the course of the hearings informed them that “Mr Loveridge is a Salmon Letter recipient. The Tribunal has received a [medical] report indicating it would not be appropriate for him to attend to give oral evidence. For the moment, it is proposed that Mr Loveridge’s statement will be taken as read ... The Tribunal will consider applications by parties for leave to administer interrogatories ...” The Salmon letter concerned his advice to Clwyd county council as County Solicitor in relation to various external and internal inquiry reports.6.59 In May 1999, after the conclusion of the Tribunal hearings, Mr Clode, who gave evidence to the Tribunal on ‘Whistleblowers Procedures’, left an answer phone telephone message at the Tribunal offices suggesting that information had been The Report of the Macur Review | 147withheld from the Tribunal. A member of the Tribunal Secretariat returned his call and the note of the conversation reads, “the information he had concerned Mrs Sian Griffiths. During the Hearing Mrs Griffiths managed the Successor Authorities Office. Prior to that she had managed the Bryn Estyn Office for Clwyd County Council. Before that she had been Senior Staff Officer and had been involved in appointing some of the staff who had looked after the children. [She] is in dispute with Flintshire County Council … has been on sick leave since the end of the Hearing and is negotiating retirement on the ground of sickness. At present she is in dispute about the settlement figure and has said that (Mr Clode’s words) ‘if the Council do not settle on her terms she will go public about information that Andrew Loveridge and Flintshire County Council asked her to keep from the Tribunal’. Mr Clode said that the source of this information was … who had heard the story from Mr Howard Marshall, a full-time official with the Union who was involved with the negotiations.” 6.60 The Clerk to the Tribunal discussed the matter with Mr Gerard Elias QC and Mr Ernest Ryder. A note of her conversation with each reveals that Mr Gerard Elias QC did not consider the matter could be taken further in light of the multiple hearsay involved and that he could not think of any information which could have been concealed. Mr Ryder was only concerned about information that would have come in at the end of the Tribunal [that is in reference to issues in relation to general child care policy] by which time she had little public part to play. The Chairman was informed. In his view, it would be difficult to take further action on the basis of the information, although it left the Tribunal in a very difficult position.6.61 I wrote to Mr Gerard Elias QC about this issue on 15 May 2015 indicating that I was minded to express surprise that this matter had not been referred to in the Tribunal Report, or referred to the NWP. He responded that he was no longer retained as Counsel to the Tribunal in May 1999, but had been contacted from time to time “during the report writing stage ... to help or comment on matters.” He believed he was asked by the Clerk to the Tribunal for his informal view over the telephone. He does not recall seeing any of the correspondence at the time, but was appraised of its “general import”. He felt that the allegation was one of “hearsay piled on hearsay”. He said it would not be his decision whether to refer the matter to the police or not for investigation into the possibility of what may have been a conspiracy to pervert the course of justice.6.62 I wrote to Lord Justice Ryder on the same day and in similar terms. Lord Justice Ryder responded confirming that he had been approached by the Clerk to the Tribunal for his views. He too indicated that at that time he was no longer retained as Counsel to the Tribunal and did not formally advise the Tribunal. However, he thought it reasonable that he should have been asked for his recollection of matters during the course of his retainer, and he considered this the real object of the exercise.6.63 Lord Justice Ryder confirmed the information recorded in the note of the telephone conversation to the effect that he could not identify anything which he had suspected of being withheld at the time of his retainer, “the Tribunal had taken 148 | The Macur Reviewpossession of computer and hard copy indices of the materials that formed part of the Flintshire record and the Jillings Inquiry record. Those indices were checked against the original documents and computer records that the Tribunal was given and no material was found to be missing.” He had advised the Clerk to the Tribunal that if the information was to be considered by the Tribunal, it would be “prudent” to ask the informants whether any were prepared to discuss matters “on the record”.6.64 Mr Clode was contacted on behalf of the Tribunal and informed on 19 May 1999 that it could only act if it was “in receipt of information which could have been called as evidence by the Tribunal”. Mr Clode indicated that he would pass on any further information he received. I have found nothing further on this point. 6.65 One contributor to this Review, Mr Mark Isherwood AM, has claimed that the Chairman told him in a private conversation, during a National Assembly for Wales event, that he was aware of the allegations regarding Ms Griffiths and believed that documentation/information had been withheld from the Tribunal. The same contributor reported that a member of FACT informed him that key information had not been submitted to the Tribunal, implicating Ms Griffiths to be responsible for this omission. Another, a victim of abuse, suggests that parts of the social services files supplied to the Tribunal were missing or altered.6.66 Several contributors, apparently unaware of this issue, question the Tribunal’s reliance placed upon the good faith of those who had been employed by the former county councils, despite the potential for a conflict of interest. One, Mr Glyn Alban Roberts, said that he had contacted the Chief Executive of Gwynedd county council in the lead up to the Tribunal and was assured that the information he gave would be forwarded to the Tribunal, but since he was not contacted thinks this may not have happened.Television interview6.67 Ms Griffiths appeared in a television programme broadcast on 8 December 2012 titled ‘The Past on Trial’. I viewed the programme from a DVD recording. In the television interview she herself implied that there was information available which was not taken into account sufficiently or at all by the Tribunal, and that there were people ‘walking free’, including establishment figures. She suggested that non-establishment figures, named by a convicted paedophile, Gary Cooke, as being involved in the abuse of children, were required to attend at the Tribunal whilst establishment figures named by him were not. She questioned the destruction of Polaroid photographs, which she understood to be by order of the Crown Court, which apparently showed the presence of members of a paedophile ring and which would lead to their identification (see also paragraph 6.42). 6.68 As will be apparent from the contents of Chapter 9, her recorded comments about establishment figures named by Gary Cooke were inaccurate, and her insinuation about the Polaroid photographs probably misinformed. That is, Gary Cooke did not name public figures other than Lord Kenyon and his son, Thomas, when giving evidence before the Tribunal, both of whom were dead. There was evidence before The Report of the Macur Review | 149the Tribunal, and I take judicial notice of the fact, that it is normal practice for a destruction order to be made of offensive/pornographic material at the conclusion of trial. The Polaroid photographs are referred to in the Tribunal Report.4 6.69 I requested an interview with Ms Griffiths and met with her in Chester on 24 April 2013. Prior to interview, I wrote to Ms Griffiths indicating in general terms the allegations that had been made and which I wanted to discuss, namely that she may have been involved in withholding relevant documents from the Tribunal, and that she may have received a financial benefit for doing so. 6.70 She was informed of her right to be accompanied to the interview, but chose to attend alone. Ms Griffiths was distressed at one point during the interview, incongruent to the subject being discussed at the time, but answered all questions asked of her. 6.71 Ms Griffiths denied that she had withheld Tribunal materials for gain or otherwise. When reminded of her reference to Tribunal documents during the television interview, she conceded that she had kept possession of a “handful” of files, which contained duplicate documents concerning the paedophile ring; she had not done so intentionally but “went off sick” and had not returned to County Hall since. In particular, “there were four, there were five folders that were the paedophile ring which were in my house which the police have now had back.”6.72 She claimed that she had been deliberately positioned and filmed in front of a shelf “covered in folders” as she read from Tribunal documents, and sought to distance herself from the television journalist’s commentary broadcast at the time that “she was the administrative gatekeeper who kept everything and showed me only a fraction of it …” She insisted that the numerous files shown in her home during the television interview related to the Mold Rugby Club, of which she was Secretary.6.73 During my interview with her, Ms Griffiths specifically and repeatedly denied any knowledge or possession of information relating to any establishment figure, which was not produced for evaluation before the Tribunal. I am informed that police officers attended at her address on 5 December 2012, removed the files and returned the original documents to Flintshire county council. This Review has been provided with a schedule of the documents she had retained and I can confirm that the files appeared to be duplicates of other materials seen and which had been available to the Tribunal, some of them had been referred to in evidence.6.74 I wrote to Ms Griffiths on 15 May 2015 seeking any further comments she wished to make in regard to my provisional views relating to the television interview. She initially responded by email dated 31 May 2015 indicating that she had not been able to respond by the deadline of 29 May 2015 as she wished to take legal advice. Thereafter, she sent two emails dated 1 and 3 June 2015, each denying the substance of my provisional criticisms of her and adding that she did not wish to comment further on the matter. 4 See paragraph 52.67 of the Tribunal Report150 | The Macur Review6.75 I record as pertinent to this issue that in a Tribunal file of Mr Gregory Treverton-Jones, there is an ‘Analysis of Complaints of Abuse in Staff Files’: “1. For the purpose of earlier Inquiries, all of the Clwyd Local Authority staff files had been researched by Mrs. Sian Griffiths ... in order to discover whether there were any complaints of abuse contained in those files. 2. Having identified a large number of alleged abusers from the Police Inquiry witness statements, the present Inquiry team researched in detail all of those staff files in which complaints of abuse had been discovered by Mrs Griffiths. In addition, and in order to ensure that Mrs Griffiths’ research had been thorough and comprehensive, the Inquiry team researched a further 100 staff files on a random basis. No evidence of child abuse, or complaints of abuse, were found in these files, indicating that Mrs Griffiths’ research had indeed been both thorough and comprehensive ...”Handling of documents by the Tribunal6.76 One contributor to this Review commented adversely on the state of files returned to Bryn Estyn at the close of the Tribunal. She described them as in disarray and questioned whether they had been handled or stored appropriately with regard to their sensitive contents. 6.77 In a letter dated 2 September 1998, addressed to the Welsh Office, the Trust’s Chief Executive complained that “there are still a number of Gwynfa files that appear to be missing. Because the Tribunal failed to catalogue the records as they originally agreed, we have no definitive list of the records which were taken into the Tribunal’s custody. What we do have, is the list compiled from the Gwynfa Admissions Book and also a list of files which are known to be missing ... We were told by Tribunal staff at the time that the Gwynfa files were being split up and filed with the other documents relating to individuals ... the probability seems to me that the absent files have been sent back with other papers to either Local Authorities or to whoever else papers were returned to.” 6.78 An email to the Clerk to the Tribunal from the Tribunal Assistant Administrative Officer dated 17 September 1998, headed ‘Bryn Estyn Log Books’ reports, “I met with Mrs Sian Griffiths last week and she was able to hand over a further four files from the missing files list for Gwynfa ... Sian can trace no record of having booked in or received files for [six others]. It is always possible that we never received these files. Gwynfa do not have a list of what was sent to the Mold Office. It is also possible that they remain in the Successor Authorities office but they have been misfiled.”6.79 On 26 November 1998, the Tribunal Assistant Administrative Officer wrote to the Trust’s solicitors enclosing five of the missing files and reporting that, “According to your records there remain 9 files which your clients cannot trace on their premises and which they conclude were forwarded to the Tribunal offices and have not been returned ... We have run these names through the Successor Authorities computer The Report of the Macur Review | 151system and this has provided us with the following information: [in relation to four names] no record of a Gwynfa file; [in relation to a further four names] no file; [in relation to one name] file returned to Gwynfa on 27/5/98. We obviously cannot rule out human error and the possibility that a file was received and was not entered onto the computer but this seems unlikely as I understand that a secondary system was in operation by the Tribunal Office and that this corroborates, insofar as it is able, the Successor Authorities records ... [which] suggests that no Gwynfa files were used by the Inquiry. Files were not usually called for unless they were going to be used and this may therefore question whether they were ever received. However, our records do show that there are three pages in the PII material of [E] which would appear to have come from her Gwynfa file. The remaining six names, with the exception of [T], do not appear on the Schedule of Abuse for Gwynfa. In the absence of information to the contrary therefore we would conclude that with the possible exception of [E] the Tribunal would not have sought the production of files for these individuals ...”6.80 I indicate in paragraph 6.198 that it is evident from notes between Counsel to the Tribunal and the Chairman that a staff file was lost during the course of the Tribunal relating to Keith Bould.Part 2: Witnesses6.81 The Tribunal could not expect that the allegations of physical and sexual abuse in the documents they obtained would give other than an indication of the wider picture to be investigated in accordance with the terms of reference set. The identification, engagement and encouragement of witnesses to give evidence, whether orally or in writing, was therefore crucial to the Tribunal’s work. 6.82 A decision was made, ‘as a general rule’, that the only evidence of abuse that the Tribunal would consider would be from complainants traced and willing to make a statement to the Tribunal. This part of this chapter examines those aspects of the Tribunal’s procedure which dealt with the seeking out and tracing of witnesses, the support provided to them, the obtaining of fresh statements and the practical arrangements made to facilitate them giving evidence. 6.83 The Tribunal’s working documents reasonably anticipated that many prospective lay witnesses, who could provide evidence in relation to child abuse, may be reticent to do so for a variety of reasons. In a meeting in July 1996, between the NWP and Mr Lambert, it was indicated that “the police are very willing to share their wealth of experience on methods of approach to witnesses ... They are also able to help substantially in the tracing of witnesses. Also in helping name people referred to in statements by their first names or by nicknames.” In August 1996, the NWP Solicitor suggested that difficulties could be anticipated when approaching many of the potential witnesses by reason of their past experiences. She indicated that some “have now established a new life for themselves and their period in care is unknown to their new families and friends. Some of the witnesses present a suicide risk and should be treated with the utmost care and delicacy. Many of the witnesses are unlikely to respond to an approach by telephone or letter and indeed, it is the 152 | The Macur Reviewconsidered view of the North Wales Police that many of those previously interviewed will only respond if approached, in the first instance, by the officer with whom they established sufficient trust to be able to provide an account of what happened to them...” The Solicitor to the Tribunal responded, “I can see that we will need the help of the police in tracing some witnesses in due course. My present view however is that it would not be appropriate otherwise to involve the police.”6.84 In this regard, I note that at the bottom of one NWP statement is recorded, “1205pm 19/10/92 Refused to sign statement but agreed with its contents. The witness was most uncooperative with enquiries and made it clear he was anti police. Signature [WPC]”. This clearly indicates antipathy towards the police, for whatever reason, and therefore prospective lack of engagement. 6.85 Mr Loveridge had echoed the views of the NWP in a meeting on 9 July 1996, when he reported that “alot of the abused will not want to be identified as have [sic] been abused. Alot of the families of the abused will not be aware of this aspect of their past. Also, the abused are wary of the Police and the Authorities and of course the Press ... these people will not want to be seen at or near the location of the Tribunal or the place where the written statements are taken ... (if Sian Griffiths or Andrew Loveridge … are approached with names, they could warn on the individuals traits??)” 6.86 This suggestion that Ms Griffiths or Mr Loveridge should advise the WIT in relation to the characters of the complainants to be approached was not formally countenanced at this stage.6.87 The Tribunal commenced to seek witnesses on its own behalf. The Tribunal’s advertisements seeking witnesses6.88 In a letter dated 27 August 1996, Mr Lambert informed a firm of solicitors already approached by prospective Tribunal witnesses that “advertisements will be published and there will be accompanying media press notices ... The advertisements will appear in the Daily Telegraph, the Birmingham Evening Mail, the Manchester Evening News, Liverpool Daily Post and Western Mail. Neither the advertisement nor the accompanying press statement will invite persons to come forward to give evidence. A further advertisement to be placed in most national newspapers at a later date … will invite persons to come forward. By the time that this subsequent advertisement is published, a counselling service will be available to help to give support …” 6.89 The further advertisements appeared in local and national newspapers in the fashion of inviting anyone “including former residents of the homes, former foster children, families, staff and the general public to come forward with any evidence relating to the Inquiry” and providing contact details for the Tribunal team. At the relevant times, public notices were issued giving details of the timing and location of preliminary hearings, their purpose and inviting anyone with a relevant interest to attend. The Report of the Macur Review | 153Other advertisements6.90 On 18 September 1996, a file note from a member of the Tribunal’s legal team alerted the Solicitor to the Tribunal to the fact that one solicitor’s firm was requesting those abused as children to come forward. HTV Wales were reported to have aired a news item on 18 September 1996 indicating that the solicitor’s firm in question was holding a “meeting” at a hotel in Bangor for this purpose. The Daily Post had printed a “news item” the previous day making a similar request. The Liverpool Daily Post featured an advert from the solicitor’s firm on 18 September 1996. Complaints were made to the Welsh Office and the Tribunal about these advertisements by complainants and other solicitors, particularly in light of the absence of adequate counselling services.6.91 Submissions have been made by two contributors to the Review, to the effect that they had not been aware of the establishment of the Tribunal or its proceedings. This is contradicted by submissions made by a solicitor, who appeared before the Tribunal on behalf of complainants, who stated “nobody in North Wales could possibly have been unaware of the existence of the Tribunal during its sittings from the publicity provided by newspapers, TV, radio, friends or conversations in pubs and clubs. Victims had every opportunity and encouragement to be heard.”Telephone helpline6.92 The advertisements contained the number of the Tribunal telephone helpline, established to field calls from prospective witnesses and deal with other inquiries. Telephone operators were briefed in the appropriate manner of response to likely queries raised. I have seen records of telephone calls and a brief description of the nature of the query and response that were kept. Telephone calls made out of office hours were recorded and a written record subsequently made. Generally speaking, individuals contacting the Tribunal helpline who appeared to possess relevant information were invited to be interviewed by the WIT, or on some occasions, the Solicitor to the Tribunal. Pro forma documents were created with initial details and, presumably, passed on for action. 6.93 However, for the sake of completeness, I note that the available records in relation to two telephone calls received from indicate that one was not passed on for follow up without reason given, and the other apparently not adequately responded to. In the first case, which involved allegations of physical and sexual abuse against unnamed members of male and female residential care staff at a children’s home between 1976 and 1980, there is no record of action. It is possible that follow up documentation which indicates that the message was actioned was mislaid, although this seems unlikely in the context of what appears otherwise to be a complete set of this documentation. In the second case, in which a caller was seeking to make a Tribunal statement reporting additional allegations of physical abuse to those contained in his police statement, the operator’s response appears to have been formulaic. That is, the caller was informed that his police statement was available and his additional 154 | The Macur Review comments noted. The same complainant telephoned again five days later asking about the Tribunal’s progress and offering to give evidence regarding Bryn Alyn. There is no record of the response given, but searches reveal that no statement was taken and the complainant was not called to give evidence. There is no document found which explains the reason to reject the offer made of further evidence. I make clear that neither call suggested the involvement of an establishment figure. The Tribunal’s random selection of witnesses6.94 A ‘Briefing Note’ prepared by Jones Health Statistics Analysis explains the reason and method adopted by the Tribunal to select potential witnesses who had not responded to the advertisements or otherwise made themselves known, “The aim is to examine a sample of records relating to people who, when children, had stayed in any of the Children’s Homes in Clwyd or Gwynedd since 1977. The sample will be made up of 5 per cent of the residents over this (about 20 year) period. The records are currently being retrieved and it has been assumed that there will finally be about 12,000 ... The figure of 12,000 is a rough estimate ... A 5 per cent sample (600 records out of the 12,000) was thought to be a fair compromise between the accuracy of the resulting estimate and the effort expended in examining increasing numbers of records. Annexe A gives two sets of random numbers (generated using the statistical software package ...): one for Clwyd, one for Gwynedd ... Taking a sample using these random numbers means that each record will have an equal probability of being picked. A person’s being picked will not depend on their length of stay or the number of separate stays. It will make no difference to the validity of the sample whether the records themselves are in a random order or in some logical sequence ...”6.95 Further statistical advice was needed when it transpired that the number of files were significantly lower than at first thought (see paragraph 6.11 above). The advice indicated that, “the consequence of a much lower total number of records - about 7,000 instead of 12,000 - is that a much smaller number of sample records will be extracted ... In order to achieve the same accuracy you will still need to sample 600, but this will represent a larger fraction of the total number of records ... If you do want to extract a sample of 600, you will need an additional scheme of numbers from us ...” The number of children’s files recorded as seen by the Tribunal is 9,500 not 7,000. 6.96 The ‘Random 600’ as it continued to be referred to within the Tribunal working papers was not universally approved. A Chief Executive of one of the successor authorities wrote on 4 November 1997, “I must record our disagreement with this method of survey. Choosing files from such a small sample of children dealt with by the previous Social Services Authorities, is likely to lead to unbalanced conclusions. The number of complainants represents only a small proportion of the children actually dealt with between 1974 and 1996.” In response, the Solicitor to the Tribunal defended the decision, “1(a) The random sample is a statistically relevant sample as advised by the expert statistician whose advice will be produced in evidence to justify the sample. 1(b) Our Terms of Reference direct us to the association between abuse and social services processes, and not an analysis of child care practice in general. It is therefore appropriate to limit the sample to those who have given evidence to the Tribunal, oral or read.”The Report of the Macur Review | 1556.97 In any event, as it transpired, the exercise was not fully implemented in execution. A Tribunal ‘Working Note’ dated 5 March 1998 and headed “The Random 600” reads as follows, “1. The Tribunal Investigating Team have recorded that they have completed inquiries into 111 of the Random 600 ... Of these … 52 either refused to make statements or were unable to do so due to age, ill health or demise … 37 provided statements averring that they had no complaint to make ... 12 made statements of complaint, although not all of these were complaints of physical or sexual abuse ... and some of the 12 were already Tribunal witnesses having made complaints to the Police during the 1991/1992 investigation. 2. In the light of this general level of response, together with the volume of evidence already obtained from other witnesses, it was felt inappropriate to seek to interview the balance of the 600”.6.98 The Tribunal Report does not specifically indicate that the process was discontinued prior to completion. Evidence sought in support of allegations made in police statements6.99 The Tribunal was supplied with the police statements of approximately 650 complainants of abuse seen during the 1991 investigation. A “Note re Administrative Systems” by Mr Treverton-Jones reveals that a team was “presently researching police statements made during earlier inquiries …” Some of those complainants were also part of the sample selected by the ‘Random 600’ (see above) and also the ‘volunteers’ who had come forward as a result of the Tribunal’s advertisements. 6.100 A WIT progress report filed on 11 October 1996 notes, “statements and last known addresses have been filed in alphabetical & numerical order ... currently the Master Copy List shows 671 witnesses which will probably be increased via Helpline/Solicitor/Others.” If accurate, the note corroborates the efficiency and industry of the WIT. Other documents record the efforts of the WIT to trace witnesses through the Benefits Investigation Branch and other bodies with varying degrees of success. In some cases where last known addresses were obtained the witness is reported as not traced (see, for example, paragraph 6.199). 6.101 In opening, Mr Gerard Elias QC referred to the fact that social services files had been researched for approximately 70% of those who had made police witness statements, and in about 35% of cases, their current address had been traced. He stated, “efforts to trace have been followed, where successful, by a detailed re-interview and by a careful targeting of the tracing efforts we are confident that most of those who made the more serious allegations in 1991/92 will by now have been covered by our new investigation.”6.102 There are complainants who had made police statements who apparently were not sought by the WIT, it seems on the basis that assurances had been given to those they accused (see below) or when Salmon letters sent to those individuals withdrawn or that there was sufficient other evidence dealing with the nature of abuse which their allegations concerned. 156 | The Macur Review6.103 The documents reveal other prospective witnesses that the WIT did not seem to attempt to trace, without reason given or apparent to me. One such complainant, had made a police statement alleging physical abuse against Nefyn Dodd, but also had seemed to refer to abuse in foster care, as recorded in her social services files, which a file note from Mr Treverton-Jones suggested should be followed up. In another case, the complainant, made allegations in a police statement of serious sexual abuse against a foster father, convicted in relation to other foster childrens’ allegations. The Tribunal Report referred to her allegations but concluded that she “was not called to give evidence to us and we are unable to say whether there was any truth in her allegations.”5 There are no documents available to me which indicate what, if any, attempts were made to locate her or assess her competence to give evidence. Another complainant, alleged a significantly more serious physical assault against a care worker concluded to have been responsible for other lesser assaults, but does not appear to have been sought.6.104 Two contributors to this Review, have queried why, despite what they think should have been contained in their social services records, they were not approached on behalf of the Tribunal and asked to give evidence, saying they could have provided relevant evidence, including that relating to paedophile links in other areas. I note that at least one of these contributors had not made a police statement. said that he had refused to make a police statement for fear of reprisals.Schedule of allegations6.105 Writing to a regional union officer in October 1999, the Chairman indicated that, “Counsel to the Tribunal prepared, for the assistance of the three members of the Tribunal, two ‘Schedules of abuse’: one of these listed, in respect of each individual against whom a complaint had been made, the name of each complainant, the latter’s period of stay at the relevant home, and the category of alleged abuse; and the other schedule listed the same allegations by reference to each residential establishment ...”6.106 This Review’s analysis of the Tribunal’s schedule of allegations contained in the police and Tribunal statements confirm it to be largely accurate. There were a small number of omissions or an incorrect categorisation of the abuse alleged; none of which involve an allegation against an establishment figure (see also paragraphs 2.46 and 2.47). However, it is important to note that this Review has not been able to trace all police statements referred to in the complainants’ Tribunal and/or other police statements or referred to in the daily transcripts. 6.107 I deal in later chapters with particular inquiries directed to be completed in relation to specific offenders and topics of interest to the Tribunal. Generally, it is clear from the Tribunal documents that Counsel to the Tribunal sought to lead evidence of allegations dealing with the spectrum of abuse within residential establishments and 5 See paragraph 25.69 of the Tribunal ReportThe Report of the Macur Review | 157 in foster care, more particularly the serious abuse, as informed by the Schedules compiled. By way of example, there is a query raised in a ‘Note to the Tribunal’ from Counsel to the Tribunal, “At present, we have no statement of complaint directly against (the subject of allegations by 11 individuals) or Ken Taylor, (the subject of allegations by 17 individuals). Unless the Tribunal takes a different view, we propose to send out the W.I.T. team to obtain evidence of abuse by these individuals.” In manuscript alongside is written “agreed”. Witness interviews6.108 At the commencement of the second preliminary hearing held on 15 October 1996, the Chairman stated that “investigations … have now reached such a stage that I am able to outline the arrangements that have been made to interview potential witnesses who may be called to give evidence ... and to invite anyone who may have relevant evidence or information to give to the Tribunal to get in touch ... Anonymous information is unlikely to be acted upon, but anyone coming forward may request that his or her identity be not disclosed publically … and we will give the most careful consideration to any such request. Certainly, no-one will be identified in public without our consent having been given ...” The Tribunal address and free telephone number were given. 6.109 In a letter dated 8 November 1996, the Solicitor to the Tribunal made clear to one of the firms of solicitors on record as representing a number of complainants, why the Tribunal was adopting the approach of taking its own statements as opposed to accepting proofs from solicitors and/or other third parties. That is, the Chairman wished to have evidence “which is, and which is seen to be, as untainted and independent as possible”. He explained that for this reason there needed to be a uniform approach, the witnesses needed to address questions posed by the Tribunal as opposed to other extraneous matters and to be seen to be independent from each other and not to have their evidence presented as part of a “package” by a solicitor acting for a number of complainants. Therefore, the WIT would continue to invite those it contacted to make statements, specific to purpose and with a minimum of delay.6.110 On 6 January 1997, a solicitor representing complainants who were members of NORWAS (North Wales Abuse Survivors) wrote to the Clerk to the Tribunal setting out the terms upon which they would be willing to engage with the WIT. These included provision as to counselling, which it was specified should not be restricted to the Tribunal’s witness support service and with no arbitrary restriction on duration and practical arrangements for making a statement including when complainants should have the option of having their solicitor present, to have all previous statements made available, to make unlimited amendments and supplementary statements, to choose a male or female interviewer, for there to be no limitation on appointment time and a choice of venue. The majority of the conditions were agreed by letter on 7 January 1997. 158 | The Macur Review6.111 Instructions were given to the WIT when dealing with witnesses at the Tribunal premises or in their own homes, in terms:In the case of the former: “1. All volunteer complainants [witness who has voluntarily responded to call for evidence] should be contacted as soon as possible and in any event within a week ... Counsel should be informed if contact within that period is impossible.2. The volunteer should be told that the Inquiry will pay his reasonable travelling expenses... if the travelling distance is great … [refer] to the treasury solicitor ……4. When the volunteer arrives at the Council offices, he should be met, and taken to a private room or area if he cannot be seen immediately. It is essential to prevent contact between the volunteer and other volunteers who may be present in the building at the time.5. If the volunteer is accompanied, his companion should not be permitted to sit in on the interview if the companion is or may be a witness before the Tribunal. If the companion is not a potential witness, he or she may be permitted to sit in on the interview, but … he or she cannot take an active part in the interviewing process.6. If a problem arises … a member of the treasury solicitor team will be available to assist.”In the case of those seen in their own homes and those selected randomly:“1. ... great care is required in contacting and interviewing potential witnesses. The assurance of confidentiality will be vital and each person will need to be approached with tact and sympathy.2. Some may have concealed the fact that they were in care ... Some may require professional help, legal advice and/or counselling. Some may be difficult or dangerous … [or] suspicious.3. ... bear in mind at all times that you are not seeking to produce any particular outcome from your meeting - you are not encouraging or discouraging complaints or allegations; you are recording whatever the witness wishes to tell you....5. Anyone requesting an interviewer of the opposite sex to the person first allocated should be told that this can be provided and, if possible, arrangements should be made for an interview at an agreed time and place.The Report of the Macur Review | 1596. Anyone requesting a consultation with a solicitor or counsellor before answering any questions is to be given that opportunity7. The Witness Meeting Record … should be filled in by you …8. The “witness assessment” at the foot of the document does not envisage that you will make an assessment of the truthfulness or otherwise of the witness’s allegations, if any. It is intended [to] give … the Tribunal a guide as to the degree of willingness/reluctance to give evidence.” 6.112 The instructions could not anticipate the time necessary to be spent with individual witnesses. A member of one of the support groups protested at the time that two witnesses were kept waiting for six hours at the Tribunal premises on 7 November 1996, when a previous interview had taken far longer than expected. 6.113 In interview with me, the second Solicitor to the Tribunal considered that the WIT was closely supervised, but voiced reservations about the quality of the assessments made by them. He considered they had followed the ‘script’ and I understood him to suggest thereby that they had not used much initiative in the interviewing process. That is, they had failed to follow through answers which suggested a further line of inquiry. The second Solicitor to the Tribunal said that he had required the WIT to return to ask further questions on occasions.6.114 There are some statements which do contain unintelligible information which may demonstrate this. Equally, I note that manuscript notes taken during the interview may have been incorrectly deciphered when typed. 6.115 In one case I note that a serving prisoner, who wrote to the Tribunal saying that he had seen a man believed to be visiting a children’s home and who was subsequently visited by the WIT, did not include the same information in his Tribunal statement. There is no record to indicate whether he was asked about this previously imparted information.6.116 One contributor to this Review complained that the WIT only appeared interested in allegations of sexual abuse. Others are reported by the immediate past Children’s Commissioner for Wales to have claimed to have been constrained in giving evidence or advised not to refer to parts of it. It is unclear whether this complaint relates to the WIT at the time of taking the statement or Counsel to the Tribunal deciding which evidence to lead. 6.117 Mr Lambert in a note dated 26 September 1996 indicated that he had raised with Mr Ryder his concern about possible repercussions to the department of the ‘cold calling’ of the retired policemen at people’s houses, “I foresee a possible number of criticisms … I understand the proposal of Leading Counsel to the Tribunal is that ... persons named in the local authority files will be chosen at random and … will then be visited by the retired police, irrespective of whether or not they gave a statement to the North Wales police during their investigation … I am troubled by the fact that 160 | The Macur Reviewpeople who have not given statements to the police but who are now being called upon, perhaps for the first time since they left local authority care, will be shocked and embarrassed by the revelation to their families that they were somehow involved in the matters under investigation by the Tribunal … Junior Counsel agreed that complaints about this method of interviewing could not be discounted … He indicated that if strong objection were taken to this proposal then the Judge would have to be informed of our concerns. It also seemed as if Junior Counsel was concerned that interviews would be conducted by 2 police. He indicated that he would much prefer that a paralegal accompanied one policeman in each case so that the interviewee felt less overawed … This view was not supported by Mr Briggs, the former [Detective] Chief Inspector, who was arranging for the recruitment of the police. This may also be a matter which we might need to consider and comment upon to the Tribunal Team.”6.118 In his meeting on 31 October 1996 with Treasury Solicitors, Mr Loveridge reported complaints regarding the practice of “door stepping” complainants without prior notice, and suggested that a list of forthcoming interviewees “could be forwarded to Sian Griffiths for her to provide relevant information before the witnesses were approached.” The Solicitor to the Tribunal forwarded this suggestion to Counsel to the Tribunal. A later “File Note in Confidence” to the Solicitor to the Tribunal recorded an “off the record” conversation between Ms Griffiths and a member of the Tribunal’s legal team in which she is said to recognise the difficult position she and the local authorities were in, with respect to conflicts of interest, “but she is in the unique position, because of her role in the police inquiry, of having personal knowledge of many of the interviewees. Rather than sending her a list of those interviewees, it was agreed that … she would liaise with me in the future on an unofficial basis to prevent any further avoidable upsets which could do untold harm.” 6.119 A solicitor to some of the complainants contacted the Solicitor to the Tribunal anxious that “we warn her before we approach any of her clients.” She was told that it was not “possible to comply with the request … to forewarn the solicitors about our interviews, that would be administratively unworkable ... but … I have warned our interviewers about the state of mind of some of the solicitors clients.” However, during the third preliminary hearing on 26 November 1996, Leading Counsel to the Tribunal stated that the WIT would not approach any person known to be represented by a solicitor without first contacting the solicitor “so no-one who is prepared to give a name and address at this stage ... need worry that he or she will be approached without the solicitor first being contacted and only then if the solicitor says that it is satisfactory for that to be done.” Apparently, in accordance with this assurance, I have seen a letter to the Tribunal from a solicitor’s firm providing names and addresses of potential witnesses and indicating in each case whether a solicitor would need to be present when interviews were conducted.6.120 In June 1997, Mr Loveridge notified the Tribunal that an individual who had confided in his social worker, but not his wife about abuse, had agreed to see a member of the WIT. The Solicitor to the Tribunal arranged that Mr Reginald Briggs would first contact Mr Loveridge “to discuss the best method of approach” before visiting the complainant. The Report of the Macur Review | 1616.121 Whilst I am not in a position to determine the reliability of all complaints made, it does appear that the WIT may have been wrongly maligned in a number of instances. For example, when on 11 October 1996, the Solicitor to the Tribunal asked for information since “a relation of one of our witnesses had rung the Flintshire Enquiry Office ... very worried about a note which had been dropped through her door ... were they bona fide”, the response, which is in manuscript, indicates “the telephone No. of the office was left with [the witness’s] father. The lady … is [the witness’s] girlfriend - she has been assured … 2 occasions … that there were no problems … did not say to her what we wanted to speak to [the witness] about ...” On 18 November 1996, one firm of solicitors representing a number of complainants wrote to the Solicitor to the Tribunal “concerned that one of [her] clients ... has already been approached by the Tribunal and feels that inappropriate pressure has been placed upon her.” A full explanation was given including that the relevant complainant had been undecided about where she wished to be interviewed by the WIT and the several approaches which were made were to clarify the position. Salmon letters6.122 Salmon letters, giving indication of the criticisms to be made, were sent to those against whom allegations were made explicitly or implicitly within the documentation obtained. This was intended to enable the recipient to answer allegations made against them. In one instance, it is apparent from the daily transcripts that a Salmon letter had not been sent to two individuals, the then adult sons of a foster parent, accused of sexual abuse. Accordingly, they were not questioned about the allegations. 6.123 Criticism was made by those representing some of the Salmon letter recipients of the length of the letters sent to those with managerial responsibilities and without regard to their actual responsibilities. Some were subsequently withdrawn, as indicated in paragraphs 6.207 to 6.209 below. Leading Counsel representing a large number of those accused of abuse complained of the timing of dispatch of the letters and consequent inability to obtain advice and support during the Christmas period. One of the contributors to this Review felt that the recipients of these letters were not given sufficient time to respond to the allegations made, if they were alerted sufficiently to the allegation at all. 6.124 The Tribunal determined that in a small number of cases of people who had been “mentioned critically, some of whom are very old now and some of whom are mentioned only in relation to very ancient incidents … [that] no Salmon Letters were sent at all because the matter was so trivial that it was not proper to require them, in effect, to seek legal representation and advice.” An example of this situation is illustrated in a note to the Chairman from Counsel to the Tribunal, “One small matter of detail upon which your guidance is sought. an alleged Bryn Alyn sexual abuser, is aged over 80 and living in sheltered accommodation ... For these reasons, we have not sent him a Salmon letter ... unless you take a different view.” A manuscript comment alongside reads, “Agreed. Evidence to be adduced without naming him.” 162 | The Macur ReviewWitness support6.125 The Tribunal issued a “Statement on Counselling” which identified that a Witness Support Service had been established to meet the needs of all witnesses, including those accused of abuse, and others contacted on behalf of the Tribunal. The management of the service was to be undertaken by The Bridge Witness Support Service (‘the Bridge’), an independent national organisation, in order to avoid evidence contamination before the Tribunal. Contact particulars of the Bridge were to be given to all potential witnesses and it was made known that support would be available at all stages of the process; from the time before the taking of a witness statement to the time following a witness appearing before the Tribunal. The support staff were to be experienced counsellors (male and female, Welsh and English speaking, and able to call upon specialist assistance if necessary). The service was to be totally confidential and would be provided at a centre separate from the Tribunal premises. However, counsellors would be on hand in the Tribunal premises during the Tribunal hearings.6.126 The Bridge supplemented this statement by indicating that support would be available to those unsure of whether they wanted to give evidence in order to discuss their concerns, and following the giving of a witness statement to talk of any issues relating to being a witness. It was also made clear that a witness could be accompanied by someone during the giving of a witness statement provided it was notified to the interviewer in advance. Support was also available during the Tribunal hearings and following the giving of evidence to talk of any concerns arising. 6.127 The Bridge emphasised that the counselling was independent of the Tribunal and would be confidential, subject to the exception where a witness disclosed details of an offence against a child where the Bridge had a duty to report the information to the Secretariat of the Tribunal in order for the Chairman to decide on the action to take.6.128 In the light of adverse reporting about the Witness Support Service the Chairman issued a statement at the commencement of the day’s proceedings on 6 October 1997: “the Tribunal should respond to reports on BBC Radio and Television this morning about the provision of witness support services. The Tribunal has been very aware from the outset that amongst those who have given evidence to the Tribunal in person or in writing, and those who have been approached to give evidence, there are vulnerable men and women who may be at risk. The Tribunal is also well aware that giving evidence may increase the need for continuing support … For this purpose [he made reference to the Bridge]. The identities of those referred to in today’s reports have been made known to the Chairman of the Tribunal for the purpose of determining whether any further steps need to be taken to provide them with support. The Tribunal wishes to emphasise that in both cases the persons concerned have been offered support and advice and will be provided with the services they require ... The statement in BBC ‘Wales Today’ that the Tribunal is being lobbied to improve the counselling service is untrue ... regrettable that anything should be published … that tends to discourage witnesses from giving evidence before this Tribunal ... particularly regrettable if the reports are founded upon misapprehension.”The Report of the Macur Review | 1636.129 The Witness Support Service was incapable of completely alleviating the trauma for some of those recounting allegations of abuse or giving evidence about them. Sample letters from solicitors are instructive in this regard. One dated 22 October 1997 refers to a client’s “resurgence of memories and psychological difficulties” following him providing a statement to the Tribunal; another dated 25 February 1998 about another witness was to similar effect and indicated that the experience had begun to “severely impact on his day to day existence.” 6.130 Some complaints were made to the Tribunal about the service from an early stage, including its operation being restricted to office hours, the inadequate number of counsellors, and the service being available to abused and accused. Several contributors to this Review suggest that the counselling and therapeutic support provided by the Bridge was inadequate to alleviate the trauma of giving evidence to the Tribunal. Others have criticised the lack of ongoing therapeutic support for those abused in childhood. One has commented on his inability to physically access the service by view of its distance from his home address. Arrangements for witnesses6.131 A meeting in mid January 1997 confirmed the arrangements for witnesses who were to give evidence. Witnesses and solicitors were to be separately informed when the date selected for a particular witness to give evidence was known. It was hoped to give up to 10 days’ notice with enquiry made as to whether or not there would be problems regarding attendance. Witnesses were to be asked whether they intended to give evidence in English or Welsh. Provision was to be arranged for access of disabled witnesses. Travelling and overnight expenses were to be provided and appropriate food breaks arranged. Arrangements were discussed as to accommodation of witnesses upon their arrival at the Tribunal premises and offers to be made for the provision of a pre-evidence site visit. Witness protection was to be arranged if applicable. Transportation of witnesses6.132 On 8 August 1996, in a meeting between the Tribunal Chief Administrative Officer and the NWP, “Detective Superintendent Ackerley highlighted some of the difficulties that the police had had in tracing witnesses [during the police investigation] ... it was only by personal attendance on many of the witnesses, that the police had secured their attendance at the various court hearings. Many of the witnesses lived an alternative lifestyle ... others were frightened and apprehensive and he strongly advised that unless ... proper arrangements [were made] to secure the attendance of witnesses at the Tribunal, by dedicating staff to arrange for their attendance and putting transport at the disposal of that staff, many of the abused complainants would fail to attend ...” As indicated subsequently at paragraph 6.201, some did fail to attend regardless of the arrangements made. 164 | The Macur Review6.133 I have previously indicated that members of the WIT acted as chauffeurs and witness escorts (see paragraphs 4.75 and 4.78), apparently successfully. There were others, however, who were resistant to their role including in the capacity of chauffeur and witness escort by reason of their former employment. One contributor to the Review, when asked by me if he would have taken a lift from the WIT said, “didn’t like the witness team at all; ex-policeman all of them…Everybody was wary of them [and saying] ‘There’s no … way I’m talking to the cops’…”Other measures for witnesses6.134 Prior to the hearings commencing, one solicitor wrote on behalf of her clients suggesting that “it is important that completely separate facilities are provided - cloakrooms, cafe, etc in addition to a waiting area in order to minimise potential problems” between complainants and accused. She suggested that there should be an independent firm of security guards, since a local firm were staffed by former police officers and that a “safe house or houses” may be preferred to hotel accommodation by some individual witnesses.6.135 There is indication in the documents reviewed that tensions existed between complainants themselves. Some of this originated from separate organisations formed and claiming to be more appropriately representing the survivors of abuse than the other. On one occasion the Chairman made clear that reported incidents of verbal and physical abuse arising would not be tolerated.6.136 Other efforts were made to accommodate witnesses within reason. A letter from the Assistant Solicitor to the Tribunal reads “there is no doubt that the Tribunal would wish to hear your son’s evidence, based upon what you have told, but of course, that is a decision only he can make. Were he to choose to send us a signed statement, this would be read in open court. Public funding would not extend to flying [your son] from New Zealand, but his travel within the UK and any subsistence needed to attend the Tribunal would be paid. Legal representation and counselling would also be available ...”6.137 Rearrangements of dates when witnesses were anticipated to give evidence were made to accommodate late disclosure, ill health or other reasons for indisposition. For example, a note dated 3 March 1997 in the Welsh Office papers indicates “the Tribunal have also just received a statement from in which he names 40 individuals against whom allegations are made. Around a dozen of those named are not already the subject of a Salmon letter. In order to provide adequate notice ... it is proposed that [the complainant’s] evidence should be heard on 17 April (the first day after the adjournment).” 6.138 I am aware that considers that some promised financial assistance for child care, accommodation and the like failed to materialise. This has been a consistent complaint of his, and was notified to the Chairman during the course of the Tribunal, although no other complainant appears to have made a similar complaint at the time or subsequently.The Report of the Macur Review | 1656.139 In his written closing submissions, criticised several aspects of the procedure and the facilities made available for witnesses. He wrote, “we have been asked to come here and tell of our horrendous past in front of 20, 30, 40 people. I wonder how many of you could have come here and talk about your fears and nightmares without having some difficulties when asked certain questions ... survivors could not get a drink when they wanted, there was no room that could be used by survivors, there was no facilities available, apart from … when you were giving evidence, and that was laughable ... the way this inquiry room is laid out ... To expect survivors to sit next to the person or persons they are making accusations against is, at best, insensitive.” 6.140 This complaint is reflected in an independent observer’s comment to this Review that lay witnesses were inadequately supported or prepared for giving their evidence on such sensitive issues before a large audience.6.141 Another contributor claimed that the Chairman refused him a hearing loop to compensate for his hearing loss.6.142 In March 1997, a solicitor expressed concern and asked “if some arrangement ought however to be made to contain a distressed witness, who leaves the witness box, from coming into contact with those yet to give evidence. We suspect that it was the distress of the [one witness] that distressed [another] and brought about the panic attack.” There is no indication of what steps were taken in response to this query, although implicitly it appears to have been resolved in the absence of subsequent, similar complaint.6.143 In another respect, I note that in July 1996 one of the successor authorities invited the Tribunal to consider sitting in a venue in the West of the region and suggested that signposting would be required for the route from North Wales. Whilst I have received no submissions relating to the inability to access the Tribunal by reason of its location, although one contributor suggested that the Tribunal’s distance from her home, approximately 15 miles, deterred her participation, the Tribunal Report6 recognised the “disincentive” to those witnesses living far afield required to attend before a Tribunal sitting in North Wales. Another contributor has remarked upon the difficulty he experienced in transportation, albeit it did not prevent him from attending the Tribunal every day for 16 months; and contemplated that the location of the Tribunal was a deliberate deterrent to wider participation. Part 3: The hearings6.144 The nature of the evidence gathered on behalf of the Tribunal would only be revealed to the public during the Tribunal’s hearings, most of which were heard in open session (see paragraph 6.162 below). A comparison of the oral evidence and the Tribunal’s analysis of and conclusions upon it can be made against the Tribunal Report. However, the public could not know the extent of the evidence amassed by the Tribunal, since its deployment would be dependent upon the prior determination 6 See paragraph 21.105 of the Tribunal Report166 | The Macur Reviewof the Tribunal as to relevance in the context of the terms of reference. In the light of this opportunity to suppress evidence, this part of this chapter considers the arrangements made for and management of the hearings themselves, the methods of giving evidence, the evidence adduced and the criticisms made of this aspect of the Tribunal procedure. Preliminary hearings and rulingsLegal representation6.145 Preliminary hearings dealt, amongst other things, with the issue of representation, “any complainant who made a written statement to the Tribunal would be granted representation by Counsel and Solicitor, if he or she wished to be represented. [The Tribunal] did so on the grounds that it was necessary in the public interest that their views on a range of issues should be put to the Tribunal with professional assistance. It was necessary also that persons against whom they made allegations should be cross-examined on their behalf ...”76.146 In August 1996, wrote to the Secretary of State for Wales representing the views of NORWAS, “as the Judicial enquiry [sic] is about to start very soon, we must and need financial backing from the Welsh Office without delay. It is not right, practical or fair to let other bodies to organise counsellors, support workers or safe houses etc. This was said to be done for us the victims in the past and believe us the so called help and support we got was a complete waste of money. It caused the death of victims, so consequently this must not happen again. We know the people we want to work for us and we know the people we would pick to support us. This takes money, but this time it will be money well spent ... We also want your guarantee we can have our own legal representation ... Quite simply because we need to make sure everything comes out and that our interests in this are put across in full ...”6.147 High level legal representation was ensured for all living complainants who had made a statement to the Tribunal, albeit not necessarily individually nor by Counsel of choice. Informed of the potential for conflict between those complainants who had been abused by other complainants who had been abused themselves, the Tribunal determined during the third preliminary hearing held on 26 November 1996 that it would be perfectly possible for one Leading Counsel “to keep above the fray so far as that kind of internal conflict is concerned, leaving it to the junior counsel involved in the separate groups to conduct cross-examination ...” On the basis of the larger number of complainants represented by one firm of solicitors, the Chairman indicated that the Tribunal thought that the Leading Counsel intended to be briefed by those solicitors would “really be the appropriate person to be selected …” as opposed to the one chosen by the organisation “Voices from Care”, although the Tribunal would be “most reluctant to force that …” Two individual complainants attending the hearing each objected to not being granted representation by counsel 7 See Appendix 4 (16) of the Tribunal ReportThe Report of the Macur Review | 167of choice. One argued that there should be a choice of Leading Counsel, and that there should be a male and female QC and a male and female Junior Counsel representing the complainants. 6.148 The Chairman answered the criticism by saying that the Tribunal was “bending over backwards to ensure that representation is of the person’s choice” since a complainant intending to make a Tribunal statement could go to any solicitor. The solicitor would then be invited to act through one of the solicitor’s firms nominated as leaders in co-ordinating the cases to ensure the representation by Leading and Junior counsel. He indicated that the concept of individual representation was unrealistic in terms of cost and the ultimate burden upon the tax payer. 6.149 At the fourth preliminary hearing held in January 1997, the Tribunal agreed that different representatives would appear for survivors of abuse and those who had also abused.6.150 It is clear that the Tribunal wished to encourage witness engagement or participation in the Tribunal proceedings in this fashion and to ensure the “elucidation of the facts” and “protection of the interests of the complainants.” 6.151 One contributor refers to legal representation being withdrawn half way through, but there are no documents to suggest that this was the case for any living complainant. Tribunal authorisation of the attendance of solicitors, and thereafter the payment of their costs, was scaled back after completion of the evidence from complainants, but representation was not withdrawn. Significantly, Leading Counsel appearing for the majority of the complainants accepted the “Tribunal’s view that in phase 2 [i.e. the conclusion of the complainants’ evidence] onwards there should be but one team of representatives on behalf of the Complainants ... can foresee no conflict in our accepting the responsibility for those previously given separate representation ... without prejudice to any application by, for example, those currently representing and others, to be present for the purpose of cross-examining specific witnesses where evidence bears directly upon such client (e.g.police) ... As Counsel however, we do support at the very least the importance of separate solicitor representation for the two distinct geographical Groups.” This submission was apparently acceded to.6.152 Those criticised were also to have representation made available to them. Many were still members of unions who funded it. Others had their costs met by the Welsh Office. One contributor to the Review criticises the Tribunal for sanctioning this. Leading and Junior Counsel were engaged. The Tribunal encouraged collective representation where there was no conflict of interest. 6.153 The Chairman had declined in one preliminary hearing to grant representation to deceased members of staff of children’s homes. He acknowledged the understandable concerns raised by a representative of FACT that people now deceased may have their name taken in vain and that it was regrettable. Some 168 | The Macur Reviewcontributors to this Review have criticised the fact that those accused, but deceased, were not permitted representation to defend their reputations. Others have criticised the absence of representation for deceased complainants.6.154 There was no application for the defunct local authorities of Gwynedd county council and Clwyd county council to be separately represented. It is clear from the Chairman’s comments in three of the four preliminary hearings that he was anxious to ensure that former employees of the defunct authorities and Councillors should be represented.6.155 In the first preliminary hearing, Leading Counsel for the successor authorities indicated that the interests of former social services employees would be protected to the extent that it was proper to do so, but that the successor authorities did not wish to be “hamstrung” by receiving instructions from individuals which required them to defend what they might think to be the “indefensible”. Upon hearing that a former director for social services in Clwyd sought independent representation and financial assistance to arrange it the Chairman, when granting his application, queried the position in relation to other senior administrative members of staff in the former county councils and requested that some investigation be made as to whether joint representation could be arranged for those at the level of director of social services and above in view of the potential criticism that may be made. At the following preliminary hearing, the solicitor then representing the former director said that enquires had been made of former colleagues. Some had maintained their union membership and would be represented accordingly. Leading Counsel who had added them to her clients informed the Chairman that there were “28 who think they will need representation but there may be others who have their heads in the sand ...”6.156 In the second preliminary hearing the Chairman asked if there was anyone present on behalf of individual Councillors. A legal representative informed him that two “other” Councillors had approached his firm requiring representation and the firm had written to the secretary of Gwynedd county council and Chief Executive of Flintshire county council inviting any former council members seeking representation to contact them, but had been informed that “most councillors are reserving their position but will require representation if and when they are required to attend.” 6.157 Despite these attempts made, a former Chief Executive of the former Gwynedd county council wrote on behalf of other past officers to the Secretary of State for Wales, complaining that, “former (pre-reorganisation) Gwynedd County Council ... in no way represented before the tribunal ... evidence which the Council would, if represented, have challenged went unchallenged, witnesses who could have commended the council were not contacted, searches for misplaced records were not pursued to the extent which might otherwise have been possible, and collaboration between individuals with a view to piecing together forgotten episodes going back to 1974 could not take place ... Generally speaking, the whole atmosphere was more akin to that of a criminal trial ... In such an atmosphere, some witnesses tried, inevitably, to shift any blame alleged on to others, while potential witnesses were discouraged from coming forward ... the case of the former Gwynedd County Council is substantially different from that of the former Clwyd County Council and should, perhaps, have been heard by a separate tribunal.”The Report of the Macur Review | 1696.158 Leading Counsel for the Welsh Office was obviously in agreement with this point of view as is apparent from a note dated 22 January 1998 (see paragraph 6.217) where she wrote, “It was no part of the [Welsh Office] case, nor any other party, to take up the cudgels on behalf of the defunct local authorities but the consequences of there having been no counsel before the Tribunal with a vested interest in so doing is that the picture presented to the Tribunal has lacked balance. Had the stance adopted by the Tribunal been different this would not have been such a significant failing because the questions asked by the Tribunal members or upon their behalf could have filled this gap. The restrictive adversarial approach has meant that local government responsibility, and the difficulties inherent in it, which should have been advocated upon Clwyd and Gwynedd’s behalf has been all but absent.”6.159 The Tribunal Report8 refers to the difficulties faced by the Tribunal in examining the responses of the former Clwyd county council in relation to child abuse allegations and the lack of representation. Subsequently, in the Tribunal Report,9 the Tribunal makes reference to unidentified Councillors’ lack of discharge of their respective personal responsibility for the welfare of children in specific community homes. Anonymity6.160 A decision to grant anonymity to complainants of physical and sexual abuse and to persons against whom such an allegation was or was likely to be made was announced at the first preliminary hearing in September 1996. The Chairman indicated at a meeting with Counsel to the Tribunal on 14 October 1996 that, “names will be used in the Tribunal hearings unless specific application is made. There will be a general order preventing the reporting of witnesses’ names, addresses, photographs and other pictorial representations i.e. materials tending to identify a person. Addresses need never be released.” This decision was challenged by the BBC and two local newspapers.6.161 The ruling made on their application in February 1997 maintained the direction prohibiting publication of name, address or other identifying features, save in the case of names already within the public domain, and is recorded in full in the Tribunal Report10 and attached at Appendix 3 of this Report. In summary, the justification given for the direction was the protection of privacy of those who made complaint and the encouragement of those who were accused of abuse “to give as full and true an account as they can of the facts within their knowledge.” In addition “we have had in mind also that, in the context of the first paragraph of our terms of reference, the identities of particular complainants or persons against whom allegations are made is of much less importance than the question whether the alleged abuse occurred and the circumstances in which it is alleged to have happened.”8 See paragraph 28.02 of the Tribunal Report9 See paragraphs 29.68 - 29.70 of the Tribunal Report10 See Appendix 4 of the Tribunal Report170 | The Macur Review6.162 Importantly however, as indicated above, the Tribunal made clear that the hearings would take place in public and that names would be given during the course of the hearings.6.163 Nevertheless, in an October 1997 press release, speaking of the decision about anonymity, the Right Honourable Ms Ann Clwyd MP said, “The fact that alleged paedophiles have been granted the privilege of anonymity now puts particular responsibilities on the Police and Crown Prosecution Service. We now need assurances ... that in every case where prosecution is possible, even at this late stage, they do proceed. When I objected in the House of Commons to the Order to set up this Inquiry, I warned that the form of Inquiry could actually hinder the investigation to find out the truth. The form of this Inquiry has meant it shut down discussion in the House … the public who are unable to attend the hearings in Ewloe for themselves, have a right to know the full facts.”6.164 On 26 November 1997, the Chairman wrote to her, “to avoid any misunderstanding I must reiterate that the anonymity ruling extends only to the press. At the daily hearings in public there is no anonymity and all those named are recorded on the daily transcripts. The police are fully aware of the evidence … and are free to pursue new or further investigations … without any restraint ... The anonymity ruling does not, therefore, inhibit police action in any way”.Procedure and management decisions during the hearingsDisclosure of documents 6.165 As with other litigation, the question of disclosure of relevant documentation to interested parties needed to be considered by the Tribunal. Clearly, there was a difficult balance to be drawn between disclosure of evidence which may undermine the case against those accused of abuse and revealing personal information concerning prospective complainants.6.166 In a meeting held on 28 July 1996, the Chairman emphasised that “everything is subject to fresh statements ... There will be no disclosure of information unless and until it is decided to call the witness .... [or] if there is anything in the documents which is material to the defence of somebody and that person ought fairly to know that in order to defend themself [sic]. It is then for the Judge to decide whether disclosure of that information to that party should be made even though the witness is not being called … If there is a conflict between the statement taken by the [Tribunal] and the one taken by the Police then, the person named will probably be entitled to see the police statement too. But there will be no general disclosure of police statements.”6.167 The reality was that the majority, if not all, police statements of those called as a complainant witness by the Tribunal would be disclosed on the basis that there had either been an explicit confirmation of the contents of the police statement without more, or else amplification or alterations in the allegations made.The Report of the Macur Review | 1716.168 Contrary to the suggestion made that the successor authorities should be responsible for decisions as to whether or not files would be produced in light of prospective public interest immunity (PII) and legal privilege claims, the Tribunal had previously directed that all documents which may be subject to claims of PII by the successor authorities were to be disclosed to the Tribunal for inspection. The initial trawl to assess relevance of these documents was to be undertaken by the paralegal team under supervision, the second by the Tribunal’s legal team, and the final decision made by the Chairman. Parties were at liberty to apply for disclosure of any specific documents that were withheld. 6.169 Once the hearings commenced, the issue of disclosure was revisited. Writing to the Chairman on 30 January 1997, Mr Gerard Elias QC suggested it “may be worthwhile rehearsing our reasons for as ‘open’ an approach to the problem as can reasonably be made: (a) we have underlined the ‘no stone unturned’ approach with all that this implies for the Tribunal to have regard to all relevant material; we are very anxious to avoid a final judgment on the Tribunal from any direction which begins with the assertion ‘They did not look at this or that relevant aspect ...’ (c) There may be all the difference in the world between the need for the Tribunal to have regard to the fullest particulars of a complainant or alleged abuser & the need to permit any/extended cross examination in respect of those particulars. Thus, in the case of a particular individual, matters which may go, for example, to his credit may be highly material to the Tribunal’s general or specific findings but are not necessarily matters which require any reference when the witness is giving evidence. Of course, such matters will always be subject to such proper comment in closing addresses as is appropriate; Problem ... As I believe you are aware, the real objection seems to be more to do with the exposure of some complainants to what is perceived to be difficult/irrelevant cross examination, going to credit rather than to any principle of disclosure ... We take on board the very valid point made by Booth [representing 19 complainants, including NORWAS] that Complainants may be discouraged if the Tribunal permits cross examination upon ‘extraneous’ matters & we may find that a number do not turn up. Proposed Solution … ‘Wide’ pro forma be completed … & distributed … to all parties. No reference may be made to its contents … without prior application to the Chairman. Any application for wider disclosure … subject of a specific application to the Chairman … in writing specifying the information sought, the aspect of the applicant’s case to which it relates & the suggested relevance to the Tribunal’s deliberations ... believe that the above, accompanied by a direction as to permitted limits of x exn [cross examination] should allay the fears ... whilst ensuring that the Tribunal’s credibility remains high & the approach open.”6.170 The “Practice Statement: Discovery of Social Service materials” subsequently issued adopted these points. The Solicitor to the Tribunal was to make available replies to interrogatories in a pro forma document in accordance with a list of contents approved by the Tribunal. The contents of the pro forma would be admitted into evidence before the Tribunal without further direction or need for examination 172 | The Macur Reviewor cross examination. Any applications for specific discovery/production needed to state the precise document sought and the grounds relied upon which must include the relevance that it was contended the document had. The Chairman would have all social services and health files that supported the pro forma and the complainant’s antecedent form. The Chairman would consider the documents in advance of a witness being called so as to determine whether any of the documents contained relevant material. If a document was determined to be relevant, the Tribunal would invite the successor authorities or health service bodies and the complainant to consider production. In the event of disagreement, the Chairman would hear further submissions6.171 On 1 July 1997, the Solicitor to the Tribunal reported that few inquiries had been made for disclosure prior to the Practice Direction being issued, but not since. Witness packs6.172 It was intended that after core bundles of all relevant documents had been created, ‘Witness Packs’ would be produced containing all relevant documents likely to be necessary for the purpose of a witness giving evidence before the Tribunal. 6.173 In the main, they contained statements taken by the WIT and other statements and documents as considered appropriate. Other documents were sometimes added to the pack in relation to information which the Tribunal subsequently decided to introduce into evidence.6.174 The Tribunal maintained a distinction between inter partes inspection of materials and the production of the materials upon which reliance was placed and therefore included in the witness packs. In a letter dated 22 May 1997, the Solicitor to the Tribunal made clear to the Solicitor for the Welsh Office that the Tribunal would not be deemed to know the contents of all documents informally inspected if not disclosed. It follows that the Tribunal would be reliant upon the parties raising the issue of relevance following inspection of any document not otherwise disclosed in the witness packs. Management of evidence6.175 Oral and written evidence was adduced to the Tribunal. Witness statements of those called to give oral evidence were deemed to have been read in advance and to stand as evidence in chief, subject to clarification for the purpose of subsequent cross examination. Witness packs which contained other documents as indicated above were prepared for each witness as relevant.6.176 This procedure did not command universal favour and some contributors to this Review have complained that not all relevant evidence was considered by the Tribunal. The Report of the Macur Review | 1736.177 In April 1998, Councillor Malcolm King expressed dissatisfaction “with the way in which my evidence … was not, supplied to the Tribunal ... feeling profoundly cheated by the events surrounding my giving of evidence.1. … consistently advised by [my own Counsel] ... not to supply certain ‘evidence’ to the Tribunal ... virtually all of these matters have concerned the North Wales Police.2. As a result of [my Counsel’s] resistance to virtually all my statements regarding the Police, I watered it down ...3. The basis for much of his arguments for withdrawing most of what I wanted to say about the Police was either that it would harm my reputation, or that it would not stand up as evidence in a court of law ... I am left to conclude that I would have been able to put before the Tribunal more ‘evidence’ ... than I eventually gave. If it had been deemed to be irrelevant or inadmissible, so be it, at least I would have done my best to supply the Tribunal with everything I believed to be relevant.4. Preceding my giving evidence, a decision was taken ... without my knowledge or consent to not hand to the Tribunal any of my supplementary documents, many of which were mentioned in my statement5. I was advised by [my Counsel] that he would be taking me through my evidence in chief. It was not until the day before giving evidence that he apparently discovered that this was not possible ...6. He did not inform me at any time that details which I provided in my statement would not be considered as evidence by the Tribunal unless it was read into the Tribunal by their Counsel or other Counsel or solicitors ...7. The haphazard way that the Tribunal supplied participants with other parties’ statements meant that I was not given sufficient time to consider either the Welsh Office statements or the Insurer’s statement before answering questions on them. There are a number of ways in which I would have been able to answer more fully and forcibly had I had an opportunity to read them properly.8. Most crucially, I did not receive a copy of my proposed cross-examination by the Police, or know of its existence until after I had finished giving evidence. I feel betrayed and seriously misrepresented ... I wish to make it clear publicly to everyone concerned that I am profoundly unhappy with the way that … the process and events have meant that I have not given the evidence I would have wished and had intended ...”174 | The Macur Review6.178 Councillor King repeated some of these matters when I saw him in Wrexham and interviewed him at his request in London thereafter. In fact, the Chairman had responded by letter on 16 September 1998 in terms, “I regret very much that you feel that you were prevented from presenting your full thoughts and potential evidence to the Tribunal … I am rather mystified that you should think so … 1. Your Tribunal statement was submitted to the Tribunal before you gave evidence … 2. All witnesses [other than Salmon letter recipients] … were taken through their oral evidence first by one of the three Counsel to the Tribunal and not by their own Counsel. 3. After reading your Tribunal statement [Leading Counsel to the Tribunal] as a matter of courtesy, indicated to your Counsel the topics on which he intended to question you … considered to be relevant to Tribunal’s terms of reference, bearing in mind general principles of admissibility. 4. It was the helpful practice of each Counsel to let the other Counsel involved know of the subjects on which they proposed to question a witness but not the details of the proposed cross examination. The purpose ... to avoid as far as possible unnecessary duplication …5. As far as I am aware Mr Moran [Leading Counsel for the NWP] followed this procedure ... his list of subjects was based on your full statement rather than the more limited topics selected by [Leading Counsel to the Tribunal]. It was inappropriate for [Leading Counsel for the NWP] to suggest ‘a Damascene conversion’ on your part because you had not decided what questions you would be asked … subject to next sub paragraph.6. The transcript does show that, when you were questioned by your own Counsel, he asked you twice whether there were any other points not yet dealt with that you wished to raise (Day 170 pages 25261 and 25266). This was your opportunity to say anything further that you wished, subject only to any ruling that the Tribunal might have had to give on admissibility. … the members of the Tribunal and Counsel to the Tribunal were not aware of any other admissible matters that you wished to raise. The test of admissibility is, of course, broader ... but a Tribunal must confine itself to the terms of reference that it has been given and must not abuse its privileged position by canvassing potentially defamatory matters outside those terms of reference. This test applies to documents as well as to oral evidence and I can assure you that [Leading Counsel to the Tribunal] would have asked for any relevant and admissible supplementary documents referred to expressly or by inference in your full Tribunal statement ... everyone present was well aware that you had other criticisms to make of the North Wales Police in respect of matters not within the Tribunal’s terms of reference ... The Report of the Macur Review | 175there was nothing haphazard about the procedure. From the earliest days of the hearings the Tribunal team pressed for delivery of other parties’ statements and detailed time-tables were given but rarely complied with. The Welsh Office itself presented an intolerable mass of documentation, which had to be pruned over and over again, but the Welsh Office statements and documents in seven files were distributed during the summer of 1997. Some amendments and alterations were made later ... but they did not alter its basic case. In any event it was presented orally over many days ... surprised that you, as experienced politician, felt at a disadvantage in criticising it. The insurers’ case presented a different problem because the relevant facts were quite short and not in dispute and the Jillings inquiry was at the boundary of relevance to the Tribunal’s terms of reference. Moreover, the insurers conceded that they were at fault. It was for that reason that the Tribunal did not require a representative of the insurers to give oral evidence. If you felt at a disadvantage in commenting upon their role, your Counsel could have included any additional comment that you wished to make in his final submissions on your behalf ...” 6.179 In his closing written submissions, also commented adversely on “the system whereby you have to apply for a specific document, not knowing what … documents are available, or even exist, leaves the statement made by this inquiry of leaving no stone unturned somewhat contestable … The second problem with documentation is that of the way in which people were given vast amounts of documents to read, sometimes on the day that they were giving evidence. Whilst we understand that there was a vast amount of paperwork involved with this inquiry, it should have been managed better with more time allocated for people to read relevant documents … [Police] should have been forced to hand everything over to the Inquiry, and not just what they wanted to … why should they … be forewarned about the questions that they were going to be asked?” 6.180 A contributor to this Review, Mr Michael Barnes, representing FACT complained that the evidence which ran counter to abuse was not adequately presented before the Tribunal. He complained that those accused were not allowed to adduce evidence of good character or good practice, the contra indications of abuse having occurred, false memory syndrome, the compensation culture or the negative impact on credibility of the police and/or the WIT trawling for witnesses. Others made similar points and one complained that complainants of abuse were afforded more licence and protected against robust cross examination, unlike several of those accused. Another contributor, Mr Gareth Taylor, who had been a resident in one of the children’s homes and had not complained of nor been accused of abuse, complained of the apparent dismissal of his evidence since it did not report abuse, and observed upon what he perceived to be a lack of fair process for those who had received Salmon letters. He had been told he need not attend the Tribunal and that his written submission was sufficient. Nevertheless, he had felt it important to attend the Tribunal hearings. He suggested that others holding the contrary view had been deterred from participating in the Tribunal. In his view, the 176 | The Macur ReviewTribunal appeared to be tailoring the evidence adduced to correspond with their pre-conceived views of systematic abuse and to “protect a range of individuals and organisations that could in some way be criticised or held to account.” The Tribunal Report11 indicates that the Tribunal had borne some of these issues in mind in reaching the conclusions it did.6.181 Mrs Alison Taylor told me in interview that she did not feel that the Tribunal tried to restrict or contain her evidence, but criticised the procedure which led to late production of documents with no sufficient time for the witness to familiarise themselves with the contents before cross examination. She has complained that the Tribunal did not adequately examine evidence relating to her suspension and subsequent dismissal, glossed over mismanagement of staff and resources, did not adequately consider local Welsh ‘chapel’ influences nor give due consideration to the issue of misconduct in public office. She and other contributors to the Review question whether adequate examination was made of the alleged and/or suspected complicity of the NWP in failing to investigate allegations of child abuse. Mrs Taylor wondered whether the Tribunal had been sufficiently alert, indicating that someone had told her that the Chairman had appeared to fall asleep when she was giving evidence.6.182 Two journalists have queried in particular the failure of the Tribunal to call a witness, Mr Desmond Frost, to give evidence. He was employed with the Bryn Alyn Community between June 1975 and February 1985 and then associated with the Community for a further year on a self-employed basis. He has spoken to reporters and appeared on television suggesting that he had notified Cheshire police officers of rumours concerning John Allen’s sexual abuse of boys in his care. He said he heard nothing further from the Cheshire police but had received a visit from a local police officer, who he said was acting on behalf of the Durham constabulary investigating a possible blackmail attempt by a former Bryn Alyn resident who had written to John Allen asking for money. Mr Frost is reported by one publication to have indicated that he had not repeated what he had told the Cheshire police and deliberately avoided alerting NWP fearing that John Allen would discover that he was the source of the information. In fact, he said that he had indicated that the request for money made in the letter was part of an “aftercare” system. Mr Frost was contacted by the Tribunal as a result of evidence from another witness concerning this issue. He made a Tribunal statement on 24 October 1997. In it he relates informing police officers from Chester police station of rumours concerning John Allen sexually abusing young boys in care. He asked the police officers to pass the information on to Wrexham police. He had not repeated the rumours to a local police officer who had called subsequently to investigate the potential blackmail attempt. He had not made a connection between the ‘blackmail letter’ and the rumours. He did not think it was “a big deal” to have gone to the Cheshire police as these rumours could have been false. He was uncertain as to when he had raised his concerns with the police. The Tribunal was informed that investigations were made with the Cheshire police in regard to Mr Frost with nil return. 11 See paragraphs 6.06 and 6.07 of the Tribunal ReportThe Report of the Macur Review | 177 Mr Frost’s evidence was orally summarised by Mr Treverton-Jones. His statement was therefore deemed to have been read into the evidence before the Tribunal without challenge. His evidence is referred to in part in the Tribunal Report.12 Evidence read or deemed to have been read6.183 Not all witnesses who had given statements and were expected to give oral evidence were called to do so. In one category were those witnesses who had been unable to face the prospect of giving evidence in public, including those who actually attended the Tribunal premises in order to do so, but had then been overwhelmed by the circumstances. Other witnesses were prevented from attending at the Tribunal by virtue of their own ill health, or that of close relatives, domestic circumstances or death including suicide. In another category were those witnesses who the Tribunal decided it was unnecessary to call. Other reasons indicated in the documents include: logistical problems, for example, one Category A serving prisoner was not called to give evidence by reason of the difficulties in arranging his attendance with all necessary security measures, another inmate was suggested to have significant mental health problems; avoiding duplication of evidence relating to a particular form of abuse at the hands of a particular abuser or within an institution; relevance to the terms of reference; or statements deemed by Counsel to the Tribunal to contain insufficient evidence to justify the calling of the witness concerned. In these cases, the evidence was generally read, summarised or deemed read into the proceedings. 6.184 It is clear that some witness statements read, or deemed to have been read, into the proceedings were considered by the Tribunal in reaching its conclusions. Different weight was attributed to the witness statements in different circumstances depending on the nature of the evidence contained in the statement and the subject matter with which it dealt. The Tribunal Report13 records that, “we have assessed the written statements before us in the appropriate conventional way, having firmly in mind that they have not been subject to cross-examination. The evidence in them has been very useful in filling out the general picture before us and in giving us a much wider cross-section of views about the relevant issues but we have not based any of our findings adverse to individuals upon the contents of the written statements, except in the very small number of cases in which the facts were admitted or virtually indisputable.” 6.185 One witness, who was to give evidence concerning his time in Bryn Alyn telephoned the Tribunal saying he had expected to be called but had been informed that his statement was to be or had been read. A member of the Tribunal staff explained that he had not been called in view of the abundance of evidence and advised that his evidence would be entered into the transcript in any event. 12 See paragraph 50.40 of the Tribunal Report13 See paragraph 6.19 of the Tribunal Report178 | The Macur Review6.186 In some cases, it is clear that Counsel to the Tribunal had formed the view that statements containing allegations against named individuals were unreliable by virtue of extraneous and incontrovertible fact. In other instances, there is no record of the reason why a witness was not called or his evidence not otherwise referred to. These statements may have been regarded as duplicating other similar allegations. 6.187 The daily transcripts reveal that when reading from the majority of statements containing allegations against unnamed police officers, no reference was made to the paragraphs containing such allegations. A live witness, whose statement included an allegation of physical abuse against a police officer, was not questioned about that allegation, although he was questioned about those he made against others who were not police officers (see paragraph 8.97).6.188 I wrote to Mr Gerard Elias QC and Mr Treverton-Jones QC on 15 May 2015 inviting comment on the fact that these complaints were not referred to in public. Mr Gerard Elias QC responded indicating that the unredacted statements of all witnesses save as to sensitive material, addresses and telephone numbers, were served on all parties. These statements would have included the allegations made against unidentified police officers and could have been pursued by other Counsel or members of the Tribunal if thought relevant to the terms of reference. Mr Gerard Elias QC raised the difficulty of evaluating a complainant’s evidence in a vacuum, that is, without an identified perpetrator. 6.189 Mr Treverton-Jones QC responded that to the best of his recollection there was no policy of deliberately not leading allegations against unidentified police officers. Counsel to the Tribunal liaised closely with the Tribunal members and Sir Ronald Hadfield and were influenced by their views on the evidence they wished to have examined orally. He too made clear that the relevant witness statements containing any such allegations would have been available to the Tribunal and counsel representing complainants and therefore would have comprised evidence before the Tribunal.6.190 I record that Counsel representing other parties before the Tribunal did take the opportunity to request that some witnesses, whose statements would otherwise be read, be called to give oral evidence.Evidence not admitted by the Tribunal Late submissions6.191 During the last days of the hearing, Mr Treverton-Jones reported that there were two statements that “had come in recently” and that, in those circumstances, Counsel to the Tribunal did not consider that the individuals accused could “reasonably be expected to answer the allegations in them”. Therefore, they were not treated as evidence before the Tribunal.The Report of the Macur Review | 1796.192 On 28 April 1998, the National Youth Advisory Service contacted the Welsh Office, “our Solicitor … notified [Counsel to the Tribunal] ... of the existence of new evidence and submitted a copy of ... statement. This followed a letter of 31 March 1998 which I wrote to Sir Ronald Waterhouse, seeking guidance and clarification of the matter of principle on the position of young people who wished to give evidence to the Inquiry but who are genuinely both in fear of their lives and in a precarious mental state. This has led to our receiving the assurances of the Tribunal that any information disclosed will be referred for the consideration of the Chairman alone.” 6.193 Others contacted the Tribunal by telephone or letter after the hearing or, in some cases, after the Tribunal Report had been delivered. One said he had only just summoned up courage to get in touch, although he had been contacted in May 1997. Another would “always regret not coming forward”. Another explained that he was writing “after the news tonight, which has opened a can of worms which I thought was well and truly closed ... I have kept it all deep down inside of me because of the humiliation of it all after seeing those lads on the news after all these years, has destroyed me again. So I am more than prepared to point the finger at the 3 monsters that operated in Chevethey [sic] because they must be still going on undetected, because the fear and intimidation they put into you, anyway who would believe a dishonest x-con, but I am available to speak to who ever wants to know ...”Evidence deemed to fall outside the Tribunal’s terms of reference6.194 In other cases, witnesses who wished to give evidence were determined to be outside the terms of reference. On 12 May 1997, the Solicitor to the Tribunal wrote to a firm of solicitors, “I reiterated the point that your client’s evidence fell outside the Terms of Reference of the Tribunal of Inquiry ... I have since put the complete file before the Chairman. He has asked me to indicate that Tribunal staff took a statement from your client last November in order to ensure that your client’s history was properly considered ... The Chairman however considers that it is abundantly clear that the alleged abuse by your client falls outside the Tribunal’s Terms of Reference.” I confirm that the evidence concerned was outside the time frame of the terms of reference, was not relevant to a pattern of offending on the part of a particular abuser, did not demonstrate a particular ethos in a residential care establishment nor provide an illustration of the response to a complaint which was not otherwise available in other evidence (see paragraph 5.9). Victims of suicide or unlawful killing who may otherwise have given evidence6.195 A number of previous residents of the children’s homes being investigated were known to have committed suicide. Although the Tribunal did not investigate the circumstances of the suicides, it did obtain the Coroner’s files in most cases. Save in three instances, where a police statement had been made previously by a suicide victim it was read to the Tribunal. The three police statements that were not read, those of did not contain allegations of significant abuse of a nature not covered in the evidence of others.180 | The Macur Review6.196 Another individual, who may have been a witness to the Tribunal, had perished in an arson attack in Brighton. Some suspected that John Allen was responsible for instigating the fire. An internal Tribunal note records the Chairman as “not interested in seeing the box of material containing evidence from the Inquest [of one of the deceased]. His basic view is that the Brighton fire is a red herring.” The Solicitor to the Tribunal has noted underneath “I suspect that it would be prudent if we opened this Pandora’s Box of evidence.” 6.197 The Tribunal was informed that a police re-investigation had taken place into the circumstances of the fire. The police press release and briefing “Palmeira Fire Reinvestigation” made available to the Tribunal indicated: “the re-investigation confirmed that the original suspect [who committed suicide three days later] was responsible for starting the fire. There is no new evidence to indicate either that anyone else was involved or that he was acting as another’s agent. Two large sums of money which appeared in his bank account during 1990 appear to coincide with a redundancy payment, and the sale of a property. All surviving people who attended the party at Palmeira Square have been traced, with the exception of one man who is not central to the enquiry. None has been able to offer any new evidence. There is no disagreement among experts that the seat of the fire was the settee in the ground floor hallway. It will never be known whether the arsonist also set fire to other objects on his way down the stairs. Among those interviewed was John Allen, a central figure in the North Wales child abuse inquiry. Two of the victims of the fire were former residents of Bryn Alyn, but the team found no evidence to corroborate any involvement of Allen with the fire, and no evidential links were established between the fire and the events under investigation in North Wales. The circumstances of the death in 1995 of who survived the fire, have been the subject of considerable speculation. It is also clear that [he] himself had become more suspicious over time about the cause of the fire and this too has affected his surviving family. The investigation has been able to resolve several of the outstanding issues surrounding his death.” Allegations not dealt with for other reasons6.198 I indicate in paragraphs 6.77 to 6.80 that the Tribunal mislaid evidence. It is further evident from notes between Counsel to the Tribunal and the Chairman that a staff file was lost during the course of the Tribunal relating to Keith Bould. Keith Bould was for some time registered as a foster carer with Clwyd county council and allegations of sexual abuse had been made against him by four young girls. He was convicted. Counsel to the Tribunal had formed an early decision that the alleged abuse should not be investigated by the Tribunal as it did not fall within its terms of reference, apparently under the misapprehension that all but one of the complainants had been cared for by Keith Bould’s wife as registered child minder, not foster carer, and the other was a relative of theirs. At the later date, when the Chairman queried this decision, it was established that the file was missing. Subsequent investigation revealed that at least two of the three complainants, and were in the care of Clwyd county council at the time of the indecent assaults and would have fallen within the terms of reference.The Report of the Macur Review | 1816.199 One complainant, who had alleged physical abuse against three residential home care staff in a police statement, complained in a 1999 television documentary that the Tribunal had failed to contact him (see also paragraph 6.100). This prompted Mr Treverton-Jones to contact the Clerk to the Tribunal, saying that he “simply cannot remember why we did not make contact with him … The Gwynedd complainants tended to come forward voluntarily, but as he was the allegedly ‘dull wicked boy’ of [the 1986 police] Reports, I feel sure that we would have specifically tried to contact him.” There is a record that the WIT obtained a contact address for the complainant, but no follow up documentation to indicate what action was taken or outcome achieved. 6.200 Eight alleged abusers were subject to ongoing police investigation at the time of the Tribunal hearings. The Tribunal records its general policy not to receive evidence in support of complaints still under police investigation in the Tribunal Report. None of the eight would constitute an establishment figure. Generally, complainants whose predominant allegation concerned those who were subject to police investigation were not called.6.201 One complainant, failed to attend the Tribunal on several occasions without good reason, despite his repeated assurances that he would do so and a witness summons being issued to compel his attendance. The Chairman raised the issue during the Tribunal hearings, raising the distinction between his case and those who had good reason not to attend or said they did not feel able to give evidence, in which case their statement was read. In this case, the complainant appeared “to be playing hot and cold”, had been offered counselling but failed to attend for that purpose, and in the circumstances, it was decided that no reliance would placed upon his evidence at all.Progress of the Tribunal6.202 My reading of the documents relating to Tribunal “Progress Meetings” reveal the revision in plans necessitated by unforeseen events and the encroachment of time, inevitable in a public inquiry of this scale. The oral evidence in the first phase of the hearing obviously took longer than anticipated. A note from Counsel to the Tribunal to the Chairman suggested that, to ensure completion of Phase 1 by the end of July, the number of live witnesses in the remaining part of Phase 1 be reduced by removing trivial allegations from the evidence, alternatively to impose time limits for cross examination. 6.203 On 10 June 1997, notice was given in relation to the management of the Tribunal timetable that statements would no longer be read out during the course of the proceedings, but would be entered into the computerised transcript overnight. If the statement was from a complainant, the passages which contained allegations of abuse would be read and the remainder summarised. If the statement was from a Salmon letter recipient, his or her advocate would be invited to say publicly in a few sentences what needed to be said about the evidence. The statement was to be issued to the press at the same time the statement was put before the Tribunal.182 | The Macur Review6.204 A list of witness statements to be read indicates a range of reasons for doing so in addition to those matters indicated previously in paragraph 6.183. Five witnesses indicated they were willing to give evidence, but could not then be traced. Three, who had been willing to give live evidence, declined to do so for no specified reason. Two indicated from the outset that they were unwilling to give live evidence. One witness was assessed to be of very low intelligence and with a very limited ability to concentrate. Another was unable to attend because of child care responsibilities.6.205 A letter to the Chairman from Mr Treverton-Jones concerning the “Final sweep up” indicates the necessity of “further statements to be read” since in one case “unfortunately, the statement was mislaid, and was only found a matter of days before the Tribunal adjourned …”6.206 Further decisions as to the management of the evidence were made. A note of the meeting on 13 June 1997 between Counsel for the Welsh Office, one of Counsel to the Tribunal and the Solicitor to the Tribunal records that: “1. ... Chairman had made a decision to exclude evidence which will not provide examples of systems and procedures, and systematic abuse. Evidence of serious allegations will not, however, be excluded but the intention is that certain representative evidence will be given. There will not be any area of evidence that will not be covered … aim is to eliminate duplication. 2. … evidence relating to Bryn Alyn … Welsh Office had some concern that with such an extensive list of potential witnesses only 25 people were being called … [Counsel to the Tribunal] said that the Chairman would not be receptive to any arguments that he would not hear enough about Bryn Alyn from those who were being called. [He hoped the other (approximately 75) statements would be read out, but this had not yet been discussed with the Chairman]. It may be that only the very significant statements would be read out … this would provide a record of allegations but as the evidence would not be tested it would not be used to make findings in relation to the scale or extent of abuse. [Counsel to the Tribunal] said that the Chairman had no difficulty in believing the nature and extent of abuse based on the evidence he had already heard. 3. Gwynedd evidence… Tribunal would not need to hear a vast amount of evidence to get the picture.”Withdrawal of Salmon letters6.207 In a ‘Note to Chairman’ dated 14 May 1997 concerning progress, past and future, Counsel to the Tribunal wrote, “1. In our view we must ensure that Phase 1 is completed by the summer break … 2. If we do not complete Phase 1 by the end of July, we do not see how we could complete the Inquiry this year; 3. In order to meet this self imposed deadline, we consider that we shall have to reduce radically the number of Salmons who give live evidence ... On the other hand, it is obviously important that the Tribunal should hear a sufficient spread of evidence to be able to reach proper conclusions. In our view, we should seek to reduce the number of The Report of the Macur Review | 183Salmons … to around 30. This can be achieved as follows: 3.1. the Tribunal should issue a list of those from whom it wishes to hear live evidence (these will be the most serious alleged abusers, and/or those in the more senior positions); 3.2. by and large, those who do not wish to give evidence should not be forced to do so; 3.3. those willing to give evidence, against whom only 1 or 2 allegations are made ... provided that the allegations are not of the most serious kind, should be informed that, in the absence of admissions, cautions or convictions, it is highly unlikely that they will be named/criticised as abusers in the Report, and that it is not necessary for them, therefore, to give their evidence orally. The same principles do not apply to those who have indicated that they do not wish to attend to give evidence who are not on the list at 3.1 above ...” In this last respect, I note that witness summons were issued to compel recalcitrant convicted abusers to attend the hearings to give evidence.6.208 A separate note to the Chairman from Counsel to the Tribunal at paragraph 4.5 reads, “we have as yet given no assurance to the legal advisers of the ‘read’ Salmons that their clients will not be criticised as abusers in the Report. We believe that unless such an assurance is given, some, perhaps all, of those representatives will wish their clients to give live evidence ... 4.5.1. In our view little would be lost by providing some form of limited assurance, since we believe that the Tribunal will not be concerned to resolve one-off issues of fact involving less senior members of staff at the homes. 4.5.2. However, we also believe that the matter will have to be approached carefully, probably on a person-by-person basis, as some of these Salmons have made admissions, and there may be further documentary evidence in respect of others. Above all, the Tribunal will not wish to tie its hands as to the future. 4.5.3. We recommend that the Tribunal indicates through Counsel that in the absence of admissions, or other documentary evidence tending to confirm the truth of the complaint, the Salmon will not be criticised as an abuser in the Report without being given an opportunity to give live evidence to the Tribunal ...” In manuscript alongside appears “Ch agreed”. 6.209 Some Salmon letters were consequently withdrawn. In other cases, ‘assurances’ were given that alleged abusers would not be named in the Tribunal Report. 6.210 The Chairman indicated on day 65 of the hearing that there was a “category of persons against whom very few complaints are made, and against whom the complaints are very much at the lower end of the scale ... those persons ... evidence may be read.” He said that the Tribunal was “giving the limited assurance … about not naming them because of the marginal relevance of their identity to any conclusions that we come to”. However, he made clear that if the Tribunal received fresh evidence requiring the witness to be called, the assurance would be of no effect. 6.211 This stance is confirmed in the Tribunal Report, where it is said that the Tribunal considered that “we should exercise a restrictive discretion in naming alleged abusers in our report. We have, for example, been able to give assurances in advance to a substantial number of persons in this broad category because of the comparative triviality of the allegations against them or the very limited number of minor allegations made against them over a long period.”1414 See paragraph 6.15 of the Tribunal Report184 | The Macur Review6.212 Assurances were given to approximately 70 alleged abusers. Some recipients of the assurances had been subject of several allegations, including physical and sexual abuse. Save for two police officers, and the former against whom there had been a single but serious allegation of sexual abuse made, no other recipients of the assurances were establishment figures. Analysis of the materials makes clear that in some cases there were evidential difficulties, and in others, it was not unreasonable to consider them of “comparative triviality” in the light of other more prolific and serious alleged abusers. 6.213 Referring to the management of the proceedings indicated above in their written closing submissions, Counsel to the Tribunal asserted that “the evidence receiving part of this investigation could well have occupied two, three or more years, and but for a number of practical steps, taken with the full agreement of parties affected at the time, may well have done so.”Issues raised by witnesses giving oral evidence6.214 One contributor to my Review, a witness against whom allegations had been made, complained of the insensitivity shown in insisting on his attendance at the Tribunal at a time when his wife was in hospital. Another complained that his treatment was not conducive to giving evidence on such sensitive issues, in that he was “taken to the Tribunal in a pair of handcuffs and a six foot long chain by prison officers and was kept like that all through giving evidence.” He said that he found this “embarrassing” and he “did not want to be a part of the process because of this situation.”6.215 However, another witness serving a sentence of imprisonment brought from prison to give evidence to the Tribunal wrote to the Chairman subsequently, “I think that I handled myself ok ... but it hit me when I got back to my cell ... After all this was only my 2nd time of talking about it. Being put on the spot as I was I was unable to think fully ... I want to thank you and those who treated me with respect like a victim and not a prisoner. This I found very helpful.”Adversarial nature of the proceedings6.216 The preliminary hearings resolved the order in which the evidence would be called, the manner in which the evidence would be adduced and also that the nature of the hearings would be adversarial. The Chairman’s note on procedure (see Appendix 3 of this Report) records, “although there are some advocates of wholly inquisitorial proceedings in investigations of this kind, in which the questioning is conducted almost exclusively by the Tribunal itself or Counsel on its behalf, I reached the firm conclusion that such a procedure would be inappropriate in this inquiry. It was essential, in my view, that complainants should be given a full opportunity to put relevant matters based on their own special knowledge to persons against whom they made allegations. Conversely, it was equally important that alleged abusers should have their cases put as they wished to the complainants who made allegations against them. This adversarial factor in the proceedings was inescapable, having regard to the nature of the allegations that the Tribunal had to consider.”The Report of the Macur Review | 1856.217 A note from Leading Counsel for the Welsh Office expresses criticism at the adversarial nature of the proceedings, although it appears that this criticism is restricted to those phases of the hearing dealing with managerial responses to allegations of abuse. Her note on 22 January 1998 complains “it seems that [the Chairman] has continued to view this Inquiry as a normal piece of litigation in which it is incumbent upon the parties, through their counsel, to invite his attention to relevant documents and make submissions which balance those of their opponents so that he, when he comes to write his report, can adjudicate upon them, identifying which argument he prefers. Thus, if difficulties are not highlighted by counsel and arguments and solutions are not presented in evidence and/or submissions it is unlikely that they will be alighted upon by the Tribunal ... It is an unusual stance for the Chairman of such a Tribunal of Inquiry to adopt.”6.218 More significantly, the impact upon some complainants was traumatic. At the conclusion of the hearings, the Chairman in writing to thank the members of the Bridge team expressed that he was “perturbed that some witnesses have said that it was a worse experience than giving evidence in the Crown Court and that a prisoner said that he felt ‘dirty’ after doing so. I wish that it had been possible to devise a more informal way in which to hear the evidence but the need to enable those against whom allegations are made to challenge the complainants by cross-examination is the fundamental problem. I have done my best to eliminate crass ‘liar’ suggestions and unnecessary but disturbing peripheral questions; but it would be a breach of the Salmon rules to prevent proper cross-examination and the number of interested parties cannot be reduced ...” 6.219 One former children’s home resident, Mr Gareth Taylor, complained that the Tribunal hearings were too adversarial, complaining of “the overwhelming adversarial fisticuffs that currently holds sway, as well as the deferential and ‘grand inquisitorial’ style that seems to have become the norm by default and lack of scrutiny.” He wrote three months later to the Chairman to report “ has suffered a heart attack ... I wrote to complain of the way in which [she] was dealt with as a witness to the Tribunal recently ... I put it to you that people are actually dying to a greater extent because of the Tribunal and its failure to provide adequate support and protection to witnesses. Furthermore, this Tribunal has whipped up an atmosphere of rumour, innuendoes and salacious gossip ... It is these lies, the suggestive accusations of collusion, of ignorance and of actual abuse that has I would argue, led to several members of former staff dying prematurely, several former residents committing suicide or attempting the same ...” He repeated the substance of these criticisms when he spoke to me in Wrexham. 6.220 In its written closing submissions, Voices from Care indicated that it “has been concerned by the number of people who have been granted party status to the Tribunal and who have been allowed to cross-examine witnesses on a daily basis. At times, cross examination of witnesses has been conducted as if the Tribunal was not merely engaged in an investigative process but acted as if it were a criminal court. It is the view of Voices from Care that representatives of parties have been too much concerned with putting their clients’ cases rather than assisting in the fact finding role of the Tribunal.”186 | The Macur Review6.221 Several contributors to the Review have also highlighted the anxieties engendered by giving evidence on such sensitive issues in public and may well reflect the intimidatory aspect of an adversarial process (see also paragraph 6.139). Mrs Alison Taylor considered that the quality of her evidence was adversely affected by the adversarial nature of the proceedings, and equally it may have affected other witnesses. She complained that the Tribunal did not intervene during cross examination of her by Counsel for Gordon Anglesea, when it should have been apparent that she had no knowledge of the police investigations. who gave evidence to the Tribunal, told me in interview that he felt “mauled” and treated as a criminal rather than as a victim.6.222 However, other witnesses were satisfied as to the special arrangements put in place to facilitate their giving evidence. One, had notified his fears in January 1997 when, in a telephone call to the Tribunal, he indicated concerns for his own safety. Part of his evidence was heard in closed session, that is, in the absence of members of the public, but representatives of all other parties being able to attend. 6.223 Some closing speeches were also considered inflammatory. On 6 January 1999, wrote to the Chairman complaining of a term used by Mr Gerard Elias QC which he considered to be disparaging. He went on to say: “ …you of all people should have made sure Mr Elias was not allowed to make comments like this and judge people like this, considering I am a victim ... I was very critical of some of the police officers who took statement after statement from me and I was very critical of the tribunal team [WIT], who took statements, with very good reason ... a person who I was told did not exist appeared before Wrexham magistrates court this month charged with sex offences, dating back to my time in care. I told North Wales Police about [them] ... These are people who I was told did not exist ... I never told any lies at the tribunal, but I could have said a great deal more, but as you know my health was not so good ... I think this Tribunal has left a heap of stones unturned, part of which Mr Elias must take the blame and Mr Moran.” 6.224 The Chairman replied on 8 February 1999 challenging the use of the term by Counsel to the Tribunal saying, “he would not have done so but, if by an aberration, he had used the expression, I would have intervened to correct him. The words that you probably have in mind were said only in Mr Elias’ final submissions and were put in such conditional (if) form by way of possible argument that it would have been unjudicial for me to stop him. I made it clear, however, at the close of his submissions that the views that he had expressed were not to be taken to be the views of the Tribunal itself.”The Tribunal Report6.225 The Clerk to the Tribunal confirmed in her interview with me that the Chairman’s manuscript draft of the Tribunal Report was faithfully reproduced in typescript, and then submitted to him for further handwritten editing. My ‘spot check’ of manuscript and various drafts seems to confirm this approach. No parts of the Tribunal Report were redacted or amended, save by the Chairman.The Report of the Macur Review | 1876.226 The Tribunal Report does not refer specifically to all of the allegations of abuse evidenced before it, whether orally or contained within the witness statements read or deemed to have been read into the proceedings. Indications in internal Tribunal notes would suggest that there were some allegations where the Tribunal entertained doubt as to reliability of the evidence. In any event, the Tribunal Report makes clear that it would have not been “practicable or appropriate ...to attempt to reach firm conclusions on each specific allegation that has been made...bearing in mind the overall objectives of the Inquiry underlying our terms of reference.”15 6.227 The Tribunal Report does not record the evidence of witnesses who made allegations against unidentified police officers nor make findings in relation to them.6.228 This Review has identified some relatively minor factual discrepancies in the Tribunal Report when compared with the evidence adduced, for example: an inaccurate number of complainants alleging abuse against individual residential care workers, or number of complaints received in relation to a particular establishment; whether a complainant was in care at the relevant time; and, in one case whether a complainant had made a Tribunal statement or offered to give evidence. 6.229 In the Tribunal Report, it is said that, “In a small number of cases potential witnesses were not called or written statements were excluded because there were clear pointers to their unreliability.”16 However, where there is evidence which does not appear to have been taken into account and/or reported upon by the Tribunal in reaching its findings on the particular topics of freemasonry, establishment names and the paedophile ring. I make further reference to it in Chapters 7 to 9 of this Report. 6.230 The Tribunal Report17 explains the Tribunal’s rationale in relation to the question of “naming names”. In summary, complainants of sexual abuse were covered by section 1 of the Sexual Offences (Amendment) Act 1992 and since many also alleged physical abuse would have presented a technical problem by their identification in respect of only part of their allegation. Others had made difficult decisions to reveal their past experiences and it was not considered within the public interest to expose them. In the case of alleged abusers, a “restrictive discretion” not to name was exercised in all the circumstances revealed, save in the cases of those subject to court proceedings, or against whom a significant number of complaints had been made, or who had featured prominently in the evidence, or who should be “identified in the public interest in order to deal with current rumours” and those not subject to allegations of abuse but who were in positions of responsibility. 15 See paragraph 6.02 of the Tribunal Report16 See paragraph 6.17 of the Tribunal Report17 See paragraphs 6.13 to 6.16 of the Tribunal Report188 | The Macur ReviewConclusions Documents6.231 Inevitably, missing documents will have hindered the Tribunal’s preparation or process of investigation. In some cases, the documents could have provided corroboration for evidence which was not otherwise considered sufficient upon which to make findings or could have undermined findings that were made. However, I am satisfied that conscientious efforts were made by the Tribunal to acquire all relevant materials.6.232 I consider that most of the issues raised as to ‘missing’ documentation are likely to have innocent explanations and arise from authorised destruction policies, inappropriate storage and inadequate record keeping or the passage of time. It is not unusual or suspicious for organisations to operate a specified destruction policy of some categories of materials to ensure effective archiving. The advance of computer technology may well obviate the need to do so which is necessitated by limited storage space. Specifically, it is unsurprising that files appear to have been destroyed a significant time prior to any government consideration of the necessity for a public inquiry. There is no evidence to suggest a deliberate destruction of materials after the announcement of the establishment of the Tribunal. 6.233 Allegations that documents were deliberately withheld from the Tribunal are concerning. In this respect, I regret that I considered Ms Griffiths to give an unsatisfactory account of herself in interview with me. She did not reveal that she had retained Tribunal documents until confronted with the evidence that she had done so, patently revealed during the course of the television interview. Her attempt to distance herself from the claims she is seen to make during the television interview as being the result of editing was unconvincing. Nevertheless, I am not in a position to determine conclusively whether she did or did not withhold files from the Tribunal, and if so which and at what stage. However, the files that she collected and collated during the Tribunal process were not the only ‘source’ of allegations to be examined by the Tribunal, and therefore the identities of alleged abusers were unlikely to be protected. The random selection of files concerning children in care would have been beyond her manipulation. What is clear is that she certainly did not repeat in interview with me her televised claims about the Tribunal’s omissions. Nevertheless, they will undoubtedly have undermined public confidence in the Tribunal process and lent support to claims of a ‘cover up’.6.234 I accept the validity of Mr Gerard Elias QC and Lord Justice Ryder’s responses to the queries raised by the Clerk to the Tribunal in relation to Mr Clode’s information concerning Ms Griffiths. Whilst it was not unreasonable to seek their views on the factual context, the decision as to what should happen was one for the Chairman alone. Overall, I deem the response of the Chairman in respect of the late allegations against Ms Griffiths to be reasonable. The difficulties in investigating the hearsay evidence at that stage of the proceedings were correctly balanced against her limited ability to skew the outcome of the Tribunal. However, I am of the view The Report of the Macur Review | 189that in the interests of transparency, the Chairman should have alerted the police to the suggestion that she may be responsible for perverting the course of justice, and that an allegation that files had been withheld from the Tribunal and was subject to police investigation should have been referred to in the Tribunal Report as a matter of public interest. 6.235 I considered account of her conversation with Mr Marshall to be consistent and reliable. There is no indication that she was responsible for altering her statement in the way I have described in paragraphs 6.51 and 6.52, nor that she knew of the apparent amendment prior to my meeting with her. Since Mr Marshall had denied the relevant conversation with when asked by DI Roberts, it is unsurprising that the investigation was curtailed. However, a more rigorous investigation may have resulted if the Chairman of the Tribunal had reported this matter to the police.6.236 I conclude that the possibility of other deliberate destruction, for example the Pickfords fire, is improbable. The Tribunal had access to documents from multiple sources. Tribunal statements were independent of other documents and not necessarily consistent even with relatively recent police statements, as demonstrated by additional and/or more serious allegations of abuse which emerged within them. In a few cases, allegations were amplified or made for the first time in the oral evidence given. 6.237 The small number of errors in the Tribunal’s safe keeping and recording of the whereabouts of files will fuel suspicion, but is more likely the result of human error in the light of the scale of the documentation involved. Witnesses6.238 I conclude that the Tribunal was sufficiently well and widely advertised in the United Kingdom. The telephone helpline was generally well administered and operated well. The advice proffered to callers was uncontroversial. 6.239 The preparatory work in terms of seeking witnesses and the planning of the Tribunal hearings appears to me to have been conducted in the main with all due diligence and expedition. The errors in the schedule of allegations were minimal and did not adversely impact upon the overall effectiveness or conclusions of the Tribunal.6.240 I consider that the Tribunal was justified in seeking its own statements of complaint from witnesses, whether those complainants were represented by solicitors or not, for the reasons indicated in paragraph 6.109. 6.241 The Tribunal was reasonable in relying upon the results of the police re-investigation and declining to inquire into evidence arising during the Inquest into one of the victims of the Brighton fire. There was no apparent reason to discredit the police re-investigation and conclusions.190 | The Macur Review6.242 The statistical exercise which should have resulted in a “Random 600” witnesses was entirely reasonable in principle and could have provided either corroboration or moderation of the scale of the abuse that was to be determined. It is unfortunate that the Tribunal Report does not record that the process was not followed through to conclusion for the sake of completeness. However, the abandonment of the process was reasonable on the basis of proportionate yield of results as against time and other sources of information. 6.243 The employment of former police officers as members of the WIT may have alienated some witnesses, but I do not detect any suggestion that it was deliberately designed to do so. There was little realistic alternative open to the Tribunal. The tracking down or visiting of complainants long since dispersed from the area, and the necessity that they should provide a statement of relevant information in a standard form within a limited time frame, could not otherwise have been achieved as comprehensively as it was.6.244 The offer of the NWP to provide serving officers to assist was rightly declined in the light of their party status and the sensitivity of those who considered the force to have ignored or contributed to the abuse. Equally, it was appropriate to decline the initial invitation of Mr Loveridge and Ms Griffiths to assist in identifying the characteristics of prospective witnesses prior to the WIT approaching them. The subsequent involvement of Ms Griffiths in this respect was in my view pragmatic, but with hindsight of her subsequent behaviour as indicated above, regrettable. Whatismore, it did not adequately reflect the potential conflict of interest created by her employment with an authority whose behaviour was under review. However, for the reasons given above, I think it entirely unlikely that she was able to manipulate the inquiry to her own or any other individuals’ advantage. 6.245 It would have been unrealistic for the Tribunal to attempt to trace all witnesses who had made complaints, as noted in their social services files or police statements, in the past relating to more minor allegations of abuse within the limited time frame available. Specifically, the nature of the information indicated by the two individuals calling the telephone helpline (see paragraph 6.93) would have been unlikely to have added to the overall picture. Equally, it would have been disproportionate to attempt to trace witnesses in relation to allegations made against those who had received assurances, whose Salmon letters had been withdrawn or not issued, or in cases where there was already a sufficiency of evidence to establish the range of abuse alleged. I have referred to cases where no explanation is given for the WIT’s failure to attempt to trace various witnesses. These are comparatively few in number and, for the avoidance of doubt, do not concern allegations against establishment figures.6.246 I regard the WIT briefing notes as well prepared. To enable a witness to have a solicitor or third party present at the taking of their statement was a protective measure for both interviewee and interviewer. I think the criticism of the Solicitor to the Tribunal regarding the WIT’s restrictive approach to be an inevitable product of a strict adherence to the instructions rather than indicative of indifference.The Report of the Macur Review | 1916.247 The Witness Support Service was independent and was introduced for the purpose of mitigating the impact of the traumatic process of making a statement alleging abuse and/or giving oral evidence before the Tribunal. It appears to have been properly co-ordinated and maintained confidentiality of those who used the facility. It was not unreasonable to offer the same service to abused and accused assuming appropriate arrangements could be made to ensure their segregation, each from the other. No service would be capable of alleviating all distress or anxiety. 6.248 The arrangements made for the hearings probably did not cater adequately for the welfare of all witnesses before and after giving evidence, as indicated in the complaints made at the time and subsequently. However, it is difficult to devise a process that could have catered for every individual witness in the light of the emotive subject matter to be investigated. Approaches to witnesses, delay in taking their statement, the changes made to the Tribunal timetable and intended live witness lists, and the adversarial nature of the proceedings carried inherent risks which I consider were unavoidable. The necessity of a working practice to ensure due process may have appeared unfeeling to some of the participants. Its impact on an individual witness’s comfort is regrettable, but I consider it unlikely to have significantly impeded the quality of evidence given by the majority. Specifically, it would have been unrealistic to have contemplated the Tribunal sitting in more than one location by virtue of the personnel and equipment involved.Hearings6.249 The Tribunal’s rulings on representation were reasonable and not designed to impede access to justice. I am satisfied that it would have been impossible to meet demand for representation in financial terms. Recognising the importance of protecting the reputation of deceased witnesses, whether abused or accused, I am nevertheless satisfied that it was reasonable for them not to be represented. The Tribunal’s terms of reference did not centre upon particular allegations and it was necessary to have regard to proportionate use of resources, finances and length of hearings. 6.250 I am satisfied that no complainant was disadvantaged by reason of the decision made to scale back the number of solicitors at the conclusion of Phase 2 dealing with complainants’ evidence. There is some merit in the argument that the defunct local authorities should have been independently represented from the Welsh Office and the successor authorities from the objective perspective of ‘equality of arms’. The Chairman sought to ensure this in the preliminary hearings. However, whilst some personal criticism of previous Councillors may have been deflected, it is unrealistic to suppose that their separate representation would have undermined the overall conclusions of the scale of the abuse or the inadequate managerial response that had occurred. 192 | The Macur Review6.251 The Tribunal’s ruling as to anonymity was not designed to protect abusers of whatever status, rather to facilitate the giving of evidence. The public hearing was recorded. Names were used throughout and appear on the daily transcripts. The ruling prohibited the reporting of a witness’s identification, or those accused, in the media, but not the public naming of either during the Tribunal hearings. The benefit of encouraging greater participation of witnesses in the Tribunal process outweighed the prospect of identifying witnesses and those they accused to members of the wider public unable to attend the hearings. 6.252 The management of the disclosure process appears to have been well ordered and appropriate to guard against unnecessary fishing expeditions and to protect confidential child care and medical records, whilst ensuring observance of due process.6.253 The procedure adopted by the Tribunal in relation to the witness statements of live witnesses standing as their evidence in chief is uncontroversial. I consider that the Chairman’s response to Councillor King’s complaint as to process to be accurate and well balanced. The selection of witness statements to be read involved an exercise of discretion in the context of the whole and, as a practice, was merited to limit the length of the hearings appropriately. I do not regard any of the individual decisions made by the Tribunal to read or summarise a statement, rather than call the maker to give live evidence, to be unreasonable. Specifically, I do not regard the decision not to call Mr Frost to be at all questionable. His evidence as to the approach he made to Cheshire police was seemingly not challenged by any party to the Tribunal. His attitude that “it was no big deal” and his description of the information he gave to be rumours would not have indicated a necessity to call him, and may well have accounted for the fact that the Cheshire police officers did not consider it sufficiently important to log or pass on to the NWP. What is clear from the evidence is that, for whatever reason, the Tribunal did not do so.6.254 The provision of witness packs should have assisted a well ordered investigation. Records of decisions made to exclude evidence show that they were made for practical reasons. I do not consider it unreasonable to disregard the evidence of witnesses who repeatedly failed to attend the Tribunal, or those who volunteered late in the day, or could not add to the overall picture of the evidence already available. Case management was a necessary component of a well ordered inquiry on this scale. 6.255 Specifically, it was reasonable for the Tribunal to review its practices and amend its procedures with a view to conclude the hearings within a reasonable time frame.6.256 I have not discovered any indication of bad faith on the part of the Tribunal or Counsel to the Tribunal in relation to the management of evidence or due process. The reluctance to compromise police investigations or prospective criminal prosecutions was merited. Decisions made in respect of elderly abusers appear uncontroversial in the scheme of the Tribunal. Arguably some allegations were wrongly identified as “very limited” in number or “minor” in nature to lead to assurances being given to alleged abusers that they would not be named in the The Report of the Macur Review | 193Tribunal Report, however it was necessary for a judgment to be made not only as to the categorisation of the nature of offences alleged, but also the available evidential foundation in relation to them. Different conclusions could have been reached in some cases in this regard, but I do not conclude that the decisions made by the Tribunal or Counsel to the Tribunal were outside the band of reasonable decisions. The decisions made in regard to the withdrawal of Salmon letters and the giving of assurances were otherwise justified in an effort to foreshorten the hearings in the context of the other evidence available. 6.257 I consider that the Tribunal was right to decline to investigate the cases of those complainants who had committed suicide. The Tribunal was not in a position to review the Coroner’s verdicts. Neither was the Tribunal in a position to gainsay the results of the police investigation into the circumstances surrounding the Brighton fire. 6.258 I do not regard the complaints made that the Tribunal ignored evidence running counter to the evidence of abuse to be objectively justified in the context of the Tribunal’s findings that not all complaints of abuse were sustained. The Tribunal’s expertise was such that it was unlikely to require expert evidence which dealt with the contra indications of abuse. The high level representation of those accused rendered this redundant. Cross examination of complainants was capable of revealing any factor which undermined reliability. I do not consider it was necessary or reasonable for the Tribunal to investigate the evidence concerning Mrs Taylor’s employment, or otherwise to allow her or Councillor King to give opinions on the evidence of others. I consider that the Chairman’s response to Councillor King’s complaint as to process to be accurate and well balanced. Noting Mrs Taylor’s views as to the inadequacy of the investigation by the Tribunal of managerial response in respect of children in care or the role of the NWP in the investigation of child abuse allegations, I nevertheless conclude from my reading of the documents as a whole and the Tribunal Report that this criticism is not justified. 6.259 I recognise the inherent difficulty in assessing the reliability of accusations made against unidentified police officers. The prospect of reaching a determination on the validity of the individual complaints was unlikely. In these circumstances, it was not unreasonable to concentrate on the substantive allegations made against named individuals. 6.260 The apparent omissions in admitting available evidence into the proceedings are comparatively few. Some, as indicated above, were reasoned decisions. In respect of the others, I would not discount the possibility of human error, or oversight, in view of the quantity of the materials involved. 6.261 The selection of an adversarial process rather than an inquisitorial process provided a forum for any evidence to be led and cross examination made in relation to all allegations whomsoever they concerned. This particularly so by reason of the legal representation of complainant witnesses. The Tribunal would not have been likely to select such an approach if it had wished to suppress evidence.194 | The Macur Review6.262 The daily transcripts reveal that Counsel to the Tribunal were robust in their approach in cross examination of alleged abusers and showed no distinction between classes of those accused. That on occasions offence was said to have been caused to some of the Tribunal witnesses by Counsel to the Tribunal may indicate an over combative manner but undermines any suggestion of a lack of enthusiasm to establish the case of institutional abuse. Other Counsel were also criticised for their cross examination of the witnesses. 6.263 It appears to me that Leading Counsel for the Welsh Office’s criticism of the adversarial approach adopted by the Tribunal was articulated in relation to the stage of the hearings dealing with managerial responses to allegations of abuse and not the determination of factual issues of abuse. If it was more wide ranging, it was, in my view, unreasonable and unfounded. If limited to the stage dealing with managerial responses, the argument is more finely balanced, but I consider the scale comes down in favour of a consistent approach. The Tribunal Report6.264 The Tribunal was not intended nor devised to be a series of quasi criminal trials returning verdicts on all allegations. The omissions and factual discrepancies I have identified are few in number and hardly surprising in a report of its length and breadth. It would be unrealistic to expect every piece of evidence to be mentioned or to assume that it was not therefore considered by the Tribunal. Specifically, given the continued issues raised by the two journalists referred to in paragraph 6.182 herein, it appears to me that the nature of Mr Frost’s evidence was sufficiently imprecise to enable findings to be made either as to when he informed the police officers in Chester or whether they had adequately informed Wrexham police.6.265 The Tribunal Report may be inaccurate in reporting that “The evidence before us shows that there were three officers only against whom allegations of sexual abuse were made …”18 There were allegations made by a small number of witnesses who may have been in care which arguably complained of sexual abuse against other police officers, albeit that they were unidentified. A far greater number complained of physical abuse by police officers. In view of the repeated allegations of a police ‘cover up’ in the lead up to the establishment of the Tribunal, I consider it would have been appropriate to refer to the number of allegations made against several unidentified police officers by witnesses and the reason why no conclusions were drawn. The failure to do so is likely to continue speculation of cover up of police complicity. 6.266 However, overall, I adjudge the Tribunal Report to accurately reflect the preponderance of the evidence. The Tribunal Report will inevitably disappoint those participants who sought vindication for their own case or cause and did not achieve it. 18 See paragraph 51.65 of the Tribunal ReportThe Report of the Macur Review | 195Overall conclusion6.267 I conclude that the procedure identified and implemented as a general rule, and in regard to the likely majority of participants, was appropriate and reasonable in the circumstances that the Tribunal need investigate and report in a time span commensurate with the public interest and to address any unresolved local or national issues of child care practice. I am satisfied that the process was not likely nor designed to protect any individual or institution otherwise subject of allegations or legitimate criticism.196 | The Macur ReviewThe Report of the Macur Review | 197Chapter 7: FreemasonryIntroduction7.1 The issue of freemasonry formed a lynchpin in many theories of why the abuse of children in care in North Wales had been allowed to continue for so long. Those Freemasons who were not directly involved in abuse were considered likely to protect those who were, either by failing to investigate allegations adequately or at all. The rumours of the NWP being a bastion for freemasonry held firm, particularly in regard to the involvement of a high ranking officer, Gordon Anglesea, accused directly of serious sexual assault. The inclusion of this chapter in this Report requires no further explanation.Tribunal approach7.2 The Tribunal Report states that freemasonry “soon became a non-issue” in the Tribunal as “there was no evidence whatsoever that freemasonry had had any impact on any of the investigations with which [the Tribunal has] been concerned.”1 The Tribunal had investigated the issue in relation to Gordon Anglesea because it appeared “to be alleged specifically that [his] membership of the Masons had led to a ‘cover up’ of the allegations about him or to specially favourable treatment in consideration by the police of the strength of the evidence against him.” The Tribunal found neither situation to have been established. As regards Lord Kenyon, a Freemason, Provincial Grand Master, and a member of the NWP Authority in the 1980s, who was speculated to have “advocated Anglesea’s promotion for the purpose of covering up the fact that his son had been involved in child abuse activities … We have received no evidence whatsoever in support of this allegation and it appears to have been a malicious rumour.”27.3 The “very strong and impressive opening” (see paragraph 4.39) of Leading Counsel to the Tribunal did not refer to the issue of freemasonry. However, his opening speech at the beginning of Phase 4, dealing with the police investigations, covered the topic fully. Mr Andrew Moran QC, opening this stage of the Tribunal on behalf of the NWP did so berating the source of information concerning the adverse impact of freemasonry in relation to police investigations, in terms that, “an oft recurring theme ... in this force area, that a particular officer of the North Wales Police, based in Gwynedd, had because of Masonic influence failed to investigate a case of child sexual abuse ... the source of the allegation was identified and Councillor Parry ... when confronted … conceded that he knew that the unfortunate person on whom he was relying was mentally unbalanced ... the deluded ramblings of a complete ‘Walter Mitty’ like character, asserting the role of a secret service agent … In association … suggestions put about in North Wales that the police were not fit to be investigating, that because of freemasonry they would show favour in circumstances where officers of the force were suspects ... were entirely unjustified ... We can now demonstrate that Anglesea - apparently at some time a freemason - was not shown an ounce of favour ... The proof of that is incontestable in the recommendation made by Superintendent 1 See paragraph 50.42 of the Tribunal Report2 See paragraph 50.44 and 50.45 of the Tribunal Report198 | The Macur Review Ackerley that there was sufficient evidence to prosecute …Freemason at the top of 34 the North Wales Police, there are none. Freemason? Mason free zone, we would say.” 7.4 I bear in mind the complaint of Councillor Malcolm King in his letter to the Chairman and repeated to me to the effect that he was prevented from giving his evidence fully. His correspondence with the Chairman is referred to at paragraph 6.177 herein. To me, he suggested a degree of cover up, possibly with a view to protect a senior police officer who he said had investigated a member of the NWP and had told him they would like to “do [the officer] for child pornography.” For the avoidance of doubt, I record here that the NWP officer concerned was not the subject of any allegations by any witness to the Tribunal. Councillor King had spoken to this senior police officer about Gordon Anglesea in a different connection and did not specifically refer to this in the context of freemasonry. Significantly, in his address to the Tribunal, Counsel for Councillors Parry and King said that, “I had not intended to raise the wretched topic of free masonry ... It is correct that Councillor Parry and Councillor King, did suspect that there may have been such an involvement ... errors may be made by those well intentioned ... if this information [in relation to other senior police officers, including the Chief Constable’s, non membership] had been revealed [in 1991] then it may have been the end of that unfortunate story relating to free masonry.” In doing so, he appears to confirm the Tribunal’s view that it was a non-issue. 7.5 The wider issue, of course, was the appointment of two Counsel to the Tribunal and the head of the WIT who were Freemasons. This Review has specifically considered whether there is anything within the material which suggests that the investigations made on behalf of the Tribunal into freemasonry was less thorough by reason of this fact. I have found nothing to suggest this was the case and illustrate the point below predominately in relation to two establishment figures identified during the course of the Tribunal as Freemasons, namely Gordon Anglesea and Lord Kenyon, and briefly in general (see paragraphs 7.22 and 7.23).Gordon AngleseaTribunal investigations7.6 The Tribunal Report “recounted in some detail in Chapter 2 the history of the libel action brought by Gordon Anglesea against four defendants [Newspaper Publishing plc, The Observer Ltd, HTV Ltd and Pressdram Ltd] in respect of the allegation or suggestion that he had been guilty of serious sexual misconduct at Bryn Estyn because it formed an important part of the background to the appointment of the Tribunal.”3 The Tribunal recognised the jury verdict in favour of Gordon Anglesea, but reported that they had “looked carefully for any compelling fresh evidence that would drive us to a conclusion contrary to that of the civil jury.”43 See paragraph 9.01 of the Tribunal Report4 See paragraph 6.12 of the Tribunal ReportThe Report of the Macur Review | 1997.7 That part of a note of the Chairman’s meeting with Counsel to the Tribunal on 26 November 1996 referring to Gordon Anglesea, after commenting upon the further enquiries to be made in relation to establishment names appearing in the press (see paragraph 8.61) reads, “Ditto - we propose to make further investigative enquiries in relation to this individual particularly in the light of the recent information that the recommendation of the NWP to the CPS was that he should be prosecuted. Nb - we have been put on notice that NWP propose to adduce this fact in Opening their case to the Tribunal to seek to destroy the ‘Police Cover up Conspiracy’ theory - (& since [Gordon Anglesea] has been described as a ‘prominent freemason’, no doubt any suggestion of a conspiracy in that direction, also!).”7.8 Evidence was sought to supplement that which had been before the High Court in Gordon Anglesea’s libel proceedings. The WIT made repeated attempts to trace one witness, without success who had given information A firm of solicitors was reported as waiting for him to give them instructions in order to represent him at the Tribunal. It appears that he eventually made a Tribunal statement, (although this cannot be located in the Review papers) for in the last days of the Tribunal hearings, Mr Gregory Treverton-Jones made a reference to it in terms that it had arrived too late to adduce fairly into evidence since those against whom he made accusations would not have an adequate opportunity to deal with them. It appears from the Chairman’s comments at the time that the statement contained allegations against Paul Wilson and Peter Howarth or Stephen Norris. No reference was made to Gordon Anglesea, which would suggest the statement was silent on this point. 7.9 The Tribunal looked for evidence of other allegations of sexual abuse and grooming, and established Gordon Anglesea more frequent visits and greater association with Peter Howarth and Bryn Estyn than he had previously accepted. A CPS file note created by refers to a 1994 police statement in which it is said that one witness, alleged that Gordon Anglesea visited Bryn Estyn about twice a week between 1979 and 1982 in civilian clothes, and that he and Peter Howarth, together with some boys, would knock golf balls about in a neighbouring field. This witness’s address was obtained by the WIT via the Benefits Agency but there is no further indication as to whether contact was made with him. Tribunal documents show that the WIT was directed to investigate relationships between Gordon Anglesea and Peter Howarth, and Gordon Anglesea and Stephen Norris. 7.10 I observe that although a WIT record of a meeting with a Tribunal witness, refers to , there is no reference to in his Tribunal statement and no other document which expands on this entry. The witness gave evidence to the Tribunal but, unsurprisingly in the circumstances, was not asked about Another witness, who was a serving prisoner, wrote to the Tribunal referring, amongst other things, to frequent visits to Bryn Alyn. He was seen by the WIT, but did not refer to in his Tribunal statement. It is not clear whether he was asked about 200 | The Macur Review7.11 A witness, Mr seen by the WIT whilst a serving prisoner was assessed as “Fixated re Gordon Anglesea and his alleged involvement in a paedophile ring.” The statement produced records his assertions that in 1991 he had seen part of a video featuring Gordon Anglesea sexually abusing a boy and girl. The video had allegedly been stolen from a local Councillor subsequently prosecuted for possession of a large quantity of pornography. He said he developed photographs from the video and sent them anonymously to the Chief Constable of the NWP. A week later, Gordon Anglesea resigned, he thought as a result of the disclosure. This witness was not called to give evidence and there is no evidence of his statement being read to the Tribunal. A note with the statement addressed to ‘Gerard’ queries whether the allegations of sending the photographs to the Chief Constable should be followed up. There is no direct response to this in writing. However, in a Tribunal note headed “Final sweeping up evidence”, his statement was described as “deemed not credible by Counsel to the Tribunal” and his allegations “not properly supported.”7.12 Investigations were made of membership lists of the masonic lodges with which Gordon Anglesea had been affiliated, and to determine the identity of his proposer(s). Visitor’s books were inspected. Other investigations had been made of golf clubs to investigate his connection with Peter Howarth; at Bryn Estyn to establish the frequency of his visits; and at the attendance centre at which he had been Officer in Charge to question his colleagues about the manner in which he carried out his role. The investigations were commissioned on behalf of the Tribunal and apparently faithfully executed by the WIT. However, more than one contributor to this Review still question whether enough was done to find evidence against Gordon Anglesea or to properly examine the links between freemasonry and the failure to investigate child abuse allegations.7.13 This Review has noted, and I record for the sake of completeness, that one other member of the Pegasus Masonic Lodge at the same time as Gordon Anglesea was said, in other documents, to be the owner of a flat in which an indecent assault was committed against a male youth, when he was in care, by a female residential care worker, who was subsequently convicted. Another individual, who was subject to an unsubstantiated assertion of association with John Allen and “getting boys”, has a similar name to that of another member of the Pegasus Masonic Lodge at this time. However, no connection was drawn between either of them and Gordon Anglesea by any witness. Neither were they referred to by name by any witness before the Tribunal. Therefore, there were no allegations and no evidential basis to make findings against them. Unsurprisingly in these circumstances, Gordon Anglesea was not questioned about them. The Tribunal Report records that Nefyn Dodd denied that he had ever been a Freemason when specifically asked in order that “any suggestion of a ‘cover up’ [by the NWP and Gordon Anglesea in particular] in his case on that ground should be probed.”5 One other witness to the Tribunal, was for some time a member of the Berwyn Masonic Lodge at the same time as Gordon Anglesea but gave evidence that he knew him by sight and had never approached him.5 See paragraph 50.47 of the Tribunal ReportThe Report of the Macur Review | 201Tribunal hearings7.14 One witness, Mr who gave oral evidence to the Tribunal in relation to allegations against several residential care staff, refused to expand upon matters relating to in a police statement. He acknowledged that he knew and that he had seen him in Bryn Estyn in about 1974, but refused to say anything further, he said for fear of reprisals.7.15 Another witness, obviously indicated that he did have evidence relating to which did not appear in his first Tribunal statement. He was not called to give evidence, but was requested to produce a further statement containing the allegations, and did so in September 1997. He alleged that whom he later recognised as would come to Bryn Alyn regularly. He suggested that boys were called out of the room to be masturbated. The daily transcripts confirm that Leading Counsel to the Tribunal cross examined about these and other allegations. 7.16 During the course of Councillor King’s evidence, reference was made to an anonymous witness who would allege abuse against Gordon Anglesea. An attendance note dated 3 February 1998 reads, “At the short adjournment I visited Mr King in the witness room to request that he furnish me with the name of the complainant [against] Anglesea that he had referred to in the witness box ... Mr King refused to give me the name unless the undertaking outlined by the Chairman (i.e. that the complainant would not be approached without his consent) was given … the U/T [undertaking] having been given.” A file note dated 3 March 1998 records, “King telephoned. He has spoken to lead social worker at Altcourse [prison] – X has indicated that he does not wish to speak to anyone at the Tribunal, or to MK [Malcolm King]. He was most distressed after his last conversation with MK. Therefore little else we can do at this stage?” 7.17 Two ‘new’ witnesses, who complained of sexual abuse at the hands of Gordon Anglesea were called to give oral evidence. I have considered whether the decision not to call one witness, to give oral evidence was reasonable (see paragraph 8.94). was a His statement was read to the Tribunal and made reference to Gordon Anglesea. The Tribunal subsequently gave little weight to his statement on the basis that: it was the only evidence to the effect that Gordon Anglesea would ‘pick boys’ lined up for that purpose by Peter Howarth; that there was uncertainty as to whether the witness was at Bryn Estyn at a time of regular visits made by Gordon Anglesea, an inspector at the time, rather than a Chief Superintendent as he was identified by and, it contained speculation rather than direct evidence.6 statement added some weight to the fact of Gordon Anglesea’s association with Peter Howarth and the number of his visits, but not otherwise to his motive in visiting. I note there was already evidence before the Tribunal to this effect, which countered Gordon Anglesea’s assertions to the contrary. 6 See paragraph 9.28 of the Tribunal Report202 | The Macur ReviewEvidence not before the Tribunal7.18 I am aware that an allegation of a relatively minor indecent assault was made against Gordon Anglesea by an adult acquaintance of his family prior to the commencement of the Tribunal hearings. It appears that Counsel to the Tribunal was informed that “the CPS had decided to take no further action in the case on the grounds that there was insufficient evidence to support criminal proceedings”, but apparently not of the fact that Gordon Anglesea had lied, on his own subsequent admission, when first interviewed under caution about the allegation. A note to the Chairman from Mr Gerard Elias QC and Mr Treverton-Jones indicates that, “we have requested sight of the NWP file in respect of the allegation of indecent assault ...The NWP’s legal representatives are concerned that this allegation (of indecent assault upon an adult) is entirely irrelevant to the issues before the Tribunal. We believe that we should at least see the file, and unless you take a contrary view, we propose to insist upon its production to us.” However, a manuscript annotation reads “justification needed” and it does not appear that the matter was taken any further.7.19 I wrote to the present Chief Constable of the NWP on 15 May 2015 in relation to this non disclosure. The Chief Constable responded indicating that there is no material in the possession of the NWP to indicate why the file was not disclosed, but that it is possible that the file’s relevance to the issue of credibility was overlooked. Having looked into the matter, the Chief Constable noted that Gordon Anglesea had been interviewed during the course of the investigation into the indecent assault and an advice file submitted to the CPS, who decided to take no further action.7.20 On a different issue, this Review notes that a letter dated 1 October 1998, sent by Mr Treverton-Jones to the Clerk to the Tribunal states that “… had [he] seen the statement [of a complainant, it would have rung a number of very loud bells.” The statement concerned allegations of physical abuse against In the same statement, refers to the visits of to Gatewen Hall on a number of occasions while was associated with the home. Mr Treverton-Jones wrote that he was “pretty sure that [he had] never seen this statement … [and] was extremely interested in the connection between and …” Whilst accepting in the letter that “the statement somehow slipped through the net”, he went on to conclude it did not contain an allegation against and that himself had accepted in evidence that he had visited Gatewen Hall on a number of occasions at the relevant time.Lord Kenyon7.21 Lord Kenyon’s alleged manipulation of the criminal justice system on behalf of Gary Cooke to protect the interests of his son, Thomas Kenyon, and the attempt he made to persuade the Chief Constable of the NWP to withdraw a directive discouraging police officers’ membership of freemasonry, was considered by the Tribunal, as was his alleged influence to ensure Gordon Anglesea’s promotion.7 Lord Kenyon’s 7 See paragraphs 50.44 and 50.45 of the Tribunal ReportThe Report of the Macur Review | 203 previous association with the Clwyd Area Health Authority between 1974 and 1978 was not. I refer in paragraphs 5.80 to 5.95 to the impediment in the Tribunal conducting a thorough investigation in relation to Gwynfa. There is no allegation in any witness statement available to the Tribunal which suggested Lord Kenyon’s personal involvement in child abuse.Other references to Freemasons7.22 In a briefing note dated 9 October 1996 sent by (see paragraph 5.49) to the DPP and others, he notes under “other developments … I have raised with the sensitivities of Masonic influence in the case. He has assured me that he has no links whatsoever with Freemasonry.” spontaneously indicated that they had no connection with Freemasons in interview with me. 7.23 During the course of this Review, I have been informed by Mr Andrew Sutton that he was told by a police officer to “Beware of the Brotherhood”, which he took to refer to freemasonry. I have also been told by of malign masonic influence, which prevents him identifying establishment figures as abusers. I am unable to take these matters further and it was not evidence that was before the Tribunal.Conclusions7.24 I consider that the Tribunal working documents indicate that considerable efforts were made in the pursuit of evidence against Gordon Anglesea before and during the Tribunal hearings. The directions given for investigation appear to have been comprehensive and dutifully followed through in respect to his association with Freemason’s lodges, golf clubs and his association with the children’s homes. Counsel to the Tribunal appear to have been alive to the possibility of securing further evidence against Gordon Anglesea as is apparent in paragraphs 7.8 and 7.9 above. 7.25 The failure of those witnesses referred to in paragraphs 7.8 and 7.10 to mention in their Tribunal statements is noteworthy. However, the fact that records exist of their previous reference to tends to negate the possibility that they were prevailed upon not to provide this evidence.7.26 The failure or inability to trace witnesses has been referred to in paragraphs 6.100 to 6.103. The difficulties in locating witnesses are well documented. The limited information of the witness referred to in paragraph 7.9 would not justify extraordinary efforts to trace him. 7.27 The obvious antipathy voiced by the witness referred to in paragraph 7.11 against and the isolated lurid allegations would indicate the need for caution before calling him as a reliable witness of fact. In the absence of documentation, I am not able to say if his claim of sending photographs to the NWP was investigated by the Tribunal. In the absence of anything to substantiate this assertion, I do not consider it unreasonable that a judgement was made not to call him.204 | The Macur Review7.28 I consider there to be no basis upon which Gordon Anglesea could be questioned about other members of Pegasus Masonic Lodge by reason of nebulous information concerning their possible association with John Allen and the convicted female residential care worker.7.29 The statement of the witness referred to in paragraph 7.15 was obviously admitted into evidence in order to form the basis of cross examination of7.30 I am satisfied that the decision not to call Witness F, (referred to in paragraph 7.17) was reasonable. His statement was incapable of corroborating the evidence of the new witnesses called to give oral evidence of the allegations of sexual abuse by It is speculative to suggest that oral evidence would have clarified the timeframe when he said did visit and his rank at the time or the time he, was resident in Bryn Estyn, but it was unlikely to contain direct accusations not contained within the statement. Any elaboration, rather than clarification, of his written evidence would have been regarded with suspicion. The fact of status as a serving prisoner would also have to be considered in the balance. That is, not prejudging the reliability of his evidence, but in terms of the practical arrangements that would have to be made as against the nature of the information he conveyed. Further, the assessment that there was “little else we can do” in relation to the reluctance of another prisoner, referred to in paragraph 7.16 to give evidence against was clearly right.7.31 I regard the evidence that Gordon Anglesea had lied when first interviewed under caution about the allegation of indecent assault against an adult acquaintance of the family was relevant to the issue of his credibility. Counsel to the Tribunal do not appear to have been made aware of this fact and would have been at a disadvantage in justifying their request for disclosure. It is likely that the NWP overlooked the issue of credibility in favour of considering whether the facts of the alleged offence constituted similar fact evidence. This information may have been significant in the Tribunal’s appraisal of his credibility and would have been ‘fresh’ evidence to that which had been available in the libel trial.7.32 There is nothing in the Tribunal papers to suggest that the evidence relating to Gordon Anglesea was dealt with in any different way to that relating to other allegations indicated in the preceding chapter. There is no material in the documents available to me to suggest that the findings in relation to Gordon Anglesea were against the weight of the evidence available to the Tribunal.7.33 I find there is nothing untoward in the failure to recognise and investigate Lord Kenyon’s previous association with the Clwyd Area Health Authority. Since the Chairman had showed no compunction in questioning the prospective relevance of freemasonry to the issues he had to determine in other spheres, I see no reason to expect him to take a different stance in relation to health issues.The Report of the Macur Review | 2057.34 There is no material in the documents available to me to suggest that the findings in relation to Lord Kenyon and freemasonry were against the weight of the evidence available to the Tribunal, nor that the evidence relating to him was dealt with in any different way to that relating to other allegations indicated in Chapter 6 (see also paragraph 8.65 in relation to Lord Kenyon as an establishment name). 7.35 The mystery surrounding freemasonry undoubtedly continues to engender distrust. The explicit and implicit concerns that continue to surround this subject are understandable, although have not been raised excessively in the contributions made to this Review. I have discovered no reason to question the professional integrity of Counsel to the Tribunal or the head of the WIT. The impact of freemasonry on the issues concerning the Tribunal was soundly researched and appropriately presented and pursued.206 | The Macur ReviewThe Report of the Macur Review | 207Chapter 8: Establishment NamesIntroduction 8.1 There have been long standing rumours circulating in many quarters, and which continue, to the effect that many establishment figures (taken in this Review to mean prominent members of society, whether local or national) were involved in paedophile rings or paedophile activity in North Wales. Contributors to this Review and others have queried why no such individuals are named in the Tribunal Report and see the absence of their names as evidence of concealment of serious allegations of child abuse.8.2 In Chapter 3 of this Report, I address the possibility that the government wished to avoid a public airing of allegations made against those in public life when considering the delay in establishing the Tribunal. In Chapter 5, I analyse whether the framing of the terms of reference was specifically devised in order to exclude investigation of establishment names. These exercises necessarily presume that information was available to the government which was desired to be concealed. Consequently, in the first part of this chapter, I examine the sources and nature of the information that was available prior to the establishment of the Tribunal, and whether there is any indication that government was aware of allegations made against establishment figures and wished to conceal them.8.3 In Chapter 4, I examine the selection and recruitment processes of the Tribunal members and its personnel, and also scrutinise the conduct of the Welsh Office in their role as a party in the Tribunal, with a view to reaching a conclusion as to whether any of the relevant individuals or bodies were involved in covering up evidence of child abuse by establishment figures. In Chapter 6, I deal with the procedure adopted by the Tribunal in the course of its inquiry to assess the adequacy of the investigations and resultant conclusions. Therefore, in the second part of this chapter, I examine the investigations made to obtain, and the source and nature of, the information made available to the Tribunal, and whether in those circumstances the Tribunal Report could reasonably be expected to have referred to any establishment figure, in addition to Gordon Anglesea or Lord Kenyon.Sources and nature of information concerning establishment names available prior to the establishment of the Tribunal 8.4 In the first part of this chapter, I report upon the manner in which establishment names have been suggested to be involved in child abuse in North Wales. In doing so I acknowledge an unfortunate consequence to be the possibility of adding credence to claims which are not evidenced in any credible way. However, I consider it necessary for this Review to examine the claims, many of which continue to be made, against the evidence apparently available to the Tribunal, and consequently to specifically report upon them to the commissioning departments. As previously indicated in paragraphs 1.20 to 1.24, the redaction of this report is a matter for the commissioning departments.208 | The Macur ReviewInformation, police inquiries and actions revealed in HOLMES material8.5 In his Tribunal statement, DSU Peter Ackerley indicates that during the course of the police investigation commencing in 1991 all information concerning the involvement of establishment figures, however tenuous, was logged onto HOLMES, cross referenced and investigated. I have had access to HOLMES. I can confirm the process described by DSU Ackerley save in relation to as indicated in paragraphs 8.32 and 8.89 below. The collection of information from the most innocuous source is demonstrated by a documented joke’ albeit with no reference to child abuse in North Wales. However, this meant that any mention of a name from whatever source, and even if appearing in a notoriously slanderous publication, would be logged as a suspect. In this way, their name would appear on the list referred to in paragraphs 8.56 and 8.57. Objectively, and without knowledge of the basis of the list, this may well have given the impression that the police had a reasonable suspicion of a crime having been committed, or had received reliable information to that effect. 8.6 On 25 September 1996, Junior Counsel for the NWP responded to a number of queries made by Counsel to the Tribunal confirming the process of listing suspects. He distinguished between two categories of suspects on the list: the first against whom there was some evidence, albeit hearsay, in witness statements; the second on the basis of “information received – eg rumours passed on by journalists and so forth”. He confirmed that “all were referred to the CPS”. Journalists8.7 Documents derived from HOLMES indicate that in October 1992 police officers questioned the freelance journalist, Mr Brian Johnson-Thomas, the author of articles on child abuse in North Wales that had appeared in the Observer newspaper over five consecutive weeks from 30 August that year. He had referred obliquely to the identities of the alleged abusers and his sources of information in his articles. In the meeting with police officers, Mr Johnson-Thomas identified ‘the bachelor priest’ he referred to in his first article as He mentioned Lord Kenyon and as being subject to ‘homosexual gossip’, and as protecting Graham Arthur Stephens, a convicted paedophile but was not in possession of any evidence or allegations of offences against them. 8.8 The note of the meeting records that he indicated that he had based his reports on a variety of things, including a document supplied to him by Mrs Alison Taylor, the views of other journalists, his own research, information supplied by a representative of the National Association of Retired Police Officers who had established a link between Stephen Norris and other known offenders in Merseyside, his ‘interpretation’ of the conversations he had had with a named former police officer, the ‘impression’ he had received from an MP and senior officials in the county councils who he would not identify, Councillor Dennis Parry, ‘homosexual gossip’ The Report of the Macur Review | 209and information from ‘a very senior official in the Home Office’ who he refused to identify. He acknowledged that in some instances his information was out of date or misinformed. For example, he was unaware of a successful appeal against a conviction, he had made an assumption as to the number of girls and boys interviewed, and he was unaware that a particular document and statement by one witness, had been included in a prosecution file submitted to the CPS. In more than one respect, he blamed a sub editor’s error for information contained in the articles including, for example, wrongly ascribing to an accusation of cover up of criminal conduct (see above). 8.9 I wrote to Mr Johnson-Thomas on 15 May 2015 regarding this note and the nature of his subsequent contact with the NWP. In responding to my letter, Mr Johnson-Thomas disputed the accuracy of the note of the meeting and informed me of a further meeting he had with DSU Ackerley on 30 October 1996 during which he said he provided “confirmation of identities; affidavit of (which contained allegation about ); names in affidavit; outstanding documents and information.” However, if he did provide this information and documentation in a meeting on 30 October 1996 I have not seen it, and note that whilst he asserts in his response to me that his research was largely conducted by talking to victims of physical and sexual abuse, he does not identify the other informants upon which he said he relied and referred to obliquely as ‘police sources’, ‘local MPs’, ‘Clwyd County Council sources’ or ‘Home Office, unofficial source’. 8.10 Thereafter, telephone attendance notes prepared by DSU Ackerley or a member of the police investigating team show that both Mr Johnson-Thomas and Mr Peter Wilson of the News Desk, Sunday Mirror, would phone the NWP offering snippets of information, but also seeking confirmation of rumours. For example, on 26 April 1993, Mr Johnson-Thomas is recorded to have phoned the police incident room to say that an unsigned letter, typed on NWP headed notepaper, had been sent to Private Eye saying that a had been given a “gypsey’s warning” regarding his involvement with boys. He said that had worked with and both were Freemasons. He went on to repeat a “press rumour” that and were involved in child abuse. On 7 September 1993, Mr Wilson referred to “rumours regarding Lord Kenyon, and being linked to a ring and would introduce them into the story [about John Allen]”. He confirmed that he had “no evidence against those named”. On 9 September 1993 he suggested that he had information that boys from Bryn Alyn had been bussed to Lord Kenyon’s home and had caddied for men at his private golf course and then supplied sexual favours.8.11 Mr Johnson-Thomas says in his letter to me that his regular contact with the police was both to check information and to provide information (with the consent of the victims). He says that, before publication of each of these articles, “we contacted the police to find out if anyone had been charged, in order to avoid prejudicing any proceedings.” He suggests that the documents provided to me do not contain details of the full extent of his contact with the police during this period.210 | The Macur Review8.12 This information provided by Mr Johnson-Thomas and Mr Wilson and other journalists to the police was not dismissed out of hand. Actions recorded in HOLMES directed inquiries to be made into those matters which would be capable of factual verification. As a result, it was established that Lord Kenyon did not have a private golf course, neither did “the only connection with a golf club in this area is Wrexham .” Further, a check was made with the Scottish Criminal Record Office in relation to and with negative effect. The closest match was an An enquiry of the National Criminal Intelligence Services relating to knowledge of was also made with a negative result. 8.13 I confirm that there is no mention in any other document available to this Review which supports the suggestion that was a Freemason or involved in abusing boys. There is a reference in the documents to the fact that Mr Wyn Roberts MP (as he then was) had written to the AG in December 1986 on behalf of his constituents, Nefyn He had previously visited Ty’r Felin, in the presence of the Director of Social Services of Gwynedd county council and members of the Welsh Office, apparently in the course of his constituency duties. Mr Johnson-Thomas said that his information about originated from a former resident of a children’s home, I note that police statement does not make any specific allegation of abuse against but says that he visited the home and took a boy out, who seemed to have more freedom than the others. 8.14 Mr Johnson-Thomas was subsequently to assert that a witness, also known as (referred to as Witness C in the Tribunal Report), had identified from four photographs he had shown to him, as the person who had been introduced to him by John Allen, and who had indecently assaulted him. A police statement had been taken from on 5 September 1993. On 8 September 1993, Mr Johnson-Thomas asked that DSU Ackerley be informed that “has named a lot of senior people and is frightened for his safety and wants protection.” However, told DSU Ackerley that he had been told by Mr Johnson-Thomas that he was being moved to a “safe house”. On 9 September 1993, he made a further police statement to “clarify certain points”. He said, “since …1st September 1993 Johnson Thomas had been telling me names and asking what I knew about them. Even on the train he was asking me about people. All sorts of names mainly kids a lot I didn’t know. I can’t remember the names now, I know he mentioned a former Policeman called Gordon Anglesea and somebody called ...The name meant nothing to me at all. I only knew Anglesea ... because of Private Eye. Johnson Thomas didn’t ask me if I’d been abused by them he just asked if I knew them ... Over the course of time I told him how I’d been sexually abused by John Allen and he’d asked me if there were any others and I told him no ... I thought about it then it came to me that there had been another man but I didn’t know his name.”The Report of the Macur Review | 2118.15 The manner in which was said to have been led into making an identification of by the journalist is then recorded. said that two photographs were shown to him as showing his potential abuser. His statement records, “Even though I said ‘Yes’ when he asked me I cannot in all honesty be one hundred percent sure when looking at a single poor quality photograph some years later, possibly eight years later. The best I can say really is that the man in the picture is similar. At the same time I can’t say it is not him.” said Mr Johnson-Thoma’s wife “witnessed” the identification and said “It looks as if you are going to bring the Government down ... Brian was smiling.” He went on in his police statement to give further detail about the man that, if reliable, quite clearly did not correspond with a description of That is, he said “he [the alleged abuser] told me he was a barrister”. 8.16 Mr Johnson-Thomas confirmed to me that he “deliberately sought to involve my wife in the care of ”, but that she was “not involved in the ‘journalistic’ process in any way.” 8.17 Mr Johnson-Thomas was asked by investigating officers to make a statement concerning the identification of He did not agree with account, but accepted that he had shown him four photocopied photographs, two of one of and one of an MP who happened to appear next to He denied that there had been a discussion about He said that the choice of photographs had been dictated by the description given by and, particularly, by the Harrods charge and/or credit card said to have been seen by him. Subsequent investigations with the credit card providers revealed that did not hold a Harrods card.8.18 In his letter to me Mr Johnson-Thomas suggests, in relation to the photographic identification, that the whole story cannot be understood by reading this one sided account. He said that other sources, not specifically identified to me, had provided him with information which, together with some of the details suggested that the person was likely to have been He claimed that his “use of 4 photos to put to the witness was a reasonable step to take and my understanding was that the police would follow up any leads of this kind to either corroborate or disprove any such allegations.”8.19 Mr Johnson-Thomas faxed Mr Wilson in September 1993. He claimed that DSU Ackerley had confided in him on several issues under investigation in North Wales and had “agreed not to arrest John Allen until our story is published on Sunday ... The following notes/suggestions are based on my conversations over the weekend with Superintendent Ackerley and another abused boy”. The fax goes on to report allegations and claims. Under a heading “The Ring”, Mr Johnson-Thomas records, “Here Superintendent Ackerley is being much more circumspect, agreeing that he knows of, but will not comment on the substance of, the allegations against - in particular - Lord Kenyon, former Chairman of the North Wales Police Authority, former Lord Lieutenant of 212 | The Macur Review Flintshire and former Chief Scout for Wales; and Other members of the ring are understood to be ... (a ‘pretty solid’ case, according to a source in the National Criminal Intelligence Service), ... Ackerley did, however, make one interesting admission - that several members of the ring have already been dealt with by police Cautions and that the Press Office would not confirm this ... As you know, one way in which boys in care were introduced to the ring was by using the boys as caddies at Wrexham Golf Club … has confirmed ... a list of the known ‘caddies’ ...” A list of names followed and also addresses in London. DSU Ackerley in a letter to the CPS dated 14 September 1993 denied that any such conversation had taken place. In his letter to me, Mr Johnson-Thomas maintained that his account is a fair summary of his ‘off the record’ interviews with DSU Ackerley. 8.20 Complaints were made about Mr Johnson-Thomas by and the police. On 10 September 1993, DSU Ackerley reported the “appalling” behaviour of Mr Johnson-Thomas to the Deputy Chief Constable. The Sunday Mirror advised on 10 September 1993 that they were dropping the story because was creating problems for Mr Johnson-Thomas. 8.21 On 12 October 1993, Mr Wilson called the incident room asking for confirmation that as a result of the identification of he was to be subject to an official enquiry and was to be interviewed in Venice. On 22 March 1994, Mr Johnson-Thomas telephoned to advise police that as involved in a paedophile ring. was going to be reported as supplying the boys. On 10 May 1994, a journalist from the News of the World phoned DSU Ackerley saying that he had received “reliable information (from Brian Johnson Thomas) that was an offender in [the] Child Abuse Enquiry and that a file [had] been sent to CPS” and asking if he could confirm it. Mr Johnson-Thomas in his letter to me says he has no knowledge of this and makes the point that he would be highly unlikely to give another reporter the information. Child Protection Agencies8.22 The police records also contain a report prepared by Mr John Roberts of the Wrexham Child Protection Team titled “People with Influence and Power involved in Bryn Estyn” which included national and local establishment figures without indicating what their influence and power was said to be. The relevant names were (local businessman), (Roman Catholic Priest) and the (local businessmen). That there was a nefarious connotation is suggested by the remainder of the document which refers to convicted paedophiles and their The Report of the Macur Review | 213associates. There is a reference to “Social Workers also talking to boys who refuse to be interviewed by Police” and names given without any reference to allegations that may have been made. 8.23 When seen by officers on 3 December 1992, Mr Roberts indicated that, save in the case of the information regarding the establishment figures had all been provided by the National Society for the Prevention of Cruelty to Children (NSPCC). name was included since he had told Mr Roberts that Gary Cooke, a convicted paedophile, did not work for Clwyd county council, but Mr Roberts understood that he had, and felt that had not discharged his duties properly. Mr Roberts explained to police that additional information which had been added about two of the names had been the result of speculation. Other names and information had been included on the basis of rumours or second and third hand hearsay, and some names were included on the basis of an individual’s association with convicted and known paedophiles, or their association with someone else who associated with them. Limited inquiries were made in the absence of any hard evidence. The document was described in the police files as “speculative”.8.24 When seen by investigating police officers, Mr Viv Hector from the NSPCC Wales provided no further information as to the source saying that he had “received information from more than one source but predominantly from one source concerning a paediophile [sic] ring operating in the Wrexham area.” He introduced the additional name of as having been identified to him as a member of a paedophile ring and said that a had been used to deliver members of a paedophile ring to abuse boys supplied by Stephen Norris and Peter Howarth. This was described by DSU Ackerley as “shown to be nothing more than a record of some established facts and repetition of speculation.” There is no primary material that this Review has discovered to the contrary. Local authority Councillors and officials 8.25 A note of a meeting between DSU Ackerley and Councillor Malcolm King on 17 December 1992 records that Councillor King said that he thought the name of had been raised by Mr Roberts. Councillor King also raised rumours that had been involved in kerb crawling. 8.26 Councillor King had provided police officers with a list of names of men who were alleged to have abused several boys who were in care at a party specifically organised for that purpose. These men were not national figures. Inquiries were conducted. Nine of the ‘boys’ said to have been abused denied that there had been a party or that, in some cases, they knew others mentioned on the list. Two declined to cooperate with police investigations. The men, not already subject to other investigations, were interviewed. All denied the allegation. The source of 214 | The Macur ReviewCouncillor King’s list was said to be an Independent journalist, who had claimed that it had been produced in a sworn affidavit from a previous Bryn Estyn resident. When seen by police, denied all knowledge of or supplying information about the party. A similar list of names also found its way to Mr Roberts, via his supervisor, who said that he had received it from Mr John Jevons, Chief Executive of Clwyd county council. Mr Jevons also identified as the source, but said there “was no evidence of any activity by those on the list supplied to him.”8.27 Police investigations revealed that the initial source of these names or some of them may well have been a local taxi driver Eight of the names he mentioned were said to have become members of the CHE Committee He considered that these men had abused their position of trust and had used the CHE helpline to target victims for their own sexual gratification; however he could not be specific as to who had committed what offences. Another man he identified was the owner of a nightclub in Chester which “catered for gays”. said that it was “common knowledge” that teenagers would go to the club and ask for money. He believed that the owner had committed offences against boys who would then blackmail him. This information had been passed on by another individual to When seen, that individual, who subsequently gave evidence to the Tribunal as a complainant, had no first hand knowledge of any paedophile offenders. He named another man, who he now believed to be gay, on the basis that when a care officer in Clwyd House he had had two favourites who always followed him around. 8.28 In October 1992, Mr Andrew Loveridge confirmed to DSU Ackerley that he had “passed on a rumour” to a senior NWP police officer to the effect that Gordon Anglesea had removed an obscene video tape in a case being prosecuted to prevent conviction, although he was aware that the matter had been investigated and proved to be untrue. However, Mr Loveridge denied that he had claimed to Mr John Cooke, representative of the National Association of Local Government Officers, that “three others in political life” were involved in child abuse. He was however aware of current rumours that Greville Janner and Lord Kenyon had been involved in child abuse outside North Wales, but knew of no evidence in support of this. Others8.29 Mrs Taylor’s document, ‘Gwynedd County Council Analysis’ was submitted to the Tribunal and found to include “many rumours and a great deal of hearsay”.1 Mr Johnson-Thomas explicitly referred to this document as one of his source materials.1 See paragraph 2.22 of the Tribunal ReportThe Report of the Macur Review | 2158.30 A disappointed litigant in matrimonial proceedings claimed to have been told that the judge sitting in those proceedings was “subject to on going Police enquiries” and reported his suspicions that he “may be a child abuser and that he gave custody of [his daughter] to [his ex wife’s new partner] because he knew or suspected [him] to be a child abuser and was sympathetic towards him”. Whilst he did go on to say that he had “no further reasons, evidence, information or material to which to base this suspicion on”, the name of the judge has since been repeated in this context by others.Police and CPS response 8.31 On 12 May 1993, Detective Inspector John Rowlands wrote to regarding “ Granville Jenna [sic], Lord Kenyon and the Former Deputy Chief Constable” in terms, “I forward to you details of various items of rumour and innuendo concerning the above named persons. Over 4000 actions have now been completed and in excess of 3000 statements taken in respect of the Gwynedd/Clwyd Child Abuse Enquiry. No evidence has been obtained to substantiate any claims against the above … The rumour in respect of the former Deputy Chief Constable (see paragraph 8.113) seems to stem from his alleged association with a person whose relative was friendly with a known child abuser who committed suicide in 1990 as he was about to be arrested for indecency offences … Johnson Thomas … John Roberts … Viv Hector of the N.S.P.C.C. say that their information is from varying sources. I suspect that it is one main source and that the same information from that source was being re-iterated by others.” 8.32 Of the files containing names of establishment figures sent for the attention of only one appeared to seek advice “in relation to the limitation period in respect of gross indecency allegation made by against another ‘prominent’ person identified by at the behest of Johnson Thomas [journalist].” In manuscript note is written “(old? Photos of ”. The file is marked “Advice given”. Other files naming “ M’s of Parl, Dep Ch Constable, Gordon Anglesea, Lord Kenyon and his son” were supplied “for consideration” or “for information only”, one file stating of the named individuals within. “All are now deceased.” A number of files specifically referred to the source of the information as “Allegations of impropriety by journalist who named persons he believed to be members of paedophile ring. Linked to Anglesea …” noted the files to the effect, “Nothing on file on which to advise.” In his interview with me, thought he remembered the name of featuring in the conglomerate files relating to Lord Kenyon and but I have found no reference to it in the documents.8.33 The Tribunal concluded that, of the lists of individuals in respect of whom files were submitted to the CPS, there was nothing to “cast doubt upon the thoroughness of the investigation or the willingness of the police to prosecute.”22 See paragraph 51.59 of the Tribunal Report216 | The Macur Review8.34 In paragraphs 3.4 and 3.5 I have referred to contact with the AG in 1992 in relation to press reports which he felt could compromise pending criminal trials or ongoing criminal investigations. There would, however, be no other reason for to refer the files indicated above to the AG. 8.35 In paragraphs 5.39 to 5.43 I refer to the manner in which the AG was alerted to the controversy surrounding the lack of prosecution of Gordon Anglesea and the interventions that followed. There is no similar situation in relation to any other public figure. Government knowledge of information and allegations concerning establishment names 8.36 There is no indication in any of the papers delivered to this Review that the information logged onto HOLMES was referred by the police to any government department other than by way of submission to the local CPS branch as indicated in paragraphs 8.31 and 8.32 above. Equally, there is nothing in the papers delivered to this Review to suggest that the AG alerted other government departments to the names of establishment figures in connection with the NWP inquiries.8.37 I have previously referred in paragraph 3.98 to a Welsh Office document which indicated that rumours of this nature existed and were known by members of the government and officials prior to the establishment of the Tribunal. There is a report dated 27 January 1995 addressed to “PS/Secretary of State” which records that “recent correspondence to the Department about an inquiry had been from those who felt they were under suspicion and wanted an inquiry to clear their names”. The only document that I have seen which fits this description is a letter from a representative of the Bryn Estyn Supporters Group. 8.38 In a briefing note to Mr Rod Richards MP, the Parliamentary Under-Secretary of State for Wales, dated 3 April 1996, an official informed him that “A new twist was given in last Sunday’s ‘Wales on Sunday’. A copy of that article is at Doc 2. Throughout this whole issue there have been rumours about the involvement of respected and senior public figures and politicians to which Jillings refers also. This is the first time to my knowledge that these two individuals have been named in this context.” Document 2 was not in the papers available to me, certainly not identified or attached to the particular briefing paper, and therefore I am unable to ascertain the names to which he referred. However, quite clearly, they originated from press reports. Specifically, the Jillings Report did not name politicians or other establishment figures as implicated in abuse. 8.39 Amongst the Welsh Office papers, I have found a note between senior officials dated 30 April 1996 indicating that one had received a telephone call from the Director of the National Institute for Social Work, alerting him to “3 or 4 ‘phone calls” she had received within the last few days from young adults who had been in care prior to 1989. Their stories varied slightly, but in essence suggested that Lord The Report of the Macur Review | 217Gareth Williams was aware of matters relating to North Wales child abuse issues and was aware of a ring of abusers, although there were no direct allegations that he was himself involved in abuse. The note continued, “They are aware that he is a member of a London freemason lodge, barrister to the Police Federation and acted for Chief Superintendent Anglesey [sic] in his successful libel case and alluded to connections between freemasons and MI5 in procurement of young people for illicit sexual purposes. Lord Williams is the current chairman of the NSPCC on the prevention of child abuse. [The caller] is also a member of the Commission and intends to present Lord Williams with these allegations. I have absolutely no idea what, if anything, we do with this rather garbled information, but thought you should know that these allegations are being made.” 8.40 A manuscript note in response reads, “I discussed this information with [author of note]. David Lambert has apparently already been informed and they are awaiting his advice on what steps, if any, the Dept should take. Subject to his views, I said that if [the caller] was proposing to take it further that [would probably] suffice but if not we would need to consider notifying police so they [could] investigate.” 8.41 I have found no other reference to this information within the papers, whether as to further action or notification to the Secretary of State for Wales or other Ministers. Neither have I found any reference to Lord Gareth Williams on HOLMES which, in light of the contents of paragraph 8.5 above suggests that a report was not made to the NWP. I have found no document which was before the Tribunal that refers to the information being brought to its attention.8.42 Significantly, in terms of its origin and timing, I found in manuscript on the reverse of a briefing note prepared for the Secretary of State for Wales for the Lord President’s meeting on 11 June 1996, the following notes: “What do people fear that current inquiries have not dealt with?– Not everyone brought to justice, because police deficient/involved– Involvement/fault of others in LA or elsewhere not revealed.– Full extent of what happened and possible links with elsewhere not appreciated [therefore] lessons not learned.– Jillings report must have said something devastating What are the publicly known accusations that are floating around?– Several public figures in Cons Pty were involved– Police …– Paedophile ring … Who has called for public inquiry?– Crts - Media– Police - Individuals?” 218 | The Macur Review8.43 This appears to be in the Secretary of State for Wales’ handwriting. The typed briefing note is marked ‘Personal’ in manuscript at its head. It is directed to the Secretary of State and others. There is no other specific information provided as to the identities of the “several public figures” that were subject to the rumours (see also paragraph 8.37). 8.44 Hansard’s report of a Parliamentary Debate on 17 March 2000 records Mr Martyn Jones, MP for Clwyd South West/South between 1987 and 2010, as saying that it was “an open secret in the press and among those who were involved in the inquiry that many high-profile people have been named by victims … They include current and former Members of Parliament, senior members of the judiciary, members of the police force … and prominent business men.” He emailed me in January 2013 to express his continued concern that potential abusers had been omitted from the Tribunal Report and had not otherwise been investigated by the NWP with appropriate rigour. 8.45 I interviewed Mr Martyn Jones on 13 February 2013. He explained the source of his earlier knowledge to come from the accounts of two complainants, and another whose name he could not recall. He explained: “I was MP ... some of the names he was giving us, alleging as abusers were, in fact, rather controversial ... a lot of the victims ... believed they were being abused by people of importance ... we pressed and pressed and pressed and eventually we got the Waterhouse Inquiry. Then it took some time, as you know, but when it actually reported … I felt very strongly that whilst the victims had been listened to in terms of the abuse ... the problem then was that they were ignored in terms of some of the people that they mentioned … Very, very early on ... Gordon Anglesea was mentioned ... was mentioned, who was an MP … I think he may have already died by then. was mentioned, who was an MP, who was a catholic priest, was mentioned. A was mentioned, and I, at the time, thought, because I didn’t know how many there were, that it was but then later on when I went into this in greater depth with the other witnesses as well I was fair certain it wasn’t that it was another and I could speculate as to who it was, but I think the person involved is still alive ...”8.46 The Welsh Office papers show that Mr Martyn Jones was amongst a group of Labour MPs seeking to persuade the Secretary of State for Wales to establish a public inquiry. However, I make clear that I did not find any of these names, or others suspected to be involved in child abuse, referred to specifically within Welsh Office documents as being mentioned in support of his request for a public inquiry.8.47 On 27 October 2012, the Daily Mail newspaper reported that Mr Rod Richards, Parliamentary-Under Secretary of State for Wales between July 1994 and June 1996, had made “incendiary claims that one of Margaret Thatcher’s closest aides was implicated” in the “North Wales children’s homes case”. He also “linked a second leading Tory grandee - now dead - to the scandals at homes”. It is reported, “He said official documents had identified the pair as frequent, unexplained visitors The Report of the Macur Review | 219to the care homes … He added that William Hague, who was Welsh Secretary at the time of the inquiry, ‘should have seen the evidence about ... Mr Richards said he received detailed briefings about the case while junior Welsh Office Minister for health and social services. He said, ‘It fell to me to decide initially whether to hold a public inquiry. So I saw all the documentation and the files. was linked. His name stood out on the notes to me because he had been an MP. He and [the other man] were named as visitors to the homes.’ ” 8.48 I have discovered no material in the Welsh Office papers which remotely resembles the “documentation and files” or “notes” he is reported to have said he had seen which names or a “leading Tory grandee” or any other individual as “frequent, unexplained visitors to the care homes”. Consequently, I wrote to Mr Richards on 15 May 2015 seeking his comments on this matter. Mr Richards replied and confirmed that he had spoken to the journalist, Mr Glen Owen, who had initiated the conversation. However, he did not accept any responsibility for the article published by the Daily Mail, did not write any of its contents, did not have sight of the article prior to publication and had no editorial control. In short, he did not think the article gave a balanced or accurate account.8.49 Mr Richards clarified that he did tell Mr Owen that he recalled seeing name on a note, possibly hand written, but that he could not recall the context in which it appeared. However, he had made clear that he had not seen “any corroborating evidence linking to the abuse of children” and did not refer to a “second Tory grandee”. Mr Richards informed me that he had not seen the name of any other ‘Tory grandee’ linked to the North Wales child abuse allegations in any official documents. He says it was likely that he did tell Mr Owen that Mr William Hague would have seen all the official documents that he had seen, but could not be certain of that. He said it was beyond his authority as Parliamentary Under-Secretary of State, a junior minister, to decide whether to call a public inquiry. He totally denied saying that he had seen documentation linking and ‘the other man’ as visitors to the homes.8.50 I wrote by recorded delivery to Mr Owen on 23 July 2015 inviting his observations on the points made by Mr Richards. It appears that the letter was delivered, but I have received no response.8.51 I observe that in a personal note to the Secretary of State for Wales dated 16 April 1996, Mr Richards writes “Jillings ... makes particular allegations about SSIW and the Department, which I hope we can rebut. His call for a public inquiry does not stick, given that there is no evidence that there are things still to be uncovered, or that we need new recommendations for action … I hope I can continue to be involved with this issue, and am available to attend any discussions you have on it.”8.52 The substance of this note contradicts the article referred to in paragraph 8.47 above which suggested that Mr Richards decided upon the establishment of a Tribunal. Mr Richards has indicated to me that he has no recollection of writing this note, does not recognise the quoted passage and that it is not in his style. However, he did not consider it necessary to inspect the document. 220 | The Macur Review8.53 8.54 I wrote to The Right Honourable Mr William Hague further in consequence of this information. Mr Hague replied indicating that he had no recollection of any such conversation, and if he had possessed specific information about would have passed it to officials or directly to the Tribunal Otherwise, he could only speculate that he had been asked to comment on gossip that may have taken place amongst MPs.8.55 For the sake of completeness, I record that the minutes of the North Wales Working Group (established to support the presentation of the Welsh Office case to the Tribunal) dated 18 February 1997, indicate that the BBC’s failed application to lift reporting restrictions could be subject to challenge and that “there was a risk that the names of prominent people might be published in connection with serious allegations, without officials having the time to warn Ministers that this was about to happen.” However, this particular note, as with others to which I have referred, does not identify those names that it was thought may be revealed.Tribunal investigations into the involvement of establishment names in child abuse in North WalesEarly discussions8.56 Notes of a meeting between the AG, Solicitor General and the Tribunal Chairman on 29 July 1996 show that “the judge understood the police to believe that there were about 80 people who could have been prosecuted. The growing list of names in this category included some significant public figures.” This is the ‘suspect list’ referred to above and compiled in the NWP investigation commencing in 1991. The Chairman called for it. 8.57 On 23 August 1996, the NWP Solicitor wrote to Mr David Lambert in connection with this request informing him that, “the suspect list maintained on the Police Computer has 374 names recorded. Some of the suspects were identified in the statements of complainants, others were reported to the police by informants. Some of the information is extremely sensitive and must be handled with great care. To provide a list will not identify the source of the information which led to the suspect being placed on the list, nor the sensitivity of any particular names, as the suspect The Report of the Macur Review | 221list does not include any indication of title or rank, for instance. For this reason the North Wales Police wish to appear by Counsel alone in camera, so that Counsel may make representations on the contents of the suspect list.” 8.58 Mr Lambert responded indicating the Chairman to be “agreeable to your suggestion that he should be addressed in camera by Counsel alone for the North Wales Police ... [on] 30 August 1996”. There is no transcript of this appearance, although it did take place as is evident from the subsequent comment of the Chairman in open session, as indicated in paragraph 8.81 below. As I indicate below, there was no such list contained within the papers provided to this Review, and it seems that any list provided to the Chairman when sitting in camera in August 1996 was returned immediately by him to NWP. 8.59 In early August, a social work manager for the Children’s Society for Wales contacted the Tribunal indicating “recently there was the case of a ‘rent boy’ in Cardiff producing a list of highly prominent persons names in Wales including a Police Officer in Gwyneth [sic] ... Reference was made to a chart being in existence containing the names of significant people who maybe involved.” 8.60 I am unclear as to who the Cardiff rent boy is and have seen no chart, other than the HOLMES register/list referred to in paragraph 8.5 containing “highly prominent names” or otherwise. This report may have conflated and misinterpreted several sources of information.Tribunal investigations regarding establishment names 8.61 All Counsel to the Tribunal were aware of the rumours. Notes from the Chairman’s meeting on 26 November 1996, sub headed “High Profile Names”, read, “It is apparent from the enclosed cuttings - as well as from much that has been said in some TV programmes/Scallywag and occasionally in witness statements - that there is some expectation that the Tribunal will be be [sic] considering evidence relating to these high profile ‘names’. Some of the names have been the subject of rumour & speculation for some time & we doubt whether, in the interests of the Tribunal’s credibility, we can simply ignore them. Accordingly, we wish to pursue some very discreet enquiries as a first step (Records/Intelligence – further the material available via Jillings) independently of any enquiry made hitherto by the NWP, with a view either (a) to progressing the matter to the point where we could say at the Tribunal that there was no evidence to support such rumour or (b) to call such evidence as may implicate.” 8.62 There is no document in the papers I have seen which indicates that approaches were made to, or information was obtained from, any intelligence agency. When I asked Counsel to the Tribunal whether they had been supplied with or seen materials which comprised any of the dossiers presented by Mr Geoffrey Dickens, they said they had not. I have previously referred in paragraph 2.17 to my own reading of the unredacted report of the Wanless and Whittam Review and my conclusion that there was no additional information of relevance to the Review in the materials I had seen. 222 | The Macur Review8.63 There are no establishment names contained in the Jillings Report in the context of being concerned in child abuse, but the accompanying materials and other documents available to the Tribunal contain the following: Councillor King raised his concerns regarding Gordon Anglesea and and their individual participation in matters of child abuse; there is reference to which may refer to a but no further information in this respect than that already before the Tribunal; and, when interviewed by the Jillings Panel a witness, said that, if his brother had been able to give evidence, MPs would have been prosecuted. This witness subsequently gave evidence to the Tribunal in closed session. He did not refer to allegations of abuse by MPs, but said that his brother had been employed as an ‘employment liaison officer’ to obtain destitute boys from Kings Cross and bring them up to Bryn Alyn where they would satisfy the sexual needs of customers supplied by John Allen. 8.64 8.65 A specific allegation directly involving Lord Kenyon was reported to the NWP by a Sunday Mirror reporter who identified his source as Inquiries were made by the WIT to trace but with no success. However, other inquiries were made into some of the detail of the allegations; none were substantiated. The particular allegation was not repeated or referred to in any of the evidence concerning Lord Kenyon which was before the Tribunal. 8.66 Allegations about public figures identified in the media without naming a source were not followed up. Named sources of other allegations were contacted, but if denied by them were not pursued. Others, supported by allegations in witness statements were investigated in the course of the Tribunal proceedings. These matters are dealt with in the Tribunal Report.38.67 An individual, due to be interviewed by the WIT cancelled his appointment with them citing a conflict of loyalties and fear of repercussions. In a telephone call to the Tribunal helpline on 28 October 1998, he gave the name and telephone number of a farmer said to live near to a children’s home who had regularly seen drive past in a car to collect boys for the evening and return them within a couple of hours. He questioned a Coroner’s verdict in respect of a former children’s home resident, who had alleged abuse against and “Maintained conspiracy theory involving large builder/contractor & Security Services.” 3 See paragraphs 51.64, 52.02 and 52.03 of the Tribunal ReportThe Report of the Macur Review | 2238.68 There is nothing in the Tribunal documents to indicate whether or not the farmer was traced and spoken to. There is no statement from him. However, the Coroner’s file in relation to the named resident, was obtained. It did not bear out the concerns the caller had expressed in this regard. What is clear is that the issues surrounding visits to children’s homes were investigated by the Tribunal (see Chapter 7). 8.69 A disappointed litigant writing on 10 March 1997 to the Solicitor to the Tribunal, wished to “submit a list of names of all persons involved in a private law matter in North Wales. I have substantial reason to believe that throughout these proceedings evidence of child abuse and incest has been disregarded and suppressed ... I submit these names on the understanding that it is a complete list of all persons involved whatever their role, that I am not making allegations against them and that, at this stage, the information is strictly confidential. However, should any of the persons marked * arise in the course of the enquiry [sic] it should be regarded as a matter of exceptional gravity and complexity and I would wish to give evidence.” 49 names were then listed including the judge hearing the matter, barristers, solicitors, social workers, police officers, psychiatrists, psychologists and MPs to whom he appears to have written to during the course of the proceedings. 8.70 Appended to a copy of that letter, which had been shown to the Chairman, is a post it note asking for it to be shown to Mr Gerard Elias QC, who may then like to discuss it with Leading Counsel for the NWP, since it contained some names that appeared on the HOLMES suspect list. The common name was “ ”. Significantly, however, there is no evidence that supports any direct claim of abuse against him in any witness statement or evidence led before the Tribunal. No allegations were made in relation to any of the other names listed in the letter during the course of the Tribunal proceedings as being concerned in abuse or its concealment. 8.71 a regular caller to the Tribunal helpline and a previous resident of Bryn Alyn and Bryn Estyn between 1961 and 1968 was seen as a result of his claim that “ and 9 police officers ... are all involved in child abuse along with peers and politicians. He says that if names are not named in the Report he will go to the Press.” His calls were frequent, sometimes abusive and he quoted passages from the Bible. He was visited by the WIT and a statement taken. An assessment made of him as a potential witness stated, “He is a mature man who appears somewhat paranoid about his treatment in care. He is easily confused about dates and places. He has given evidence on previous occasions about his treatment in England”. He was not called to give evidence nor his statement read. 8.72 Another caller to the Tribunal helpline, identified himself as a previous police surgeon. He claimed to have spent years researching all aspects of child abuse. He apparently stated that he knew of corruption within paedophile rings involving doctors, police officers, politicians especially the Conservative party and Catholic priests. He told the operator he had been “put off road for drink by GMC”. This caller has also contacted this Review with similar claims. 224 | The Macur Review8.73 When asked by me in interview, none of the three Counsel to the Tribunal or either Solicitor to the Tribunal said they felt under pressure to avoid issues of potential embarrassment to the government of the day, or otherwise to protect establishment figures or institutions. I find nothing in the daily transcripts or notes of meetings of Counsel to the Tribunal and/or Solicitor to the Tribunal to suggest otherwise. 8.74 In response to my specific question: “Was there ever a stage during the Inquiry when you felt any anxieties or concerns that establishment figures were not being investigated for the fact that they were establishment figures?” Lord Justice Ryder said “No, quite the contrary. I think Counsel took the view that if, as it was, this Tribunal was set up to expose anybody who had been involved in something and who had managed to hide their identity it was actually our function to identify them ... we would talk for hours about why we were not finding out more information than we thought we would do, and the openings all reflected a high line ... Your aim was actually to expose not to come to a value judgment.” Evidence given to the Tribunal regarding establishment names other than Gordon Anglesea and Lord Kenyon 8.75 The name of was referred to during the Tribunal hearings, both in oral evidence and within police and Tribunal statements. 8.76 An obvious difficulty on the face of the materials related to the identity of the against whom it appeared allegations of abuse were made (see paragraph 8.15 above). In relation to evidence, the photocopied photographs were described by him at the outset as being of poor quality. In his police statements, indicated he was not “one hundred per cent sure” that the man he had identified in the photograph was the man who abused him, or whether the man who did was a at all. was traced by the WIT, made a Tribunal statement and gave evidence. His evidence recounted abuse at the hands of a man introduced by John Allen and reiterated his uncertainty as to the identity of this man. John Allen was asked about this matter in evidence before the Tribunal and denied knowing but said that he had been asked by whether he knew him. 8.77 alleged in a police statement that he had been introduced to by Thomas Kenyon, and had then been abused by him on several occasions. During the Tribunal hearings, refused to identify concerned, indicating that he had received threats and said that his house and car had been destroyed When questioned before the Tribunal, he did give evidence, however, that who had abused him had since died. also referred to who he believed to be employed by Gary Cooke (a convicted paedophile) gave evidence to the Tribunal that he had shared a cell with who had lived withThe Report of the Macur Review | 2258.78 As indicated at paragraph 8.24, minutes of a meeting between the NWP and the NSPCC on 3 December 1992 refer to the use of a plane and private airstrip owned by to transport child abusers to North Wales. However, DSU Ackerley gave oral evidence to the Tribunal that he had nothing “tangible” in relation to despite investigations conducted into the 8.79 In closing submissions, Mr Gerard Elias QC summarised the position to be “the name has hung over the rumour of abuse in North Wales by people in high places for as long as those rumours have existed. We submit, sir, the picture is no clearer after 200 days of evidence in this respect than it was before. No Christian name has ever been provided for this shadowy figure”. 8.80 did not receive a Salmon letter and was not represented before the Tribunal. No reference is made to the name in the Tribunal Report. Other establishment names8.81 Giving evidence before the Tribunal on 26 February 1998, DSU Ackerley was asked to read out a list of names where police advised no prosecution. At the name of the Chairman intervened. The following exchange took place: “… [sic] ----- THE CHAIRMAN: We are embarking on the role of fantasy now, are we not? A. Yes, sir. THE CHAIRMAN: The reference to [sic] is simply absurd and shows the nature of some of the allegations, certainly as far as this inquiry is concerned because nobody has suggested any allegation against that person. MR. MORAN: No, sir. THE CHAIRMAN: And it is quite clear that the anonymity rule must apply to him, as to MR. MORAN: Indeed so, sir. ... THE CHAIRMAN: I thought that this list dealt with persons who were actually involved in the Inquiry and allegations which had been canvassed before us. MR. MORAN: Not before you, sir, these were allegations canvassed to the police; as you say absurd material sometimes. THE CHAIRMAN: In order that the matter be clear, I was supplied by the police, at my request, with a list of all persons against whom allegations had been made, 226 | The Macur Reviewbefore the Tribunal ever began sitting, and one of the allegations that was fantastic was referred to in evidence last week, about a judge who was accused, by hearsay, of having something to do with interference with children; a malicious allegation made by somebody who failed to get custody of his children, his own children. MR. MORAN: That is so, sir. ... THE CHAIRMAN: I have no special duty to protect prominent persons, but I don’t think that anybody whose name is the subject of that sort of rumour should have it bandied about. It’s clear that the name and the name Kenyon were an entirely different category because they have been introduced in relation to matters properly within the scope of this Inquiry. ... THE CHAIRMAN: We have had a very good picture so far, and the difficulty is that I think this list, which I deliberately returned to the police, and to which no further reference has been made, is emerging, so to speak, quite unnecessarily. We are concerned to know particularly where advice was given not to prosecute in respect of persons against whom we’ve heard actual allegations ... We have got a list of people against whom specific allegations are made, of either physical or sexual abuse, and it is persons in that category, in respect of whom no prosecution took place, that we want to know about.” 8.82 At the time I interviewed the now retired DSU Ackerley, on 14 June 2013, it was clear that the list from which he had read the names to the Tribunal was not within the materials supplied to the Review. Mr Ackerley had no independent recollection of the list, but advised as to its likely whereabouts. I do not know why this document was not available in the Tribunal records delivered to the Review.8.83 Operation Pallial supplied a copy of the ‘suspect list’. On 2 July 2013, I visited the Serious Organised Crime North West Division offices in Warrington, at which the HOLMES computer relating to the 1991 police investigation is now housed. With the assistance of a trained operative, I accessed all relevant “messages”, “documents”, “statements”, “reports” or “actions” against the names of these establishment figures. I was provided with copies which had been retrieved as necessary from storage in Colwyn Bay. Save in the case of the name it is clear that all the names of national public figures referred to by journalists and others, as indicated above, were included on the ‘suspect list’ as a result of multiple hearsay, gossip/rumour/innuendo and media reports. The primary source of the allegations is unspecified. No witnesses had made allegations against them. 8.84 The ‘suspect list’ also made reference to several local prominent figures including: David Hughes, the former Mayor of Colwyn Borough Council; and, David Hughes had been convicted of possession of indecent images in 1991. The Report of the Macur Review | 227 was alleged to be a member of the CHE. had been named by a journalist as a paedophile. Gary Cooke subsequently suggested in oral evidence before the Tribunal that he might have been employed by by reason of his sexual orientation, and for the purpose of recruiting young men for sexual purposes. No witnesses had made allegations against any of them. 8.85 is also named on the list. There is an unsigned note in a Welsh Office file headed “ ”. The relevant part of the note reads, “In the summer of 1992 [ ] requested to meet with John Jevons, Director. During the course of the meeting alleged that whilst he was at Bryn Estyn he informed - who was visiting the Home - that there were boys at the Home who were being physically and sexually abused by members of staff, he also alleged that whilst in care he had been told by other children (not named) that paid children in care for sexual favours and that when he left care he was lived [sic] for a period … [in] Wrexham and had seen with young people - male and female - in his car on a number of occasions. A record of this meeting was passed to the North Wales Police who interviewed in relation to these matters - the police file was passed to the Crown Prosecution Service - who decided on the basis of the evidence not to proceed ...” This allegation was not investigated by the Tribunal. 8.86 There were other references to name in the papers. He was included in the list of “People with Influence and Power involved in ‘Bryn Estyn’” compiled by the Wrexham Child Protection Team. There is no explanation why. During a meeting at Wrexham Police Station, Councillor King’s reference to an alleged ‘kerb crawling’ incident involving was confirmed, although stated to have been marked ‘no further action’ because of insufficient evidence. Suggestions found in other documents that was a shareholder in Bryn Alyn have not been verified by the Review from direct evidence. 8.87 45 8.88 name is also on the ‘suspect list’. He had and was accused by of attempting oral masturbation upon him when he resided in a property owned by the project. gave evidence to the Tribunal, was cross examined about the allegation and denied it. No findings were made against him4 5 228 | The Macur Review8.89 name does not appear on the ‘suspect list’, despite his name being identified in one of the files referred to as indicated in paragraph 8.32 herein, but was mentioned by Mrs Taylor in her ‘Gwynedd County Council Analysis’ report, submitted to the Tribunal and to this Review, as being linked to abuse on the basis of providing accommodation to young homeless boys and men. A newspaper reporter said was known in the gay community and he had been alleged by a former children’s home resident, to have been encouraged by staff, to take boys to his house for the weekend. There was evidence before the Tribunal that had visited one of the children’s homes under investigation, but no witnesses made allegations against him. 8.90 a Catholic priest, was named in a police statement as an abuser by a former resident of Clwyd Hall, who had also made allegations against Noel Ryan, a housemaster there, subsequently convicted of abuse. gave evidence at the Tribunal, but was not asked about The allegations were serious, being of indecency and buggery. is not mentioned by name, or his calling identified, in the Tribunal Report. Unfortunately, the police statement in which these allegations are made is undated and does not indicate first name, making a cross check against the ‘suspect list’ impossible. 8.91 There is a letter dated 16 August 1996 from the NWP Solicitor to Mr Lambert, which refers to complaints received by three named individuals, including “which fall within the terms of the reference of the Tribunal”, but there is otherwise no indication of the nature of the allegation or the identity of the alleged abuser. The letter concludes, “I confirm that these matters are being investigated by the North Wales Police.” This would mean that those allegations would not be investigated by the Tribunal. 8.92 My letters to Mr Gerard Elias QC and Mr Treverton-Jones QC asked for their comments about the omission to refer to in the evidence orally adduced before the Tribunal. Each was understandably handicapped by the passage of time. Each independently suggested that the likeliest explanation for not calling the evidence was because of a potential or actual police investigation. Mr Treverton-Jones QC referred to the fact that the police statement containing the allegation would have been in the possession of the complainant’s Counsel who would be in a position to examine the witness upon the evidence if omitted by Counsel to the Tribunal in oversight or error.8.93 One such counsel, HHJ Margaret de Haas QC, as she now is, confirms in an email to Mr Treverton-Jones QC, copied to me, that it was unlikely that Counsel to the Tribunal failed to lead relevant evidence. She postulates that possible reasons for its omission are that: the allegation was not in the relevant statement or had been redacted; the witness did not wish to mention the allegation; or, the allegation had been ruled inadmissible by the Tribunal as being irrelevant or outside the remit of the Tribunal.The Report of the Macur Review | 2298.94 The statement of one complainant, read to the Tribunal, alleged that someone “introduced as would “pick little boys and take them for weekends away”. No further detail was given beyond associating him with a group of people visiting Bryn Estyn and doing the same, including evidence was referred to in the Tribunal Report in the case of but given little weight. No further investigation appears to have been made in so far as the name was concerned, and no findings were made in relation to this allegation. No other witnesses made allegations against this name. 8.95 Allegations were made in police and Tribunal statements against named police officers. Two complainants, refused to take part in the Tribunal proceedings. Evidence of specific allegations of abuse made by one witness, against Peter Sharman, a former police officer with the NWP, was heard by the Tribunal. oral evidence undermined his police statement in terms of the time frame when some of the sexual abuse was alleged to have occurred. On the oral evidence, the majority of the alleged indecent assaults occurred when was not “in care”. However, there was one occasion when the evidence indicated he was in residential care, when he said Peter Sharman had attempted to abuse him. No finding is made on this particular allegation in the Tribunal Report. The allegations against the same officer made by another witness, were dealt with in the Tribunal Report in anonymised form. The evidence as to whether or not was in care at the time of the assaults was uncertain. 8.96 At the time of the Tribunal hearings, Peter Sharman was due to face trial for serious sexual assaults against a child who was not in care. An order was made pursuant to Contempt of Court Act 1981, section 4(2) to prevent publication of any account of the Tribunal proceedings pending his trial, and if convicted, any determination of appeal or before time for serving notice of appeal had expired. He was convicted. There is no indication that any appeal was initiated or pending at the date of production of the Tribunal Report, and there would have been no bar to him being named for this reason. 8.97 For the sake of completeness, and as previously indicated, I record that there are a number of police and Tribunal statements which do include allegations of abuse against many unidentified police officers by complainants who were in care at the relevant time. These parts of the statements were not all referred to in oral evidence or read into the proceedings as indicated in paragraph 6.187. The Tribunal Report indicates that one of the reasons why complaints have not been investigated includes “lack of identification of the abuser”,6 but otherwise makes no reference to the nature of these allegations in so far as they concerned police officers. 6 See paragraph 55.06 of the Tribunal Report230 | The Macur ReviewAlleged concealment of evidence relating to establishment names8.98 alleged that he struck a deal with Leading Counsel to the Tribunal prior to giving evidence before the Tribunal and agreed not to name certain ‘names’. He repeated this allegation to me when I interviewed him in August 2014. Mr Gerard Elias QC categorically denies any such meeting or third party intervention at his direction in this regard. 8.99 When I interviewed Mr Gerard Elias QC on 5 December 2012, he provided me with emails sent to him on 1 November and 6 November 2012 on behalf of BBC Newsnight and Channel 4 News respectively, which asked for his response to an allegation apparently made by that he had refused to permit giving evidence of up to 32 names identified as his abusers on the basis that they were “high profile people including police officers”. In his response to Channel 4 News, Mr Gerard Elias QC said “... your email contains, amongst others, allegations which amount to a serious attack on my personal and professional integrity, I do consider that some immediate comment is required. Accordingly, I wish to state that there is not a shred of truth in the suggestion that, at any time, I ‘negotiated’ with as to which names could be included in his statement or that I ‘pressured’ him to alter the content of any statement he made for the Inquiry by removing names from it. No doubt you will be making the content of the recent interview with available to the judge conducting the review - I shall of course make the content of this email available to her.” Neither Newsnight nor Channel 4 News has contacted the Review. 8.100 Mr Treverton-Jones QC recalled in interview with me that he did meet with at the request, and in the presence, of solicitor. The meeting was said to be cut short due to emotional state. Mr Treverton-Jones QC said that no part of the substance of his evidence was intended to be, or had been discussed. 8.101 The daily transcripts of the Tribunal hearings show that threatened Mr Gerard Elias QC and at least one other Counsel during the course of giving his evidence. 8.102 told me in interview that there were establishment names he remains frightened to disclose. When giving evidence before the Tribunal, he complained the NWP had failed to record some of his allegations against some named individuals, and that some of his statements had not been produced. However, he did not say in oral evidence who or what these allegations involved. The Tribunal refers to these criticisms in the Tribunal Report. Further submissions made to this Review8.103 I mention my interview with Mr Martyn Jones, in which he expressed his concern that the Tribunal had not included names of establishment figures in its report, in paragraphs 8.44 and 8.45. During the course of the interview he said, “Anyway, you’re The Report of the Macur Review | 231probably aware I made some fairly empty threats actually to read out the names in Parliament … I mean I didn’t think it was going to be a responsible thing to do, but I thought it was responsible to threaten in order to try and get some action in terms of the investigation which I assumed was going on ... I mean I used the threat to mention them in Parliament under privilege as a means of getting some real information …” 8.104 He told me that the reference to the judiciary in his speech to Parliament was in relation to “Lord Kenyon, I think.” As to politicians “... it may well have been at the time, but that was not one I remember now ... I’m certain it was mentioned at the time, but by then it was also and who had got into the mix. I am pretty certain that they were not mentioned early on, whereas was a politician … was a politician, when I first heard, was a politician … I mean, to be honest I was furious, because those names had just been missed off, and I felt, regardless of the fact that whoever they were, they should be investigated.” 8.105 Mr Martyn Jones produced to me a list he said he had received from police officers in 2000 containing the names of alleged abusers, but said that there were “some notable exceptions … bearing in mind the names that I know had been given to the Waterhouse Inquiry”. He said and names were added later, but he thought they had been provided to the Tribunal. He had prepared a list of the missing “controversial” names, but it had since disappeared along with the notes that he made. He used to shred them. He recalled that when name was mentioned and was thought to be as a Labour politician he first thought, “Wow, this is dynamite if this gets out. But actually, I think, it also had the opposite effect; the fact that it was sort of ‘gossipy’ and controversial made it more difficult to believe as well … I mean some of the names were quite shocking really.” 8.106 A letter sent by the Chairman to the Secretary of State for Wales in February 2000 “in confidence” reads, “I am dismayed that Martyn Jones is reported to be intending to name between six and 50 persons under the cloak of Parliamentary privilege, alleging that they have not been adequately investigated by the Tribunal. At the moment I can only guess whom he has in mind but it seems that a serious abuse of the privilege may occur. Martyn Jones has not asked for any information or explanation from the Tribunal and, as far as I am aware, has not communicated with us ... He is said to be consulting [sic] and Councillor Malcolm King but both these persons gave evidence to the Tribunal and what they had to say was explored as fully as possible within the Tribunal powers ... they were represented by Counsel throughout ... I will be pleased to supply appropriate information about each person to be named by Martyn Jones, if and when his/her identity becomes known to you.” 8.107 A note of the meeting between the Secretary of State for Wales and Mr Martyn Jones MP on 14 March 2000 referred to the list of names and then goes on to record, under the subheading “Other issues”, as follows “the list of names was not shared at the meeting. Mr Jones said the list did not reflect the more outrageous claims that had been made in some quarters over the years, for example that 232 | The Macur Reviewgovernment ministers were involved. He explained that he has information that indicates some people whose names are on the list could not have done what was alleged against them and that some names on the list do appear in the report.” 8.108 I refer in paragraphs 1.4 and 1.34 to the telephone call made to Mr David Jones, when a prospective parliamentary candidate, by someone claiming to be a member of the Tribunal staff and saying that Sir Peter Morrison was likely to be named in the Tribunal Report. As previously indicated, I have found no Tribunal document which would support such a contention. 8.109 Other MPs are reported to have made claims to the media after the publication of the Tribunal Report, and more recently, concerning the involvement of establishment figures in child abuse in North Wales. I do not refer to them by name, since none appear to me to have been likely to have had access to any relevant “official documents” in contrast to Mr Richards by virtue of his role as Parliamentary Under-Secretary for State for Wales. None refer to a credible, or any, source of their information. None have sought to contribute to this Review. 8.110 In interview with me, referred to other alleged abusers, with freemason and judicial connections, who he said he still feared to name (see above). He made allegations against other national and local establishment figures that do not appear in his police or Tribunal statements. However, following my Salmon letter to him indicating that I was not satisfied that he had been prevented by Mr Gerard Elias QC from giving evidence identifying all those involved, he has expressed his disappointment in my Review and sought to withdraw his contribution to it. In those circumstances, I consider it would be inappropriate to refer to the detail of the allegations and/or the insinuations he made. Other contributors8.111 Investigative journalists who responded to the Review had particular interest in the allegations concerning Gordon Anglesea, but did not refer to other establishment names.8.112 Councillors King and Parry, who were urging the government to establish a public inquiry, have not implicated any public figure by name or by description as a politician, nor have they identified any such individual to me, despite my invitation for them to provide any particulars revealed to them. In the letter of complaint written by Councillor King to the Chairman, in which he claimed he had been prevented from giving all relevant evidence to the Tribunal, he does not suggest that he had first hand evidence concerning political figures.8.113 In his interview with me, Councillor King referred to allegations against and suggested that the Tribunal had insufficiently appreciated the import of his meeting with Mr Peter Joslin, Chief Constable, since he had been “closed down” in evidence. Councillor King had reported in his Tribunal statement that an unnamed Chief Constable, subsequently named as Mr Joslin, had informed him that “his investigating team had reason to believe that there was evidence that was involved in child pornography.” The Report of the Macur Review | 2338.114 There is a letter in the Tribunal papers from Mr Joslin, Secretary of the Association of Chief Police Officers, dated 16 January 1998 and addressed to the NWP Solicitor, in which he identified himself as the unnamed Chief Constable referred to by Councillor King in his Tribunal statement and confirming his meeting with Councillor King on 3 June 1993. However, he states “I do remember this issue [the Deputy Chief Constable’s alleged involvement in child pornography] being raised but, quite the contrary, my comment was that there was no evidence whatsoever to suggest that either of the Officers investigated were involved in child pornography ... during [the police complaints investigating team’s] time in Wales both the media and the public seemed to think we were investigating matters more serious than we were. There was rumour about paedophile activity and the press seemed to be seeking sexual connotations to the enquiries we were carrying out.”8.115 Ms Sian Griffiths named a former children’s home resident, said to have lived with the son of Black Rod in the Houses of Parliament. She referred to rumours that MI5 had under surveillance and saw boys emerging from a back exit to his flat. She said that Mrs Taylor and Mr Jevons had mentioned to her the and in relation to a ‘boy’ whose social services file revealed had worked on the Grosvenor Estate. She said that the probation records obtained in relation to Gary Cooke mentioned and whom she described as chauffeur. She believed that the files of two previous Bryn Alyn residents, contained information concerning offenders convicted of crimes against children and one of them acting as a rent boy when they moved to the South East. 8.116 Mrs Taylor, the prominent “whistleblower” and supporter of the complainants, did not in any of her reports/analyses previously submitted to the NWP and government departments, or in her statements to the Tribunal, nor despite being pressed by me in the interview I held with her on 25 April 2013, suggest that any who had confided in her, at the time or subsequently, alleged abuse by any of the establishment figures referred to above. She said that if they had “... they would have been included [in the documents she had prepared, prior to, for the Tribunal and subsequently]”. For the avoidance of doubt, I record that she did refer in one of the reports/analyses she prepared to allegations apparently made by a young man, concerning a Judge sitting on the North Wales Circuit but, to her knowledge, the Judge was not charged with sexual offences against him. I have previously referred to the fact that she mentioned Mrs Taylor considered that there was a “chapel hierarchy” in Gwynedd, which had not been examined by the Tribunal. 8.117 However, Mrs Taylor was aware of allegations against Gordon Anglesea and that there were allegations of assault made about but “I’m not sure what those were and I’m not sure about whether or not they were genuine ... I mean there’s been names straggling around for a long time … I mean has been in the public domain forever, and I’ve lost count of the number of journalists who, with sort of baited breath, have asked me about and I’ve said: ‘Don’t go there because the that may 234 | The Macur Review have abused children is not the you think he is’, and everybody has known this - I won’t say everybody, but I’ve known it, and a lot of other people have known this for a long time, long before was named recently… there’ve been various MPs named over the years … Not necessarily directly to me, not as abusers, but names floating around in the ether, so to speak.” 8.118 indicated to me in interview that he had a sense of unease that none of the names ‘floating about’ were called to the Tribunal. That said, he acknowledged the evidence had not come forward and did not feel that it had been concealed.8.119 My Review has been well publicised. Press reports have stated that Mr Richard Scorer, a solicitor with Pannone and Partners who represented complainants before the Tribunal, and other “former residents” of Bryn Estyn and “a retired care worker” have commented on the alleged involvement of named and unidentified establishment figures in child abuse in North Wales children’s homes. Mr Scorer refers to the allegations as being seen as “far-fetched”, says the abuse went “wider”, refers to Jimmy Savile being present when he was abused by Peter Howarth and seeing taking boys “off in smart-looking cars” and says that he was taken from the home by people in power. “Former residents” are said to have referred to and “a paedophile network” with at least one senior Conservative party figure involved. The retired care worker reported that had claimed that he “took boys out” and used sexual language to them. None have contacted me in relation to these matters. 8.120 The Children’s Commissioner for Wales’s office has assisted in notifying and offering to support those who may wish to contribute to this Review. Mr Keith Towler, the immediate past Children’s Commissioner for Wales, informed me that some of those who had contacted his office after the Tribunal had mentioned and the He gave no other details of these reports. No one, other than the contributors I refer to above, has come forward to me with information or complained that evidence of the involvement of establishment figures has been concealed or ignored. 8.121 I have not considered it appropriate to seek to meet with those who are named as being involved in child abuse, since it is patently not within my remit and there is no basis upon which to do so. I have not deemed it necessary to approach the stated ‘sources’ of media reports alleging the involvement of establishment figures in child abuse. There is no information within any of the documents I have seen which would suggest that these sources had access to any documents relating to North Wales in regard to the background to the Inquiry. I regard it as reasonable to expect that, if they did possess relevant and cogent evidence, they would have contacted this Review. The Report of the Macur Review | 235ConclusionsGovernment knowledge8.122 There is no evidence available to me to suggest that the NWP or AG had formally notified any government department of the speculation or information concerning political or public figures whose names appear on HOLMES or were otherwise contained in files submitted to the CPS for advice. 8.123 It seems that, save in the case of Lord Gareth Williams, the only information available to the government in relation to establishment names was contained in newspaper articles, magazines and television programmes. I do not know how the information concerning Lord Gareth Williams was dealt with by Welsh Office officials. The information does not appear otherwise in the Tribunal documents. There are no witness statements which make allegations against him. 8.124 There are no documents that I have seen which resemble those said to have been described by Mr Richards as establishing the politician’s visits to children’s homes in North Wales. I note that the newspaper is unusually coy in the naming of “the other man” despite the fact that he was said to be dead and therefore no issue of libel would arise. No response has been made by the journalist concerned. Equally, The Right Honourable Mr Hague makes the valid point that if he did have specific information concerning he is unlikely to have told about it rather than his officials or the Tribunal he, as Secretary of State for Wales, had established.Sources of information8.125 I regard the actions of Mr Johnson-Thomas in staging a photographic identity parade to have been extremely irresponsible. Whether he produced two or four photocopied photographs for consideration could not produce a reliable identification of an abuser and may well have contaminated any legitimate identification made with the safeguards provided in the Police and Criminal Evidence Act 1984 and associated Codes of Practice. Whatever description provided by does not resemble or the other politician shown in the photographs, and there is no explanation as to why, on his version of events, two photographs of the same man were shown. Mr Johnson-Thomas’ suggestion that mention of a Harrods card informed his choice of photographs is untenable and illogical. His indication to me that there was additional information which led him to this choice is not substantiated in any detail. 8.126 Responsible journalism may rightly claim some credit in creating and maintaining public interest in the child abuse allegations in North Wales and increasing pressure for a high level investigation. Sensationalist reporting in the media may have encouraged exaggerated or false complaints, and contributed to the taint of the authentic accounts of others and the results of the police investigations that were continuing from 1991.236 | The Macur Review8.127 The document produced by Mr John Roberts of the Wrexham Child Protection Team was described, rightly in my view, as “speculative”; it may more aptly have been viewed as tenuous in terms of those individuals named with no previous convictions for, or indicators of, paedophile offences. 8.128 I regard the Tribunal description of Mrs Taylor’s “Gwynedd County Council Analysis” as including “many rumours and a great deal of hearsay” to be accurate and fair. Mrs Taylor effectively agreed with the Tribunal’s description in her interview with me. Tribunal investigations8.129 I find that it was entirely reasonable that the Tribunal did not pursue allegations made in media articles which were unattributed and general in nature. I do not consider that it was in the public interest for the Tribunal to repeat or report rumours contained within press reports, or to regard them as reliable evidence. However, it has been necessary for this Review to examine all materials that were or should have been before the Tribunal, and for this Report to inform the commissioning departments of the nature and reliability of the information in respect of the names of individuals contained within which have based my conclusions as to the adequacy of the investigations made, and to cross reference the actual allegations made and evidence, properly called, available. That is, I do not consider that a bland assertion or general conclusions as to unidentified establishment names would be satisfactory or sufficient in the circumstances in which this Review was established. Having done so, I am satisfied that the Tribunal was reasonable to decline to investigate or identify names on the ‘suspect list’ against whom no witness had made allegations. 8.130 Counsel to the Tribunal would necessarily be called upon to make an evaluation of the reliability of an informant. Therefore, for example, a “conspiracy theory” such as that referred to in paragraph 8.67, if unspecific, would not reasonably warrant further investigation. An objective analysis of the contemporaneous records of the informant’s calls to the helpline referred to in paragraph 8.71 would rightly indicate him to be an unreliable witness. It was reasonable he was not called. The allegations of the caller referred to in paragraph 8.72 were general and broad and not necessarily in relation to North Wales. The weight able to be placed on his research/hearsay evidence may reasonably have been assumed to be negligible. I consider there would have been little merit in following up this call. 8.131 It was reasonable not to require to attend at the Tribunal to answer allegations which may have referred to him. The evidence implicating him was inadequate and unreliable. Consequently, the Tribunal had no reason to mention his name in its report. What is more, since the investigation into the (in general) was conducted in public session, and in all the circumstances above, I am satisfied that the decision not to include within the Tribunal Report cannot be categorised as perverse. Conversely, Lord Kenyon and his son were rightly named in the Tribunal Report. There was specific evidence identifying them, which accused them of serious acts of impropriety. The Report of the Macur Review | 2378.132 It seems most probable that the omission to refer to the allegations against was by reason of a potential or actual police investigation into them. Whatever the findings that may have been made against any reference to him in the Tribunal Report was likely to have been anonymised in accordance with the practice adopted in the case of those who had not been prosecuted and convicted. In these circumstances, I doubt that the absence of any reference to his name or calling in the Tribunal Report is a deliberate concealment. 8.133 The Chairman’s intervention when the list of names was being read out by DSU Ackerley was, in the circumstances indicated above, certainly correct. It was no part of the Tribunal’s function to propagate gossip or rumour. In the light of the comparative ease for me to obtain a copy of the ‘suspect list’ referred to in paragraphs 8.83 to 8.85 above from other sources I doubt that it was deliberately destroyed with a view to concealment. Tribunal Report8.134 I consider that the findings made in relation to whether was in care at the time of his allegations of abuse against Peter Sharman may be regarded as over cautious, but not perverse. The evidence of another complainant, whose evidence suggested that he may have been in care at the relevant time, is not referred to in the Tribunal Report. The decision not to name Peter Sharman in the Tribunal Report is explicable in that no findings were made against him in relation to allegations definitely covered by the terms of reference. However, it is arguable that in light of his subsequent conviction of sexual assault, the Tribunal Report should have named him and made reference to his conviction as a matter of public interest. 8.135 Since evidence was not led about all of them, the absence of any reference in the Tribunal Report to complaints made against unidentified police officers is unsurprising. I accept that to call or lead evidence against an unnamed perpetrator would have required time devoted to them with scant prospect of any meaningful finding being made. However, there is consequently an imbalance in the Tribunal Report, since none of the allegations are even acknowledged to have been made. The stark assertion in the Tribunal Report7 of the numbers of police officers against whom allegations of sexual abuse may be inaccurate, subject to the Tribunal’s definition of sexual abuse or their findings upon whether or not there was sufficient evidence as to whether a complainant was in care at the relevant time. Alleged concealment of evidence8.136 If had agreed in a meeting with Mr Gerard Elias QC not to say anything about certain individuals before he gave evidence, it is reasonable to assume that when he lost his temper with Leading Counsel during the Tribunal hearings, he would have abandoned restraint. I find it improbable that Mr Gerard 7 See paragraph 51.65 of the Tribunal Report238 | The Macur Review Elias QC would have had a private meeting with after the threat delivered during the hearings. Significantly, makes no reference to this purported agreement in the letters he wrote to the Chairman subsequently (see paragraph 6.223) complaining of Mr Gerard Elias QC’s conduct during the Tribunal. What he does say in that letter was that his evidence was compromised by ill health which prevented his full disclosure. I find it improbable that he would be amenable to any attempt to tailor his allegations to protect any part of the establishment at the behest of Mr Gerard Elias QC or anyone else. Contributors to this Review8.137 I am satisfied that Mr Martyn Jones’ concerns were genuine and not politically motivated, either at the time of the publication of the Tribunal Report or subsequently. I have no reason to doubt that he did raise other names with the police in his meetings with them. However, Mr Jones accepts that he used the list he provided to me as an aide memoire and is reliant on memory of events which occurred a significant time ago. The copy lists that he gave to me did not include the names of the public figures mentioned above. As is clear from the discussion above in relation to the information available to and the evidence given to the Tribunal, there was no mention of or As to the other names, apart from Lord Kenyon, there was good reason not to report them as I indicate above. 8.138 I doubt the accuracy of Ms Griffiths’s recall of her conversation with Mrs Taylor. Mrs Taylor did not confirm the same, nor is the substance of the conversation referred to within the comprehensive reports prepared by her. I am not able to judge whether Ms Griffiths was given this information by Mr Jevons as she indicated he may have done. However, the other information she provided to me was gossip or a repeat of other information before the Tribunal and referred to herein. 8.139 In the absence of any reference to the name of Peter Morrison in the Tribunal papers, I am inclined to conclude that the telephone call to Mr David Jones was a hoax, not made by any member of the Tribunal staff. 8.140 Some of the submissions made to me identifying alleged perpetrators of abuse, and those appearing in subsequent media reports, were not available to the Tribunal. Overall conclusion8.141 I detect no reluctance by the Tribunal to investigate allegations made against national or local establishment figures. Constraint may have been imposed by ongoing police investigations. The absence of findings against establishment names in the Tribunal Report reasonably reflects the Tribunal’s view of the absence of any, or any reliable, evidence to sustain them. I have not detected any evidence that could reasonably have led the Tribunal to a different view.The Report of the Macur Review | 239Chapter 9: Paedophile RingIntroduction9.1 In light of the long prevailing reports of a paedophile ring involving high profile or establishment figures which continued to circulate around the Tribunal hearings and subsequently, I have considered it necessary to report separately upon this Review’s examination of the evidence available to the Tribunal concerning the existence of one or more paedophile rings. Much of the substance of this chapter is already covered in Chapters 6, 7 and 8 of this Report. This examination was conducted with a specific view to investigate whether there was more revealed by the evidence than reported by the Tribunal, or which reasonably could have been investigated further. It was not confined solely to consideration of the Tribunal’s findings in relation to the involvement of establishment figures (see Chapter 8). As indicated below, the Tribunal considered the wider picture of paedophile activity connected to residential children’s homes. This Review therefore comments upon the nature of the investigations conducted. The Tribunal’s definition of a paedophile ring 9.2 The Tribunal considered that “a paedophile ring may exist in many different forms and ... the range of its possible activities is also wide.”1 The Tribunal proceeded on the basis that it was sufficiently defined as a group of individuals known to each other exploiting children for sexual gratification by passing victims and information between themselves. Tribunal approach9.3 The Tribunal considered the “main (but not sole) source of evidence”2 concerning the existence of a paedophile ring to have been It investigated: (i) paedophile activity at and connected with Bryn Estyn and Cartrefle, including the association between Peter Howarth and Stephen Norris; (ii) recruitment to children’s residential homes generally; (iii) paedophile activity in and around Wrexham town including the investigation of Gary Cooke in 1979 and involvement of CHE; and, (iv) paedophile activity on the North Wales coast. 9.4 As regards (i) and (ii), the Tribunal conducted an analysis of findings made in relation to the children’s residential homes to reveal whether there was any “connecting thread or link between the proved offenders and whether ... they shared victims or information about them.”3 As to (iii), specific attention was paid to the activities of convicted paedophile Gary Cooke, although not excluding the evidence of others called to give evidence as a result of allegations. The fourth area was more restricted on the evidence to activities in Rhyl. 1 See paragraph 52.05 of the Tribunal Report2 See paragraph 52.08 of the Tribunal Report3 See paragraph 52.09 of the Tribunal Report240 | The Macur ReviewSummary of Tribunal’s findings9.5 The Tribunal Report indicates that “no evidence has been presented to the Tribunal or to the North Wales Police to establish that there was a wide-ranging conspiracy involving prominent persons and others with the objective of sexual activity with children in care. Equally, we are unaware of any evidence to establish that there was any coherent organisation of men with that objective.”4 It concluded that it was satisfied “during the period under review, [that] a significant number of individual male persons in the Wrexham and Chester areas were engaged in paedophile activities ... Many, but not all, of these paedophiles were known to each other and some of them met together frequently ... Inevitably, some information about likely candidates for paedophile activities was shared, expressly and implicitly, and there were occasions when sexual activity occurred in a group ... To the extent that we have indicated we accept that there was an active paedophile ring operating in the Chester and Wrexham areas for much of the period under review. The evidence does not establish, however, that there was a conspiracy to recruit paedophiles to children’s residential establishments or to infiltrate them in some other way.”59.6 However, significantly, in the Tribunal Report it was considered “necessary to stress … that an inquiry of this kind cannot emulate, for example, an investigation by the police. The resources of the Tribunal and its mechanisms inevitably limit its ability to seek out new witnesses and interrogate them. Thus, in the course of probing the existence of an alleged paedophile ring, we have been unable to do more than hear what the relevant witnesses known to us have been prepared to say on the subject and there has been very little documentary evidence to assist us.”6 Tribunal’s investigation into paedophile activity in children’s residential homes9.7 The Tribunal Report makes clear the scope of its investigations into this issue which included: possible connection between Peter Howarth, Stephen Norris and others; the presence of others at the time of alleged abuse; the introduction of children to abusers outside the children’s residential establishments, including prominent individuals as referred to in Chapter 8 of this Report; and, the systematic recruitment of paedophiles as residential care staff. The contents of Chapters 6 to 8 of this Report already cover some of these areas and I do not repeat them here. However, I do set out below, the evidence available to and investigations conducted by the Tribunal in this respect, which are not otherwise referred to elsewhere.9.8 Inquiries were made regarding Peter Howarth’s possible connections with other abusers. I note some confusion obviously existed about his connection with Aycliffe School and Axwell Park School. Interviews were conducted and the Axwell Park minute book inspected. Peter Howarth’s visitors, correspondents and associates 4 See paragraph 52.07 of the Tribunal Report5 See paragraphs 52.84, 52.85 and 52.88 of the Tribunal Report6 See paragraph 55.04 of the Tribunal ReportThe Report of the Macur Review | 241whilst in prison were identified. The Ruskin College, Oxford list of students studying for the Certificate in Residential Child Care at the same time as Peter Howarth was obtained to identify possible names implicated in abuse (Matthew Arnold, former Head of Bryn Estyn and colleague of Peter Howarth at Axwell Park School, was known to have lectured in Ruskin College). Inquiries were made in local golf clubs to identify Peter Howarth’s partners, proposers and other members. These inquiries did not reveal any evidence of infiltration of the care system or a paedophile ring. 9.9 One complainant, referred in his police statements to Peter Howarth’s golfing friend being present in his flat on occasions and a possible association between Peter Howarth and ‘Gilligan’ - whom the police wondered might be reference to David Gillison (see below) - although made no allegations against them acting together and did not refer to these matters in oral evidence before the Tribunal. A deceased complainant, whose police statements were summarised to the Tribunal, referred to being sexually abused by Peter Howarth and another unidentified man at the same time. There were other complainants who said that they were abused jointly by Peter Howarth and another, and are referred to within the Tribunal Report. 9.10 Stephen Norris had worked in Greystone Heath Approved School in Warrington. Several men who worked there at the time were convicted of indecent assaults on the residents there. The Tribunal Report makes reference to two of them.7 One of those convicted was said to have maintained a link with Stephen Norris and to have visited him at Bryn Estyn. No allegations were made against that individual by any resident of Bryn Estyn in the documents that I have seen, or against Stephen Norris in relation to his employment at Greystone Heath. Whether a paedophile ring operated in Greystone Heath was outside the Tribunal’s terms of reference. 9.11 Two complainants, made allegations that Stephen Norris had introduced them to other individuals for the purpose of sexual favours. The Tribunal was unable to make findings in relation to the most serious of these allegations, which involved Stephen Norris and another man taking it in turns to rape for the reasons given in the Tribunal Report.8 In summary, failed to attend the Tribunal on several occasions, the outside abusers were unidentified and his evidence against a substantial number of other abusers was considered ‘highly dubious’. 9.12 Very few complainants alleged that they had been sexually abused by two men jointly participating or in the presence of others. Other complainants said they were abused by the same offenders at different times. Several of those accused worked together or knew of each other. The Tribunal found there was no direct evidence of a joint venture between Peter Howarth and Stephen Norris and “on the contrary the evidence suggests a degree of hostility between them.”9 7 See paragraph 29.07 of the Tribunal Report8 See paragraph 52.15 of the Tribunal Report9 See paragraph 29.12 of the Tribunal Report242 | The Macur Review9.13 The WIT was directed by Counsel to the Tribunal to carry out inquiries in relation to John Allen when a prison inmate. His visitors and names and addresses of those with whom he was in contact were obtained. 9.14 One complainant, who gave oral evidence to the Tribunal alleged that John Allen and had abused him jointly. denied the association suggested and the abuse alleged. also alleged that John Allen would host parties for men, some of whom would visit him in the night. Another deceased complainant, whose police statements were summarised to the Tribunal, alleged that John Allen had arranged for him to have dinner with the headmaster of another residential establishment, who had sexually abused him before returning him to Bryn Alyn. The Tribunal made no specific mention of these allegations in its Report. 9.15 Other complaints were made against care workers in the Bryn Alyn Community. Some complainants said that their abusers made reference to the fact of their abuse by other abusers, leading at least one, to say that he thought that he had been targeted by Gary Cooke because of information supplied by John Allen. 9.16 As a matter of completeness, I report that there was evidence before the Tribunal which gave them “cause for concern”10 regarding John Allen’s later activities in the South East. Young men leaving care in North Wales previously known to him were housed by him in several properties. Implicitly, at least, some were working as male prostitutes. Tribunal’s investigations into a Wrexham and Chester paedophile ring involving Gary Cooke and members of the Campaign for Homosexual Equality9.17 Counsel to the Tribunal indicated in a note to the Tribunal that, “there remains evidence of the existence of the so-called paedophile ring, a subject of much interest to the successor authorities. The Tribunal may feel that this issue essentially tangential to the real purposes of the Tribunal, unless it can be shown that there was either deliberate and systematic infiltration of the care system, or deliberate and systematic targetting [sic] of boys in care, by paedophiles. Although we have carried out considerable inquiries, the evidence on either ground is slim. At the present time, we have some reservations about devoting a significant amount of Tribunal time to this issue, but would welcome the Tribunal’s views.” 9.18 However, wrote to the Chairman on 21 October 1997, angered by a press article in the Welsh Evening Leader on 17 October 1997, and remonstrated that, “during this article you stated that only one person has alleged that there was and still is a paedophile ring in operation. Whilst it is clear that no-one else has named as many people as myself, numerous other survivors have named some of the same people in their evidence. You go on in this article to ask the question, are the press reporting on the same tribunal that you have been attending? I ask 10 See paragraph 21.46 of the Tribunal ReportThe Report of the Macur Review | 243 the question, are you attending the same tribunal that both myself and the press are attending? ... Throughout this inquiry you have ‘had a go’ at gays and have stated that this is a gay thing. I personally find this very offensive ... At various times during this inquiry you have put a block on barristers asking very pertinent questions. An example of this was when Mr M Hughes asked Gary Cooke if he could enlighten the inquiry as to how he identified potential victims. At this point you stated that you did not want to go down that road because it could get very messy ... It is this kind of information that could prevent possible victims of the future. Mr N Booth has also wanted to explore a number of issues throughout this inquiry and you have continually stopped him ... I must state at this point that this must stop if you are truly trying to uncover the truth ... Also on the point of relevant questions and appropriate witnesses, you are no doubt aware that we have asked that you call a number of other people to come and give evidence at the tribunal. In response to this the tribunal has stated that they will first of all see if they can find them and then wait to see what their written response is before deciding whether to call them to give evidence. I find this totally preposterous, how can you not see that these people are bound to deny what took place, after all Gary Cooke, even with anonymity, denied a large catalogue of offences. It appears to me that your system has failed so far ... The central theme that you keep on referring to when not wanting to explore certain aspects in most of the above is that of costs. Ultimately the cost of this tribunal will be a lot in monetary terms, but nothing compared to the cost of human life and personal suffering ...”9.19 The Solicitor to the Tribunal wrote to solicitors on 29 October 1997, “For your information the Chairman has received a letter from ... He has made it clear in the course of the hearings that he will not receive letters addressed to him by witnesses who are legally represented ... However, it may be helpful if I say that: (a) The Tribunal’s team is continuing to pursue possible witnesses who can give evidence about the alleged paedophile ring and no final decisions have been made about who will be called. Great difficulty is being experienced in tracing most of the persons who have been mentioned in this context. (b) If you will identify any proper issue that Mr Booth thinks that the Chairman has prevented him from exploring, the Chairman will be pleased to consider the matter. He has been anxious to allow Mr Booth proper scope throughout and not least in relation to evidence of the witness Gary Cooke.” I have not found solicitor’s response to this final point, and neither solicitor nor has contacted the Review. 9.20 In this respect, I note that following discussions with the legal advisers to the successor authorities, the WIT indicated that they had endeavoured to trace and interview 15 possible victims of a paedophile ring, some of whom had been referred to in witness statements. Their records indicate that they were unable to trace eight of them. Three of them declined to assist. One failed to attend an appointment to meet with members of the WIT. One gave a statement but did not support the evidence of One was reported as “not seen – in- patient at mental hosp[ital] for next 12 months”. The results of another inquiry is not recorded. There is no Tribunal statement from either of these last two individuals and they were not called to give evidence. 244 | The Macur Review9.21 On 12 November 1997, the head of the WIT reported to Counsel to the Tribunal on the outcome of inquiries in response to information contained in a letter sent by solicitor in respect of the ‘paedophile ring’. One alleged abuser, said to be involved in incidents in the Crest Hotel, was traced and a statement obtained, but was too ill to give evidence. Another alleged abuser was found to have absconded from a private flat two weeks previously owing £2,000 in rent arrears and his location was unknown. Another had died several years before. One of the alleged abusers denied knowing or Gary Cooke and refused to make further comment or a statement. Another had left his premises five years before and was believed to be living and working as a florist in Bournemouth. Another was seen at his place of business and declined to make a written statement but proffered some information voluntarily which did not refer to9.22 Several of the men accused by of abusing him and being part of a paedophile ring were called to give oral evidence at his solicitor’s request. was the only complainant in relation to several of the men, and the only one to give direct evidence against the majority of the named individuals. The Tribunal found it difficult to make findings on the basis of uncorroborated or ‘vulnerable’ corroborated evidence and deemed his evidence “insufficient ... to establish satisfactorily that particular named individuals committed specific offences on identified occasions.”11 However, the Tribunal found that, “he was subjected to sexual abuse repeatedly by several persons during his stay … [at a bungalow in Cheshire owned by a member of the CHE, which] … was, at least, a major cause of the overdose that he took [within weeks of moving there].”12 However, the Tribunal rejected an accusation that social services had arranged the accommodation for him, preferring evidence which indicated that he had been placed in an ‘After Care hostel’ in Chester, but left within a month to take up residence in the bungalow of his own volition.13 9.23 The Tribunal heard oral evidence from a small number of complainants who alleged that they had been sexually abused by Gary Cooke; according to their evidence, some were in care at the time. One complainant, indicated in his Tribunal statement that he had met Gary Cooke on a number of occasions in the vicinity of a children’s home, but was not asked about these matters when giving oral evidence during the hearing, since the Tribunal did not at that stage consider this aspect of his evidence to fall within its terms of reference. Two of his police statements, which are referred to in his Tribunal statement, are not found within the documents provided to the Review. A written application was made on behalf of the successor authorities to recall the witness on the basis that his police statements indicated he was in care at the relevant time. The witness was not recalled. I have found no document dealing with the reasons given for the Tribunal apparently refusing the application. 11 See paragraph 52.90 of the Tribunal Report12 See paragraph 52.79 of the Tribunal Report13 See paragraph 52.76 of the Tribunal ReportThe Report of the Macur Review | 2459.24 Both and a journalist contributor to this Review have raised concerns that Gary Cooke, named by the former as one of his abusers and a prolific convicted paedophile, was influenced by someone during the course of giving his evidence to the Tribunal. They each independently thought that although he continued to answer questions after the midday adjournment, he was less forthcoming. They each suspect that he had been spoken to and warned off.9.25 It is difficult to gauge such a change from the transcript of his evidence alone. I do note that it was necessary to enforce Gary Cooke’s attendance at the Tribunal. Tribunal’s investigations into other paedophile rings 9.26 There was some evidence that William Gerry, convicted for offences of sexual assaults upon boys in care in North Wales, had connections in Manchester and the North East, and may have been engaging in paedophile activities there, and the video recording of homosexual pornographic videos. David Gillison, his co-defendant in the criminal proceedings referred to above, lived with him for a time in Manchester. Mrs Alison Taylor, in her ‘Gwynedd County Council Analysis’, links David Gillison with the “Bryn Estyn vice ring” and also with a paedophile group with national and continental connections. She was later to suggest in a letter to the Tribunal that David Gillison was connected with John Allen in the trade of child pornography. Mrs Taylor’s analysis had been supplied to the police in 1991 and to the Tribunal and is described in the Tribunal Report as “including many rumours and a great deal of hearsay.” 149.27 William Gerry committed suicide on 1 December 1997. The evidence relating to him was provided by his ex fiancée in a police statement and must obviously be approached with some caution. David Gillison appeared before the Tribunal, but was not questioned about matters outside North Wales.9.28 complained of abuse when attending the army cadets in Connahs Quay at the hands of two of the instructors; one being Peter Sharman. Two complainants, and had made allegations of indecent assault concerning another instructor, Sergeant Michael Hayward. The relevant instructors were serving or retired police officers. Michael Hayward was subsequently to admit indecent assault upon one of the complainants and was cautioned. Gary Cooke had also been an army cadet instructor there and in evidence before the Tribunal confirmed that he knew Peter Sharman. The Tribunal Report15 records that allegations had been made against police officers working as instructors in the army cadets, although does not consider whether a paedophile ring was in operation involving one or more army cadet centres. 9.29 Gary Cooke and William Gerry were among several taxi drivers named as abusers. Another was said to be an associate of Stephen Norris. A former resident, alleged that Stephen Norris had taken him to a taxi driver, 14 See paragraph 2.22 of the Tribunal Report15 See paragraph 51.66 of the Tribunal Report246 | The Macur Review house, who on that and a subsequent occasion took photographs of him dressed in shorts and covered in cream. This was untoward behaviour at the least but made no allegation of sexual assault against him. There were other concerns referred to in the papers that the same taxi driver may have been responsible for an indecent approach to another boy, , and had offered a third boy, a trip to the cinema in exchange for washing his car. named another taxi driver as one of his abusers. referred to in paragraph 8.27, was himself a taxi driver, but was not the subject of any complaints. Subsequent representations concerning a paedophile ring9.30 An email found within the Welsh Office files dated 28 September 1998 recorded a telephone call received from who claimed to represent an organisation against child abuse. It stated that “ appeared to be forewarning us that … his organisation would be meeting the Home Secretary and then releasing information to the press about the activities of a Mr Wainright [sic], who he says was Mr John Allen’s right-hand man for 25 years. Mr Wainright [sic], he alleges, runs several children’s homes in Cheshire … and has taken children from the surrounding area including North Wales some of whom have now come forward and complained of abuse in the homes. claims to have video evidence of abuse in the homes. also claims that the network of abuse and cover-up which his group has uncovered involves the local police, the IRA and the Intelligence Services.” The author of the email describes as appearing to be genuine, but that “the extensive nature of the cover-up allegations are hard to take in.” The email goes on to record “apparently a researcher from the Inquiry had met him in Runcorn whilst the Inquiry was sitting but it was decided not to call him to give evidence … I do not know how much of this to believe. We get the occasional crank caller, but this man was clear, logical and rational throughout.” 9.31 There is no indication that this was referred to the Tribunal by the Welsh Office. There is no statement from and no record that he was seen by a member of the Tribunal. As a matter of note, I record there is no allegation of sexual abuse against Norman Wainwright in any witness statement seen by this Review. Contributions to this Review9.32 A contributor to this Review, living in North Wales, considered that the Tribunal had not made a full investigation of the links between various individuals who went on to be employed in other residential homes, and in particular ‘Corvedale Care’, one director of which was Norman Wainwright. 9.33 Another contributor considered that the Tribunal’s investigations were too narrowly focused on incidents of abuse within residential care establishments, and not those which may have occurred elsewhere but have been instigated by, or originated from, staff within the institutions. The Report of the Macur Review | 2479.34 Other contributors to this Review, and some others who have apparently given interviews to the media, have made allegations or insinuations of possible misconduct against other individuals - some of them prominent. This information was not available to the Tribunal.Conclusions 9.35 The conclusions of the Tribunal in relation to the existence of organised paedophile activity in Wrexham and Chester as indicated in paragraph 9.5 above were reasonable and consistent with the findings made upon the evidence presented. Specifically, I confirm that the Tribunal’s findings that no establishment figures were involved in a paedophile ring targeting children in care in North Wales are in accordance with the evidence. There is no indication that evidence of their alleged involvement in paedophile activities, whether acting alone or as part of a ring, was concealed. 9.36 The widespread sexual abuse of children in North Wales children’s homes by numerous care workers and others will obviously raise the possibility or belief that an organised paedophile network was in operation. However, the Tribunal’s general view that the association of those individually indicted, accused or convicted of sexual abuse may indicate a common purpose and propensity, but does not necessarily mean that they joined together in a group in furtherance of their perversions, is not unreasonable. Therefore, I consider the Tribunal was rightly cautious about making findings that other paedophile rings did exist within the residential care system. 9.37 It was not unreasonable for the Tribunal to determine that the allegations in relation to individual members of staff introducing children to outsiders for sexual purposes were nebulous in their substance. The absence of specific reference in the Tribunal Report to each and every allegation made is unsurprising in the wider context of the nature of the investigations. Those which are not specifically referred to in the Tribunal Report tend to be isolated from a common theme, involved unidentified participants and added little to the more specific findings made against named individuals throughout the other parts of the Tribunal Report . 9.38 Counsel to the Tribunal’s note referred to in paragraph 9.17 may suggest an early reluctance to continue in the inquiries regarding an external paedophile ring, but the subsequent documents and directed actions do not bear this out and the cross examination of Gary Cooke and other individuals, including members of the CHE, suggests otherwise. Counsel to the Tribunal directed the WIT to conduct inquiries in relation to the paedophile ring said to be operating in Wrexham and Chester. The WIT appears to have done so conscientiously.9.39 I cannot comment upon the reasons for the failure to recall the complainant referred to in paragraph 9.23, in the absence of any document regarding the same. Clearly this evidence could not have corroborated the specific allegations of and was unnecessary to inform the general conclusions of the Tribunal concerning the existence of a paedophile ring or the activities of a significant number of individuals, including Gary Cooke.248 | The Macur Review9.40 An objective assessment of the relevant parts of the transcript of Gary Cooke’s evidence suggests that his performance when giving evidence appeared to border on the theatrical at times. He was demonstrated to be an unreliable historian. There is no evidence that he was silenced and no reason to consider that he had ‘bigger names’ in store. If Gary Cooke became more truculent it may well be that he had tired of the experience of fencing with the advocates as time wore on.9.41 I regard the Tribunal’s difficulties in making particularised findings against named individuals on the basis of uncorroborated evidence to be well explained and therefore cannot be deemed perverse. 9.42 The Tribunal did not consider and/or find that other paedophile rings were in existence, including in terms of recruitment of residential home staff members or by reason of common employment as taxi drivers. This was not unreasonable on the direct evidence before it. The information provided by Mrs Taylor in relation to the existence of a wider paedophile ring on this issue was multi-handed hearsay evidence and the conclusions drawn by her amount to speculation. 9.43 I have previously indicated that the Tribunal Report fails to refer to the number of allegations made against, in the main, unidentified serving or retired police officers. I note that several army cadets made allegations against their instructors who happened to be retired or serving police officers. There was doubt as to whether one such witness, was in care at the relevant time. In these circumstances, and by extension, it is arguable that reference could have been made to the possibility of a paedophile ring involving the targeting of army cadets, as defined in paragraph 9.2, being in existence. However, I do not consider the failure to do so reflects a protective attitude towards the NWP, rather a cautious approach to the evidence and strict adherence to the terms of reference. The Report of the Macur Review | 249Chapter 10: Concluding Remarks and Recommendations10.1 The ongoing debate between 1992 and 1996 about the necessity to establish a public inquiry rightly considered the possible traumatic impact upon a complainant by the public revelation of childhood sexual abuse and the difficulties in examining historical events. However, in my view, the case for a public inquiry into the abuse of children in care in the former county council areas of Gwynedd and Clwyd in North Wales was eventually and correctly recognised as incontrovertible. There was an obvious need to establish, reliably and openly, the nature and the extent of the abuse beyond that indicated by the criminal convictions of several residential care staff, to assess the adequacy of local managerial response and national government oversight and then address the deficiencies in the system and to seek to ensure that such a situation would never arise again. That is, there was a clear purpose to improve and then promote good child protection procedures. 10.2 As it was, the Tribunal made 72 wide ranging recommendations1 including in relation to the prevention, detection and response to abuse by police and other bodies working co-operatively and to whistleblowing procedure. Recent events in some areas of England since publication of the Tribunal Report may suggest that the basis and rationale behind the recommendations has been overlooked. Regrettably it seems that the detail and length may have deterred a close reading of the Tribunal Report. However, many of the Tribunal’s recommendations for safeguarding vulnerable children are as pertinent as ever. 10.3 I do not underestimate the benefits of the cathartic process for complainants to know that their evidence had been heard in public and that they had been listened to. Nevertheless, it is all too apparent to me that a public inquiry or review into historical child sexual abuse should not be thought to provide a process which will substantiate an individual’s complaints or denials and bring them any sense of finality in this regard. There is difficulty in attempting to determine events that occurred many years ago absent a proficient police investigation and the protection of the criminal trial process without risk of grave injustice. 10.4 Unfortunately, despite the repeated reminder of the Tribunal at the time that the inquiry did not constitute a series of quasi criminal trials, some contributors to this Review, both individuals or associations supporting complainants and accused, see an absence to consider and determine all issues, or to make reference to the same in the Tribunal Report, to be fatal to the integrity of the public inquiry. It appears to me that several fail to appreciate that my role has not been an appellate one. Similar misunderstandings may prevail in the context and purpose of any overarching inquiry or review and should be clearly addressed. 1 See paragraph 56.05 of the Tribunal Report250 | The Macur Review10.5 Equally, whilst a failure or inability to investigate every individual complaint will not undermine the overall determination of the fact of child abuse and/or mismanagement to some extent, it should be appreciated that an inquiry or review may fail to reveal the full extent of the problem. There are many compelling reasons which will deter individuals from making a complaint of sexual abuse when it occurs or subsequently. Whilst my professional experience would support the fact that, even since the publication of the Tribunal Report, public awareness of the problem of child abuse expands and public authorities attitude towards complainants becomes the better informed, it is still a daunting prospect for any person, let alone a child or young person, to disclose or discuss abuse however distant, or for those close to them to accept the prospect of it having occurred. In these circumstances, it is only right to observe that some complainants who gave evidence before the Tribunal and may have wished to contribute to this Review, have been reluctant to re-open painful past experiences and may not consider doing so in any other arena. Others, apparently and understandably, could not bring themselves to participate at the time. 10.6 The establishment of the Tribunal pursuant to the Tribunals of Inquiry (Evidence) Act 1921 (since repealed) was an exceptional step. It is not surprising in those circumstances that repeated challenges to the integrity of the Tribunal, apparently based on reliable information in the context of allegations of historical sexual abuse said to have been concealed by other public bodies, led the government to instruct this Review. 10.7 In conducting this Review it is all too apparent to me that I have the distinct benefit of hindsight and that my comment on matters concerning the Tribunal should acknowledge the changing perspective given to sexual abuse allegations by children and young persons, sometimes against celebrities and establishment figures, which continues to evolve. 10.8 Recent prosecutions have resulted in the conviction of several individuals in relation to the historical child abuse of children who had been in care in North Wales. However, the fact of a successful prosecution does not of itself support a case that the Tribunal inquiries were deficient, or otherwise that evidence was ignored or misinterpreted in any significant degree by the Tribunal. The Tribunal was not constituted as a body with the power or responsibility to detect and produce evidence of criminal activity.Recommendations1. In order to obtain and maintain public confidence, it is essential that every effort is made to ensure that a public inquiry or investigation or review will be objectively viewed as above reproach. There is a clear need for due diligence in appointments made to avoid the undermining of findings legitimately and reasonably made. 2. The preservation and correct archiving of materials, including computer records, of an important public inquiry or review is essential. Those materials which still exist in relation to the Tribunal should be preserved and archived without undue delay. The Report of the Macur Review | 2513. All government departments should possess an accurate database of the documents and materials held by them, and should conduct a necessary review and inspection to identify those relevant to inquiries or reviews established by the government, in order to make prompt disclosure of the same. If the relevance of any such materials is in doubt then the default position should be to proffer the materials for inspection by the inquiry or review.4. I do not advise the establishment of a public or private inquiry or review into the individual allegations of abuse that were not investigated during the course of the Tribunal’s hearings or referred to individually in the Tribunal Report. Operation Pallial continues to investigate the allegations of complainants of historical sexual abuse which occurred in residential children’s homes, foster homes, and other establishments attended by children in the care of the former Clwyd and Gwynedd county councils. Arrests have been made and continue to be made. Criminal proceedings have been instituted and trials have taken place. Due criminal process inevitably will take time, but is better suited to disposal of any unresolved complaints and allegations of the time, rather than a public inquiry. 5. I do advise that consideration is given as to whether it would be appropriate for a police investigation in due course to consider whether there is sufficient evidence and public interest relating to matters of malfeasance in public office and/or perverting the course of justice. 6. In general, I would advise caution in embarking upon a review of the workings of previous tribunals or boards of inquiry without a considered opinion of the time likely to be involved and the consequent outcome to be achieved. The conclusions of a rapid investigation into a broad and complex topic will be unlikely to allay the concerns and anxieties of interested parties or the public in general. An exhaustive review will produce results that may no longer be relevant to the circumstances which initiated the investigation. In any event, it should be appreciated that the conclusions of any such body will not meet with universal approval. Those with an interest, personal or otherwise, will seek justification for their views and be unlikely to accept the contrary. 252 | The Macur ReviewThe Report of the Macur Review | 253Appendices Appendix 1: Lady Justice Macur, DBE’s letter of appointment dated 14 January 2013Appendix 2: The Macur Review TeamAppendix 3: Appendix 4 of the Tribunal Report: Note by the Chairman of the Tribunal on its procedures. Preparations for the hearingsAppendix 4: Blank pro forma detailing the universal process adopted by the ReviewAppendix 5: The Macur Review Issues Paper Appendix 6: Acronyms254 | The Macur ReviewThe Report of the Macur Review | 255Appendix 1: Appointment Letter256 | The Macur ReviewThe Report of the Macur Review | 257Appendix 2: The Macur Review TeamChair: The Right Honourable Lady Justice Macur, DBE Review SecretariatDiane Caddle, SecretaryAshleigh Freeman, Solicitor Marie Colton, Business Manager Review Paralegal TeamTjubi AdebiyiTom HennessyLuke ManzarpourMarium RiazEmma WellsSecretariat and paralegal assistance at earlier stages of the ReviewStephen Knight, Deputy SecretaryMike Dillon, Clerk to Lady Justice MacurPaul BarnettSinead DalyJane DeboisAyesha DevliaRoxanne MansonAmber MunParia Shahidi-AslKim Lindsay Smith258 | The Macur ReviewThe Report of the Macur Review | 259Appendix 3: Appendix 4 of the Tribunal Report ‘Lost in Care’APPENDIX 4Note by the Chairman of the Tribunal on its proceduresPreparations for the hearings1 Leading Counsel to the Tribunal, Gerard Elias QC, made his opening speech on 21 and 22 January 1997, seven months after the setting up of the Tribunal had first been announced by the Secretary of State for Wales and just under five months after the members of the Tribunal had been formally appointed. This was the very minimum period required for preparation, having regard to the large number of potential witnesses to be seen, the enormous number of documents to be inspected and the widespread dispersal of both documents and sources of information that had occurred on local government reorganisation with effect from 1 April 1996.2 All three Counsel to the Tribunal were fully engaged in the preparations from early in September 1996 onwards. By that time the Treasury Solicitor had appointed a small team of lawyers, led by Brian McHenry (who had wide experience of public inquiries) as Solicitor to the Tribunal, to instruct Counsel and supervise a large group of up to 30 (from time to time) paralegals and two trainee solicitors in the preliminary work. This involved at first the examination of some 9,500 unsorted children’s files, numerous staff files and 3,500 statements made to the police as well as the records of both former County Councils and of about 85 children’s homes. In the end 12,000 documents were scanned into the Tribunal’s database, including documents extracted from the large number of files submitted by the Welsh Office.3 A Chief Administrative Officer to the Tribunal, Evan Hughes, was seconded from the staff of the Welsh Office and he had a team of eight working under him to provide administrative and financial support. He was responsible, under the Welsh Office budget holder, for authorising expenditure and dealt with all the ancillary services as well as the processing of bills. There was a memorandum of understanding with the Welsh Office.4 We were fortunate to secure about half of the former but new headquarters of the Alyn and Deeside District Council at Ewloe in Flintshire, near major road junctions, as the venue for our hearings and as the office for the Tribunal and the main part of its staff. It was necessary, however, to obtain separate accommodation at the Shire Hall, Mold, for the purpose of housing many of the documents and carrying out the initial trawl through them. The former Council Chamber at Ewloe was specially adapted for the hearings with convenient working space for Counsel and solicitors and seating accommodation for the public.5 Preliminary matters that had to be negotiated under the leadership of the Welsh Office and with the guidance of its legal adviser, David Lambert, included the appointment of a witness interviewing team (WIT) comprised of former detective officers of the South Wales Police and adjacent forces, the engagement of a witness support service (The Bridge 260 | The Macur ReviewChild Care Development Service[929]), including a detailed specification of the service to be provided, and the provision of a Live Note transcript service by Sellars Imago, including document imaging. A Press Officer, David Norbury, was appointed in January 1997.6 Inspection of the statements to the police disclosed that about 650 former children in care had made complaints of abuse of varying gravity. The Tribunal itself advertised its proceedings widely with a request that complainants should make themselves known and about 100 persons responded to this request. In addition, the Tribunal’s legal team selected at random as potential witnesses 600 former residents of children’s homes in North Wales (about ten per cent) who were not known to have made any complaint. The members of the WIT were eventually able to interview 400 widely dispersed witnesses and travelled over 80,000 miles.7 The Tribunal decided that, as a general rule, we would receive evidence of abuse only from complainants who could be traced and who were willing to make a statement to the Tribunal. This involved, for most of them, making a statement to a member of the Tribunal’s WIT, who was provided with a proforma containing guidance as to how the interview should be conducted; and complainants were informed that they could have their solicitor present at the interview, if they wished, and of the availability of the support service, if they required it.8 Two major problems intensified the work of the Tribunal’s legal team throughout the preparation for the hearings and the subsequent proceedings. The first of these was the need to draft “Salmon letters” to all those who were alleged to have been guilty of abuse and to those who were likely to be the subject of other criticism, giving adequate particulars of what was said against them. In the case of alleged abusers, the problem was mainly one of timing because the evidence of the complainants had to be obtained before the letters could be drafted. Most of the alleged abusers had been interviewed by the police so that they had at least a general recollection of what might be alleged but the Salmon letters had to be based on the available up to date evidence, which, in some cases, included new allegations. To our great regret many Salmon letters had to be posted for this reason during the pre-Christmas period because of the urgent need to begin the hearings.9 The Salmon letters addressed to administrators and some others presented the different problem of diffuseness. They had to be drafted before the Tribunal’s legal team had received any clear evidence of divisions of responsibility within the two former social services departments and the Welsh Office; and, even if the legal team had received some preliminary evidence about this, it would still have been necessary for the Salmon letters to have been drafted in wide terms, covering a broad range of issues. The result was that some Salmon letter recipients had to undertake considerable work, referring to forgotten files, in order to deal with the matters raised in the letters. Moreover, it was inevitable that informal interrogatories had to be addressed to some of the recipients, after their statements had been received in order to remedy omissions or clarify matters that remained unclear.The Report of the Macur Review | 26110 I confess that I have not been able to devise a practical solution to the problem of over-diffuse Salmon letters. If matters of potential criticism are omitted, the Tribunal is open to the criticism of unfairness unless it grants an appropriate adjournment; and successive adjournments would cause major difficulties for everyone involved. A form of preliminary hearing or investigation could take place before each Salmon letter in this category was sent out, but that would also lengthen the hearings considerably in any complex case; and the procedure would not necessarily lead to a more concise statement of issues unless the relevant lines and areas of responsibility were clear cut. It may be that our own procedure was the only practicable one open to us, having regard to the fact that we had to investigate nearly a quarter of a century of administrative and other activity.11 The other main problem was that of disclosure of documents to the interested parties. Public interest immunity from disclosure was claimed by the successor authorities as a matter of principle in respect of a large proportion of the two former social services departments’ documents, particularly the children’s files and staff personal records. In the event, we adopted a procedure whereby the initial selection of relevant documents for each witness was made on a broad basis by the paralegal team under supervision; a narrower selection was then made on the basis of relevance by the Tribunal’s legal team; and the final choice was made by me after weighing the public interest issue. The result was that all relevant documents, as far as the Tribunal was aware of them, were disclosed. In the case of police documents (other than statements to the police) they were divided, by agreement between the Tribunal’s Counsel and Counsel for the North Wales Police, into two categories, namely, documents that could be copied by the parties and those that could be inspected but not copied. Inspection of documents and disclosure were made subject to appropriate undertakings limiting the use of information or documents to the purposes of the Tribunal. Parties were at liberty to apply for disclosure of any specific documents that had been withheld.12 On the basis of these procedures, core bundles containing all the main relevant documents were formed. These were, however, too large and unwieldy for repeated reference to in the course of a witness’ evidence. A relevant smaller bundle was therefore prepared by the Tribunal’s legal team for each witness; any other documents required by any of the parties were added to it; and the witness was then able to read and cope with the selected bundle before and in the course of giving evidence.13 On the whole, the procedure for disclosure of documents worked quite well with the co-operation of Counsel and solicitors but the volume of documentation to be absorbed in a short time undoubtedly imposed considerable strain on those most closely involved, including some witnesses. There were comparatively few complaints of being taken by surprise and short adjournments were granted whenever asked for on the ground of late disclosure. The Tribunal itself was assisted greatly in assimilating and dealing with the documents and in all other respects by its Clerk, Fiona Walkingshaw, a solicitor who joined us full time in December 1996, after secondment by the Welsh Office to the European Commission in Brussels, and who remained as de facto Secretary to the Tribunal until the presentation of our report. 262 | The Macur ReviewPreliminary hearings14 It was necessary for the Tribunal to hold four preliminary hearings at intervals of five or six weeks beginning on 10 September 1996, mainly to deal with questions of representation. Before our first hearing HM Attorney-General authorised the Tribunal to say that anything any witness said in evidence before the inquiry would not be used in evidence against him or her in any criminal proceedings, except in relation to any offence of perjury or perverting the course of justice.15 We decided at the first preliminary hearing to grant anonymity to complainants of physical or sexual abuse and to persons against whom such an allegation was or was likely to be made, in the terms set out in paragraph 1.08 of our report and for the reasons given in the following paragraph of the report. On 11 and 12 February 1997 an application was made by Leading Counsel on behalf of the British Broadcasting Corporation, the Liverpool Daily Post and the Western Mail that we should set aside this “direction”. The application was refused and the Tribunal’s reasons for rejecting it, as explained by me on 12 February 1997, are annexed to this Appendix together with the revised notice given to the press and media after the application.16 We indicated at the first preliminary hearing that any complainant who made a written statement to the Tribunal would be granted representation by Counsel and solicitor, if he/she wished to be represented. We did so on the grounds that it was necessary in the public interest that their views on a range of issues should be put to the Tribunal with professional assistance. It was necessary also that persons against whom they made allegations should be cross-examined on their behalf and that they should have the protection of legal representation when dealing with any counter-allegations that might be made against them.17 The obvious problem was that a wide range of solicitors had already been consulted by complainants, some in connection with civil claims and other firms because of their known experience of inquiries into child abuse of a similar kind. Without going into unnecessary details, it became possible by agreement for one silk and two juniors to represent 119 of the complainants and for a separate junior Counsel to represent 18 other complainants. One firm of solicitors acted for 45 of the complainants and another for 18 whilst 61 were represented by 16 firms, forming a Wales and Chester Group led by Gwilym Hughes and Partners for the purpose of joint representation by Counsel[930]. The other 14 complainants were represented by 11 firms of solicitors. In this way nearly all the complainants who gave oral evidence to the Tribunal were legally represented as well as a small number of those who gave written statements but who were not called. 18 A similar approach to the problem of representation of Salmon letter recipients was adopted as a result of very helpful co-operation by them and by their solicitors. In the event 103 of these recipients were represented by Anna Pauffley QC and Rachel Langdale. The 103 were mainly former residential care workers, including Officers-in-Charge, but some were former senior officers of the Social Services Departments. Representation of other Salmon letter recipients was more diffuse but some former teachers at Bryn Estyn, for example, were jointly represented. The Report of the Macur Review | 26319 An early objection to these arrangements when they were at the discussion stage was that there were potential conflicts of interest between clients within the same group. A similar problem in more acute form had been faced and overcome, however, in the course of the Aberfan Tribunal’s hearings despite wide joint representation, and we considered that the range of experienced Counsel instructed on behalf of the various parties was sufficient to enable any conflict to be accommodated without professional embarrassment. In the event we are not aware that any difficulty arose and we are satisfied that each of the “parties” who required legal representation was fully and fairly represented. 20 In any prolonged inquiry of this kind the question of legal representation is inextricably linked with the issue of costs, which, in other forms of litigation, would be dealt with separately. In the present inquiry few of the “parties” had sufficient means to meet the cost of their own legal representation. On the other hand the Tribunal itself had no power to make any order for costs: it could only make a recommendation to the Secretary of State for Wales, who had set up the inquiry, that the costs of a particular party should be met out of public funds.21 Guidance on this subject was given by HM Attorney-General in answer to a Parliamentary question on 29 January 1990[931] in the following terms: “Tribunals and Public Inquiries can be set up in a variety of ways. So far as ad hoc tribunals and inquiries are concerned the Government already pays the administrative costs. So far as the costs of legal representation of parties to any inquiry are concerned, where the Government have a discretion they always take careful account of the recommendations on costs of the Tribunal or inquiry concerned. In general, the Government accept the need to pay out of public funds the reasonable costs of any necessary party to the inquiry who would be prejudiced in seeking representation were he in any doubt about funds becoming available. The Government do not accept that the costs of substantial bodies should be met from public funds unless there are special circumstances.”22 Since the Tribunal’s hearings ended the Treasury Solicitor’s Department has issued a memorandum[932] containing further guidance on the payment of costs, dealing with such matters as the basis of representation, the control of costs and the process of assessment, including provision for appeals. 23 A particular problem that arose in this inquiry was that several of the Salmon letter recipients were members or former members of trades unions which had a discretion, usually to be exercised by the union’s executive committee, as to whether or not the member or former member should be given support in the form of legal aid in defending himself/herself against allegations in relation to the performance of his/her duties whilst still a member. It is not surprising that, with varying degrees of hesitation, all but two of the relevant trades unions decided against giving legal support in this inquiry and we do not know of any means by which that decision could be challenged successfully. In these circumstances the Tribunal felt bound to recommend that the costs of the past and present members of the unions that had made that decision should be met out of public funds in the light of the Attorney-General’s guidance.264 | The Macur Review24 The other two trades unions declined to make a decision either way before the Tribunal made its own decision on the costs issue; and Counsel representing the seven Salmon letter recipients affected by this refusal renewed his application that the Tribunal should recommend that his clients’ costs be paid out of public funds on the penultimate day of our sittings. Faced with this situation, we agreed to make the recommendation to the Secretary of State for Wales that was sought but to inform him of the background circumstances in which it was made. The Tribunal’s dilemma on this issue highlights a real difficulty about the Attorney-General’s statement in 1990. Underlying that difficulty is the question whether a “party” whose union agrees to provide legal support is less meritorious than one whose union refuses to do so.The Tribunal’s hearings25 As we have said in paragraph 1.11 of the report, we sat on 201 days between 21 January 1997 and 7 April 1998 to hear evidence and submissions. In all 264 witnesses gave oral evidence and we received the written evidence of 311 further witnesses. Evidence was read for a wide variety of reasons, including the deaths of some witnesses, but the range of reasons need not be canvassed here. No important evidence on an abuse issue was read in the face of objections to it. The contents of much of the written evidence that was read were not agreed but it was possible to agree a number of substantial written statements. 26 Counsel for the various “parties” were invited to make opening statements on their clients’ behalf at the conclusion of the opening address by Leading Counsel to the Tribunal.27 For convenience, the evidence was divided into successive phases. In Phase 1 we heard the main evidence of alleged abuse (including evidence from alleged abusers), dealing with the various categories of residential establishments in Clwyd and Gwynedd in turn. In Phase 2 we heard the evidence of senior staff and officers from Officer-in-Charge of residential homes upwards to Directors of Social Services. Phase 3 comprised the evidence of the Welsh Office and Phase 4 that of the North Wales Police. In Phase 5 we dealt with Chief Executives and Councillors whilst Phase 6 covered the role of the insurers and Phase 7 the evidence of the six successor authorities.28 This division into phases was helpful for a number of reasons. The most important was that it enabled the Tribunal’s legal team to formulate an orderly time-table for serving Salmon letters on higher officials and for their responses. Another benefit was that Counsel to the Tribunal were able to present opening statements at the beginning of each phase, clarifying the issues in the light of evidence that had already been given and the Salmon letter responses as well as inter-party discussions in the course of the hearings. Counsel for some of the “parties” chose to make opening statements at the beginning of the phase affecting them.29 In view of the distances those involved in the hearings had to travel, the length of the Inquiry, the number of clients to be seen and the documentation, the Tribunal sat for four days each week from 2 pm on Mondays to 1 pm on Fridays, daily from 10.30 am to 1 pm and from 2 pm to 4.30 pm. We sat in sessions of about six weeks with short breaks in between to enable the preparatory work for each session to be completed in the intervals. The Report of the Macur Review | 26530 Although there are some advocates of wholly inquisitorial proceedings in investigations of this kind, in which the questioning is conducted almost exclusively by the Tribunal itself or Counsel on its behalf, I reached the firm conclusion that such a procedure would be inappropriate in this inquiry. It was essential, in my view, that complainants should be given a full opportunity to put relevant matters based on their own special knowledge to persons against whom they made allegations. Conversely, it was equally important that alleged abusers should have their cases put as they wished to the complainants who made allegations against them. This adversarial factor in the proceedings was inescapable, having regard to the nature of the allegations that the Tribunal had to consider.31 In the event Counsel for the many parties exercised proper restraint in questioning the witnesses and there were comparatively few occasions when I had to intervene because of the nature or manner of cross-examination. There were a small number of regrettable incidents and some complainants resented “being put in the dock” as they would describe it but most of them recognised that it was inevitable that their allegations would be challenged by close questioning. It must be said also that Counsel were economical in their cross-examinations with the result that no witness was detained for an excessive time.32 In order to save time the written statements to the Tribunal by complainants called to give evidence and any earlier statements to the police that they confirmed were taken as read and formed part of their evidence. Complainants were called by Counsel for the Tribunal and then cross-examined and re-examined in an agreed order. All other witnesses were witnesses of the Tribunal but Salmon letter recipients were led in evidence initially by their own Counsel in order to introduce themselves and to amplify or clarify any matters in their written statements to the Tribunal that they wished to before they were cross-examined. 33 At the conclusion of the evidence on 12 March 1998, Counsel and solicitors were given time to prepare full written submissions, including any recommendations that their clients wished to make. The Tribunal read these submissions before convening again on 31 March 1998 for a week to hear final oral submissions, limited to 30 minutes for each “party” or group of “parties”. Leading Counsel to the Tribunal then made concluding oral submissions supplemented by detailed written submissions.34 We held a well attended seminar on 6 and 7 May 1998 to discuss possible recommendations that the Tribunal might make. The expert panel at this seminar comprised Sir William Utting CB, Sir Ronald Hadfield QPM, DL, Adrianne Jones CBE, Brian Briscoe, and Dr Anthony Baker[933]. Questions were addressed to the panel by Counsel to the Tribunal and by other Counsel and solicitors on behalf of the “parties”, supplemented by questions from members of the Tribunal.266 | The Macur ReviewNORTH WALES CHILD ABUSE TRIBUNAL OF INQUIRYAnonymity12 February 1997Giving the Tribunal’s reasons, the Chairman of the Tribunal, Sir Ronald Waterhouse, said “I must say, first of all, that this is not a ruling in any meaningful legal sense. It is an explanation of action taken by the Tribunal, given as a matter of courtesy in response to submissions made on behalf of the BBC and some newspapers. In giving the explanation I should say that, in so far as I touch on matters of law, they represent my view, but so far as questions of general assessment are concerned, they are the view of the Tribunal collectively. I accept that this Tribunal has no power to make an order affecting the press, apart from statute, and I make clear that no order has been made by the Tribunal under either section 4 or section 11 of the Contempt of Court Act 1981. The word `direction’ that appears in the material guidance is, at least partly, a misnomer. The word was used only in the sense of a practice direction explaining procedure and was intended to be an indication to the parties involved in the Inquiry as to how the Tribunal was intending to proceed, coupled with an intimation to the press as to the view that the Tribunal would take, and in particular, the action I would take as Chairman, if the identity of any person in the `anonymous’ categories referred to in the document was to be disclosed in a publication. The background to the action we have taken is that the Tribunal has received requests from virtually all the potential witnesses who are complainants of abuse and from the persons against whom allegations of abuse are made that they should be granted anonymity in the proceedings. We have been given information about the impact of the Inquiry and the gathering of evidence upon potential witnesses and we have reached the firm conclusion that there is substantial risk that the course of justice and the proceedings of the Tribunal would be seriously impeded and prejudiced if there were to be general publication of the identity of the abusers and persons against whom allegations of abuse are made. For that reason we regard it as necessary that anonymity should be conferred as far as possible upon the witnesses referred to in order to avoid the risk of serious prejudice of the kind that was discussed in the House of Lords in the case of Attorney-General versus Leveller Magazine reported in 1979, as well as that specified in the Contempt of Court Act 1981. In considering what we should do, we have had a large number of considerations in mind. These include the terms of reference which we have to follow, the background to the setting up of the Inquiry and the need for full disclosure by witnesses to avoid any continuing suggestion of cover-up. By `full disclosure’ I mean the interviewing of every available potential witness and the objective that those witnesses shall give as full and true an account as they can of the facts within their knowledge both in their written statements and in their oral testimony if and when they are called to give evidence.The Report of the Macur Review | 267 We have had in mind also that, in the context of the first paragraph of our terms of reference, the identities of particular complainants or persons against whom allegations are made is of much less importance than the question whether the alleged abuse occurred and the circumstances in which it is alleged to have happened. We have obviously had regard also to the provisions of the Sexual Offences (Amendment) Act 1992 to the extent that they are relevant. These are all matters that we have had in mind in making our assessment that the course of justice in these proceedings is likely to be seriously impeded if anonymity is not conferred upon the potential witnesses in the first part of our inquiry. The difficulty that we had to face, however, is that, despite the need for anonymity, there is no practical means of conducting the actual hearing within the Tribunal Chamber by adopting a series of symbols for witnesses; neither a numerical nor an alphabetical system would be readily comprehensible, bearing in mind the large number of persons involved. The problem is not confined to intelligent Counsel and solicitors steeped in the case, but extends, of course, to witnesses and the transcribers of the evidence. The prospect of a witness, probably ill-educated because of circumstances beyond his control, being faced with the problem of not naming persons to whom he wishes to refer, but identifying them by a code set in front of him in the witness box, is too appalling to contemplate. The length of the proceedings and the extra public expense involved in that procedure would be intolerable, and the ultimate report of the Tribunal might be delayed by many months. An alternative possible procedure would be for the Tribunal to sit `in camera’ but that would defeat one of the major objects of the setting up of the Tribunal, namely, to assuage public anxiety about what has occurred in the past. It could lead to unjustified suggestions of a cover-up and we have rejected it, bearing in mind what was said by the Salmon Commission about the need for hearings to be in public. Taking fully into account that guidance, we have decided that it is necessary for the hearings to take place in public and for names to be given in the course of the hearings. In the event the prejudice to the witnesses is likely to be, and has proved to be, minimal because attendance at the Inquiry by the general public has been very limited. The proceedings have been entirely open, but attendance has been largely confined to persons who have a direct interest in the subject matter of the Inquiry, most of whom are legally represented or who are at least potentially witnesses. Thus, the result of names being given in the hearings involves only a minor breach of the anonymity which we wish to confer upon the witnesses to whom we have referred. Most of the people who hear names in the course of the hearing would be entitled to know the names because of their position in relation to the Inquiry and would not therefore be covered by the anonymity rule.268 | The Macur Review Having considered all the difficulties, and not least the exchanges that occurred in Parliament when the announcement was made that the Inquiry would take place, we decided to proceed as we have done but to indicate to the press in clear terms that in our view the publication of material enabling the public to identify witnesses who are either complainants of abuse or persons against whom allegations of abuse are made would seriously impede and prejudice the course of the hearings of this Inquiry. It would do so because it would tend very strongly to dissuade witnesses of either category from coming forward and telling the full truth, and such a disincentive would affect also such independent witnesses who were either residents at the relevant care homes or present there as employees or in some official other capacity from giving honest evidence. In giving that express intimation, we believe that we were following the guidance given, in particular, by Lord Edmund Davies in the Leveller case and the spirit of what was said by Lord Diplock in his opinion. In our view, there can be no misunderstanding of that intimation to the media. I stress that the consequences of any publication of the identity of a witness of the prohibited kind would have to be considered on its merits if and when it occurred. If that event were to happen, there would have to be a complaint about the matter and the Tribunal would have to consider it. I would have to decide whether in the circumstances it was appropriate to certify the matter in accordance with section 1(2) of the Tribunals of Inquiry (Evidence) Act 1921 to the High Court, and ultimately it would be a matter for the High Court to consider. It is for that reason that it would be inappropriate to call this explanation a ruling. But it is proper for me to say that, as a matter of law, I regard it as highly doubtful whether an editor could rely on the defence provided by section 4(1) of the Contempt of Court Act 1981 if a publication that did seriously prejudice the course of justice in these proceedings were to be published now, despite the intimation given by this Tribunal, supported by senior counsel on all sides, who are fully acquainted with the nature of the evidence and the circumstances in which it has been obtained. Apart from the argument as to whether the particular publication did offend the strict liability rule defined in the Act of 1981, there would be the question whether the material was published in good faith. I will say only that it would surprise me if a court were to hold that publication in the face of an express warning was `in good faith’. But that would be an issue to be decided upon the facts of the particular case rather than as a theoretical question. Finally, I should say that our intimation applies only to witnesses in the first stage of this Inquiry. The intimation is without time limit, subject to the provisions of the legislation, but it applies only to witnesses who are either complainants of abuse or the subject of allegations of abuse and witnesses who give evidence touching upon those allegations. Different considerations entirely will arise when we pass at a later stage to administrative matters relating to the children in care.The Report of the Macur Review | 269 We will keep under review the question of the application of the anonymity principle. We have already excepted persons whose names are already in the public domain, namely, those who have been convicted of offences forming part of our Inquiry and one of the complainants who is well known through the press as a potential witness in these proceedings[934]. But, if any particular question arises in relation to a specific witness, we will consider it and our Press Officer is always available to advise the press and the media if there is any matter left in doubt.”North Wales Tribunal of InquiryImportant information for the Assistance of the Press and Media1 The Tribunal wishes to indicate that it will regard the following as prima facie evidence of a contempt of court: publication of any material in a written publication (as defined in section 6(1) of the 1992 Act) available to the public (whether on paper or in electronic form), or in a television or radio programme for reception in England and Wales, which is likely to identify any living person as a person by whom or against whom an allegation of physical or sexual abuse has been or is likely to be made in proceedings before the Tribunal, with the exception of those who have been convicted of criminal offences of physical or sexual abuse of children in care. 2 The Tribunal considers that such publication is likely to create a substantial risk that the course of justice in the proceedings of the Tribunal would be seriously prejudiced or impeded, not least because in the event of such publication, potential witnesses may be deterred from testifying, or from testifying fully, to the Tribunal. In the event of such publication, the Chairman would be minded, subject to any representations made to him at that time, to refer the matter to the Attorney General, and/or to the High Court, under the Contempt of Court Act 1981, and the Tribunals of Inquiry (Evidence) Act 1921.3 This is a general intimation. It is open to the Tribunal to give a different intimation in relation to any specific witness. The intimation will be subject to continuous review both during the proceedings of the Tribunal, and at the time of publication of the Tribunal’s report.929 See Appendix 5 for the report by The Bridge on its work. 930 See Appendix 3 for the details of representation. 931 Hansard, 29 January 1990, Col 26. 932 Guidance on payment of legal costs to parties represented at public expense in public inquiries, June 1998. 933 See para 1.12 of the report. 934 This witness subsequently applied for and was granted anonymity. 270 | The Macur ReviewThe Report of the Macur Review | 271Appendix 4: Blank Pro Forma detailing the universal process adopted by the ReviewMACUR REVIEWStage 1 - Review of specific allegations of abuse considered by the Waterhouse TribunalNB. Include reference to documents (i.e. document number) reviewed on Magnum where appropriate to support analysis.Name of complainant:Placement from which social services area?(e.g Clwyd / Gwynedd / other e.g Manchester, London)Name of home attended:Name of alleged abuser(s) and description of allegation(s).Was there a criminal prosecution in respect of the complainant’s allegations and/or the alleged abuser?If so:Allegations included in the indictment?Allegations left on file? (if so, details)Allegation included on indictment, but no evidence offered?How did the allegation come to the attention of the Waterhouse Tribunal?(e.g. police statement, direct approach to Tribunal, third person)Did the allegation appear to fall within the Tribunal’s terms of reference?(i.e. child in care of Clwyd or Gwynedd, since 1974, etc)272 | The Macur ReviewWas the complainant interviewed by the Witness Investigation Team? Does the WIT appear to have followed the Trib A or B guidance appropriately? (i.e. refer to Trib guidance, is the statement in the appropriate format, address the relevant points etc?)Did the complainant return a signed statement?(If not, reason?)Was the complainant’s evidence put before the Tribunal?If so, in what format and why? (i.e in person, read, unread) If the complainant gave evidence in person:• Which Counsel led evidence in chief? (GE or GTJ?)• Which Counsel cross examined?If the complainant’s evidence was not put before the Tribunal, why not? (e.g. witness did not respond to correspondence – in which case what attempts were made to contact? Credibility issues – who made assessment of credibility?, etc)Was there reference to the complainant in the Waterhouse Report? If so, do the findings in relation to the complainant appear to accord with the primary material?List all search terms used:Miscellaneous (e.g. other lines of enquiry pursued / movement between homes or regions?)Completed by: Date: The Report of the Macur Review | 273Review of the Tribunal of Inquiry into the Abuse of Children in Care in North WalesIssues Paper8 January 2013Appendix 5: 274 | The Macur ReviewContentsIntroduction 1Background 1Evidence and Information for the Macur Review 2Questions on which we seek your views 2We hope to hear from you soon 3Alternative formats 4Confidentiality 4The Report of the Macur Review | 275Introduction1. The Macur Review is an Independent Review, chaired by Mrs Justice Macur and required by our Terms of Reference ‘To review the scope of the Waterhouse Inquiry, and whether any specific allegations of child abuse falling within the terms of reference were not investigated by the Inquiry, and to make recommendations to the Secretary of State for Justice and the Secretary of State for Wales.’Background2. The Terms of Reference of the Waterhouse Inquiry announced on 17 June 1996 were:a) To inquire into the abuse of children in care in the former county council areas of Gwynedd and Clwyd since 1974;b) To examine whether the agencies and authorities responsible for such care, through the placement of children or through the regulation or management of the facilities, could have prevented the abuse or detected its occurrence at an earlier stage;c) To examine the response of the relevant authorities and agencies to allegations and complaints of abuse made either by children in care, children formerly in care or any other persons, excluding scrutiny of whether to prosecute named individuals; d) In the light of this examination, to consider whether the relevant caring and investigative agencies discharged their functions appropriately and, in the case of the caring agencies, whether they are doing so now; and to report its findings and make recommendations to the Secretary of State for Wales.3. The Inquiry delivered its report “Lost in Care” on 16 February 2000.276 | The Macur ReviewEvidence and Information for the Macur Review4. We have been provided with evidence obtained, and large volumes of material relating to, the original Inquiry. We are working hard to ensure that all documents that would or should have been available to the Inquiry or now may inform our Review are provided to us.5. We would also very much like to hear from anyone with information relating to the remit of our Review. We have set out below some questions of interest to us.Questions on which we seek your viewsi. Were the terms of reference for the Waterhouse Inquiry sufficiently wide to address all matters of legitimate public interest and/or disquiet concerning allegations of continuing abuse of children in care and the nature of child care procedures and practice in North Wales?ii. Was any undue restriction placed upon the terms of reference to prevent a full inquiry or examination of the evidence in order to protect any individual or organisation?iii. If not, did the Tribunal appear to restrict the terms of reference to avoid investigation or examination of relevant evidence?iv. Was any pressure brought to bear upon those participating in the Inquiry whether as members of the Tribunal, its staff, legal teams, witnesses or contributors to deflect, deter or conceal evidence of relevance to the Waterhouse Inquiry?iv. Were witnesses prevented or discouraged otherwise from giving relevant oral evidence or making statements? If so, by whom and/or in what circumstances.v. Were all relevant witnesses invited to furnish statements and/or be heard by the Inquiry? If not, why not?6.The Report of the Macur Review | 277vi. Were witnesses given adequate support (e.g. legal advice, advocacy or counselling) to facilitate giving evidence to the Inquiry?vii. Were the arrangements made for the Inquiry, including but not limited to, notice of the Inquiry and its proceedings, witness interviewing, location of Tribunal headquarters, configuration of hearing chamber, oral evidence taking, conducive to encourage the participation of relevant witnesses.7. We will not draw any conclusions until all the evidence available to us is considered.We hope to hear from you soon8. We look forward to hearing your views on these and any related issues you think are raised by our Terms of Reference. We would like to receive your views as soon as possible and in any event by 29 March 2013. Unless you specifically request otherwise, all responses will be made public.9. All submissions should be sent to the email or postal addresses below. Please indicate whether you would object to being contacted by a member of the Review if further clarification of your response appears necessary: [email protected] Macur Review Room TM 10.02 Royal Courts of Justice Strand WC2A 2LL10. Anyone who would prefer to make their submissions by telephone can do so by using our dedicated Freephone telephone number, with automatic recording, at 0800 313 4139.278 | The Macur ReviewAlternative formats11. If you require this information in an alternative language or format or have general enquiries about the Macur Review, please contact us by email at [email protected] or telephone us at 020 7071 5770.ConfidentialityAll written representations and evidence provided to the Macur Review will, unless publication is unlawful, be made public unless specifically requested otherwise. If you would like any of the information provided in your response to be treated confidentially, please indicate this clearly in a covering note or e-mail (confidentiality language included in the body of any submitted documents, or in standard form language on e-mails, is not sufficient), identifying the relevant information and explaining why you regard the information you have provided as confidential. Note that even where such requests are made, the Macur Review cannot guarantee that confidentiality will be maintained in all circumstances, in particular if disclosure should be required by law. If you have any particular concerns about confidentiality that you would like to discuss, please contact the Macur Review at [email protected]. The Macur Review is not subject to the requirements of the Freedom of Information Act 2000. However once the Macur Review has completed its work its papers are likely to be passed to the Government. In these circumstances information formerly held by the Macur Review may then be subject to the requirements of that legislation. Members of the Macur Review are data controllers within the meaning of the Data Protection Act 1998. Any personal data provided will be held and processed by the Chair and Secretariat only for the purposes of the Review’s work, and in accordance with the Data Protection Act 1998. Once the Macur Review has completed its work then any personal data held is likely to be passed to the Government for the purpose of public record-keeping.The Report of the Macur Review | 279Macur ReviewRoom TM 10.02Royal Courts of JusticeStrandWC2A 2LLT: 020 7071 5770E: [email protected]/about/macur-review280 | The Macur ReviewThe Report of the Macur Review | 281Adolygiad o Dribiwnlys yr Ymchwiliad i gam-drin plant mewn gofal yng Ngogledd CymruPapur Materion8 Ionawr 2013282 | The Macur ReviewCynnwysCyflwyniad 1Cefndir 1Tystiolaeth a Gwybodaeth ar gyfer Adolygiad Macur 2Cwestiynau yr ydym eisiau eich barn amdanynt 2Gobeithiwn glywed gennych yn fuan 3Fformatau eraill 4Cyfrinachedd 4The Report of the Macur Review | 283Cyflwyniad1. Mae Adolygiad Macur yn Adolygiad Annibynnol, a gadeirir gan Mrs Ustus Macur ac sy’n ofynnol fel rhan o’n Cylch Gorchwyl ‘I adolygu cwmpas Ymchwiliad Waterhouse a pha un ai oedd unrhyw honiadau penodol o gam-drin plant a oedd yn berthnasol i’r cylch gorchwyl heb eu hymchwilio fel rhan o’r Ymchwiliad, ac i gyflwyno argymhellion i’r Ysgrifennydd Gwladol dros Gyfiawnder ac Ysgrifennydd Gwladol Cymru.’Cefndir2. Roedd Cylch Gorchwyl Ymchwiliad Waterhouse, a gyhoeddwyd ar 17 Mehefin 1996, fel a ganlyn:a) Ymchwilio i gam-drin plant mewn gofal yn ardaloedd cyn-gynghorau sir Gwynedd a Chlwyd ers 1974;b) Edrych a fyddai wedi bod yn bosib i’r asiantaethau a’r awdurdodau a oedd yn gyfrifol am ofal o’r fath, drwy leoli plant neu drwy reoleiddio neu reoli’r cyfleusterau, atal y cam-drin neu ei ganfod yn gynt;c) Edrych ar ymateb yr awdurdodau a’r asiantaethau perthnasol i’r honiadau a’r cwynion am gam-drin a wnaed naill ai gan blant mewn gofal, plant a arferai fod mewn gofal neu unrhyw unigolion eraill, ac eithrio craffu ar a ddylid erlyn unigolion sydd wedi’u henwi; d) Yng ngoleuni’r archwiliad hwn, ystyried a oedd yr asiantaethau gofal ac ymchwiliol perthnasol wedi cyflawni eu swyddogaethau’n briodol ac, yn achos yr asiantaethau gofal, a ydynt yn gwneud hynny yn awr; a chofnodi ei ddarganfyddiadau a gwneud argymhellion i Ysgrifennydd Gwladol, Cymru.3. Cyflwynodd yr Ymchwiliad ei adroddiad “Ar Goll Mewn Gofal” ar 16 Chwefror 2000.280 | The Macur ReviewTystiolaeth a Gwybodaeth ar gyfer Adolygiad Macur4. Rydym wedi derbyn y dystiolaeth a sicrhawyd, a chyfrolau mawr o ddeunydd perthnasol i’r Ymchwiliad gwreiddiol. Rydym yn gweithio’n galed er mwyn sicrhau bod yr holl ddogfennau a fyddai neu a ddylai fod wedi bod ar gael ar gyfer yr Ymchwiliad, neu a all fod yn sail i’n Hadolygiad ni yn awr, yn cael eu rhoi i ni.5. Byddem hefyd yn hoff iawn o glywed gan unrhyw un sydd â gwybodaeth am gylch gwaith ein Hadolygiad. Rydym wedi datgan isod rai cwestiynau sydd o ddiddordeb i ni.Cwestiynau yr ydym eisiau eich barn amdanynti. Oedd cylch gorchwyl Ymchwiliad Waterhouse yn ddigon eang i roi sylw i’r holl faterion o ddiddordeb cyhoeddus cyfreithlon a/neu anniddigrwydd ynghylch honiadau o barhau i gam-drin plant mewn gofal a natur y gweithdrefnau a’r arferion gofal plant yng Ngogledd Cymru? ii. A osodwyd unrhyw gyfyngiadau gormodol ar y cylch gorchwyl er mwyn atal ymchwiliad neu archwiliad llawn o’r dystiolaeth er mwyn gwarchod unrhyw unigolyn neu sefydliad?iii. Os na, oedd y Tribiwnlys yn ymddangos fel pe bai’n cyfyngu ar y cylch gorchwyl er mwyn osgoi ymchwilio i’r dystiolaeth berthnasol neu ei harchwilio?iv. A roddwyd unrhyw bwysau ar y rhai a oedd yn cymryd rhan yn yr Ymchwiliad, boed fel aelodau’r Tribiwnlys, ei staff, y timau cyfreithiol, tystion neu gyfranwyr, i fwrw i’r naill ochr, atal neu gelu tystiolaeth o berthnasedd i Ymchwiliad Waterhouse?iv. A gafodd yr holl dystion perthnasol wahoddiad i gyflwyno datganiadau a/neu gael eu clywed gan yr Ymchwiliad? Os na, pam?6.The Report of the Macur Review | 281v. A gafodd yr holl dystion perthnasol wahoddiad i gyflwyno datganiadau a/neu gael eu clywed gan yr Ymchwiliad? Os na, pam?vi. A gafodd y tystion gefnogaeth ddigonol (e.e. cyngor cyfreithiol, eiriolaeth neu gwnsela) i hwyluso rhoi gwybodaeth i’r Ymchwiliad?vii. Oedd y trefniadau a wnaed ar gyfer yr Ymchwiliad, gan gynnwys, ond heb fod yn gyfyngedig i hysbysiad yr Ymchwiliad a’i weithrediadau, cyfweld tystion, lleoliad pencadlys y Tribiwnlys, cyfluniad siambr y gwrandawiad, cymryd tystiolaeth lafar, yn annog cyfranogiad y tystion perthnasol?7. Ni fyddwn yn llunio unrhyw gasgliadau nes bod yr holl dystiolaeth sydd ar gael i ni’n cael ei hystyried.Gobeithiwn glywed gennych yn fuan8. Edrychwn ymlaen at glywed eich safbwyntiau ar y materion hyn ac ar unrhyw faterion cysylltiedig a godir gan ein Cylch Gorchwyl yn eich tyb chi. Hoffem dderbyn eich safbwyntiau cyn gynted â phosib ac erbyn 29 Mawrth 2013 fan bellaf. Oni bai eich bod yn gwneud cais penodol fel arall, bydd yr ymatebion i gyd yn cael eu cyhoeddi.9. Dylid anfon pob safbwynt i’r cyfeiriadau e-bost neu bost isod. Os ydych yn gwrthwynebu i aelod o’r Adolygiad gysylltu â chi os bydd yn teimlo bod angen eglurhad pellach o’ch ymateb, nodwch hynny os gwelwch yn dda: [email protected] Adolygiad Macur Ystafell TM 10.02 Y Llysoedd Barn Brenhinol Strand WC2A 2LL10. Gall unrhyw un sy’n dymuno cyflwyno ei safbwyntiau dros y ffôn wneud hynny drwy ddefnyddio ein rhif ffôn Rhadffôn arbennig, gyda recordiad awtomatig, ar 0800 313 4139.282 | The Macur ReviewFformatau eraill11. Os oes arnoch angen yr wybodaeth hon mewn iaith neu fformat arall, neu os oes gennych chi unrhyw ymholiadau cyffredinol am Adolygiad Macur, cysylltwch â ni drwy e-bost ar [email protected] neu ffoniwch ni ar 020 7071 5770.CyfrinacheddBydd unrhyw safbwyntiau a thystiolaeth ysgrifenedig a ddarperir i Adolygiad Macur yn cael eu cyhoeddi oni bai fod eu cyhoeddi’n anghyfreithlon ac oni bai y gwneir cais fel arall. Os hoffech i unrhyw ran o’r wybodaeth sydd wedi’i chyflwyno gennych chi yn eich ymateb gael ei thrin yn gyfrinachol, nodwch hynny’n glir mewn nodyn i gyd-fynd â’r ymateb neu e-bost (nid yw’r testun cyfrinachedd sy’n rhan o gorff unrhyw ddogfennau a gyflwynir, neu’n safonol mewn negeseuon e-bost, yn ddigonol), gan ddatgan yr wybodaeth berthnasol ac egluro pam eich bod yn ystyried yr wybodaeth rydych chi wedi’i chyflwyno fel gwybodaeth gyfrinachol. Hyd yn oed pan wneir ceisiadau o’r fath, ni all Adolygiad Macur warantu y bydd y cyfrinachedd yn cael ei gynnal o dan bob amgylchiad, yn arbennig os yw datgelu’r wybodaeth yn ofynnol yn gyfreithiol. Os oes gennych chi unrhyw bryderon penodol am gyfrinachedd yr hoffech eu trafod, cysylltwch ag Adolygiad Macur ar [email protected]. Nid yw Adolygiad Macur yn dod o dan ofynion Deddf Rhyddid Gwybodaeth 2000. Er hynny, unwaith y bydd Adolygiad Macur wedi cwblhau ei waith, mae ei bapurau’n debygol o gael eu hanfon ymlaen at y Llywodraeth. O dan yr amgylchiadau hyn, gall yr wybodaeth a gadwyd o dan Adolygiad Macur fod yn rhan wedyn o ofynion y ddeddfwriaeth honno.Mae aelodau Adolygiad Macur yn rheolyddion data oddi mewn i ddiffiniad Deddf Diogelu Data 1998. Bydd unrhyw ddata personol a ddarperir yn cael eu cadw a’u prosesu gan y Cadeirydd a’r Ysgrifenyddiaeth at bwrpas gwaith yr Adolygiad yn unig, ac yn unol â Deddf Diogelu Data 1998. Unwaith y bydd Adolygiad Macur wedi cwblhau ei waith, yna mae unrhyw ddata personol a gedwir yn debygol o gael eu hanfon ymlaen at y Llywodraeth at bwrpas cadw cofnodion cyhoeddus.The Report of the Macur Review | 283Adolygiad MacurYstafell TM 10.02Y Llysoedd Barn BrenhinolStrandWC2A 2LLT: 020 7071 5770E: [email protected]/about/macur-review284 | The Macur ReviewThe Report of the Macur Review | 285Appendix 6: Acronyms AG Attorney GeneralAGO Attorney General’s OfficeCHE Campaign for Homosexual EqualityCPS Crown Prosecution ServiceDPP Director of Public ProsecutionsDSU Detective SuperintendentFACT Falsely Accused Carers and TeachersGLD Government Legal DepartmentHOLMES Home Office Large Major Enquiry SystemNORWAS North Wales Abuse SurvivorsNSPCC National Society for the Prevention of Cruelty to ChildrenNWP North Wales PolicePACE Police and Criminal Evidence ActPII Public Interest ImmunitySSIW Social Services Inspectorate WalesWIT Witness Interviewing TeamISBN 978-1-5286-0022-4CCS0817897938 |
NC046129 | Death of two siblings and their mother. Child A and his mother died on the 12 July 2013 following a fall. The body of Child B was found later that same day at their home address. The inquest into the deaths found that the mother took her own life and that Child A was unlawfully killed. An open verdict was recorded in respect of Child B. Children were living with their mother following a short period in foster care from the 28 April - 17 May 2013 whilst their father was charged with the assault of their mother. Mother had a history of self-harm and suicide ideation, depression and anxiety, domestic abuse and childhood experiences of abuse. Identifies findings, including: a lack of management challenge within agencies; lack of rigorous risk assessment due to the use of different assessment tools, relying on self-report, across and between agencies; an over reliance on formal disclosure of abuse and a failure to recognise the potential impact of historical abuse on parenting capacity. Uses the Social Care Institute for Excellence (SCIE) systems model to pose questions to Torbay Safeguarding Children Board. Includes a summary of actions taken in response to the findings of the review up to October 2014.
| Torbay Safeguarding Children Board In association with Safer Communities Torbay & Torbay Safeguarding Adults Board Serious Case Review C42 Jim Connelly-Webster & Lisa Jennings November 2014 2 This review was conducted using SCIE’s Learning Together methodology, based on principles directly drawn from systems theory 3 Index Index 3 1. Introduction 4 Why this case was chosen to be reviewed 4 Succinct summary of case 5 Family composition 6 Timeframe 6 Organisational learning and improvement 6 Methodology 7 Reviewing expertise and independence 8 Structure of the review process 9 Acronyms used and terminology explained 9 Perspectives of parents, family and friends 9 2. The findings: 12 Introduction 12 Appraisal of professional practice in this case: a synopsis 13 In what ways does this case provide a useful window on our systems 18 Findings in detail 20 Finding 1 20 Finding 2 23 Finding 3 27 Finding 4 30 Finding 5 32 Finding 6 35 Finding 7 38 Finding 8 41 References 44 Appendix 1 46 Glossary of terms 46 Appendix 2 48 Summary of recent changes (at time of SCR completion) 48 4 1. Introduction Why this case was chosen to be reviewed 1.1 Child A died on the 12th July 2013, along with his mother following a fall. The body of Child B was found later that same day at their home address. 1.2 The incident was immediately recognised as serious and meriting a review through a Serious Case Review (SCR) process. This was discussed by the Independent Chair of the Torbay Safeguarding Children Board (TSCB) and the Director of Children’s Services on the 15th July 2013, this decision was communicated to the SCR Subgroup for further consideration and ratification. 1.3 The circumstances surrounding the deaths were considered at a meeting of the SCR Subgroup on the 22nd July 2013 where it was agreed that the criteria for undertaking a SCR had been met. The decision was made with reference to guidance contained in Working Together 2013 (page 68): 1.4 Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) set out an LSCB’s function in relation to serious case reviews, namely: 1.5 5 (1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. 1.6 (2) For the purposes of paragraph (1) (e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either - (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 1.7 The SCR Subgroup was aware that the family had been known to Torbay Children’s Services since April 2013 when police had been called to a domestic incident. 1.8 A meeting of the Torbay Safeguarding Adult Board (TSAB) SCR Subgroup was held on the 2nd August 2013 to consider the death of the mother and concluded that the criteria for an adult SCR had been met in that a vulnerable adult had died and abuse or neglect was suspected to be a factor in the death. The decision was made with reference to the guidance contained in the TSAB Guidance for Conducting Serious Case Reviews1. 1.9 On the 8th August 2013 the Community Safety Partnership (CSP) considered whether a Domestic Homicide Review (DHR) should be completed. A DHR is undertaken in circumstances in which the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by: 1 Torbay Safeguarding Adults Board (2009) Procedures and Guidance for Serious Case Reviews www.torbaycaretrust.nhs.uk/ourservices/SafeguardingAdults/Documents/SCR%20Procedures%20and%20Guidance.pdf 5 (a) A person to whom he was related or with whom he was or had been in an intimate personal relationship, or (b) A member of the same household as himself. 1.10 The review is held with a view to identifying the lessons to be learnt from the death2. 1.11 The CSP recommended that the desired outcomes of a DHR (i.e. identifying learning and improvement) could be accomplished within the TSCB SCR without the need for an additional DHR process. 1.12 It was agreed by the respective partnerships that one review should be carried out, led by the TSCB which captured the requirements of a TSCB SCR, TSAB SCR and CSP DHR. Succinct summary of case 1.13 This case is concerned with the services provided to two children and their mother following a domestic incident in April 2013 that resulted in the mother self harming in an apparent suicide attempt and the children being accommodated in foster care whilst the father was charged with assault. 1.14 Following the incident a range of services became involved to support the children and their mother. These initially included police and children’s services, but soon expanded to include mental health services and domestic abuse support services. 1.15 The children were looked after by foster carers from the 28th April 2013 to the 17th May 2013 before returning to their mother’s full time care. During this period the mother disclosed a history of domestic abuse and difficulties in her childhood. 1.16 The mother sought support in the form of counselling and was seen by the Depression and Anxiety Service (DAS) but was not eligible to receive a service whilst the court case against her partner was ongoing. 1.17 The mother continued to receive support from children’s services in respect of the children and domestic abuse support services in relation to the pending court case against her partner. To family, friends and professionals she appeared to be coping well, there were no concerns that she would self harm or that she posed any risk to the children. 1.18 Tragically, several weeks before the court case, the mother aged just 24 years, took her own life and that of Child A on the 12th July 2013. The body of Child B was discovered later that same day at the home address. 2 Home Office (2013). Multi-agency Statutory Guidance for the Conduct of Domestic Homicide Reviews www.gov.uk/government/uploads/system/uploads/attachment_data/file/209020/DHR_Guidance_refresh_HO_final_WEB.pdf 6 1.19 The inquest into the deaths was held on the 15th September 2014. The coroner ruled that the mother took her own life and that Child A was unlawfully killed. An open verdict was recorded in respect of Child B. Family composition 1.20 The family comprised of the mother and her partner who was the father of their two children, Child A and Child B. Timeframe 1.21 The timeframe for the review was set at the initial meeting between the Lead Reviewers and the Review Team on the 9th September 2013. The agreed time frame was from April 2013 (when the mother went missing and the children were placed in the care of the local authority) until the 12th July 2013. 1.22 Within the period under review, eight key practice episodes (KPE’s) were identified (covering the period from 28th April 2013 until 10th July 2013). These KPE’s were then analysed in detail to provide insight into not only what happened with the children and their mother but also why things happened as they did. It was from this process of detailed analysis that the learning from the review (presented later as findings) was generated. Organisational learning and improvement 1.23 Statutory guidance on the conduct of learning and improvement activities to safeguard and protect children, including serious case reviews states that: Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children. (Working Together 2013: 66) 1.24 The TSCB identified that the SCR of this case held the potential to shed light on particular areas of practice and set out to: � establish what lessons are to be learnt from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of vulnerable adults and children; � identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; 7 � apply these lessons to service responses including changes to policies and procedures as appropriate; and � improve intra and inter-agency working and better safeguard and promote the welfare of vulnerable adults and children. Methodology 1.25 Statutory guidance requires SCRs to be conducted in such a way which: � recognises the complex circumstances in which professionals work together to safeguard children; � seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; � seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; � is transparent about the way data is collected and analysed; and � makes use of relevant research and case evidence to inform the findings. (Working Together 2013: 67) 1.26 It is also required that the following principles should be applied by LSCBs and their partner organisations to all reviews: � there should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice; � the approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined; � reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed; � professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith; � families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process (Working Together 2013: 66-67) 1.27 In order to comply with these requirements the TSCB has used the SCIE Learning Together systems model (Fish, Munro & Bairstow 2010). 8 Reviewing expertise and independence 1.28 The review has been carried out by a Review Team led by two people, Jim Connelly-Webster, independent of the case under review and of the organisations whose actions are being reviewed and Lisa Jennings, TSCB Business Manager. Both are trained in the SCIE Learning Together systems model. 1.29 Jim Connelly-Webster, Independent Lead Reviewer Jim is an independent consultant working in the fields of training and leadership. He served as a police officer for 31 years in posts across the country including Head of CID for Devon and Cornwall Police. He was an executive member of the Plymouth Children Safeguarding Board. He has conducted reviews in the UK and abroad. He has been trained in the SCIE methodology and has had the benefit of SCIE mentoring during this review. 1.30 Lisa Jennings, Lead Reviewer Lisa is a registered Social Worker and has completed the SCIE Learning Together Foundation Course and has previous experience of undertaking SCIE reviews. Whilst undertaking the review she was independent of the services provided by the TSCB partners and was employed by the Board as Professional Adviser and Business Manager. Lisa now works for Torbay Council as Quality Assurance Manager for Children’s Services. 1.31 The Lead Reviewers received supervision from SCIE as is standard for Learning Together reviewers. This supports the rigour of the analytic process and reliability of the findings as rooted in the evidence. This involved case consultation, supervision and a findings clinic for the Lead Reviewers. Additional mentoring through SCIE was also provided to support both Lead Reviewers. 1.32 The Review Team was made up of senior representatives from the different agencies that had been involved with the children and their mother. The role of the Review Team members is to provide expert knowledge in relation to the practice of their individual agency, to contribute to the analysis of practice and to the development of the findings from the review. No members of the Review Team had any direct case management responsibility in relation to the services offered to the children and their mother. 1.33 The Review Team was made up as follows: Name Job Title Organisation Jim Connelly-Webster Lead Reviewer Independent Reviewer Lisa Jennings Lead Reviewer Torbay Safeguarding Children Board Head of Behaviour Support Torbay Council 9 Executive Head Community Safety Torbay Council Designated Nurse for Child Safeguarding South Devon and Torbay Clinical Commissioning Group Detective Sergeant Devon & Cornwall Police Associate Director of Adult Social Services Torbay and Southern Devon Health and Care NHS Trust Named Nurse for Safeguarding Children Devon Partnership Trust Children in Need Service Manager Torbay Council General Practitioner Structure of the review process 1.34 Professionals who worked with or made decisions about the family were invited to be part of the Case Group. They were invited to share their experiences of working with the children and their mother through a process of individual conversations. A total of twenty two conversations were held with individual practitioners. Two members of the Review Team were involved in each conversation. 1.35 Using the SCIE model, gathering and making sense of information about a case is a gradual and cumulative process. Following the individual conversations with practitioners the Review Team held a series of analysis meetings. The emerging narrative and learning from these, the findings as viewed at this point were presented to the Case Group in what are known as ‘Follow On’ meetings. 1.36 Over the course of this review the Review Team met eight times. Three of these meetings included the Case Group, for half days - one for an introductory session and then for two half-day (Follow On) meetings to present the emerging analysis. 1.37 Attendance at all meetings was challenging for those involved. Despite this, all Review Team and Case Group members were committed and were keen to add value to the process. During the process there were a common core of attendees at the meetings and all Review Team members completed tasks between meetings. Within the Case Group and Review Team, there has been a willingness to engage with the process, however this was difficult and led to some members feeling pressurised to go through a difficult situation several times over. Acronyms used and terminology explained 1.38 Statutory guidance requires that SCR reports be written in plain English and in a way that can be easily understood by professionals and the public alike (Working Together 2013: 70). 10 1.39 Writing for multiple audiences is always challenging. In the Appendix we provide a section on terminology to support readers who are not familiar with the processes and language of safeguarding and child protection work. Perspectives of parents, family and friends 1.40 The Independent Chair of the Safeguarding Children Board wrote to the father of the children shortly after the decision was made to conduct a SCR to inform him that a review into the circumstances of the children’s deaths and that of their mother was to be completed. Following the appointment of the Lead Reviewers further contact was made to invite him to meet with the Lead Reviewers if he wished to do so. Contact with the father of the children was not effective until after the inquest. The Lead Reviewers then met with him and he was able to set out his experiences and views. 1.41 The Independent Chair of the Safeguarding Children Board also wrote to the mother’s father, the grandfather to the children, shortly after the decision was made to conduct a SCR to inform him that a review into the circumstances of the children’s deaths and that of their mother was to be completed. Following the appointment of the Lead Reviewers further contact was made to invite mother’s father to meet with the Lead Reviewers. The Lead Reviewers met with a 2nd cousin of the mother on the 17th October 2013 and the 28th October 2013. The Lead Reviewers also met with the mother’s brother, uncle to the children on the 7th December 2013 and made telephone contact with the mother’s sister, aunt to the children. 1.42 The Lead Reviewers also wrote to several close friends of the mother. Two friends indicated that they wished to be involved in the review. The Lead Reviewers met with the friends separately on the 13th November 2013 and the 14th November 2013. 1.43 The contribution of family members and friends was extremely helpful, both in terms of understanding what the children and their mother were like, as well as understanding the mother’s experiences of what it was like to be involved with the services who were working to support her and the children. There were several key factors that came through in these conversations. The first and overriding message was that the children’s mother was a loving, caring and competent mother, who in her normal life would do anything to protect her children. The next was that she was very keen to display a positive aspect to anyone in a position of authority; she was very able to understand and display what was expected of her. Several of those we spoke with indicated that while she was able to display this positive aspect, because of early interactions with children’s services, she was in fear that if she did not do what was expected of her, her children might be taken back into the care of the local authority. 1.44 The mother’s family and friends were as shocked as the professionals who worked with her by the tragic outcome; there were no signs that they could see that would have predicted what was to happen. 11 1.45 The extended family felt that they were a resource which could have been used to support the children’s mother. They felt excluded from the work of the agencies with the mother but acknowledge that her consent would have been required. 12 2. The findings: Introduction 2.1 Statutory guidance requires that SCR reports: Provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence (Working Together 2013: 71). These processes should be transparent, with findings of reviews shared publicly. The findings are not only important for the professionals involved locally in cases. Everyone across the country has an interest in understanding both what works well and also why things can go wrong (Working Together 2013: 65). 2.2 A case review plays an important part in efforts to achieve a safer child protection system, one that is more effective in its efforts to safeguard and protect children. Consequently, it is necessary to understand what happened and why in the particular case, and go further to reflect on what this reveals about gaps and inadequacies in the child protection system. The particular case acts as ‘a window on the system’ (Vincent 2004: 13). 2.3 Case Review findings therefore need to say something more about the LSCB area/agencies and their usual patterns of working. They exist in the present and potentially impact in the future. It makes sense to prioritise the findings to pinpoint those that most urgently need tackling for the benefit of children and families – and these may not be the issues that appeared most critical in the context of a particular case. 2.4 In order to help with the identification and prioritisation, the systems model that SCIE has developed includes 6 broad categories of these underlying patterns. The ordering of these in any analysis is not set in stone and will shift according to which is felt to be most fundamental for systemic change: 1. Innate human biases (cognitive and emotional) 2. Family-professional interaction 3. Responses to incidents 4. Longer term work 5. Tools 6. Management systems 13 2.5 There is a brief explanation of the meaning of these headings in the summary of the findings. Each category may have many subcategories and it is the subcategories that are elaborated in this report. There is, of course, overlap between categories. 2.6 The Findings start by looking at how the issue manifested itself in the case, and attempts as far as possible to say in what way it is an underlying issue, and what the review has gleaned from those involved about its prevalence. They end by summarising the issue and raise questions for TSCB, TSAB and CSP consideration. Appraisal of professional practice in this case: a synopsis 2.7 It is important to recognise that all of the practitioners involved in this case were concerned about the children and their mother. While the appraisal of practice below and the subsequent findings point out gaps in service delivery, the overall context of this case is one of caring professionals doing their best for a family they cared about. 2.8 The review has uncovered no evidence to suggest that the areas for improvement either had a causal relationship to the children and their mother’s death or would have led to a different outcome if practice had been different. 2.9 The review has highlighted the pressure services are under to meet ever increasing demands at a time when they are faced with cut backs. As such the review has identified areas where inter agency and single agency work could have worked more effectively. This is a tragic case for all those that it has touched, but even where there are gaps in service delivery, these tragic deaths do not appear to have been predictable or preventable. 2.10 Prior to April 2013 there had been routine contact between the children, their mother and a variety of agencies including their school, nursery, GP and the housing department but nothing that caused, or should have caused, undue concern. 2.11 Concerns about the family emerged on the night of the 28th April 2013 when police were called to a domestic violence incident and on arrival found the children asleep upstairs while their father, the mother’s partner, was drunk and aggressive outside. The children’s mother had run away having taken an overdose of pills. The police immediately identified the serious nature of the situation and the risk posed to the children and their mother. The children’s father was arrested and a large scale search started for their mother. Torbay Council Emergency Duty Service (EDS) attended and worked with the police to place the children with an emergency foster carer under police powers of protection. This was good practice, the police and children’s services responded promptly and worked together to protect the children and their mother. 2.12 Despite a well organised police search the children’s mother was not located until late afternoon on the following day. She was taken by ambulance to the emergency 14 department of the local hospital and following an initial assessment of her physical needs was referred to a ward for an assessment of her mental health. 2.13 Despite the overdose and being missing overnight the children’s mother presented well, she revealed no current thoughts of self harm and the overdose was seen as an isolated incident which was a response to the domestic abuse. The significance of the domestic abuse as a contributory factor to her actions was recognised. The practitioner undertaking the assessment researched available support and provided the children’s mother with relevant information in relation to local domestic abuse support services. This was good practice. 2.14 The assessment determined that there was no evidence of mental illness and it was decided that admission was not required and a referral to the GP was appropriate. This issue is considered in Finding 2. The children’s mother was signposted to her GP Surgery for further support and the outcome of the assessment was sent to the surgery as per standard practice. However, the assessment was not communicated to children’s services, nor asked for by them. The sharing of information at this point would have provided children’s services with a fuller picture of the mother’s situation. The issue of information sharing is explored further in Finding 3. 2.15 Following her discharge from hospital on the 30th of April the children’s mother was video interviewed by the police and a specialist Domestic Abuse Police Officer completed a Domestic Abuse, Stalking and Honour Based Violence (DASH) tool to assess the risk to the mother. This placed the mother as a high risk and led to a referral to the Multi Agency Risk Assessment Conference (MARAC) and appointment of an Independent Domestic Violence Adviser (IDVA). The police also made arrangements for additional security measures to be installed in the family home. The use of the DASH tool nationally is good practice which seeks to standardise police approaches. In this instance it led to a proactive response to the domestic violence presented; however the lack of consistent assessment tools across different agencies is explored further in Finding 2. 2.16 On the same day the father of the children, mother’s partner, appeared at court and was charged with common assault. He was released on bail with a range of bail conditions including not to contact the children or their mother. 2.17 During this time children’s services were working to ensure the safety of the children who remained with foster carers. Whilst placed with foster carers Child A disclosed details of both domestic abuse and neglect that occurred within the family home. The foster carer appropriately referred this into children’s services. This issue is discussed in Finding 5. 2.18 Assessments began into the mother’s ability to care for the children and regular contact was facilitated between the children and their mother that was flexible and tailored to 15 the needs of the children. It also allowed children’s services to assess mother’s parenting ability. 2.19 Children’s services completed a Section 47 Investigation and a core assessment. The outcome of the Section 47 Investigation was a recommendation that the children be reunited with their mother as soon as possible and that a comprehensive core assessment be completed alongside a risk assessment. Whilst a return home to their mother was child focused the Section 47 Investigation did not take into account the domestic violence witnessed by the children, the incident of self harm nor mother’s mental health and the impact this would have on her ability to safeguard the children. While the father had been removed from the premises, the investigation did not take into account any subsequent risk he may have posed to the children. The issues surrounding the Section 47 Investigation are explored further in Findings 1 and 5. 2.20 The core assessment was informed by information from the police, school and the children’s mother. The mother met with the Social Worker completing the assessment and it was during this meeting that she disclosed that she had experienced difficulties in her childhood. There was no contact with mental health services, the GP in respect of mother’s health, health visiting or school nursing resulting in an incomplete assessment of the situation. The impact the childhood difficulties had on the children’s mother and her parenting should also have been explored further. The Review Team felt this was a missed opportunity to look at the wider family situation and understand mother’s overdose. See Findings 2 and 3. 2.21 The potential risks associated with the childhood difficulties mother disclosed were identified by children’s services but there was no clear policy as to how such disclosures should be managed. The lack of a clear policy to escalate concerns is potentially unsafe and is explored in further detail in Finding 4. 2.22 The assessments were signed off by a manager, not the social worker’s manager, late into the evening after the manager had already completed a full day at work and was finishing paperwork at home. This workload is unsafe practice and is not sustainable. The lack of multi-agency input in the core assessment was not challenged but an action plan was set out by the manager. This action plan included that the children return home under a written agreement, this did not happen. This demonstrates weaknesses in management challenge. Further explanation can be found in Findings 1 and 2. 2.23 On the 9th of May the children’s mother was seen by her GP. She gave a history of having separated from her partner and disclosed being physically and emotionally abused by him, that he had been charged with assault and that her children were in foster care. The mother also disclosed a history that included difficulties in her childhood and unresolved grief following the death of her mother. The GP did not observe any evidence of mental illness or any indication of suicide risk and following a discussion about the support available through the Depression and Anxiety Service (DAS), the children’s mother agreed to self refer and was provided with a leaflet. 16 2.24 Although the children’s mother presented as a person who was progressing well, her situation was complex, involving a recent incident of self harm and an ongoing court process regarding domestic abuse amongst other factors. The referral to DAS merited more detail than the self-referral process allowed for. A written referral or telephone contact with the service may have revealed that DAS were not able to deal with this case and referral to another agency may have been achieved. This is discussed in Finding 6. 2.25 The children returned to their mother’s full time care on the 17th of May. Additional support was provided in the form of a dedicated family support worker from children’s services who provided ongoing support to the children and their mother. It was good practice that a series of child in need meetings were held to monitor progress and consider the ongoing needs of the children and support for their mother All the professionals involved believed the children’s mother was looking forward to her future. The children were seen to be progressing well and there were no concerns about her parenting ability. 2.26 The case was discussed at MARAC on the 4th of June. The meeting considered information from health, education and children’s services. Consideration was also given to mother’s mental health in light of the self harm. It was felt that this had been a reaction to her domestic situation and as the relationship was over, there were no ongoing concerns. The meeting felt that the risks to the mother by her ex partner had been addressed by the support provided, mother’s cooperation, her focus on the children and the bail conditions. As a result the case was discharged from the MARAC list. The Review Team felt that given what was known at the time this was a proportionate response. 2.27 The sharing of information at MARAC was good practice and provided a mechanism for partner agencies to share what information they had and reach an informed decision as to risk. However, there was no written record of the meeting, making it difficult for anyone unable to attend to access the information shared. See Finding 2. 2.28 The two IDVA’s coordinated their support well. The children’s mother was apprehensive about the impending court case but indicated that she supported the police investigation and proposed prosecution. A range of special measures were explored to support her. Although the IDVAs were preparing the children’s mother for her court appearance, they were independent and focussed on her wishes, if she had indicated she did not want to proceed her views would have been advocated to the Crown Prosecution Service and police. The Review Team felt this was good practice. 2.29 On the 25th of June the children’s mother was seen by the DAS service. The DAS target is to assess within 28 days, in this case she had to wait six weeks to be seen between self referral and assessment, indicating a service unable to meet its demands. The DAS service is discussed in Findings 6 and 7. 17 2.30 The children’s mother was assessed using a national scoring tool as being moderately to severely depressed with severe anxiety. It was felt that there was nothing to indicate that she was actively suicidal or had serious thoughts of self harm. It was generally believed that her scores were in keeping with someone in her situation and that she was building a new life for herself and her children. This is explored further in Finding 7. 2.31 The mother’s scores had deteriorated by the time of a follow up telephone call two weeks later, on the 10th of July, indicating deteriorating mental health. This was not considered unusual as scores often fluctuated and there was no clear evidence of active suicidal thoughts. See Finding 2. The DAS service did not share information on changing scores with other agencies due to client confidentiality other than with the GP via a letter. 2.32 The mother was advised during this call that there was an exclusion criteria for clients experiencing domestic abuse and she was therefore not appropriate for DAS services at that time, although she could access the service once the pending court case had concluded. 2.33 The mother was signposted to the Domestic Abuse Support Service (DASS) for further advice and support. This occurred some eight weeks after she first contacted DAS for support. It would have been helpful for the children’s mother to have been signposted or referred to the correct service at the outset. 2.34 The series of referrals, from hospital to GP, from GP to DAS from DAS to DASS, was each individually rational, but the overall effect was that the children’s mother believed she would receive some form of counselling along this referral route which she did not obtain. It would appear that she did not contact DASS, however, had she done so this was also unlikely to have resulted in a service as they will not take clients deemed to be at high risk and her case had been graded as such at the MARAC. 2.35 On the morning of the 11th of July the children’s mother contacted Child A’s school, leaving a message on the answer phone stating that Child A had a sickness bug so would not be in. Child A’s absence the following day did not give rise to concern as the protocol is to be off school for 48 hours following a sickness bug. Given the relationship between the school and the children’s mother this was proportionate. 2.36 On the 12th of July Child B was due to attend nursery, when Child B did not arrive and there was no contact from Child B’s mother to explain the absence the nursery attempted to contact her by telephone. Unable to do so they notified children’s services of Child B’s absence. This was good practice. That same morning the Family Support Worker visited the home address. There was no answer as the children’s mother and Child A had already left the family home and there was not sufficient concern for children’s services to take further action at that time. 18 2.37 Tragically, later that day on the 12th July the children’s mother took her own life and that of Child A; the body of Child B was discovered at the home address. In what ways does this case provide a useful window on our systems 2.38 As with all cases there are features of this case that are unique to this family in terms of background and circumstances, however it was the view of the practitioners involved from the Case Group and the Review Team that there were a number of aspects of this case that were typical of the difficulties that professionals sometimes experience in Torbay. 2.39 This case illustrates the difficulties that professionals have in tending toward a parent centred practice rather than focusing on the needs of children. This case also illustrates the challenge for professionals in accessing appropriate and timely mental health services for clients in the community. The case also reminded those involved in the review of the need to constantly recognise the impact of domestic abuse across many aspects of life but specifically parenting capacity. 2.40 Another important issue which emerged in this case was the challenge for professionals of remaining ‘respectfully uncertain’ when dealing with very compliant and apparently engaging clients. 2.41 The Review Team has identified eight findings for the Board to consider. They are presented in priority order and give an insight into the functioning of the safeguarding system. The eight findings are: MANAGEMENT SYSTEMS Are elements of management systems a routine cause for concern? Finding 1: The lack of management challenge within agencies of the work of practitioners creates the possibility of unsafe practice and does not promote the welfare of adults or safeguard the interests of children. TOOLS What has been learnt about the tools and their use by professionals? Finding 2: The use of different assessment tools (which themselves rely on client self-report) across and within agencies can lead to an absence of rigour in the assessment process and makes the prediction of future risky behaviour less likely. RESPONSE TO INCIDENTS Are there particular good or bad aspects to the patterns of how professionals respond to specific incidents e.g. allegations of abuse? 19 Finding 3: There is a culture of professionals working in isolation to address the individual needs of their clients/patients and not always linking with other professionals. Finding 4: Not recognising the significance of historical abuse and responding appropriately limits the ability of professionals to offer appropriate support to victims and safeguard the welfare of children. Finding 5: Over reliance on formal disclosure of abuse, via video interview or other means, can result in professionals ignoring other indicators of child abuse and neglect. Finding 6: Are there gaps in services in Torbay for people in need of psychological support but who do not present with acute needs? Finding 7: The absence of overt symptoms of mental illness makes appropriate intervention and support to those at risk of suicide less likely. FAMILY-PROFESSIONAL INTERACTION What patterns are discernible in the ways that professionals are interacting with different family members, and how do they help and or hinder good quality work? Finding 8: There is a pattern of professionals being positively disposed towards cooperative, help seeking adults, which in some cases can lead to the absence of rigour in the assessment processes and can adversely impact on promoting the safety and welfare of children. 20 Findings in detail Finding 1 The lack of management challenge within agencies of the work of practitioners creates the possibility of unsafe practice and does not promote the welfare of adults or safeguard the interests of children. (Management systems) How did this issue manifest itself in this case? 2.1.1 There were aspects of good management oversight in this case but there were also some agencies where the scrutiny by managers was limited and insufficient. Formal safeguarding supervision arrangements were not in place for all agencies and some members of the Case Group reported finding it difficult to access appropriate management support. 2.1.2 There was significant agency involvement in this case and the Review Team identified a number of areas of good practice in relation to management oversight. Examples included the school’s provision of regular ongoing support to teaching staff and the structured supervision evident in both the DAS and the IDVA service. There was also good support available to foster carers. 2.1.3 The Review Team found limited management oversight in parts of health provision. One example of this was in the work of the Health Visiting Service. At the point of the initial domestic incident in April 2013 there was no prior involvement between the family and the service, other than for routine developmental assessments. Normal practice following such an incident, particularly when children are taken into care, would be for the Health Visiting Service to make contact with the mother and arrange a visit to see the children. 2.1.4 An attempt was made to contact the family via a letter; when there was no response to this letter this was not followed up. Given the risk factors present in the case it is expected it would have been taken to Child Protection Supervision for discussion. This did not happen and was a missed opportunity to provide management oversight and ensure the service actively engaged with the family and could then contribute to the assessments undertaken by children’s services. 2.1.5 Management oversight in children’s services was not sufficiently robust. Frequent changes in line management and managers with insufficient experience can lead to practitioners not receiving the challenge to practice, advice and support that they require. 2.1.6 The lack of available managers also meant that the S47 Inquiry was not signed off until six days after it was completed, at the same time that the core assessment was signed 21 off. When the assessments were signed off they were done so by a service manager, not the social worker’s manager, late into the evening whilst the manager was working from home. The service manager had limited knowledge of the case resulting in the lack of rigour in the assessments going unchallenged, as set out in Finding 2. How do we know it is an underlying issue and not something unique to this case? 2.1.7 Whilst there have been some improvements in supervision practice in children’s services as noted by Ofsted3 in March 2013 who observed supervision taking place more regularly they also found evidence in some cases that: “supervision entries were brief and showed little evidence of challenge or consideration to the progress being made”. 2.1.8 All of those we spoke to in the course of this review from children’s services talked of high workloads, with evening and weekend working routine and necessary. In the 12 months leading up to the period under review children’s services had seen a 30% increase in the number of contacts received by the Safeguarding Hub. As a result case loads had risen significantly, especially in the initial response team. How prevalent and widespread is this issue? 2.1.9 Previous SCRs in Torbay have identified a legacy of poor practice in this area. Several past reviews have cited supervision as an area for improvement culminating in the recommendation that the TSCB should consider the feasibility of the development of agreed standards for supervised structured safeguarding reflection (supervision) across the children’s workforce that: � is proportionate and appropriate to the role, ways of working, experience and competence; � challenges assumptions and fixed thinking, promotes curiosity, critical and systematic thinking and the exercising of confident professional judgement; � addresses the emotional impact of working with children and families. 2.1.10 A previous review also recommended that the TSCB develop a competency framework, supported by appropriate training and guidance to ensure that supervisors have the relevant knowledge, skills and attitudes to support this supervision. Why does it matter? What are the implications for the reliability of the multi-agency child and adult protection system? 2.1.11 All professionals should have access to a supervisory relationship within which they can reflect on the biases, values and assumptions that may be influencing their assessments and decisions. 3 Ofsted carried out an announced inspection in March 2013 which focused on Safeguarding and Looked After Children’s Services in Torbay Council. 22 2.1.12 It is well recognised that good supervision and support is essential to good child protection. Supervision is, according to Lord Laming (2009) the ‘cornerstone’ of good social work practice; an opinion reiterated by the Munro Review (2011). Lessons from SCRs have reinforced this with Brandon and colleagues noting, for example: � Practitioners who are well supported, receive supervision and have access to training are more likely to think clearly and exercise professional discretion (Brandon et al 2005) � Effective and accessible supervision is essential if staff are to be helped to put in practice the critical thinking required … it needs to help practitioners to think, to explain, to understand … it is essential to help practitioners cope with the emotional demands of the job (Brandon et al 2008) FINDING 1 The lack of management challenge within agencies of the work of practitioners creates the possibility of unsafe practice and does not promote the welfare of adults or safeguard the interests of children. (Management systems) During the period under review and indeed subsequently staff across various agencies in Torbay worked under considerable pressure, dealing not only with their case load but the challenge of reducing resources. Professionals can develop an over committed approach to their work and it is at these times that effective supervision to maintain safe practice is even more important. If managers have to adopt the same over committed approach systems can become stretched, unreliable and potentially unsafe. Questions for the Board � Is the Board aware of the workload pressures within the partner agencies and the impact this has on service delivery? � Is the Board satisfied that there is sufficient management oversight of practice across the partner agencies to deliver safe, effective solutions for adults and children? � How will the Board be assured that adequate management oversight is in place? 23 Finding 2 The use of different assessment tools (which themselves rely on client self-report) across and within agencies can lead to an absence of rigour in the assessment process and makes the prediction of future risky behaviour less likely. (Tools) How did this issue manifest itself in this case? 2.2.1 The significant agency involvement in this case led to a number of assessments being undertaken using a variety of different tools. These tools were either questionnaires as in Torbay Hospital and DAS, forms to complete as in the assessments carried out by children’s social care and the police or scoring mechanisms as used by DAS. These were largely informed by the mother of the children’s self reporting and did not take sufficient account of potential future risk. 2.2.2 Within health a range of assessment tools were used to score mother’s mental health. Following the incident of self harm on the 28th of April a screening assessment was undertaken at the hospital to establish if the children’s mother should be admitted or not. This was not designed to be a comprehensive mental health assessment and was only shared with the GP. It helped to inform the work of the GP, who was reassured by the content of the assessment which indicated that something in life had sparked this (the domestic violence) which had now been removed as the relationship had ended. 2.2.3 The children’s mother was signposted to DAS for further support and was sent two nationally recognised questionnaires (PHQ9 and GAD7)4 to complete. The questionnaires provide a useful framework to assess where people are in respect of their mental health and provide evidence as to whether someone is improving or not. The mother’s score on the PHQ9 questionnaire was 19/27, indicating moderate/severe depression. On GAD7 she scored 17/21 for severe anxiety. At the follow up telephone appointment the assessment questionnaire and scores had deteriorated from 19 to 23 for depression and 17 to 19 for anxiety. This was not considered unusual as scores often fluctuated and was not shared with other agencies. 2.2.4 The police completed a Domestic Abuse, Stalking and Honour Based Violence (DASH) assessment tool to grade the risk posed to the children’s mother. This is a standard approach to all domestic abuse incidents and is a required part of the record keeping by police. The data in the DASH form is used for police purposes and in high risk cases is shared with other agencies via the Multi-Agency Risk Assessment Process (MARAC). Lower risk cases can be shared with the consent of the client. 4 These easy to use self-administered patient questionnaires are used as a screening tool and severity measure for depression and generalised anxiety disorder. 24 2.2.5 The core assessment completed by children’s social care was a key document that defined and guided the work of children’s services. As a tool it provides a structured framework for children’s social care to record information gathered from a variety of sources to provide evidence for their professional judgements, facilitate analysis, decision making and planning. However, the assessment in this case did not take into account the information held by partner agencies arising from their assessment processes. Based solely on information obtained from the children’s mother the police and the school there was no contact with mental health services, the GP in respect of mother’s health, health visiting or school nursing resulting in an incomplete assessment of the situation and did not lead to an overall judgment of risk. How do we know it is an underlying issue and not something unique to this case? 2.2.6 The majority of agencies involved in the review relied on some form of assessment tool in their day to day work with clients. It was clear from conversations with the Case Group that issues regarding capacity mean people often complete these tools hastily and use them as a recording tool as opposed to an aid to understanding and analysing risk. 2.2.7 The tools themselves rely on self reporting by the client which will be skewed if the client is seeking to portray a particular version to the professional. How prevalent and widespread is this issue? 2.2.8 A number of screening and assessment tools have been validated and are generally available within health and social care. 2.2.9 Different professionals use a range of assessment tools for different situations. Although assessment tools are useful in determining risk, the tools themselves should never replace the process of analysis and reflection that is required for any assessment of an adult or child’s situation. Why does it matter? What are the implications for the reliability of the multi-agency child and adult protection system? 2.2.10 Whilst assessment tools can be helpful in guiding understanding they cannot be relied upon to provide definitive answers to levels of risk faced by adults and children. 2.2.11 In order to manage risk, assessments need to ask the right questions and identify what has been happening, what is happening now, what might happen, how likely it is and how serious it would be. 2.2.12 Evidence from a range of sources has identified that although practitioners are good at gathering information about children and families, they find it challenging analysing complex information in order to make judgments about whether a child is suffering, or 25 is likely to suffer, significant harm. This is consistent with recent research highlighting the poor accuracy of much decision making in the child protection field, with assessments being not wholly reliable (Dorsey et al 2008 in Barlow et al 2012). 2.2.13 There is also increasing consensus about the need to move toward the development of Structured Professional Judgment in which professional decision making is supported by the use of standardised tools. 2.2.14 Research by the Department for Education, (Barlow et al 2012) into the use of a variety of assessment tools has set out the importance of a unified, agreed set of assessment tools. The paper concludes with 8 criteria for such assessment tools. � Provide a balance between professional judgement and standardised tools � Encourage assessment and analysis that covers the full range of assessment domains � Be sensitive to the various stages within an assessment � Incorporate clear guidance with regard to assessing parental “capacity to change” � Provide guidance or pointers to how the concept of Structured Professional Judgment could be incorporated into a whole system � Be underpinned by a mode of ”partnership working” with children and families � Be clearly based on best available evidence about which factors are associated with significant harm to children � Acknowledge and promote the tools use within the context of an effective relationship between the children’s services professionals and the children and adults being assessed. 2.2.15 None of the tools reviewed for this DFE research met all of these criteria, though some provide partial fulfilment of them. The DFE work gives some clear direction for potential development in Torbay. FINDING 2 The use of different assessment tools (which themselves rely on client self-report) across and within agencies can lead to an absence of rigour in the assessment process and makes the prediction of future risky behaviour less likely. (Tools) Assessment tools are developed based on evidence, to guide practitioners to effective decisions. They allow for a structure to be put into complex decisions on resource allocation and service provision. They also allow for standardisation and comparison between cases. If practitioners do not fully understand the nature of the tool, or if tools are used mechanistically without understanding the underlying issues, or if they lack time or effective supervision, it can become just another form to fill in and its value can be lost. 26 Questions for the Board � Does the Board think that practitioners fully understand the nature of risk and how it is assessed and analysed? � Are there any models of risk assessment and analysis that are in use in partner agencies that can be adopted more widely to improve practice? � Do partner agencies invest sufficient resources to train practitioners in risk assessment and analysis? � Does the Board have a view about what “risk sensible” practice is in Torbay and how partner agencies can contribute to delivering appropriate, proportionate “risk sensible” interventions? � Does the Board know how many assessment tools are in use in Torbay? � Should the Board move toward a shared system of assessment and develop a process of structured professional judgement that allows the aggregating of agencies data? � How will the Board monitor and measure progress on this issue? 27 Finding 3 There is a culture of professionals working in isolation to address the individual needs of their clients/patients and not always linking with other professionals. (Response to incidents) How did this issue manifest itself in this case? 2.3.1 During the period between April 2013 and July 2013 there were a significant number of agencies involved in this case. The Hospital, GP, DAS, Health Visiting, School Nurse Service, Police, Children’s Services, School, Nursery and IDVA Service were all involved but largely working independently of each other. 2.3.2 Although there were good examples of communication between professionals, practice in this area was not consistently good and some professionals did not actively look to seek or share information to assist assessment processes. There was a tendency for professionals to work in ‘silos’ i.e. to view aspects of need narrowly, solely from the perspective of their own discipline. This was compounded in part by a lack of awareness of other agencies and how they operate. For example, when the children’s mother attended hospital following the incident of self harm on the 28th of April, the Senior Night Nurse tried to access appropriate domestic abuse support services for her but had no clear guide on where or how to refer her. 2.3.3 Most of the services had some knowledge of some indicators of potential risk and vulnerability but this was not brought together into a holistic assessment. An example is that the mental health assessments did not consider sharing information about the potential impact of mother’s mental health with children’s services, and in undertaking work on core assessments, children’s services did not seek information from health professionals about mother’s mental health. How do we know it is an underlying issue and not something unique to this case? 2.3.4 In the course of this review it became evident from the Case Group that individual professionals do not always routinely seek or share information with other agencies as part of their assessment processes. 2.3.5 Developing a working knowledge and confidence in how other services operate, what they have to offer and how to refer and access information from them would help professionals to navigate local pathways for mental health and children’s services. How prevalent and widespread is this issue? 2.3.6 This tendency to work in isolation was highlighted in the recent Ofsted report ‘What about the children? (2013). In that report they found that ‘in assessments where there were issues of parent or carer mental ill health, professionals did not routinely approach 28 the assessment as a shared activity between children’s social workers and adult mental health practitioners, in which each professional drew on the other’s expertise. As a result, the majority of assessments did not provide a comprehensive and reflective analysis of the impact on the child of living with a parent or carer with mental health difficulties.’ The Ofsted report noted that in most cases they reviewed when parents had been admitted to hospital, joint working was poor in ensuring that plans for discharge took the children’s needs into account. 2.3.7 Lessons from national SCRs also describe the extent to which help that is provided to vulnerable children or troubled families is delivered through a “silo” approach where individual people and services are focussed on their single agency issues (Brandon et al, 2008) Why does it matter? What are the implications for the reliability of the multi-agency child and adult protection system? 2.3.8 The importance of sharing information effectively and using it to help inform assessments is essential in order to identify parent-based risk factors, address safeguarding issues and ensure that services share responsibility for improving outcomes for families. 2.3.9 Professor Eileen Munro’s review of the child protection system called for a wider family focus to safeguarding children, so that all staff are aware of their responsibilities, and recognise that meeting the needs of family members who may put children at risk benefits the child, the adult, and the family as a whole. FINDING 3 There is a culture of professionals working in isolation to address the individual needs of their clients/patients and not always linking with other professionals. (Response to incidents) Hidden Harm (first published in 2003) alerted professionals working with adults to the need to regard their patients/clients and parents/carers to be aware of the possible impact of their personal difficulties on their parenting capacity. All agencies that mainly serve adult service users must consider, when deciding if an individual meets their threshold for a service, the possible impact on the individual of any caring responsibilities for children. All agencies that mainly serve children and young people must also consider, when deciding if the child or young person meets their threshold for a service, the possible impact on the child or young person of having a parent/carer with additional problems (for example, families affected by domestic violence, drug or alcohol misuse, parental mental ill health, parental learning difficulties or disabilities, disabled parents or parents with long term health problems). Relevant information about ex partners should also be considered. 29 Questions for the Board � Was the Board already aware of this issue? � Does the Board understand the obstacles to effective inter and intra agency communication? � What options are available to the Board to improve information sharing between adult and children’s services? � How will the Board know when information sharing and “joined-up” working has improved in Torbay? 30 Finding 4 Not recognising the significance of historical abuse and responding appropriately limits the ability of professionals to offer appropriate support to victims and safeguard the welfare of children. (Response to incidents) How did this issue manifest itself in this case? 2.4.1 Following the incident of self harm on the 28th of April the children’s mother disclosed that she had experienced difficulties in her childhood. She was not specific about this and whilst it was noted down it was not shared with other agencies. How do we know it is an underlying issue and not something unique to this case? 2.4.2 In the course of this review it became clear to the Review Team that professionals were unclear about what processes to follow and when to take action in dealing with historic disclosures. 2.4.3 Part of the underlying issue is that professionals struggle to work with victims of historic abuse, to enable them to come forward as witnesses, to deal with their own needs for counselling or to consider the ethical challenge of breaching personal confidentiality in the interests of children generally. This is further complicated when there are not specific children at risk, thus it is not clearly one agencies responsibility and therefore rapidly becomes no-one’s responsibility. How prevalent and widespread is this issue? 2.4.4 There is an increased willingness on the part of victims to come forward and report historical offences of all kinds (MPS & NSPCC, 2013). We cannot know the number of disclosures which may be made but it is an important area for the Board to consider. Why does it matter? What are the implications for the reliability of the multi-agency child and adult protection system? 2.4.4 The impact a history of child abuse and neglect has on an adult's quality of life is well documented. Evidence indicates that people who have experienced childhood abuse are at greater risk of social, physical, emotional and mental health problems in adult life; for example, such individuals are more at risk of self-harm and suicide than the general population. Adults who were abused themselves as children can have difficulties in keeping their own children safe. This makes it all the more important that when they do make a disclosure, they are provided with appropriate support. 31 FINDING 4 Not recognising the significance of historical abuse and responding appropriately limits the ability of professionals to offer appropriate support to victims and safeguard the welfare of children. (Response to incidents) Events that happened many years ago can still have an impact on adults much later in their lives and can significantly impact on their ability to safeguard and promote their children’s welfare. When an adult begins to disclose historical abuse professionals need to have a thought through process for managing both the potential crime and the emotional impact on their client and others. Questions for the Board � What significance does the Board attach to this finding? � What does the Board consider would be “fit for purpose” arrangements to address this issue? � How will the Board be assured that adequate arrangements have been made to address this issue? 32 Finding 5 Over reliance on formal disclosure of abuse, via video interview or other means, can result in professionals ignoring other indicators of child abuse and neglect. (Response to incidents) How did this issue manifest itself in this case? 2.5.1 Following the incident on the 28th of April when the children’s mother went missing the children were placed with foster carers. Child A disclosed to the foster carer details of both domestic abuse and neglect that had occurred within the family home. Child A was able to recount specific details. The foster carer appropriately referred this into children’s services. 2.5.2 Children’s services shared this information with the police and the child was seen at school later that day by a police officer and social worker. Child A was video interviewed two days later. Child A did not confirm the allegations neither when seen at school nor in the interview. As there was no formal disclosure no further criminal action was taken. 2.5.3 At the time of the disclosure and police interview the S47 Investigation was ongoing; despite this consideration was not given to the concerns about abuse and neglect of the children and the potential risk to them was given no further consideration in the core assessment and was not subsequently used in care planning. How do we know it is an underlying issue and not something unique to this case? 2.5.4 The Review Team were of the view that this approach is not unusual and were able to recall other occasions where the lack of a formal disclosure resulted in no further safeguarding action being taken. How prevalent and widespread is this issue? 2.5.5 We do not know how widespread an issue this is but it is an important area for the Board to consider. Why does it matter? What are the implications for the reliability of the multi-agency child and adult protection system. 2.5.6 All disclosures of abuse and neglect by children need to be taken seriously. The fact that the disclosure was not repeated in the video interview did not mean that the abuse and neglect had not happened. This information should have been taken into account in the assessments that followed in order to assess risk and to help inform future assessments. 33 2.5.7 The police and Crown Prosecution Service (CPS) must seek evidence to progress a criminal prosecution. A prosecution must pass the two tests for crown prosecutors, firstly that conviction is more likely than acquittal and secondly that the prosecution is in the public interest. If the police/CPS determine that no prosecution will follow this does not mean that a child is not suffering or is not likely to suffer significant harm. 2.5.8 Local authorities, with the help of other organisations as appropriate, have a duty to make enquiries under Section 47 of the Children Act 1989 if they have reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm, to enable them to decide whether they should take any action to safeguard and promote the child’s welfare. 2.5.9 A good assessment, as set out in Working Together 2013 is one which investigates the following three domains: 1. the child’s developmental needs, including whether they are suffering or likely to suffer significant harm; 2. parents’ or carers’ capacity to respond to those needs; and 3. the impact and influence of wider family, community and environmental circumstances. It is important to gather comprehensive data from all relevant agencies. FINDING 5 Over reliance on formal disclosure of abuse, via video interview or other means, can result in professionals ignoring other indicators of child abuse and neglect. (Response to incidents) This case demonstrates the importance of different practitioners within the safeguarding system understanding the constraints within which agencies work. If practitioners place undue emphasis on there being an evidential disclosure of abuse to the police in order for action to be taken, this can prevent or limit other action. The police will seek evidence to prove a case “beyond reasonable doubt”, where as children’s services practitioners take protective action on “balance of probability” or “reasonable suspicion”. It will often be the case that police decide that there is insufficient evidence to support a prosecution; this should not prevent further action or assessment by children’s services or other agencies involved. Questions for the Board � Does the Board recognise this finding as problematic? � Is the current guidance for practitioners about their individual role and responsibilities 34 sufficiently clear? � What options are available to resolve this issue? � How will the Board be assured that practice has improved? 35 Finding 6 Are there gaps in services in Torbay for people in need of psychological support but who do not present with acute needs? (Response to incidents) How did this issue manifest itself in this case? 2.6.1 Following the incident of self-harm in April 2013 the children’s mother was seen by her GP and requested some form of counselling. Having considered the options available the GP referred her to DAS, a cognitive therapy service. This service undertook an assessment of the mother but determined that their service was not appropriate. At the time of her death she had not received a service despite the request being made six weeks earlier. 2.6.2 The referral to DAS was for cognitive therapy which is not counselling, rather a procedure to help with the management of thinking. The children’s mother was seeking “help to cope”. The GP had 4 options for referral: a. A&E in an emergency b. Crisis Resolution Home Treatment Team for those who are actively suicidal c. Well Being & Access Team by written referral d. Depression & Anxiety Service by self referral / written referral 2.6.3 Of these the Depression & Anxiety Service (DAS) seemed the most appropriate route. In any event, due to her current situation and ongoing domestic abuse proceedings DAS service criteria meant the children’s mother was not able to receive support from them at that time. Utilising a self-referral process, supported by a leaflet, meant that DAS did not receive the full picture of the mother’s complex situation until their first meeting. A written referral would have assisted and is likely to have led to a telephone discussion with the referring GP. 2.6.4 The children’s mother was a woman who was well able to engage with professionals and explain her situation. She did not give evidence of critical need, rather as was recorded in a variety of assessments, she presented as a person who had been through a difficult time and was finding a way out of it. If her need had appeared more critical or if she had presented as a person at real risk of taking her own life, there were referral routes available. In the mother’s case, the range of options, including DAS, DASS and IDVA support had different exclusion factors and scoring regimes that together left her in a complex maze of service offers, which did not in the end lead to the service provision she was seeking. How do we know it is an underlying issue and not something unique to this case? 36 2.6.5 Members of the Case Group reflected on the situation that the mother found herself in and felt that it was not unusual in Torbay and referred to other similar situations in conversations and follow on meetings. 2.6.6 The issue of referral into DAS, the subsequent proposal that she self refer into DASS and the lack of any counselling support has been discussed in detail with the Case Group and the Review Team. Each step is logical on its own, but taken as a whole system can leave the individual without effective service delivery. 2.6.7 The issue of DAS exclusion criteria has now been addressed by DAS with further communication to GPs and others. This issue is not simply DAS service exclusions, but rather the range of options open to GPs and others to refer patients into who do not have acute needs. The 2014 Torbay Mental Health Directory set out some 22 routes for emotional support and 34 for counselling with a further 3 national bodies. There were routes and services available, but no clear guide to help a client through the routes. 2.6.8 This issue has been addressed in the 2011-2016 Torbay Mental Health, Housing, Support, Accommodation and Day Service Strategy. It describes mental ill health / poor mental health as generally referring to difficulties we may experience with our mental health that affect us in our everyday lives. Poor mental health can affect the way we feel, the way we think and the way we function. They can be mild or serious, fleeting or long-lasting. The strategy sets out various aims including, "Services should be commissioned (bought) within a “Right Service, Right Time, Right People” philosophy (way of life and values). The strategy sets out the importance of GPs being able to commission a range of services to support people with mental health problems. In this case the client was offered a referral route which did not meet this aspiration. How prevalent and widespread is this issue? 2.6.9 The Review Group reflected that the range of services available to refer into for non-acute mental health services is complex and poorly coordinated. It is also apparent that since this review was started there have been cuts to the budgets of some of the agencies mentioned. Some of the services provided to the children’s mother would not now be available. Why does it matter? What are the implications for the reliability of the multi-agency child and adult protection system? 2.6.10 Services are initially designed to meet client population needs, within the constraints of resources. Referrers can only refer into the services that are available. If individual client need does not meet available services there is a risk that the referrer is driven to fit the client into the best available referral route. This can lead to the client receiving either an inappropriate service or no service and the initial reason for attending the GP or elsewhere remaining unaddressed. 37 FINDING 6 Are there gaps in services in Torbay for people in need of psychological support but who do not present with acute needs? (Response to incidents) Some of the most vulnerable people in Torbay, at their most vulnerable periods, seek a form of help which they would refer to as counselling. They want someone to talk through how they feel and how it is affecting their lives and hope that the medical and mental health professionals can help them. The services that are in fact available are limited in scope and duration but importantly have exclusion criteria which can prevent the most needy receiving them. These exclusion criteria are not sufficiently clear to clients or referrers. Questions for the Board � Was the Board aware of the issue prior to this Serious Case Review? � What level of priority does the Board believe should be given to this issue on the overall provision of services to people with mental health difficulties? � Is there a role for the Community Mental Health Team to play a greater part in assisting people through the maze of service options? � What are the commissioning options available to deliver a person focused approach for clients in need of psychological support? 38 Finding 7 The absence of overt symptoms of mental illness makes appropriate intervention and support to those at risk of suicide less likely. (Response to incidents) How did this issue manifest itself in this case? 2.7.1 Between April 2013 and July 2013 when the children’s mother became known to a number of agencies she engaged positively and in a way which appeared to indicate that she was making good progress. All agencies involved found her positive to work with and felt that she was making good progress. However, she had very recently carried out a significant act of self harm i.e. taking an overdose and fleeing her house. Her positive engagement appears to have blocked the view of her underlying issues. 2.7.2 A number of professionals observed that there was no evidence of mental illness; rather that the mother’s behaviour was an appropriate response to her current circumstances. This was apparent in the various assessments that were carried out including by the Hospital, GP and DAS. The DAS assessment indicated high levels of depression and anxiety, but these were seen as consistent with her current situation, rather than indicative of deeper, underlying problems. 2.7.3 Each professional that the children’s mother was engaged with thought that, in the light of her domestic abuse situation and her financial difficulties, she was coping remarkably well. She indicated perceived appropriate behaviour for someone in her situation and appeared to be looking forward to a future on her own with her two children who were considered a strong buffer against any future self harm. 2.7.4 Family, friends and the professionals involved with the children’s mother did not think that suicide, let alone the death of her children, was likely. How do we know it is an underlying issue and not something unique to this case? 2.7.5 In the course of this review it became clear to the Review Team that professionals were less likely to consider the risk of suicide when there are no obvious symptoms of mental ill health. 2.7.6 Many people who commit suicide do so without disclosing they are thinking about it or planning it and whilst some people who commit suicide have an identifiable mental health problem others do not (DoH, 2014). How prevalent and widespread is this issue? 2.7.7 About 5,000 people die every year in the UK by suicide with suicide more than three times as common in males (12.4 per 100,000 for males in 2010-12, compared to 3.7 for 39 females) and over half of those who die by suicide having a history of self-harm (DoH, 2014). 2.7.8 The unlawful killing of a child followed by the suicide of a parent (filicide-suicide) is thankfully very rare. Research indicates that it is more often motivated by altruism where the parent’s suicidal feelings are often extended to the child, because they do not want to leave them behind. 2.7.9 A study of 297 cases of convicted filicide and 45 cases of filicide-suicides in England and Wales occurring between January 1997 and December 2006 found that 37 per cent of parents and step-parents who killed their children were suffering from some form of mental illness and 12% had been in contact with mental health services within a year of the offence (Sandra et al, 2013). 2.7.10 Lessons from national SCRs highlight that parental mental health problems feature in the majority of SCRs with suicidal or self-harming behaviour particularly prominent. Brandon et al noted that: “Parental suicidal or self-harming behaviour needs to be taken very seriously, and the potential risks to the children thoroughly assessed. Being a parent is generally perceived to be a protective factor in relation to adult suicide or self-harm; thus when a parent is threatening or actually carrying out suicidal or self-harming behaviour, this protective element may have been lost”. (Brandon et al, 2012) Why does it matter? What are the implications for the reliability of the multi-agency child and adult protection system? 2.7.11 Whilst cases of filicide-suicide are very rare the seriousness of the outcome make it even more important that agencies need to entertain the possibility of suicide where an attempt has been carried out, particularly where there is any history of mental health issues. FINDING 7 The absence of overt symptoms of mental illness makes appropriate intervention and support to those at risk of suicide less likely. (Response to incidents) Research and experience suggest that there is a high correlation between mental illness and suicide. The connection between overt symptoms of depression and self-destruction is probably the most clear. However, as was evident in this case, it is not always necessary for the individual to appear suicidal (or to give notice of their intentions) before they kill themselves. A failure to recognise this and a willingness of practitioners to accept at face value assurances by clients that they are positive and forward looking without looking more sceptically at the individuals circumstances and behaviours make the prediction of suicidal behaviour more problematic. 40 Questions for the Board � Was the Board aware of this issue before the review? � Are practitioners from partner agencies sufficiently well trained in recognising and responding to people at risk of suicide particularly those who wish to disguise their intentions? � Does the Board have a view about the tension between the individuals’ right to self-determination and the professionals’ duty of care to adults and children? � Does the Board believe that additional guidance is required for practitioners? Which agencies are best placed to develop such guidance? 41 Finding 8 There is a pattern of professionals being positively disposed towards cooperative, help seeking adults, which in some cases can lead to the absence of rigour in the assessment processes and can adversely impact on promoting the safety and welfare of children. (Family-professional interaction) How did this issue manifest itself in this case? 2.8.1 In the course of this review professionals held a view of the children’s mother which helped allay their concerns and led to underlying issues and background not being fully considered in the assessment processes. There was however, evidence of checking and challenging, particularly in relation to her relationship with her estranged partner. 2.8.2 From the time the children’s mother became involved with agencies in April 2013 she cooperated with professionals, doing everything that was asked of her. For the agencies involved this was a very positive case to be involved with. It was a good story, in that she was engaging and making progress. The children’s mother was described as “showing all signs of putting her life back together” … that it was “unusual to have a family wanting to work with us” and that “there was nothing of concern with this case”. 2.8.3 The mother’s cooperation, which was always considered to be genuine, contributed to a lack of focus on the children. For example; having taken an overdose and going missing overnight she was admitted to hospital on the 29th of April. Whilst in hospital she was assessed by a mental health worker and spoken to by the police and children’s services. As set out in Findings 6 and 7 she was seen to be ‘seeking help’ and the incident of self harm was perceived to be a response to a difficult period which she had now removed herself from. 2.8.4 The mother’s overriding concern at this stage was the welfare of her children who had been placed in emergency foster care. This led professionals to see her as a “loving protective mum” and that the children were “strong buffers” against any further self harm. Insufficient consideration appears to have been given to the fact that she had fled the family home leaving the children behind. The focus of children’s services appears to have been to ensure the children returned to the care of their mother as swiftly as was safely possible. 2.8.5 The result was that no in depth analysis was undertaken of the mother’s parenting capacity. The significance of mother’s attempted overdose and potential risks to the children were overlooked as the focus centred on reuniting the children to the care of their mother. 42 How do we know it is an underlying issue and not something unique to this case? 2.8.6 The ‘rule of optimism’ that can affect decision making in child protection was first identified by Dingwall et al (1983). The key concern here is that the worker wishes to see the best in people, and have hope and optimism that their interventions can help a family function better, including for the child involved. 2.8.7 From discussions with the Case Group and individual conversations with professionals the Review Team were left with a feeling that workers wish to see the best in client’s / patients. 2.8.8 In the Victoria Climbié inquiry, Lord Laming (2003) suggested social workers needed to practice “respectful uncertainty”, applying critical evaluation to any information they receive and maintaining an open mind. How prevalent and widespread is this issue? 2.8.9 Research findings and systematic reviews of child abuse death inquiries / SCRs demonstrate that this is a widespread concern. Ofsted’s evaluation of 67 Serious Case Reviews (2011) concluded that “practitioners focused too much on the needs of the parents, especially on vulnerable parents, and overlooked the implications for the child”. 2.8.10 In Brandon et al’s review of 189 serious case reviews between 2005-7, they found that “good parental engagement sometimes masked risks of harm to the child’. Why does it matter? What are the implications for the reliability of the multi-agency child and adult protection system? 2.8.11 The rule of optimism is more likely to exist when staff feel under pressure and this can be very dangerous for children who are at risk. This is also where good supervision can make a real difference. 2.8.12 A safe system would recognise the error and bias that parent centred practice and ‘rule of optimism’ thinking can introduce into the risk assessment process. A safe system would have in place processes including challenging, reflective supervision and access to specialist support. See Finding 1. FINDING 8 There is a pattern of professionals being positively disposed towards cooperative, help seeking adults, which in some cases can lead to the absence of rigour in the assessment processes and can adversely impact on promoting the safety and welfare of children. (Family-professional interaction) 43 This case is an example of parented centred practice and ‘rule of optimism’ thinking (as in so many other SCR’s). Professionals, family and friends did what they did because of the way they interacted with the children’s mother, she told them things that they believed. When she said she felt better (even when she didn’t) they were reassured. Questions for the Board � Is the Board aware of the risks that such practice introduces into the safeguarding system? � What are the options available to counter such potentially unsafe practice? � How will the Board be assured that practice in this area has improved? 44 References Advisory Council on the Misuse of Drugs (2003). Hidden Harm: Responding to the needs of children of problem drug users. ACMD Barlow, J., Fisher, J.D., Jones, D. (2012). Systematic review of models of analysing significant harm. London: The Stationary Office Brandon, M., Belderson, P., Warren, C., Howe,D., Gardner,R., Dodsworth, J and Black , J. (2008). Analysing Child Deaths and Serious Injury through Abuse and Neglect: What Can We Learn? A Biennial Analysis of Serious Case Reviews 2003-2005. Research Report DCSF–RR023. London: Department for Children, Schools and Families. Brandon, M., Bailey, S., Belderson, P., Gardner, R., Sidebotham, P., Dodsworth, J., Warren, C. and Black, J. (2009). Understanding Serious Case Reviews and their Impact: A biennial analysis of Serious Case Reviews 2005-07. Research Report DCSF-RR129 London: Department for Children, Schools and Families. Brandon, M., Bailey, S., Belderson, P., Sidebotham, P., Hawley, C., Ellis, C., Megson, M. (2012). New learning from serious case reviews: a two year report for 2009-2011. Research Report DFE-RR226 Warwick: University of East Anglia & University of Warwick. Department of Health, Department for Education and Employment, and Home Office (2000). Framework for the Assessment of Children in Need and their Families. London: The Stationery Office. Department of Health (2014). Preventing suicide in England: One year on - First annual report on the cross-government outcomes strategy to save lives. DoH: London Dingwall, R., Eekelaar, J., and Murray, T. (1983). The Protection of Children: State Intervention and Family Life. Oxford: Basil Blackwell Dorsey, S., Mustillo, S.A.,Farmer, E.M.Z & Elbogen, E. (2008). Caseworker assessments of risk for recurrent maltreatment: association with case-specific risk factors and re-reports. Child Abuse and Neglect, 32, 377–391. Fish, S., Munro, E. and Bairstow, S. (2008). Learning together to safeguard children: developing a multi-agency systems approach for case reviews, London: Social Care Institute for Excellence. HM Government (2013). Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. London: The Department for Education. 45 Laming, Lord, (2003). The Victoria Climbie inquiry: report of an inquiry by Lord Laming (PDF). Norwich: TSO P205. Lord Laming (2009). The Protection of Children in England: Progress Report. London: The Stationery Office. MPS & NSPCC. (2013) Giving Victims a Voice - A joint MPS and NSPCC report into the allegations of sexual abuse made against Jimmy Savile under Operation Yewtree. London: MPS & NSPCC Munro, E. (2011). The Munro review of child protection: final report − a child-centred system, London: DfE. Ofsted (2011). Ages of concern: learning lessons from serious case reviews. Manchester: Ofsted Ofsted (2013). Inspection of safeguarding and looked after children services Torbay. Available at: http://www.ofsted.gov.uk/sites/default/files/documents/local_authority_reports/torbay/051_Inspection%20of%20local%20authority%20arrangements%20for%20the%20protection%20of%20children%20as%20pdf.pdf Ofsted (2013). What about the children? Joint working between adult and children’s services when parents or carers have mental ill health and/or drug and alcohol problems’ Manchester: Ofsted. Sandra M. Flynn, Jenny J. Shaw, Kathryn M. Abel. Filicide: Mental Illness in Those Who Kill Their Children. PLoS ONE, 2013; 8 (4): e58981 DOI: 10.1371/journal.pone.0058981 Torbay Council (2011). Torbay Mental Health Strategy www.torbay.gov.uk/mentalhealthstrategy.pdf Torbay and Southern Devon Health and Care NHS Trust (2014). Torbay Mental Health Directory www.tsdhc.nhs.uk/yourlife/adult_social_care/Documents/MHD.pdf Vincent, C. (2004) 'Analysis of clinical incidents: a window on the system not a search for root causes', Quality and Safety in Health Care, 13: 242–243. 46 Appendix 1 Glossary of terms Case Group: Staff directly involved in the case from all agencies Child in Need Meeting: A regular multi-agency meeting to develop and review plans for a child/children Cognitive Therapy: A form of psychotherapy (a psychological approach to treatment) based on scientific principles that help people change the way they think, feel and behave Core Assessment: An in depth assessment undertaken by a social worker to help establish whether action is required to safeguard and promote the welfare of the child or children who are subject of the enquiries CSP (Community Safety Partnership): A partnership made up of statutory agencies to reduce crime and disorder and make areas safer CPS (Crown Prosecution Service): The Crown Prosecution Service is responsible for prosecuting criminal cases investigated by the police in England and Wales DAS (Depression and Anxiety Service): A psychological therapy service for people in the South and West of Devon who are over 18 years of age and who are feeling stressed, anxious, low in mood or depressed DASH (Domestic Abuse, Stalking and Honour Based Violence) Assessment Tool: A common checklist used by the police for identifying and assessing risk DASS (Domestic Abuse Support Services): Provides support to men, women and transgender individuals in Torbay who are experiencing or have experienced domestic abuse DHR (Domestic Homicide Review): A review of the circumstances in which the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect EDS (Emergency Duty Service): The Emergency Duty Service is a generic social work service covering Childcare, Adult and Mental Health referrals out of normal office hours within the Torbay area Findings: What has been learnt from the particular case about the general functioning of the local multi-agency child protection system First follow-on meeting: Discussion meetings held where staff directly involved in the case are asked to check, correct and amplify the analysis of the Review Team to date IDVA (Independent Domestic Violence Advisor): An IDVA's role is to support 'high' risk victims of domestic abuse. The key outcome is to increase the safety of survivors of domestic violence; and their children KPEs (Key Practice Episodes): Episodes in the case that have been highlighted for detailed analysis Lead Reviewers: The pair who lead the case review process MARAC (Multi-Agency Risk Assessment Conference): A meeting to discuss high risk victims of domestic abuse Operation Yewtree: A police investigation into sexual abuse allegations, predominantly the abuse of children, against the British media personality Jimmy Savile and others. The investigation, led by the Metropolitan Police Service, started in October 2012 47 Police Powers of Protection: The power of the police to intervene to safeguard children. These powers are governed by Section 46 of the Children Act 1989. Under this law, the police have the power to remove children to a safe location for up to 72 hours to protect them from "significant harm". Police do not require a court order to take such a step Review Team: Group of senior representatives from the involved agencies who conduct the case review. Generally the expectation is that they should have had no direct decision making role in relation to the case Risk Assessment: an assessment to determine how safe children are in their environments and what is the level of risk for future harm SCIE (Social Care Institute for Excellence): SCIE is an independent charity and, working with Professor Munro, has been developing the Learning Together systems methodology for case reviews and SCRs since 2006 SCR (Serious Case Review): A review of the circumstances in which a child or adult dies or is seriously injured and abuse or neglect is known or suspected. The aim is to help agencies learn lessons about how they can work better together to protect children and adults from serious abuse Second follow-on meeting: Discussion meetings held where staff directly involved in the case are asked to compare their handling of the particular case with their ways of working in other cases and more generally Section 47 Investigation: An investigation carried out by children’s services under the Children Act 1989 when they have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm Window on the system: The phrase has been coined by a health academic called Charles Vincent to capture the goal of a case review Written agreement: Used by children's services to help ensure the safety and welfare of children during periods of assessment and/or intervention, by outlining what is required from parents in terms of compliance with assessments and appointments, living arrangements or involving supervisory arrangements with other family members 48 Appendix 2 Summary of recent changes (at time of SCR completion) The SCR was initiated in July 2013 and was signed off following the inquest in October 2014. In this time, agencies have reported that there have been a number of actions taken in response to the findings which are detailed below: Torbay Safeguarding Children Board In order to help improve the quality of decision making and interventions the Board has developed a set of standards for supervision that help challenge assumptions and fixed thinking, promote curiosity, critical and systematic thinking and the exercising of confident professional judgement. To support the standards the Board is developing a competency framework, supported by appropriate training and guidance, to ensure that supervisors have the relevant knowledge, skills and attitudes to support this supervision. In order to enable partner agencies to work together more effectively the Board has introduced regular Best Practice Forums. The forums are open to all frontline staff and managers from across the partnership and meet on a regular basis to look at safeguarding issues. The Board has arranged a series of targeted workshops for children’s services and adult mental health services to improve relationships and explore opportunities for joint working. The Board has also undertaken a review of its SCR procedures and produced a new toolkit. The toolkit contains guidance as to how the Board determines whether to undertake a SCR, a judgment about the methodology to be adopted in particular cases and how best to support staff through the process. Depression and Anxiety Service (DAS) DAS have completed a number of actions, including: � A review of their ‘decision tree’ so that it is more specific regarding risk which has been circulated to all GP surgeries. � Staff, particularly in the Torbay team have received information and training regarding domestic violence and the role of the IDVAs. � Representatives from DAS have attended the adult mental health directorate meeting and asked for guarantees that all DPT staff will not facilitate self-referrals and will write formal referrals to DAS. � DAS will continue to liaise with services to ensure the appropriateness of referrals. Children’s Services Children’s Services now has a stable work force with reduced workloads and an appropriate level of expertise. 49 The service is in the process of implementing a Single Assessment Framework (SAF) in order to provide a systematic way of analysing, understanding and recording what is happening to children and young people within their families and the wider context of the community in which they live. This multi-agency assessment will reduce the need for other professional assessments and allow professionals working with a family to have a shared understanding of the families’ strengths and what support they need to thrive. It will mean that families don’t have to experience multiple assessments undertaken by a wide variety of professionals. The service is also in the process of introducing a new social work model ‘Signs of Safety’ which is intended to help practitioners with risk assessment and safety planning in child protection cases. Its purpose is to enable practitioners across different disciplines to work collaboratively and in partnership with families and children. The introduction of Signs of Safety is supported by the Safeguarding Children Board along with health and education. A policy for managing historical allegations and a programme of mandatory refresher training in relation to assessments and supervision is in the process of being rolled out to all relevant staff within social care. South Devon and Torbay Clinical Commissioning Group (CCG) South Devon and Torbay CCG have had a consistent engagement process with the local community with over 500 people attending 7 specific mental health focused events. All of the feedback from these has helped shape a Devon wide mental health strategy and has supported the transformation planning of an enhanced local Acute Care Pathway. There has been an enhanced perinatal mental health service to include all pregnant women. The “Head Up Heart Strong”, a film about recovery from perinatal mental health problems, starring 6 women from Devon and Torbay has been produced and shown widely across the county particularly within services and wider stakeholders to raise awareness among practitioners across organisations to improve the join up and coordinated approach to women. There has also been an extension of existing liaison psychiatry and night nurse practitioner services as well as plans to introduce telephone helpline and peer support. Safer Communities A contract for an Integrated Domestic Abuse Service in Torbay was awarded to the Sanctuary Group and the service began on 2 September 2014. The service provides outcome focused integrated domestic abuse services for high and medium risk victims, survivors and members of their household including children. The service aims to deliver enhanced safety, promotion of recovery and support to prevent reoccurrence. The service includes the following components: � Independent Domestic Violence Advisors (IDVAs) � Outreach / floating support � Accommodation via a Refuge and Safe Houses (12 units in total) 50 � Volunteer led telephone helpline (not yet active) � Group work � Specific activity with children and young people � Partner Link Worker � Awareness raising � Survivors Group � Standard risk support The service is available to both female and male victims of domestic abuse. The service works in partnership with a variety of organisations many of which are represented within Torbay’s Domestic Abuse Steering Group (which includes sexual violence services) to ensure that victims receive appropriate support. Referrals into the service can be made by any professional, community based worker or victim. |
NC047202 | Death of a 1-year-11-month-old boy in July 2013 following methadone ingestion. His mother had given him the substance to pacify him. Mother was sentenced to six years for manslaughter. Mother had a history of: substance misuse, criminal activity, anxiety and depression, and involvement in sex work. The mother's other child had previously been subject to a child protection plan for emotional abuse. Learning includes: the importance of considering any potential safeguarding issues relating to parents' methadone use or substance misuse, substance misusers' lack of engagement with medical reviews should be seen as a significant risk factor in regard to children, and methadone must either be kept in safe storage by the client or consumption should be supervised. Uses a systems approach to examine why and how decisions and actions were made. Sets out desired outcomes for children based on key findings from the review, including: timely pre-birth assessment of risk to unborn children of parents who misuse substances or are subject to methadone programmes, and for the voice of children to be heard by professionals.
| Title: Board Response to Case Number BSCB 2013-14/2: overview report LSCB: Birmingham Safeguarding Children Board Author: Paul Sharkey Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Birmingham Safeguarding Children Board has chosen to include identifying details of the children and the perpetrators as this information has been in the public domain. Final Version 21.03.16 1 Birmingham Safeguarding Children Board Response to Case Number BSCB 2013-14/2 Final Version 21.03.16 2 Case Number BSCB 2013-14/2 Birmingham Safeguarding Children Board Response into the death of Fenton Hogan (DoD 01.07.13) 1.1 This Serious Case Review (SCR) was conducted following the tragic death of Fenton Hogan as a result of ingesting a lethal dose of methadone administered by his mother. His mother did not intend to take his life, and the findings of manslaughter at her trial confirm this was the case. Fenton’s death was neither predictable nor intended, and none of the agencies involved with him and his mother did anything which directly contributed to his death. 1.2 The Birmingham Safeguarding Children Board (BSCB) received this Serious Case Review at their Executive meeting of 20th October 2015. The Board accepted the Report in full, as it provide extremely important learning for the Board about how to improve practice and ensure similar risks of methadone ingestion (both accidental and deliberate) are minimised in future. The Board recognised that whilst no agency or individual contributed to his death, there were many agencies and professionals involved during his short life. Between them they could have taken steps to better promote his and his sister’s safety and wellbeing, reduce the risk of ingestion and its potentially fatal consequences, and improve their life experiences. 1.3 This is of considerable regret to the Board and it is imperative that his death is a catalyst for major improvements in safeguarding and support services to all other children and families in the city and across the West Midlands when substance abuse impacts on their lives and safety. It is also of considerable regret that much of the learning was already known and available regionally and nationally as a result of similar Serious Case Reviews and research into the treatment of substance abuse of those who are also parents. 1.4 Much of the learning in the report was addressed and applied during the process of undertaking the review. Of particular importance for BSCB during this process was the fact that the specialist provider of substance abuse treatment involved in Dudley, CRI, won the tender to provide integrated substance abuse services in the whole of Birmingham. The learning informed the commissioner relationship with CRI as well as the way CRI implemented their service here. The service “went live” in March 2015 and the Board have sought assurance from the commissioners and from CRI at regular intervals. 1.5 The SCR recognises that most parents with substance abuse problems can and do parent their children appropriately. The report also recognises there is an inherent risk in working with such parents in balancing their right to parent and Final Version 21.03.16 3 be supported to do so, and the right of their children to be safely parented and get all their needs met. It is how agencies responded to the need to constantly undertake such a careful balancing exercise that is the issue in this SCR 1.6 Following a decision by agencies (after the Board meeting) to be family member led in terms of our approach to publication, we have subsequently consulted with both the maternal and paternal extended family. In undertaking that consultation, we have weighed up in particular the best interests of Fenton’s older sibling. 1.7 We had two different views expressed. The paternal family wanted us to publish the case proactively. The maternal family were appropriately protective of Fenton’s sibling, and whilst accepting a form of publication was necessary, did not want that to be proactive. After careful consideration the Independent Chair has decided to publish the report reactively, primarily and most importantly to minimise the chance of very distressing coverage two and a half years after Fenton’s death for his maternal extended family and in particular his older sibling who has important exams at the end of the summer term 2016. 1.8 On considering the SCR the Board has agree that • Fenton’s death was a tragic one that should not have happened • His mother has spent time in prison as a result of her action in giving Fenton methadone • There is no doubt things could have been done differently by those professionals involved with Fenton and his family. This did not directly or causally result in his death but the review concludes this would have reduced the possibility. This is a matter of considerable regret and we have collectively let down Fenton and his family • Much of what we have learnt reflects learning from similar SCR’s across the region as well as national learning and research. This is also a matter of serious regret for all the many agencies involved in this SCR in that the learning available had not been applied across the areas involved. • A significant number of different local authorities, police, probation, NHS and substance abuse services were involved during Fenton’s life as the family moved regularly. Birmingham was the last local authority area they lived in. Although there were some individual areas of good practice, none of the areas or agencies were as effective as they should have been. • The learning indicates it is the understanding, knowledge, rigour and assertiveness of front line practice that most needs to change. This requires extensive workforce development, learning and improvement activity across the West Midlands as well as in the City of Birmingham Final Version 21.03.16 4 • Better support is required for frontline staff working with substance abusing parents in order to ensure they are able to identify, assess and manage the balance between drug treatment activity and empowerment of those parents to parent, and the risks of doing so • Prescribing and administering alternatives for the management of opioid dependency properly, in a way that minimises the risk of accidental or deliberate ingestion by children, is essential • Listening to and engaging family members and especially siblings in terms of understanding what is happening is essential • It also requires changes in the way those services involved supervise, performance manage and quality assure their practice in relation to substance abusers who are also parents, to ensure respectful uncertainty, high support and high challenge are all common features of practice Board Action Points 2 In response to the SCR and the learning points contained in it we have agreed a serious of actions as follows: 2.1 The Board agreed to remit the learning points for specific agencies for those individual agencies to review and act on as necessary. The Board will maintain a record of which learning points were disseminated to whom, and review progress on those actions when they receive each organisation’s section 11 self-assessment and audit, Annual Report for 2015/16 and Annual Assurance statement. Any areas not sufficiently addressed will be followed up with individual agencies. 2.2 The Board also agreed to produce a “learning bulletin” for wide circulation by agencies to their front line staff delivered through learning briefings, workforce development activity, training and learning activity, team briefings and supervision addressing the overarching key learning from the SCR report. This will be done after publication. These lessons relate to the following key learning points: • All learning relating to pre- and post-birth recognition and risk assessments of parental substance misuse, what evidence tells us about best practice, what is expected of front line practice, and where to find appropriate guidance and support on the Board’s policies, procedures and processes • The central importance of recognising, listening to, and talking to children and young people living in families where substance misuse is a key part of their daily life experiences • The importance of recognising when intervention requires escalation into formal safeguarding processes and ensuring that occurs • The learning from the six key findings from similar SCRs. Final Version 21.03.16 5 2.3 Each agency agreed to disseminate the bulletins and expect their front line managers to ensure that staff use it to improve their own professional practice and managers use it to assess the impact of that learning in their working practice as part of their regular assurance activity. 2.4 Following discussions after the completion of the SCR with NHS West Midlands we also noted the need for substance abuse services and clinicians to consider when prescribing and administering treatment for the management of opioid dependency, what the safest treatments are, whether methadone is more appropriate than buprenorphine and what most facilitates a family centred approach to safe treatment. 2.5 The Independent Chair will write to chairs across the West Midlands, drawing their attention to the review, the learning points and the common themes reflected in the review of all six SCR’s in the area, asking them to consider whether there should be some regional thinking about how best to promote the learning. In addition, the BSCB agreed to • Work with the Birmingham Early Help and Safeguarding Partnership (EHSP) as it develops assessment tools and intervention tools which support a “think family” approach to families where adults have issues in their own lives which require professional support and which can potentially compromise their parenting ability • Ensure the EHSP integrates the learning from this SCR into the development of those tools • Take and develop for agreement and implementation any proposals put forward by the EHSP for establishing a comprehensive “Think Family” policy, and practice framework • Develop specific learning and development material to be used by agencies that provide services to adults with challenges in their lives who might also be parents, for specific focussed training and learning to improve the skills of those professionals. 2.5 The Board will consider during 2016/17 whether to undertake a thematic audit or review of agencies’ work with parents who are misusing substances, in order to evaluate the application of the learning from this review. Jane Held 21st March 2016 Final Version 21.03.16 6 SERIOUS CASE REVIEW ‘Working Together to Safeguard Children’ In respect of the death of Fenton Hogan. Case No. BSCB 2013-14/2 Report by: Paul Sharkey (MPA) November 2015 Final Version 21.03.16 7 Contents 1. Introduction 3 2. Parental Substance Misuse-The Wider Context 3 3. Summary and Overview 4 4. Purpose of the Serious Case Review 7 5. Terms of Reference 8 6. Timescale of Serious Case Review 8 7. Methodology 8 8. Parallel Enquiries 10 9. Family Involvement 10 10. Summary of Family Circumstances 10 11. Summary of Key Events: February 2011-July 2013 11 12. Analysis of Key Issues 24 13. ToR1 24 14. ToR2 52 15. ToR3 64 16. ToR4 65 17. Family Views 66 18. Key Learning and Findings from Similar SCRs 70 19. Key Findings, Learning and Desired Outcomes 72 20. Finding 1 72 21. Finding 2 73 22. Finding 3 73 23. Finding 4 79 24. Finding 5 84 25. Finding 6 91 26. Finding 7 92 27. Finding 8 93 28. Seven Overarching Lessons 94 29. Glossary of Terms 95 30. References 97 31. Appendix 1 99 32. Appendix 2 101 33. Appendix 3 102 34. Appendix 4 103 35. Appendix 5 105 36. Appendix 6 106 37. Appendix 7 110 Final Version 21.03.16 8 Introduction 1. The subject of this Serious Case Review is the child, Fenton Hogan1 who was born on the 18.07.11 to Kelly Emery at Russells Hall Hospital, Dudley in the West Midlands. He died on the 01.07.13 at home in Birmingham, just two weeks short of his second birthday; the cause of death being methadone ingestion. He was given the substance by his mother to make him sleep whilst she took cocaine. 2. Kelly Emery was found guilty at Nottingham Crown Court on the 5 March 2015 of the manslaughter of her son and sentenced to six years imprisonment2. She was a long standing substance misuser of heroin, cocaine and alcohol and had been on a methadone programme with a substance misuse support agency in Dudley since 2009. She had a criminal record for shoplifting and other forms of acquisitive crime to support her drug habit and was also known by the West Midlands Police to be a sex worker. 3. Fenton’s father (FFH) was serving a custodial sentence at the time of the death of his son. Fenton also had a half-sister, (SFH) who was twelve at the time of her brother’s death. The child had spent the weekend before his death with his paternal grandparents who had played an important role in his short life. 4. The Serious Case Review sub-group of the Birmingham Safeguarding Children Board discussed the death on the 13.12.13 and recommended to the Independent Chair of the Board that the criteria3 was met for the holding of a Serious Case Review. The Chair, after consideration, agreed that the criteria were met and duly decided on the 19.12.13 to commission this Serious Case Review, hereafter referred to as a SCR. Parental substance misuse and the impact on children and young people The Wider Context 5. The significance of the dangers to children from parental substance misuse was brought to early professional attention with the publication of ‘Hidden Harm’ by the Advisory Council on the Misuse of Drugs in 2003. The publication contained a number of recommendations aimed at raising professional awareness of the impact of parental substance misuse on children and taking steps to decrease 1 His real name is being used as it is already in the public domain through press reporting of his death and his mother’s subsequent trial. Likewise, his mother’s name has also been used. 2 This also included a guilty cruelty verdict to run concurrently. 3 See Government statutory guidance, ‘Working Together to Safeguard Children’ (2013) at paragraph 12, page 68. The guidance was updated in March 2015 but this SCR has been completed under the 2013 guidance given that it was commissioned in December 2013. Final Version 21.03.16 9 the risk of harm to them through co-ordinated inter-agency working between adult drug services and services for children. 6. Reportedly (Adfam; 2014), as of 2009, there were around 120,000 children in the United Kingdom living with a parent who was engaged in drug treatment. Moreover, there were 60,596 adults in treatment in England in 2011-12 who had parental responsibility, an opiate problem and were receiving a prescribing intervention. 7. Adfam (2014) found that there were 20 Serious Case Reviews between 2003-2013 where Opium Substitute Treatment (OST) drugs such as methadone were ingested by a child. These Reviews involved 23 children of which there were 17 deaths. Methadone was referred to in 19 of the Reviews and was the cause of 17 deaths, all of which were very young children (with an average age of two) who had been given the substance by a parent, usually in the misguided belief that it would pacify them. 8. Whilst every child death is a tragedy, the incidents of methadone ingestion, both accidental and parent administered are very rare, when set against the wider context of the number of parents in OST and their children. Arguably, it is this relative infrequency of intentional administration by parents that accounts for the minimal recognition by professionals of the possibility of such an eventuality (Adfam;2014) 9. However, as commented on by Adfam, whilst low in incidence, deliberate parental administration of opiate substitutes such as methadone are, ‘Not isolated, but that they have happened with quite depressing regularity’. (Adfam;2014;4) Report Summary and Overview 10. Fenton was born in Dudley in July 2011 and lived with his mother and older sister (SFH) in nearby Sandwell in the West Midlands until February 2012 when the family moved to Birmingham where he remained until his death in July 2013. His father (FFH) was absent during Fenton’s short life whilst serving a custodial sentence. Fenton had significant contact with both sets of grandparents. He died after being given a lethal amount of 10 mls of methadone by his mother to pacify him and enable her to take illicit drugs. 11. Kelly Emery was found guilty of manslaughter at Nottingham Crown Court in March 2015 and given six years custody. The act of manslaughter by definition Final Version 21.03.16 10 meant that she did not intend on killing Fenton. The evidence of this SCR and the criminal trial suggests that his death was not predictable. 12. However, there were many agencies and professionals involved with Fenton and his family during his short life that between them could and should have taken steps to have better promoted his and his sister’s (SFH) safety and wellbeing. Tragically, this was not done. Indeed, as will be evidenced in the following sections of this report, there were significant shortcomings in the way that agencies, both individually and collectively, responded to the safeguarding needs of Fenton and his sister. 13. That said, it is not possible to conclude with any causal certainty that Fenton’s tragic death could have definitely been prevented had there been effective multi-agency intervention, given his death was manslaughter and that Kelly Emery did not intend to kill him. However, the Review concludes that the likelihood of his death could have been reduced had effective inter-agency action been taken to recognise and assess the known risks to Fenton and his sister from Kelly Emery’s substance misuse, methadone use and lifestyle; and implement an effective inter-agency response. 14. His mother Kelly Emery was known by West Midlands Police and the drug agency that was treating her with methadone, to have been a substance misuser of heroin and crack cocaine prior to Fenton’s birth. The specialist midwifery service responsible for her ante-natal care was aware that she was on a methadone programme. None of these agencies recognised or assessed the potential risks to the unborn child from Kelly Emery’s substance misuse and methadone usage. 15. There should have been a joint early review of the potential risks from Kelly Emery to Fenton by the drug agency and specialist midwifery service and a referral made to Sandwell Children’s Social Care for a pre-birth risk and needs assessment. This episode was an early missed opportunity to have done so. Had this happened it is possible that Fenton and his sister would have been made the subject of some kind of co-ordinated early multi-agency intervention such as a Common Assessment or a Child in Need Plan or possibly, even a Child Protection Plan and placed on the inter-agency ‘Radar’. This did not happen and the reasons why are analysed in later sections of this report. 16. To its credit, the Staffordshire and West Midlands Probation Trust which was supervising Kelly Emery in 2011/12 for shoplifting offences had assessed her as a medium risk to her children because of her substance abuse and made a child protection referral to Sandwell Children’s Social Care shortly after Fenton’s birth. Sandwell Children’s Social Care should have undertaken an initial assessment in compliance with its own procedures but did not, partly because of staff shortages Final Version 21.03.16 11 and internal organisational difficulties, but also because of sub-standard practice and ineffective managerial oversight. 17. Instead, it closed the referral down on the basis of some overly positive information from involved agencies and Kelly Emery herself, which suggested that she was being well supported by the drug agency, midwifery and health visiting services and her extended family. The reality was that this was not the case as evidenced by her very sporadic engagement with the drug agency, move to Birmingham in the Spring of 2012 following harassment from threatening individuals in December 2011 and tensions with her mother. This episode was another missed opportunity to have assessed the potential risks to Fenton and SFH from Kelly Emery’s methadone use and substance misuse. 18. Kelly Emery’s involvement with the Probation service ended on completion of the community order in June 2012 by which time Kelly Emery and the two children were resident in Birmingham. The drug agency in Dudley should have transferred the responsibility for Kelly Emery’s methadone treatment to the service in Birmingham but did not. Kelly Emery continued to receive her methadone prescription by post despite sporadic engagement, missing reviews and no provision of drug test samples. There was no liaison with Kelly Emery’s new GP in Birmingham as there had not been when she was in Sandwell. These were risk factors that were not recognised or acted upon by the drug agency which should have reviewed Kelly Emery’s treatment regime and reverted back to the practice of, ‘supervised consumption’, i.e. taking her methadone in the pharmacy under supervision. The agency did not consider the wider needs of the children and continued down a misguided ‘silo’ path of adult focused ‘harm reduction’ with Kelly Emery. 19. The new health visitor in Birmingham (actually from Worcestershire Health and Care NHS Trust) did not become involved until November 2012 because of a delay in transfer of notification from the Sandwell health visiting service. The Worcestershire health visitor did not consider the potential risks to Fenton from Kelly Emery’s methadone use or contact the drug agency for more information. 20. The West Midlands Police had involvement with Kelly Emery and the children in January and November 2012 regarding reports that she was dealing in drugs from her home and involved in sex working. The responses were ineffective in relation to the potential risks to the children on both occasions with no internal referrals being made to the Police specialist child protection unit or a child abuse non-crime number generated. These episodes were missed opportunities to have intervened and gained an understanding of the children’s situation in the care of their mother. Final Version 21.03.16 12 21. Kelly Emery’s GP service in Birmingham was aware of her methadone treatment and periods of depression in 2013 but did not seek to liaise with her drug support agency in Dudley or consider the impact of the methadone and mental health issues on the children. 22. SFH’s school became aware of concerns from neighbours about her and Fenton in April/May 2013 that included allegations of drug and alcohol abuse. Standard safeguarding reporting procedures were not followed by staff and the concerns were not referred onto Birmingham Children’s Social Care. 23. Birmingham Social Care received referrals on the children in August 2012 (anonymously) and April 2013 from the West Midlands Police burglary unit. The first was ineffectively responded to by a Referral and Advice officer and closed without going for an initial assessment with Children’s Social Care. The second was subject to an initial assessment by Children’s Social Care which wrongly concluded that there were no concerns about Kelly Emery’s care of the children and no evidence of harm to them. The case was closed in May 2013. These were two further opportunities for a multi-agency intervention that could have safeguarded and promoted the children’s wellbeing. 24. Thereafter, there was no further involvement from the agencies, apart from ongoing health visiting and a proposed visit in July to offer some parenting support to Kelly Emery which was sadly, made irrelevant by his death in early July 2013. Purpose of the Serious Case Review 25. The overall purpose of a SCR is to, • ‘Look at what happened in the case, and why, and what action will be taken to learn from the review findings, so that, action results in lasting improvements to services which safeguard and promote the welfare of children and help protect them from harm; and • There is transparency about the issues arising from individual cases and the actions which organisations are taking in response to them, including sharing the final report of the SCR with the Public’ ( ‘Working Together to Safeguard Children’, 2013, page 65, paragraph 4) 26. The reasons for the SCR were that; • Fenton died. Final Version 21.03.16 13 • Abuse, through being given methadone by Kelly Emery, was a known factor in his death. Terms of Reference (ToR) 27. See Appendix1 Timescale of the SCR 28. The timescale of this SCR is from mid-February 2011 when Kelly Emery first booked in her pregnancy with the Russells Hall midwifery service to the beginning of August 2013, some two weeks after Fenton Hogan’s death. Methodology The SCR Panel 29. The SCR Panel (henceforth known as the Panel) comprised senior agency representatives who considered the information obtained from agency chronologies, Individual Management Reviews, the Learning Event, supplementary follow up commentary from agencies, and Court documents. 30. The Panel (see appendix 2 for membership) was chaired by Mrs Sheila Sutherland who qualified as a social worker in 1972. She has over thirty years’ experience in working within or managing social care services for children; including a total of fourteen years as Head of Services for Children and Families in Cumbria and Blackpool. Since September 2009 she has worked as a self-employed consultant to Children’s Social Care Services. She worked for three years with the Centre of Educational Leadership (CEL), Manchester University, as Social Care Learning Development Consultant on the development and delivery of Children’s Social Care Leadership Programmes. She continues to be a consultant to CEL Leadership and Change, on social care issues. She has worked as a consultant with Blackburn, Blackpool, Bury, Bradford, Cumbria, Leeds and Rochdale on both Serious Case Reviews and as an investigating officer in case and staff conduct enquiries. She has had no previous involvement with the Birmingham Safeguarding Children Board or any of its partner agencies prior to this SCR. Additionally, she has had no previous involvement with the other three Local Safeguarding Children Boards, namely Sandwell, Dudley and Worcestershire or their partner organisations. Final Version 21.03.16 14 31. The Lead Reviewer was Mr Paul Sharkey (MPA)4 who has wide experience of both writing and chairing Serious Case Reviews since 2002. He is presently an independent safeguarding consultant with over thirty years background in both statutory and third sector child protection agencies. He completed the Department of Education/NSPCC/Action for Children/‘Improving Serious Case Reviews’ course in July 2013 and is on the Association of Independent Chairs of LSCBs register for independent SCR Chairs and Lead Reviewers. He has had no previous involvement with the Birmingham Safeguarding Children Board or any of its partner agencies prior to this SCR. Additionally, he has had no previous involvement with the other three Local Safeguarding Children Boards, namely Sandwell, Dudley and Worcestershire or their partner organisations. 32. The Overview Panel met on the following dates, • 8 May 2014 • 24 June 2014 with IMR authors • 22 September 2014 • 6 October 2014 with IMR authors • 10 November 2014 with IMR authors • 8 December 2014, Learning Event • 16 February 2015, Scrutiny of Draft 1 of Overview Report • 20 April 2015, Scrutiny of Draft 2 of Overview Report • 15 June 2015, Scrutiny of Draft 5 of Overview Report 33. Individual Management Review [IMR] authors spoke to their reports with the Panel on the above dates (see Appendix 3 for the list of agency IMRs). Key Practice Episodes5 (see appendix 4) were identified by the Panel and the Lead Reviewer. These informed the basis of analysis of the four Terms of Reference conducted at the Learning Event of 8.12.2014, which all Panel members, IMR authors and relevant front line practitioners attended. 34. The Learning Event was facilitated by the Lead Reviewer using the, ‘5 Whys’ and the Cause and Effect/Fishbone’, analytical techniques in an attempt to understand from a systems perspective why and how decisions and actions were made within the context of prevailing organisational and agency practices and expectations of the time. The Panel and Lead Reviewer were mindful of hindsight and outcome bias in conducting the analysis. The Panel critiqued a draft of the 4 Master’s in Public Administration ( 2007) from Warwick University Business School 5 These are episodes from the case that require further analysis and are thought to be significant to understanding the way the case developed and was handled. They are not restricted to specific actions or inactions but can extend over longer periods. See SCIE ‘Learning together to safeguard children, developing a multi-agency systems approach for case reviews (2008). Final Version 21.03.16 15 Overview Report on the above dates and agreed the final draft in September 2015 35. This SCR took longer than usual to complete. This was because of delays in receiving finalised agency Independent Management Reviews. In addition it was necessary to wait for the receipt of the transcript of the trial judge’s sentencing comments which informed this SCR. This was received at the end of August 2015. The interviews with family members in late July also prolonged the length of the Review and Kelly Emery could not be interviewed until late October 2015. 36. The SCR Overview Panel had sight of the draft report in late August/early September 2015 and ratified it on the 18.09.15. The final draft of the SCR was seen and commented on by the Birmingham Safeguarding Children Board Serious Case Review sub-group on the 09.10.15 and ratified by the Executive Board on the 20.10.15. Parallel Inquiries 37. The West Midlands Police started a criminal enquiry into the death of Fenton in July 2013 which reached a conclusion on the 5 March 2015 at Nottingham Crown Court when Kelly Emery was found guilty of the manslaughter of (and cruelty to) Fenton and sentenced to six years imprisonment. Family Involvement 38. Both sets of grandparents and Fenton’s father were seen by the Chair of the SCR Panel and the Lead Reviewer in late July 2015. Kelly Emery was seen by the Lead Reviewer and Overview Panel Chair on the 26 October 2015. 39. For the purposes of identity protection and confidentiality a family structure and genogram is not provided in this Report. However, a full genogram was compiled as part of the overall Review process. Summary of Family Circumstances 40. Fenton Hogan (hereafter referred to as Fenton) was born on the 18.07.11 at Hospital 1(Russells Hall) in the West Midlands. He lived with his mother (Kelly Emery) who was born in 1980 and his elder sister SFH who was born in 2000. His father, FFH who is in his early thirties did not live with the family during Fenton’s lifetime. Fenton had regular contact with his paternal grandparents (PGP) and his maternal grandmother, (MGM). He died at the age of nearly two years on the 01.07.13 of methadone toxicity as a result of being given the substance by Kelly Emery to pacify him so that she could take drugs. His father was in custody at the time of his son’s death. The family lived in Birmingham at Final Version 21.03.16 16 the time of Fenton’s death. They had previously lived in Sandwell and moved to Birmingham in April 2012. 41. The family are of white British heritage from the West Midlands whose only language is English. It is not known what, if any, their religious background is. 42. Kelly Emery had a long standing background of substance misuse (heroin, cocaine, cannabis and alcohol), acquisitive criminal behaviour and involvement as a sex worker. She had been involved in a methadone programme with a substance misuse agency in Dudley since 2009, having been with a previous Dudley service for methadone users since 2007. 43. Fenton’s sister (SFH) was placed with relatives following her brother’s death. She had earlier been subject to a child protection plan (emotional abuse; concerns around Kelly Emery’s substance abuse and lifestyle) in 2009 (30.01.09-09.07.09) whilst living in Sandwell. The case was closed by Sandwell Children Social Care on the 25.08.09. Summary of Key Events: February 2011- July 2013 2011 44. Kelly Emery booked in for her ante-natal care (for Fenton’s birth) with the midwifery service at Hospital 1 at 20 weeks gestation; around mid-February 2011. Kelly Emery was known to have been a methadone user (recorded on the 02.03.11) and receiving services from Dudley Crime Reduction Initiative (CRI), the aforementioned voluntary sector substance misuse support agency. Kelly Emery was also linked to a specialist substance misuse midwife during the period. There was no contact made with Sandwell Children’s Social Care (CSC) or any evidence of a risk assessment being done regarding the impact of parental substance misuse on the unborn child by either the midwifery service or the substance misuse agency. 45. Between May to July 2011 Kelly Emery was brought into custody four times by the West Midlands Police. She was visibly pregnant and known to be using drugs. Kelly Emery had told custody staff on the 12 May that she was a methadone user and had taken cocaine that morning and admitted occasional use of heroine. Kelly Emery had tested positive for cocaine. None of the investigating officers or custody staff generated a child abuse non-crime number for the unborn child (Fenton) or SFH. There was no record of a referral to Final Version 21.03.16 17 Sandwell CSC. A single intelligence log of the information was submitted on the 19.05.11 but was not disseminated.6 46. Fenton was born at Hospital 1, Dudley, on the 18.07.11. Kelly Emery and baby were discharged on the 21.07.11 into the care of the community midwife (CM1) and health visitor (HV1) (Sandwell and West Birmingham Hospitals Trust/ Sandwell PCT). Fenton showed no signs of drug withdrawal (neo-natal abstinence) but arrangements were made with the hospital to monitor this through visits to the neo-natal unit. No safeguarding concerns were raised at this time. 47. In early June 2011, Kelly Emery was subject to a twelve month Community Rehabilitation Order to Staffordshire and West Midlands Probation Trust for a shoplifting offence. She was assessed by the agency on the 24.06.11 as a medium risk of harm to children. This was based on her drug use; she had told a duty officer on the 20.06.11 that she, ‘occasionally had a line of cocaine’, the last being the previous week; and her methadone use (65 mls daily) was known to the agency. Kelly Emery mentioned that SFH had previously been subject to a child protection plan in 2009. On the 06.07.11 The Probation Service Officer (PSO1) was informed by Kelly Emery’s GP certificate that she was suffering from depression which was also known about by the midwife. PSO1 made a referral to Sandwell Children Social Care on the 20.07.11, based on Kelly Emery’s ‘medium risk’ to children classification; also expressing concerns about Kelly Emery and her partner’s methadone use. The Probation worker felt that a social work assessment was required given the presence of the new baby. 48. Sandwell Children Social Care contacted the Probation Service on the 22.07.11 to say that there was no involvement from them. A duty social worker from Sandwell Children Social Care spoke to a community midwife on or around the 22.07.11 who said that Kelly Emery was engaging with and receiving support from Dudley CRI, the specialist substance misuse midwife, the health visitor, family and friends. The duty social worker contacted the Probation service to say that there would be no input from Sandwell Children’s Social Care at that time. Advice was given to make a referral to Children and Young People Services in the event of any further concerns, or to complete a Common Assessment if Kelly Emery needed any further support. There was no indication that the midwife (including the specialist midwife) or Dudley CRI had considered the implications of any risk to Fenton or his sister from their mother’s methadone/substance misuse. 6 The WMP IMR views this period as a ‘significant lost opportunity’ for professionals to have intervened to protect FH-page 13. Final Version 21.03.16 18 49. A Probation visit by PSO1 and the Probation Officer was made on the 02.08.11 when Fenton and his sister were seen. Kelly Emery said that Sandwell CSC had recently visited (there was no evidence that this had, in fact, happened) and was liaising with the midwife who would shortly be handing over to the health visitor. Kelly Emery said that she was also getting support from her mother but was vague about any support from Fenton’s father. Follow up calls were made by the Probation service to Sandwell CSC in September 2011 and February 2012 to check if there were any further concerns. Sandwell CSC reported that there was no open case and that the family were receiving support from other professionals and the wider family. 50. On the 02.08.11, a care plan review was held on Kelly Emery by the Dudley CRI. She did not attend. It was decided to take her off the Dudley case load and transfer her to the Sandwell drug intervention programme, given she lived in Sandwell. 51. On the 11.08.11, Kelly Emery and Fenton were discharged from the care of the neo-natal midwife. The health visitor (HV2) saw them both at the home of the maternal grandmother on the same day and reported Fenton to be feeding well with good weight gain and appeared settled. HV2 noted that Kelly Emery was on a methadone programme and was given contact details of her drug’s worker. Kelly Emery’s partner was said to be ‘working away’ and that support was being given by the grandparents. HV2 made a telephone call to the drug’s worker the next day but with no reply. 52. Fenton was taken to the GP practice by his mother on the 19.08.11 for his six-eight week check and first immunisations with ‘satisfactory development parameters’ recorded. Kelly Emery and Fenton attended a Probation office visit on the 23.08.11 and were seen by the duty officer who recorded that Fenton appeared happy and healthy with no safeguarding issues identified. 53. A Probation office visit on the 13.09.11 by Kelly Emery (with Fenton) recorded that she was coping ‘OK’. She said that she was not ready for a proposed reduction in her methadone dosage, that she was stressed looking after Fenton and lacked sleep. She was now at home (having left her mother’s home) and being supported by her mother and Fenton’s paternal grandmother. Although her partner (who was, in fact in prison) was not living with her, Kelly Emery said that he visited every day which suited her as she felt they got on better under this arrangement. On the same day the health visitor recorded the receipt from Hospital 1 of a missed appointment for Fenton on the 06.09.11 at the neo-natal clinic. A further appointment was offered for three months’ time. Fenton attended a Sure Start clinic on the 14.09.11 where his weight was recorded as 5.68 kgs with no centile recorded. Final Version 21.03.16 19 54. Kelly Emery was sentenced on the 26.09.11 to a twelve month Community Order and forty hours of unpaid work for a previous shoplifting offence of the 31.05.11 and a breach of a conditional discharge. The Probation Service Officer (PSO1) contacted Sandwell Children’s Social Care on the 27.09.11 querying the previous referral of the 22.07.11 and was advised that Kelly Emery had a lot of support from her family and other agencies. The Children’s Social Care view did not indicate that there were any concerns about Fenton. Agencies should continue to monitor the situation and refer if any new concerns arose regarding Fenton or his older sister. 55. Kelly Emery was seen by PSO1 on the 28.09.11 and maintained her status as a medium risk to children because of her continued use of methadone. A further Probation assessment review took place on the 17.10.11 which continued with her ‘medium risk’ status on the basis of her daily methadone use and previous class A drug misuse. It was recorded that Sandwell CSC had concluded that there were no concerns about the wellbeing of the children as the mother had a good support network from her family, the drug services and Sure Start. Part of the community order concerned work around drug awareness and drug testing on a voluntary basis by the Dudley CRI. PSO1 tried to contact the substance misuse worker on the same day by telephone to check up on Kelly Emery’s progress but there was no reply and a message was left. 56. Kelly Emery and Fenton were seen by PSO1 at the office on the 25.10.11 when the baby was reported as appearing well and had his first injections the previous day. Kelly Emery was seen again on the 10.11.11 and the 22.11.11 when she was commended for her good progress on the community order. It was reported that her drugs worker was to visit her the following week; that she was stable on her current methadone dosage and was coping with caring for Fenton, with the support of the grandparents. It was also recorded that the baby ‘appeared to be thriving’. 57. Kelly Emery was recorded by PSO1 at an office appointment of the 06.12.11 as appearing stressed due to money worries and having gained no relief by refraining from drugs and trying to do things the right way. She reported that her methadone use remained stable. The Sandwell health visiting service recorded on the 15.12.11 that baby Fenton had defaulted on his second neo-natal appointment to Hospital 1, scheduled for the 08.12.11. Another appointment was arranged for three months hence. 2012 58. The PSO1 saw Kelly Emery on the 03.01.12 at an office visit. She mentioned moving to an area that was not linked to drug use, possibly to be near her father in Rubery (Birmingham/Worcestershire border) who could offer her some Final Version 21.03.16 20 support. The health visitor (HV1) did a home visit on the 06.01.12 and saw both Kelly Emery and Fenton who was noted to be below the 75 centile. Kelly Emery said that she had been burgled on the previous 25 December and had reported this to the Police. She felt insecure and invaded and wanted to move. Her methadone use was discussed; she said that her usage was monitored and she was supported daily. Safe storage was discussed. Neither of the missed neo natal appointments for Fenton at Hospital 1 were mentioned. There was no record of HV1 following up with the Dudley substance misuse service to corroborate Kelly Emery’s self-reporting or engagement with the programme. 59. The West Midlands Police filed an intelligence report on the 10.01.12 suggesting that Kelly Emery was dealing drugs from her house (a smell of cannabis) and that various males had come to her property over the Christmas period. On a separate occasion the drugs worker (DW1) from the Dudley CRI visited the home on the 17.01.12, noted a broken front window and agreed to contact a housing officer. 60. A further Police intelligence log was made on the 28.01.12 suggesting that Kelly Emery was drug dealing from her home (in Sandwell) where there were also young children. Kelly visited PSO1 on the 31.01.12 on her own (she said that Fenton was with his paternal grandmother) and reported that he was going through his ‘clingy’ stage and she was finding it difficult to get on with anything around the house. She was finding it difficult to cope on benefits and hoped to be moving to Rubery, nearer to her father where she could be more supported. PSO1 agreed to contact the Housing department on her behalf. 61. On the 10.02.12 Kelly Emery reported to the Police that a brick had been thrown through her window. She told DW1 (Dudley CRI) on the 13.02.12 (via the telephone) that she would be looking for hostel accommodation following the brick throwing incident. There was no recorded follow up by DW1 in liaising with other agencies regarding the safety and welfare of Kelly Emery or the two children. An assessment review by PSO1 on the 16.02.12 identified increased difficulties for Kelly Emery around her finances. She had been receiving support from Fenton’s paternal grandmother but felt that her own mother had given her little credit for her progress and was quite critical of her. PSO1 recorded that she had tried unsuccessfully to contact the drugs worker (DW1) to discuss the case. CRI’s records indicate they had responded but had indicated they needed consent to share information with PSO1. However, there had been no concerns raised by other agencies and no indications from Kelly Emery that she was at risk of relapsing or having difficulties in coping with her situation. 62. DW1 was informed by Kelly Emery by telephone on the 24.02.12 that she was in temporary housing in Birmingham. She failed to attend an office supervision appointment with PSO1 on the 28.02.12. PSO1 enquired with Sandwell Children Final Version 21.03.16 21 Social Care on the 29.02.12 whether there were any concerns about the two children and was told that there was no open case regarding them. 63. On 29.02.12 PSO1 managed to speak on the telephone to the drugs worker (DW1) who confirmed that Kelly Emery was drug free and stable. It was not evident as to how DW1 knew this to be true. He told PSO1 that he was not going to transfer Kelly Emery’s script to another agency (as he was told to do in supervision of the 02.08.11) as she did not have stable accommodation and might be remaining in the area (i.e. Sandwell). He planned to keep responsibility for the case until Kelly Emery had settled in permanent housing. DW1 and PSO1 discussed whether there were any concerns regarding the children. DW1 said that he had undertaken home visits and an assessment and felt that Kelly Emery was coping well. Any concerns he had were linked to her living in the previous address and the recent two incidents of criminal damage to the windows. DW1 thought that Kelly Emery would do better now she was in the process of moving to another area. It was mentioned that her partner/ex-partner (Fenton’s father,) was in prison and PSO1 made a note to ask Kelly Emery about this matter. 64. Kelly Emery phoned PSO1 on the 29.02.12 and told her that she had moved with Fenton to temporary hotel accommodation in Northfield. SFH was staying with the maternal grandmother to facilitate her continuing her schooling. On the 06.03.12 Kelly Emery visited PSO1 and said that she was still in temporary accommodation in Smethwick awaiting rehousing. Fenton’s care was being shared between herself and her mother with SFH being at her maternal grandmother’s. Her partner was in prison and her father had not been supportive whilst she was in the hotel. She was told to keep PSO1 informed of her whereabouts and any final moving address. DW1 was told over the phone by Kelly Emery on the 23.03.12 of her temporary address. 65. Sandwell health visiting service received notification from Hospital 1 on the 28.03.12 of Fenton’s third missed neo-natal appointment of the 08.03.12. A new health visitor (HV3) made a ‘futile’ unplanned home visit to the former Sandwell address on the 02.04.12 to be told by an unknown female that the family had moved. HV3 asked that her details be passed on to Kelly Emery with a request to contact her. There was no record of HV3 liaising with the GP practice or other services to try and locate the family. 66. Kelly Emery failed to attend two office supervision appointments in early April with the PSO and warning letters were sent to her. PSO1 tried to contact the drugs worker (DW1) by phone on the 11.04.12, leaving a message to contact her with Fenton’s current address but received no reply. CRI has no record of this call. Final Version 21.03.16 22 67. A medical review by DW1 and Dr 1(the prescribing doctor) was held on the 16.04.12 in Kelly Emery’s absence which was caused by a reported ‘death in the family’. There was no recorded evidence of any link or liaison with the Probation service or any other agency to inform the medical review. 68. On the 18.04.12 Kelly Emery did attend an appointment along with Fenton with PSO1 and said that she would be moving to a new permanent address in Rednal, Birmingham, in two weeks. She also said that her methadone usage was stable. DW1 was informed over the telephone by Kelly Emery on the 20.04.12 of her new address to which she would be moving in four days’ time. She and Fenton were seen by DW1 on the 27.04.12 at the service; and both looked well. An appointment was made for Kelly Emery to see Dr 1 about reducing her methadone. 69. Kelly Emery and the children eventually moved into their accommodation in Frankley, Birmingham, on or around the 15.05.12. Her final Probation appointment was on the 17.05.12 when she saw a duty officer (PSO1 was not available). She believed that she had done well in completing the order and said that she and the children were settled. She was reminded that the order did not finish until the 6 June. On the 21.05.12 Kelly Emery had a medical review with Dr 1 and discussed the transfer to the Birmingham substance misuse service. She was not keen to do so as she had been working with DW1 (from Dudley CRI) for some time. 70. On the 29.05.12 the GP and health visitor in Sandwell were notified of a defaulted neo-natal appointment at Hospital 1 for Fenton. A further appointment was offered for September 2012. Kelly Emery finished involvement with the Probation service on the 06.06.12 on completion of the order. It was noted that there were no current concerns regarding the children raised from Sandwell Children’s Social Care. Her self-reported methadone use understood to be stable, her partner was in prison and she had moved to Frankley because she had not received much support from her own mother and hoped to form new relationships of friendship and support. 71. Kelly Emery’s methadone script continued to be posted out to her new address by the Dudley CRI. DW1 was advised by his manager on the 11.07.12 to transfer the case to the Birmingham service. The health visitor (HV3) undertook a futile home visit to the previous address on the 07.08.12 when it had been known since April that Kelly Emery and the children had moved away. HV3 liaised with the GP practice to ascertain the new address to find that this was not on the system. She also contacted Sandwell (not Dudley) substance misuse service to find that (unsurprisingly) Kelly Emery was not known to the agency and did not have a current address. DW1 saw Kelly on the 21.08.12 and recorded that the methadone reduction was going well. Final Version 21.03.16 23 72. In late August the Birmingham Children Social Care (BCSC) Integrated Access team received an anonymous report of concerns from a friend of a neighbour of Kelly Emery alleging the use of heroin and crack in front of SFH, noisy parties attended by local drug dealers and an ‘old man’ encouraging SFH to take drugs. The caller was asked to contact BCSC directly but became agitated and declined to give her (or her neighbour’s) details. Apart from being recorded on Carefirst there was no evidence that the referral went to a team manager for assessment or any action. 73. DW1 visited Kelly Emery on the 03.09.12 and recorded that she presented well with a neat and tidy home. She reported that the methadone programme was going well. On or around the 07.09.12 a letter was sent by the neonatal consultant to the Sandwell GP practice reporting Fenton’s non-attendance at the arranged appointments of the 08.12.11 and 20.03.12 in relation to the ongoing monitoring of his neo-natal abstinence syndrome. Albeit, that he was not suffering from the syndrome, the letter requested the GP to ask the health visitor to investigate and carry out a Common Assessment (CAF) if needed. Fenton was offered another appointment. No action was taken as the family had by this time moved to Frankley. It seemed that the letter was not passed on, as the family’s whereabouts was not, at that time, known to the GP practice and the health visitor in Sandwell. 74. On the 18.09.12 Fenton was registered at Frankley Health Centre having been in the area since May. He was given his first set of immunisations by the GP on the 25.09.12, aged fourteen months. By October, Kelly Emery’s methadone script was being sent to her mother’s address as she was not able to attend the Dudley service. Fenton was seen by the GP on the 05.10.12 for a chesty cough. 75. A verbal telephone handover was made between HV3 and the new health visitor (WHV1) on the 09.11.12. Only limited information was exchanged including Kelly Emery’s methadone use, the futile home visits made and that the last visit had been made in the previous April. There was no mention of the missed neo-natal appointments for Fenton although a reference was made to him being under the care of a neonatologist. There was also no reference to the recent letter from the neo-natalist to the Sandwell GP requesting that a CAF should be considered. The neo natal service at Hospital 1 was notified of the new address by HV3. A letter was sent on the 16.11.12 by WHV1 to Kelly Emery arranging for a first home visit for the 28.11.12. 76. The West Midlands Police (WMP) received an anonymous call from the public on the 11.11.12 reporting concerns that a woman (Kelly Emery) had been leaving her eleven year old daughter to look after her sixteen month brother while she Final Version 21.03.16 24 'goes out to prostitute’; that the woman also had sex with men in her home. Two officers attended the given address and found the children to be ‘safe and well’ in the care of a women who was not Kelly Emery but was ‘babysitting’. No referral was made to the Police Public Protection Unit. 77. Kelly Emery told DW1 on the 27.11.12 that the methadone reduction was ‘going ok’. However, she was reportedly below 30 mgs and showing signs of withdrawal. An appointment was made for her to see the agency doctor. It was also noted that she was ‘drug free’ although there was no test result recorded. On the 28.11.12 Kelly Emery telephoned WHV1 to cancel the arranged home visit as apparently, a family member had had a heart attack and she was taking her mother to hospital. 78. WHV1 telephoned Kelly Emery on the 04.12.12 to arrange for her to bring Fenton to the health centre baby clinic for the 06.12.12. He was not brought to the appointment by his mother who later told the health visitor that she had had a disturbed night with him teething. A new appointment was arranged for the 18.12.12 which was later (12.12.12) changed to the 15.01.13. Kelly Emery visited her GP on the 10.12.12 due to asthma; it was noted that she was a methadone user. Fenton was also seen by the GP for vomiting and a viral illness. Appropriate medical advice was given. SFH was seen by the GP at the Frankley health centre on the 20.12.12 with Kelly Emery for hearing problems and was appropriately referred. No significant concerns were raised. 79. Kelly Emery visited her GP on the 14.12.12 due to anxiety and depression which she claimed had started ‘two years ago’ in her pregnancy with Fenton. Kelly Emery denied any suicidal thoughts although she had written a note to the GP asking for help and describing a difficult emotional situation. The Hospital, Anxiety and Depression (HAD) scale was used and anti-depressants prescribed. There was no evidence that any enquiries were made about the implications of Kelly Emery’s mental state for the children. A medical review was held by Dr1 at Dudley CRI on the 17.12.12 when it was decided to continue with the methadone reduction. Kelly Emery reported that she was ‘clean’ on reduction and stable on 27mgs of methadone. Dr1 advised that drug testing was needed. There was no evidence of any liaison with the GP or other services (the pharmacist) in Frankley. 2013 80. WHV1 and a student health visitor undertook the ‘New to area home visit’ on the 15.01.13. It was recorded that Fenton’s father was in prison and the details of Kelly Emery’s drug’s worker were given. SFH’s details were confirmed and ‘Good family support’ identified. Kelly Emery continued to receive her methadone script during January. Final Version 21.03.16 25 81. In January 2013 two intelligence reports were submitted by officers of the WMP suggesting that Kelly Emery was dealing drugs from her home where it was known that two children were living. The intelligence record generated on the 17.01.13 by a Police Community Support Officer (PCSO) was almost identical to the one received on the 11.11.12. A child abuse non-crime record was not created. 82. Kelly Emery was seen for a follow up from the consultation of the 14.12.12 by her GP on the 01.02.13 for her anxiety and depression. She remained on a high level of symptoms similar to the previous December 2012 consultation. Apparently she was not complying with her medication (50 mg of sertraline daily) and was advised to start correctly and review in four weeks’ time. There was no exploration of the impact of Kelly Emery’s mental health and methadone use on her children and no liaison with other members of the primary care team such as the health visitor. 83. Kelly Emery had cancelled an appointment with DW1 on the 28.01.13 and had re-arranged for the 08.02.13. WHV1 had re-booked an appointment on the 06.02.13 for Fenton to be seen at the neo-natal department of Hospital1 and asked to be copied in to promote attendance. A planned appointment at Birmingham’s Children’s Hospital (BCH) on the 07.02.13 for Fenton was re-scheduled for the 18.02.13. Kelly Emery reported on the 08.02.13 to DW1 that she was suffering from psoriasis (not mentioned in the GP records) and wanted to delay methadone reduction until it had cleared up. 84. Fenton was not brought to BCH for his audiology appointment on the 18.02.13 and no further appointments were made. There was no record of WHV1 or the GP being notified of this so that a follow up could happen. 85. Kelly Emery was seen by her GP on the 04.03.13 for a review of her anxiety and depression. She reported improvements and was willing to increase her dosage of anti-depressants (up to 100 mgs of sertraline) with a review in four weeks’ time. There was no record of any liaison with the Dudley CRI or WHV1. An appointment was made by DW1 on the 04.03.13 for the 14.03.13 and a script posted. 86. The NSPCC Helpline received a call on the 06.03.13 from an anonymous female expressing concerns for Fenton and his sister. She stated that drugs, cars and loud music were happening at the house all night long and was really horrendous at weekends, really rough, really bad, with shouting and screaming at the children. It had been going on for about eight months. The referral was sent by e-mail to Birmingham City Council (Integrated Access team) at 10pm on the Final Version 21.03.16 26 same day. There was no record of the access team receiving the referral or of any follow up. 87. Kelly Emery did not attend the Dudley CRI appointment on the 14.03.13 as arranged. DW1 rebooked it for the 27.03.13. 88. Kelly Emery phoned the Police on the 16.03.13 late at night to report a criminal damage and disorder incident. A visit was made but Kelly Emery provided minimal explanation and no offence was recorded with no mention of any children resident at the address. The incident may have been related to a drug debt owed by Kelly Emery. Two days later on the 18.03.13 intelligence was recorded by the West Midlands Police that Kelly Emery was, ‘a prostitute and heroin addict’ with men in attendance at all times of the day who threw rocks at her window to attract her attention. 89. WHV1 sent a letter on the 27.03.13 to Kelly Emery making arrangements for a development review for Fenton for the 19.04.13. On the same day Kelly Emery reported to a duty worker at the Dudley CRI that she was drug free, stable on 19 mgs of methadone, wanted to stay on this dose for a while and wanted to remain with her current worker (DW1) until the reduction was completed. 90. Kelly Emery arrived late with Fenton (despite being sent a reminder of the appointment details on the 08.04.13) for the development review of the 19.04.13. Another one was arranged for the 24.04.13. 91. On the 22.04.13 a Police Officer from the local CID Burglary Team sent a report of his child protection concerns for Fenton and his sister to Birmingham Children Social Care. These related to a previous stolen property enquiry and search of Kelly Emery’s house on the 18.03.13 when signs of drug misuse such as silver foil and spoons were found and where there were children living. Additional concerns were around Kelly Emery allegedly operating as a sex worker to fund a heroin habit, various men visiting the house, loud music at all times of the day, and the children being neglected and left alone. The Police Officer was told on the 19.04.13 by a neighbour that they had seen a child playing outside Kelly Emery’s address who looked particularly unkempt. 92. Birmingham Children Social Care received the Police report on the 22.04.13 and the referral was allocated to a senior social worker (SW1) on the same day for an initial assessment. SW1 undertook a home visit on the 23.04.13 and saw Fenton, Kelly Emery and the maternal grandmother. SFH was not seen or spoken to and was presumably at school. Kelly Emery was noted to have grazes to her hand which she said she got from two incidents of falling over when drunk at the weekend when she binge drank when the two children were with their respective grandparents. Kelly Emery said that the burnt silver foil and spoons were Kit- Kat Final Version 21.03.16 27 wrappers and yoghurt spoons used by the children. She denied ever using heroin, leaving the children alone or being a sex worker. 93. SW1’s initial assessment concluded that there was no evidence of drug abuse when visited, or that the children were being neglected or exposed to inappropriate behaviour. Kelly Emery was supporting the children appropriately with no concerns about her care of them from the professionals currently involved with her, namely, the health visitor (WHV1) and Dudley CRI. 94. However, it was the case that on the 24.04.13, SW1 telephoned Dudley CRI and spoke to the duty worker (not DW1 or his manager) stating that the Police had found possible drugs paraphernalia at Kelly Emery’s home. The duty worker said that he would leave a message for DW1 to contact SW1. There was no record of this happening, namely of SW1 speaking to DW1 for more information about Kelly Emery’s methadone use or possible substance abuse. SW1 recommended case closure on the basis that there was no evidence of harm to the children with the mother engaging well with professionals. This was endorsed by the team manager and the case was closed on the 09.05.13. CRI contacted SW1 on 29.04.13 to be told the case was closed. They did not challenge SW1’s decision. 95. On the 23.04.13 Kelly Emery was seen by her GP for anxiety and depression and was deemed to be stable on her medication. On the 22.04.13 another worker from the Dudley CRI spoke to Kelly Emery who said that her mother was collecting her script. This was agreed to with a four week script issued because Kelly Emery was being transferred to Birmingham. 96. The health visitor (WHV1) visited the home on the 24.04.13 for the planned development review but only managed to see Fenton and his mother on the doorstep. Fenton was reportedly unwell with diarrhoea and vomiting and the visit was re-arranged for when he was better. WHV1 spoke on the telephone with SW1 on the same day who fed back her conclusions of the recent home visit and Birmingham CSC’s intention of no further action given there were no concerns resulting from the lateral checks with the school and the drugs worker. A future referral could be made if necessary. 97. On the 26.04.13 Kelly Emery telephoned the GP surgery at 17.45 regarding concerns about Fenton’s diarrhoea, vomiting and possible dehydration. The GP advised her to take him to Birmingham Children’s Hospital (BCH) as he may have needed fluids. The advice appeared to have been accepted by Kelly Emery. At 18.29 hours on the same day the West Midlands Ambulance service received a 999 call from Kelly Emery who was very concerned for Fenton; he had been vomiting and suffering from diarrhoea for three days. Two ambulances attended consecutively (at 18.42 and 19.03) and Fenton was taken to BCH with his mother. On arrival at 19.41 at the Emergency Department he was noted to have Final Version 21.03.16 28 low blood glucose, was lethargic and with a four day history of vomiting and diarrhoea. 98. He was diagnosed as having gastroenteritis; was medicated, treated with dioralyte and discharged home with his mother at 23.40hours. No safeguarding concerns were noted. The GP received a letter indicating the need for follow up care. 99. SW1 telephoned a Birmingham drugs worker (BDW) on the 29.04.13 advising that Birmingham CSC was closing the case due to insufficient evidence of possible harm to Fenton and his sister. The transfer from Dudley CRI (DW1) was still outstanding. Kelly Emery had said that the spoons were from the children’s yoghurt and the silver foil was a Kit-Kat wrapper. DW1from the Dudley CRI had not been spoken to as part of the social work initial assessment and it is not known how much the Birmingham drugs worker (BDW) knew about the case. SFH’s school noted a telephone call from SW1 on the 07.05.13 about the referral. 100. Dudley CRI on the 16.05.13 recorded agreeing to post out Kelly Emery’s script and e-mailing the keyworker (DW1) to make the case transfer. On the 24.05.13 BDW received (by fax) the transfer paperwork from the Dudley CRI. It is recorded that ‘the referral (was) sent back via fax’. 101. On the 10.06.13 Kelly spoke to a duty worker at the Dudley substance misuse service asking for an update on the transfer to Birmingham which had not yet happened. She was told that the transfer would take four weeks and to call back in two weeks. 102. WHV1 completed a developmental review on Fenton on the 20.06.13. He was reported by Kelly Emery as being boisterous and destructive and was referred to the nursery nurse for support. He had a bruised right eye which, according to Kelly Emery happened whilst at maternal grandmother’s where there were lots of other children. Maternal grandmother returned Fenton to his mother so it was not clear how the bruise happened. There was no follow up undertaken by WHV1 into the bruising (e.g. a referral to Birmingham CSC given the recent initial assessment by SW1) and mother’s explanation was accepted. 103. The nursery nurse spoke to Kelly Emery on the 28.06.13 by telephone to arrange an appointment for the 12.07.13 to discuss Fenton’s behaviour. 104. Fenton had spent the weekend of June 29/30 with his paternal grandparents which was a regular occurrence. He returned home at around 17.30 on Sunday 30 June and appeared well, but tired and did not eat his food. His mother reported that she had no concerns about his general behaviour or demeanour and he reportedly fell asleep on the sofa at around 21.15. Kelly Emery awoke at Final Version 21.03.16 29 around 7 a.m. the next morning (1 July 2013) and found Fenton to be cold, covered him and went back to sleep. She woke at around 11a.m. to find him not breathing, phoned an ambulance which arrived at 11.27 a.m. and took Fenton to the Emergency Department of Birmingham Children’s Hospital. 105. Fenton arrived at the hospital at 12.02 in a cardiac arrest and was pronounced dead at 12.19 after unresponsive CPR (cardiopulmonary resuscitation). Kelly Emery was arrested by West Midlands Police in the afternoon of the 1 July 2013 and a criminal investigation was started. In September 2014 she was charged with manslaughter and found guilty as charged in March 2015, receiving a six year custodial sentence. SFH was placed by Birmingham CSC with relatives where she remains. Analysis of Key Issues ToR 1 What tools were used by practitioners to evaluate and assess the mother’s capacity to parent safely in the light of her alcohol and substance abuse? Was the degree to which that abuse could compromise her ability to parent safely taking into account in decision making? 106. The following seven agencies had involvement with Kelly Emery and her two children in both the ante and post-natal period whilst the family lived in Sandwell. These were, • The Crime Reduction Initiative (CRI) (Dudley Adult Integrated Recovery Services) • Specialist midwifery-substance abuse and drug liaison ( Dudley Group NHS Foundation Trust) • Primary midwifery ( Sandwell and West Birmingham Hospitals Trust) • Health visiting Sandwell and West Birmingham Hospitals Trust) • General Practitioner service • Staffordshire and West Midlands Probation Trust • Sandwell Children’s Social Care Dudley CRI Final Version 21.03.16 30 107. Kelly Emery had been in Opioid Substitution Treatment (OST) for her substance misuse (regular heroin misuse)7 since 2007, initially with the Warehouse charity based in Dudley, and from 2009, with the Dudley CRI. She remained with the Dudley CRI up to the death of Fenton in July 2013. The treatment regime was twofold and consisted, firstly of being clinically prescribed methadone as a substitute to address her dependence on the above substances and work towards withdrawal. The methadone programme was overseen by a medical lead (employed by the Dudley Hospital Group NHS Foundation Trust) who worked to the CRI under an ‘umbrella’ arrangement. This aspect of the programme was monitored by local General Practitioners with a special interest in substance abuse. Secondly, a non-medical key worker (DW1) from Dudley CRI whose role was to provide psycho-social support and guidance to Kelly Emery in helping her move towards recovery and withdrawal from heroin and crack cocaine. The key worker reported to and was supervised by a Team Leader (TL1). 108. Methadone is usually prescribed in liquid form with a typical maintenance dose being between 60-120 mls daily (The Methadone Handbook). It is a powerful opiate in its own right with a high mortality risk associated with ‘opioid naïve’ people (as little as 10 mls can kill a young child) and is designated as a Class A drug (Adfam; 2014). Methadone users will usually start their treatment under ‘supervised consumption’ arrangements requiring them to take their dose on a daily basis in front of a health professional such as a pharmacist for an initial period of three months. These conditions can be relaxed by the prescriber in the event of evidence of compliance through testing (NICE; 2007). However, the Department of Health ( 2007) guidance in relation to clinical management states that, ‘Prescribing arrangements should aim to reduce risks to children, and these should be taken into account before any change in prescribing regime is made.’ (Adfam, 2014, 5) 109. According to the Dudley CRI IMR, both medical reviews and drug testing were supposed to happen every twelve weeks. The prescribing aspect of the treatment was, at the time, undertaken by doctors who were not directly employed by the CRI which lead to a ‘disjointed approach to fully integrated substance misuse care’ (CRI IMR p. 7) with respect to effective collaboration with the psycho-social support worker. Moreover, Kelly Emery was not drug tested in compliance with agency policy. 110. There were no records to show that Kelly Emery had been drug tested either before Fenton’s birth or during his lifetime. Indeed the first recorded drug test 7 It should be noted that Kelly also misused cocaine. Final Version 21.03.16 31 was on the19.07.13. sometime after his death. There was a poorly executed and confusing change in drug screening guidance (frequency of urine screening was lessened) introduced by CRI management, which according to DW1 lacked clarity and contained mixed messages, leading to staff practising in different ways (CRI IMR, p.11). Records indicate that there was only one medical review within the timeframe in question, namely on the 21.05.12, when Kelly Emery was not drug tested. 111. The Panel was informed that Scottish guidance suggests 8that drug testing in expectant mothers should occur more frequently as factors such as blood volume can impact on the effectiveness of the methadone. Good practice would therefore be to test pregnant methadone programme participants much more frequently and monitor their dosage closely. 112. Kelly Emery’s attendance at appointments and general engagement with the service was sporadic and inconsistent throughout her treatment programme. She maintained telephone contact. CRI did not challenge her about her attendance at the service. Her lack of engagement meant that the one to one psycho-social support work with DW1, a significant element of the overall treatment regime, was not effective and was not integrated with the prescribing element. Moreover, lack of attendance and engagement was not pro-actively followed up by Dudley CRI. Despite this she continued to receive her methadone scripts by post without proper oversight and monitoring in an attempt to stop her returning to illicit drug use and try to keep her engaged with the service. Her misuse of heroin, crack and alcohol, was known about by other agencies such as the Police. Her lack of consistent engagement and failure to attend appointments and reviews, according to Department of Health guidance (2007), should have resulted in reverting back to a supervised consumption regime which did not happen. 113. Indeed, in relation to supervised consumption, the Methadone Handbook (at page 17) states that, ‘Drug services would normally consider someone to be stable when they are, • Turning up for appointments. • Picking up all their doses of methadone. • Not taking illicit heroin ( some services expect to see urine samples free of non-prescribed drugs before they will consider allowing take home doses) • Not drinking heavily. 8 See NHS Lothian (2003), ‘ Substance Misuse in Pregnancy- A resource pack for professionals in Lothian’ Final Version 21.03.16 32 If things are not going well, the collection regime may go back a step or two in order to help get things back under control.’ 114. There was no evidence to show that any consideration had been given by medical or non-medical practitioners associated with the Dudley CRI to the potential risks to Fenton and his sister of Kelly Emery’s inconsistent involvement with her methadone treatment. There was no record of the use at medical reviews of any practice ‘tool’ by the CRI prescribing doctor within the treatment programme. The ‘Parent Capacity Assessment ‘was used by DW1 during home visits but there was no recorded observations of the interaction between Kelly Emery and her two children. Indeed, SFH had not been seen since 2010, some- time before the birth of Fenton and had been subject to a multi-agency child protection plan whilst in Sandwell in 2009, precisely because of her mother’s substance abuse. Dudley CRI knew about this and was a member of the core group. The focus and approach to treatment ‘did not take into account the wider needs of Kelly Emery and the impact and risks associated with substance misuse on the family unit as a whole’. (CRI IMR, p.10). 115. In conclusion, the evidence indicates that the CRI did not provide a professional view as to whether Kelly Emery was able to effectively parent and safeguard her children particularly in regard to her substance misuse and methadone treatment. (see CRI IMR, p.13). It therefore follows that no account of Kelly Emery’s ability to parent her children safely was taken by CRI personnel in their decision making regarding her treatment. 116. The CRI IMR identified several key organisational and cultural factors that accounted for ineffective parenting capacity assessments and the resulting lack of an awareness of risk to the children. These included staff lacking the skills, competence, confidence and ‘Professional curiosity’ in undertaking such assessments; a belief that challenge might compromise the ‘therapeutic relationship’, an over reliance on Kelly Emery’s self-reporting, an adult focused ‘Harm reduction’ service which did not ‘Think Family’; a lack of supervisory challenge from line management and perceived high caseloads. 117. There was no record of any liaison between the CRI prescribing doctor service and the receiving pharmacist or with Kelly Emery’s own GP in Sandwell or later in Frankley (Birmingham). In the light of these and the previously mentioned deficiencies it was concerning that Kelly Emery continued to regularly receive her methadone script with no direct supervision or monitoring of her consumption by the pharmacist. It was the prescribing service that had responsibility for communicating with the family GP (in Sandwell and Birmingham) and the appropriate pharmacist. Final Version 21.03.16 33 118. In sum, the key reasons for Dudley CRI’s lack of awareness of the risks to Fenton and SFH were located within an organisational, structural and cultural context of; • CRI safeguarding policy was not fully implemented in the service. • A disconnect between the two key elements of the methadone service, namely the CRI prescribing doctor, oversight and monitoring; and psycho-social support. • A resulting lack of follow up regarding Kelly Emery’s poor engagement and attendance at reviews and drug testing appointments • A lack of clear guidance around frequency of drug screening. • A poorly trained and prepared workforce that was overly focussed on the adult service users and not sufficiently aware of the risks to their children. • A lack of staff challenge and professional curiosity about adult service users in the interests of maintaining a therapeutic relationship. • Poor management oversight and little focus on safeguarding children. • High caseloads. • No liaison with the dispensing pharmacists and Kelly Emery’s GPs. 119. The lack of awareness of risk to Fenton and his sister by the Dudley CRI resonates at a wider, national level with adult substance misuse services. In this respect, recent research from serious case reviews on the deaths of children from opiate substitution ingestion found that,’ the evidence presented shows that practitioners do not consistently recognise the possible risks to children post by OST ( Opiate Substitute Treatment), despite NICE and the Department of Health stating this requirement explicitly’ ( Adfam, 2014, p.8). 120. Moreover, although the issue of safe storage had been discussed (albeit with no storage box provided), intentional administering of controlled substances (including methadone) to children was not contemplated by any agency involved in the case. 121. The key learning points for Dudley CRI from this section are set out in the Key Findings and Learning section at paragraphs 338-341. Midwifery Service 122. The midwifery service of the Dudley Group NHS Foundation Trust had a key role in early identification of any potential risk to Fenton from his mother’s methadone use and substance misuse. 123. Kelly Emery registered for her ante natal care at the late stage of twenty weeks, which in itself should have raised questions. The specialist midwife (SPMW1) Final Version 21.03.16 34 who principally attended Kelly Emery was the named midwife for safeguarding and led on substance misuse and vulnerable women. She was therefore an experienced and knowledgeable practitioner in this area of work, although she had not received any specific training in working with women who had misused substances, other than attending relevant courses on the subject. Her role involved frequent and regular attendance at the CRI substance misuse service. The second specialist midwife, (in domestic abuse and mental health-SPMW2) who had more limited involvement, was also experienced in safeguarding children and had completed advanced training in the subject. 124. Regarding practice tools the agency IMR refers to the use of a universal midwifery care pathway which contained ‘prompts’ on specific issues relating to ante-natal care, including substance misuse and vulnerability. Moreover, there were specific guidelines for the care of substance misusing women during the ante-natal, intra-partum and post-natal periods. However, (it would appear that) there was no available pathway at the time for the recognition of safeguarding issues regarding the children of substance misusing parents. (See p3 of Panel minutes, 10.11.14). 125. It appears that the pathway, prior to Fenton’s birth, did not include a section on the consideration of safeguarding and potential risk issues to unborn children and neonates regarding the impact of parents who were substance abusing or on methadone programmes. The current (Dudley Safeguarding Children Board) threshold document (Right Services, Right Time, and Right Place) was introduced in September 2011. It contains guidance on when to request a co-ordinated multi-agency response to parental substance misuse. 126. That said, it is noted that the current Dudley Safeguarding Children Board safeguarding procedures regarding ‘Maternal Substance Misuse during Pregnancy’ ( issued in 2007 at Part C section 33, paragraphs 2.5 and 2.6 and last modified in August 2009, i.e. before Fenton’s birth) states that, ‘Maternal substance misuse in pregnancy can have serious effects on the health and development of the child before and after birth………..all maternity services should have procedures for pregnant women who use drugs that encourage them to go to ante-natal services. There should be liaison between Maternity and Drug Treatment services to review the management of the mother’s drug use and impact on the baby before and after pregnancy. If there is a concern about the parent’s child care abilities, a referral should be made to Children’s Social Care under these procedures’. 127. The apparent absence of a risk assessment tool regarding the potential impact on children from substance misusing parents therefore resulted in no effective assessment of the impact of Kelly Emery’s (and her then partner, Fenton’s Final Version 21.03.16 35 father) methadone use and substance misuse on Fenton and his sister. Indeed, the midwifery team did not record that Kelly Emery had any problem drug or alcohol use and that she had been assessed (by the CRI) as stable on her methadone programme with no safeguarding concerns. 128. This was despite the presence of numerous known risk factors such as Kelly being on a methadone treatment programme with Dudley CRI, her inconsistent involvement with the programme, the late midwifery registration, four missed ante-natal appointments , ongoing treatment for depression, failure to provide a urine specimen, a positive test for cocaine (in addition to FFH’s alleged cocaine use), her involvement in recent criminal activity and resulting community order with the Probation service; and SFH’s previous (2009) child protection plan with Sandwell Safeguarding Children Board. 129. Given these numerous risk indicators it was concerning that there was no joint review held between the midwifery service and the CRI to assess Kelly Emery’s methadone (and substance misuse) use and its potential impact on the unborn child and SFH. Indeed, the evidence suggests that there was little or no wider joint working between the two agencies in regard to Fenton. 130. In all of the circumstances and mindful of the dangers of ‘hindsight and outcome bias’, this SCR takes the view that a joint decision by the midwifery service and the CRI should have, at the very least, been taken to make a child in need and arguably, a child protection referral protection on the unborn child (and SFH) to Sandwell Children Social Care in the ante-natal period. The absence of any formal midwifery recording has hindered this Review’s attempt at understanding the rationale for the actions and decisions taken (or not taken) by midwifery professionals. 131. In conclusion, the evidence suggests that there was no recognition by the midwifery service of the potential risks to the unborn child (Fenton) and his sister from their parents’ substance misuse and Kelly Emery’s methadone treatment. Given the specific safeguarding role of the specialist midwife and her experience in working within the field of parental substance misuse, albeit that there was no formal risk assessment tool in place at the time; and the known existence of the above risk indictors, it would be reasonable to suggest that there were safeguarding concerns which should have; firstly been recognised and secondly, referred on to Sandwell Children’s Social Care for a pre-birth assessment, in conjunction with Dudley CRI. Such a course of action would have been consistent with existing Dudley Safeguarding Children Board Safeguarding procedures. The reasons and analysis as to why this did not happen and resultant learning is set out in ToR 2, paragraphs 239-248. Final Version 21.03.16 36 132. Therefore, this episode marked a missed opportunity for the Dudley CRI and the specialist midwifery service to have taken joint action to safeguard and promote the welfare of Fenton and his sister. Staffordshire and West Midlands Probation Trust 133. Kelly Emery was subject to a twelve month community order (06.06.11 to 06.06.12) with a supervision requirement to the above agency following her conviction for shoplifting (May 2011) and a breach of a conditional discharge. She was sentenced to an additional twelve month community order with a 40 hour unpaid work requirement in September 2011 for a further shoplifting offence in late May 2011. The evidence from the Individual Management Review (IMR) suggested that she adhered to the order and was a compliant and regular attender with her Probation Service Officer (PSO1). 134. The agency’s primary purpose was to supervise Kelly Emery in ensuring that she completed the two community orders. However, the agency recognised its safeguarding responsibilities to Fenton and his sister who were observed with their mother on several occasions in the office and at home. Parent and child interaction was perceived as positive with Fenton said to be thriving and well. 135. Using the OASYS offender assessment tool the Probation service classified Kelly Emery (at the pre-sentence stage on the 24.06.11)) as a medium risk to her children because of her methadone use and known substance misuse. Key parts of the sentence and OASYS risk management plans provided that Kelly Emery should adhere to her methadone treatment with the Dudley CRI and undergo voluntary drug testing. As already noted, the evidence from the CRI was that her engagement with them was sporadic and that she did not undergo drug testing. This information was not shared with the Probation service. In this respect, the interagency communication and liaison between the two services was not effective and an important element of the risk to the children was not considered. This was also a crucial piece of information that was not taken up by the specialist midwifery service. 136. However, on the basis of her medium risk status around the methadone/substance use, PSO1, following standard safeguarding practice, made a telephone referral to Sandwell Children’s Social Care on the 20.07.11. This was some two days after being informed of Fenton’s birth by the senior nurse from the Hospital maternity ward. PSO1 correctly expressed her concerns in the referral about Kelly Emery and her partner’s (FFH) methadone use in relation to the children and felt that an assessment was needed. Final Version 21.03.16 37 137. Two days later, on the 22.07.11 a duty social worker from Sandwell CSC made a telephone call to the Probation office and spoke to PSO2 (PSO1 was not in work) who reported that Kelly Emery was stable with her methadone script and was receiving support from a drug agency (recorded as the ‘Anchor Project’; this would seem to have been incorrect as it was in fact the Dudley CRI based at Atlantic House). Kelly Emery, the new baby, Fenton and SFH were staying with her mother (Fenton’s maternal grandmother) for a few weeks. A duty social worker spoke to PSO2 on the 26.07.11 to state that in the light of further enquiries with other agencies there would be no further input from Sandwell Children’s Social Care at that stage. If there were any concerns then a re-referral could be made to Children’s Social Care, or a Common Assessment could be undertaken. 138. Fenton and SFH were seen by PSO1 and the Probation Officer during a home visit made on the 02.08.11. Kelly Emery told them that a duty social worker from Sandwell CSC had recently contacted her by telephone and that she had said that she was receiving support from the midwife who would be handing over shortly to a health visitor. Her mother was said to be supportive but there was a lack of clarity about the degree of support being given to Kelly Emery by her partner (FFH). PSO1 was aware that Sandwell Children’s Social Care was not taking any action in response to her previous referral. However, it was good practice when, the Probation service did make later follow up enquiries in September 2011 and February 2012 to Sandwell CSC regarding the children. It was informed that that the family was not an open case, that Kelly Emery was getting support from family members and agencies, which, in fact was not correct. 139. It can be concluded that the Probation Service was the only agency to have assessed Kelly Emery’s risk to her children in regard to her methadone use and substance misuse whilst the family were living in Sandwell. The assessment informed the agency’s decision to make a referral to Sandwell Children’s Social Care. Health Visiting Service (Sandwell and West Birmingham Hospitals Trust) 140. Fenton and his mother’s involvement with this service was from July 2011 to November 2012, although the family had moved out of the Sandwell area in February 2012 and were no longer in effective contact with the agency. There were three health visitors deployed during this time, HV1 from 03.08.11 to 06.01.12, HV2 for one week from the 05.08.11 and HV3 from the 02.04.12 to the 09.11.12. HV1 had one contact with Fenton and Kelly Emery on the 06.01.12, HV2 had two on the 05.08.11 and 11.08.11 and HV3 had none. Final Version 21.03.16 38 141. The service was working to an escalation plan (i.e. a declaration that that it was struggling to respond to demand) in 2011 because of a 22% health visitor vacancy rate, 16% sickness rate and average caseloads of 1000 children per health visitor. The escalation plan had been agreed with commissioners that Health Visitors would only monitor active child protection and Looked After Children. In addition, new birth visits had been extended in the previous agreed timescale of 10-14 days to 10-21 days. 142. HV1 took over the care of Fenton (along with the midwifery service for a short while) on his discharge from Hospital 1’s neo natal unit on the 21.07.11. He had been there for three days after his birth for observation regarding withdrawal from maternal methadone, of which there were no signs. It was planned for him to have a cranial ultra sound scan (USS) and a three month neonatal follow up at the hospital in three months. This information would have been included on the maternity liaison form and neonatal discharge summary given to HV1. 143. A primary visit was completed by HV2 to the maternal grandmother’s home on the 11.08.11, following an unplanned and uncompleted visit there on the 05.08.11. Fenton was noted to be feeding well with good weight gain and appeared settled. HV2 gave advice on the baby clinic and the need for an eight week check at the GP surgery. Kelly Emery informed HV2 that she was on a methadone programme and gave details of her keyworker. She said that her partner was an ex-methadone user and was working away in Scotland. He was, in fact, serving a custodial sentence between the 17.07.11 to the 04.10.13 for attempted robbery. She said that the children’s grandparents were supporting her. 144. HV2 did try and contact the substance misuse worker the next day (12.08.11) but there was no reply. There was no record of any further attempt at contacting Dudley CRI by the service. Thereafter, HV2 had no further involvement with Fenton and the family. He and his mother visited the Cradley Health Sure Start clinic on the 14.09.11 when he was weighed, although there is no record of what this was. 145. HV1 resumed case responsibility and made a visit on the 06.01.12. There had been two missed Neonatal Unit appointments notified to the service in September and December 2011. These were not raised with Kelly Emery by HV1 as they should have been. Advice was given about Fenton’s weaning and nappy soreness and Kelly was advised to make a GP appointment for a review on her son. Kelly Emery mentioned that she had recently been burgled and had reported this to the Police. Her methadone use was discussed; she said that she was monitored and supported daily by Dudley CRI. She told HV1 that the methadone was kept on top of the cupboard. She should have had a safe Final Version 21.03.16 39 storage box which she did not have (see CRI IMR). This should have been queried by HV1. A further visit was arranged in three months’ time. 146. Despite knowing about Kelly Emery’s methadone use, HV1 (an experienced health visitor) did not contact the substance misuse worker at the Dudley CRI to seek out more information about her methadone regime and any potential risks it may have presented to Fenton and SFH. The then existing Sandwell Safeguarding Children Board guidance on the ‘Children of Drug Misusing Parents’ (Chapter 4.2.6, section 2) states that , ‘A thorough assessment by all relevant agencies is required to determine the extent of need and level of risk of harm in every case’. Moreover, ‘Where there is concern that a parent is involved in drug use, the effect on the child needs to be considered’ and a list of ten relevant risk factors (including ‘ The impact of the parent’s drug use on the child’s development including the emotional and psychological well- being, education and friendships’) is set out for attention. 147. HV1 no longer works for the Trust and was not able to be interviewed for the agency management review. The reason for her not speaking to the Dudley CRI is therefore not known. However, this important omission would tend to suggest that HV1 had an insufficient awareness and understanding of the safeguarding issues around the potential impact of substance misusing/methadone using parents on children. 148. The health care needs analysis undertaken by HV2 at the primary visit on the 11.08.11 identified, amongst other things, Kelly Emery’s methadone use and indicated the requirement for ‘Active intervention’ (‘Universal Plus’) with Fenton and his mother. ‘Universal Plus’ is a service offer where the health visitor can support the child and family and is, ‘Targeted according to assessed or expressed need. Universal Plus gives a rapid response from the health visiting team when children, young people and families need specific expert help’. (Department of Health; 2011) The need for a Universal plus level of intervention suggested that the family was seen as vulnerable with some concerns about parenting (see paragraph 2.2 ‘Family focused provision’, Level 3-Universal Plus Offer, page 7, National Health Visiting Service Specification 2014/15). 149. Whilst referencing Kelly Emery’s methadone use in the health care needs analysis, there was no evidence of any additional assessment or consideration by the health visiting service into the implications of this risk factor on her parenting capacity and any potential risk presented to Fenton and his sister. Indeed, HV2, based on superficial evidence, regarded the maternal grandmother as a protective factor and recorded that she would ‘not allow any harm’ to come to the Final Version 21.03.16 40 children. This view seemed to have been based on a ‘one off’ visit in August 2011 and seemed predicated on the erroneous assumption that there was a strong and consistent supportive relationship between Kelly Emery and her mother, which was, in fact, not the case. 150. The ‘Active intervention’ and support package of the Universal Plus care plan was not forthcoming and it is not known why not. HV1 no longer works for the Health Trust and was therefore not able to be interviewed. As clinical lead she should have been informed of the outcomes of all previous contacts and any actions taken. This would have included knowledge about the intervention at Universal Plus level proposed by HV2. 151. Had there been a care plan it would likely have included the monitoring of Fenton’s health as part of a multi-agency care plan involving the health visiting service, the family GP, the Dudley CRI, Hospital 1 neonatal unit; liaison with the Probation service and if necessary, enquiries with Sandwell Children’s Social Care, when SFH’s’ previous Child Protection Plan would have come to light. Indeed, the health visiting reference card noted that the family were known to Sandwell Children’s Social Care but there was no evidence that this information was followed up by the health visiting service. 152. There should have been multi-lateral liaison and communication with these agencies, especially with the Dudley CRI to see if Kelly Emery was appropriately engaging with the programme and a consideration of any relevant implications for her children’s safety. Moreover, the health visitor care plan made reference to Fenton having a three monthly review that should have taken place in November 2011. This did not happen and despite two defaulted hospital appointments a home visit by HV1 was not arranged until some five months later in January 2012. 153. It can be thus be concluded that despite the health visitor’s knowledge of Kelly Emery’s methadone use, the lack of a Universal Plus plan resulted specifically in the absence of actions to mitigate any potential risks to Fenton from this source. More generally, there was no provision of a co-ordinated multi-agency support plan to the child and his family. This practice episode was an important missed opportunity to safeguard Fenton and promote his wellbeing. 154. The key learning points from this episode are set out at paragraphs 356-357. Sandwell Children Social Care 155. This agency’s involvement with Fenton was confined to its response to the referral made to its Duty and Assessment service on the 20.07.11 by PSO1 of the Probation service. Final Version 21.03.16 41 156. Given that the Probation referral was based upon its own medium risk to children assessment from Kelly Emery’s methadone use and substance misuse and the fact of SFH’s relatively recent (2009) child protection plan for, concerns around her mother’s substance misuse, it is a reasonable expectation that an initial assessment on Fenton and his sister’s wellbeing would have been carried out. However, there was no evidence that this was done. 157. What appeared to have happened was that a duty officer spoke to a probation officer (PSO2) on the 26.07.11 who reported that Kelly Emery was stable on her methadone script and was being supported by her mother and the drug agency. The duty officer spoke with Kelly Emery on the telephone who told her that she was being supported by her midwife and a drugs worker (DW1) at Atlantic House and was living with her mother for a few weeks. Kelly Emery said she had support from her family and friends and did not need any additional support from Sandwell Children’s Social Care. The duty officer spoke with a community midwife at Russells Hall Hospital (Hospital 1) who reported that she had no record of Kelly Emery but that she was being visited by midwifes from Sandwell. 158. The duty officer spoke with a community midwife on the 26.07.11 who reported that Kelly Emery was engaging with agencies and she was due to visit that week. She and the children were said to be living with the maternal grandmother (for a few weeks) and receiving adequate support from Atlantic House (Dudley CRI) who saw her at home every week regarding her methadone programme. She was also getting support from a specialist community midwife based at Atlantic House, in addition to family and friends and did not require support from Sandwell Children Social Care. A health visitor would shortly be taking over the health care of Fenton and his mother from the midwifery service. 159. The Common Assessment Framework (CAF) process was explained to the community midwife with advice that in the event of any concerns these could be referred on to Children’s Social Care or a CAF completed if Kelly Emery needed any further support. The Probation Service received a telephone call from a duty officer from the Children’s Services Team on the 26.07.11 confirming that there was no input from the children’s social care at that time. 160. The duty officer went on to check Children’s Social Care integrated children’s system (ICS- the electronic recording system) and noted that there were four contacts, two referrals and two core assessments. The 2007 core assessment could not be viewed and there was no record of the duty officer considering any information from the other core assessment. It was recorded that SFH was on a child protection plan in 2009 for emotional abuse and that there were concerns that Kelly Emery had been shoplifting in front of SFH who had also disclosed in a picture that her mother had been misusing substances. Final Version 21.03.16 42 161. The duty officer (on the 26.07.11) concluded that ‘Given that mother is receiving support from health and Atlantic (the key worker wrongly stated as PSO2) House there is no current role for children’s services. PSO2 has been advised to complete a CAF (Common Assessment) and re-refer if he has any concerns’ Following the duty officer’s conclusion and recommendation the team manager made the decision that, ‘Mother has family support and there is a lot of agency monitoring. There are no current concerns around the baby and agencies will continue to monitor and complete a CAF providing mother consents. Agencies will re-refer if concerns arise’. There was no further recording on file and no involvement with Fenton and his family from then on. 162. The response by Sandwell Children’s Services duty and assessment team to the safeguarding referral from the Probation Service was sub-standard and poor practice. The safeguarding referral should have resulted in the duty officer (DO) carrying out an initial assessment in line with existing agency and Sandwell Safeguarding Children Board safeguarding procedures. This stated (at the time) that, ‘Where a referral is made in relation to a child where the parents have a substance dependency, Children’s Social Care Services will undertake an initial assessment and if necessary, a core assessment. The assessment should also consider and take account of whether the person concerned is hiding or denying their substance misuse, whether they are engaged in a rehabilitation programme; whether they receive support from a partner, family or friends: the impact of the drug misuse on the quality of care given to the child and the day to day environment of the child’. (Section 4- Assessment and Initial Child Protection Conference). 163. It would seem that the duty officer was reassured from the erroneously positive and superficial reports of Kelly Emery’s situation from PSO2, the midwife and Kelly Emery herself. Given Kelly Emery’s criminal history there should have been enquiries made with the Police. There was no evidence that the family’s history and the two core assessments had been effectively assessed. SFH’s details were not noted, nor were her safety and wellbeing considered, or that any enquiries were made about her being on a child protection plan in 2009, or with her school. Had an effective initial assessment been undertaken it is likely that sufficient concerns would have emerged to have warranted a core assessment and/or safeguarding strategy discussion with the Police and other involved agencies (especially Dudley CRI), leading to a Child in Need intervention or possibly the holding of an Initial Child Protection Conference. None of these issues were raised by the team manager who did not challenge the superficial conclusions and recommendation of the duty officer. Final Version 21.03.16 43 164. The agency’s IMR makes the point that Sandwell Children’s Service was under considerable pressure at the time of the referral in July 2011 because of insufficient staffing and ineffective partnership working. The Access service was at that time, ‘Inundated with referrals and the capacity of staff to respond to the volume of work was an issue’. The turnover of staff and acceptance of inappropriate work were additional significant factors which led to poor practice. 165. The handling of the referral from the Probation Service in July 2011 by Sandwell Children’s Social Care therefore sought to ‘cut corners’, partly in response to the existing pressures described above and needs to be set within this wider agency context. 166. Self-evidently, the lack of an initial assessment precluded the use of any assessment tool regarding Kelly Emery’s parenting capacity and her potential to provide safe parenting to her children in the light of her methadone treatment and substance misuse. It can thus be concluded that Sandwell Children’s Social Care duty team’s decision not to take any further action on the Probation safeguarding referral was not informed by an initial assessment or any understanding of the potential impact of Kelly Emery’s methadone use and substance abuse on her children. This episode was a significant missed opportunity to carry out an assessment into the potential risks to Fenton and SFH and their needs; and take appropriate multi-agency action to safeguard them and promote their wellbeing. GP Services 167. Fenton was seen once by the GP service in Sandwell shortly after his birth for a first immunisation with nothing untoward indicated. He was seen three times by the GP service at Frankley health centre in Birmingham between September and December 2012 for routine health matters, an immunisation, a chesty cough and a viral illness. No safeguarding issues were identified. 168. On advice from the GP, Fenton attended the Birmingham Children’s Hospital on the 26.04.13 because of concerns from his mother about his diarrhoea, vomiting for three days and possible dehydration. He was treated for gastroenteritis, given appropriate medication and discharged home with his mother the same day. The GP received a letter from the hospital for follow up care. There was no evidence to suggest that this happened. 169. SFH was seen only once during the time in question, on the 20.12.12 for hearing problems and referred onwards appropriately. 170. No safeguarding issues regarding either child were identified by the GP services in Sandwell and Frankley. Final Version 21.03.16 44 171. The children’s mother had a long standing history of episodic depression and was seen and treated by the Frankley practice in late December 2012 and the early part of 2013. The HAD (Hospital Anxiety and Depression) scale was used by the GP and indicated a high number of depressive symptoms (see IMR at page 5). Kelly Emery was prescribed anti-depressant medication (50mg of Sertraline). The HAD scale is not a holistic tool and does not include consideration of wider family dynamics or the impact of mental ill health on vulnerable family members, including children. 172. Kelly Emery was known to be on a methadone programme but there was no liaison between the GP and the specialist prescribing doctor at Dudley CRI on her progress. The GP has since acknowledged (to the IMR author) that the practice should have been proactive in seeking information from the substance misuse service. In seeking to understand why there was no communication the IMR author spoke to the GP (principal) who explained that the primary purpose of the consultation was to review Kelly Emery’s asthma and oral contraception. The mood symptoms were presented incidentally and the HAD questionnaire was used to define these more clearly. The GP had no real explanation for why there was no liaison with the substance misuse service, save that the focus of the consultation tended to be on the immediate symptoms presented by Kelly Emery. In any event, the key lesson emerging from this practice episode is for GPs and prescribing agencies to liaise effectively where patients are involved in Opium Substitute Treatment (methadone programmes), particularly where the patient is a parent. 173. Additionally, there was no discussion with other primary health staff such as the health visitor or the school nurse about the implications of Kelly Emery’s depression and methadone use for the welfare of safety of the children. Despite two out of three of the ‘toxic trio’9, and a very vivid and distressing plea from Kelly Emery to help her, there was no consideration by the GP to exploring the family dynamics and implications for the children’s wellbeing. Indeed, there was no mention in Kelly Emery’s medical record of the children. 174. The IMR revealed that despite health visitors being co-located with the GPs there were no regular meetings between the two groups to discuss safeguarding issues. Moreover, it was not normal practice to contact health visitors or school nurses unless there was the considered to be a particular risk with the actual threat of immediate harm. In Kelly Emery’s case it had been determined that she appeared not to be at risk of suicide. Thus, it would seem that safeguarding intervention thresholds (for this particular GP) were set at a relatively high level which precluded acting on the background safeguarding risks of the mother’s 9 Namely, parental mental health, substance misuse and domestic abuse. Final Version 21.03.16 45 depression and methadone use. In essence, no risks to the children were identified by the GP and therefore no action was taken. 175. Moreover, the IMR identified that there were no safeguarding protocols or guidance in use in this practice at that time. This Review would point to the duties and responsibilities of all registered doctors contained in the General Medical Council guidance, ‘Protecting Children and Young People’ (which came into effect on the 3 September 2012). Regarding the role of all doctors it states at page 11 that, ‘You must consider the safety and welfare of children and young people, whether or not you routinely see them as patients. When you care for an adult patient, that patient must be your first concern, but you must also consider whether your patient poses a risk to children or young people. You must be aware of the risks that have been linked to abuse and neglect and look out for signs that the child or young person may be at risk. Risk factors include having parents with mental health or substance-misuse issues….’. 176. The guidance goes on to state (at page 12) that, ‘You should have a working knowledge of local procedures for protecting children and young people in your area’. This would include the Local Safeguarding Children Board safeguarding procedures, the relevant guidance in ‘Working Together’ 2013 ( and now the 2015 version) and access to named and designated doctors and nurses for advice and guidance. 177. As the IMR author (an experienced consultant community paediatrician and designated doctor in child safeguarding in Birmingham) states in his report for this SCR at page 6, ‘Overall, these consultations would certainly have been an opportunity to make enquiries as to the state of the children whom would have been very much affected by the impaired mental health of their mother’. 178. In conclusion, apart from the specific use of the HAD tool to diagnose the extent of Kelly Emery’s depression there was no evidence to show that any consideration was given to evaluating her parenting capacity in the light of her alcohol and substance abuse and mental health issues. It therefore follows that no account was taken of these matters by the GP in relation to the potential for abuse or neglect of Fenton and SFH. Decision making was solely confined to treating and managing Kelly Emery’s depression through medication and did not include any wider considerations for the safety and welfare of the children. 179. The key learning points are set out at paragraphs 398-400 Final Version 21.03.16 46 West Midlands Police 180. Kelly Emery came to the attention of the West Midlands Police on numerous occasions between 2002 to 2013 and was a known substance misuser (heroin, cocaine and cannabis) who funded her addiction through acquisitive crime (theft, robberies and shop lifting) and participation in the sex industry. Records also indicate that she was the victim of domestic abuse during the period. 181. Kelly Emery was visibly pregnant and known by the Police to be using drugs when she was brought into custody in May 2011 for shop lifting. In addition to being pregnant it was ascertained that she also had a ten year old daughter. She had told custody staff on the 12 May that she was a methadone user, had taken cocaine that morning and admitted occasional use of heroine. She tested positive for cocaine. None of the investigating officers or custody staff generated a child abuse non-crime number for the unborn child (Fenton) or his sister. There was no record of a referral to Sandwell CSC. A single intelligence log of the information was submitted on the 19.05.11 but was not disseminated. 182. This Review agrees with the West Midlands Police IMR that the lack of a referral to the (Police) Child Protection Unit and Sandwell Children’s Social Care in May 2011 was a very significant lost opportunity for multi-agency intervention to safeguard and promote the wellbeing of Fenton and his sister. Albeit, that there was no formal assessment tool for the evaluation of Kelly Emery’s parenting; the impact of her substance misuse and criminal behaviour, whilst being heavily pregnant and the mother of a ten year old child, should have been considered by the Police custody officers and a referral made. Had there been a referral it is likely that a Section 47 enquiry would have been undertaken, followed by the holding of an Initial Child Protection Conference, resulting in both children made the subjects of child protection plans. Move to Birmingham 183. The family left Sandwell in February 2012 and moved into accommodation in Birmingham in April/May of that year. They were involved with the following agencies. • Health visiting service ( Worcestershire Health and Care NHS Trust) • Birmingham People Directorate Children’s Social Care • West Midlands Police • CRI Dudley • Secondary School • West Midlands Ambulance Service NHS Foundation Trust • Birmingham Children’s Hospital • GP service- South Central Clinical Commissioning Group Final Version 21.03.16 47 Health Visiting Service 184. Despite having lived in Birmingham since April/May 2012 the transfer from the Sandwell to the Worcestershire health visiting service did not happen until 9 November 2012. The delay was caused by the Sandwell health visitor (HV3) having difficulty in locating the family’s whereabouts. In fact it was a request for Fenton’s health records on the 18.10.12 from Birmingham that alerted HV3 to the family’s location. The verbal handover from HV3 to the new health visitor (WHV1) took place on the 23.11.12 which included information on the mother’s methadone use, the recent history of ‘futile’ visits; that Fenton had not been seen since January 2012 and that he was under the care of a neo-natal consultant at Hospital 1. It was also reported, inaccurately, that Kelly Emery did not have a drugs worker. 185. WHV1, who had completed appropriate training that included awareness of the impact of substance misuse on parenting capacity, made attempts to undertake an introductory review appointment in late November and twice in December. These were all missed by Kelly Emery who said that her mother had had a heart attack or that she had flu. A home visit was eventually made on the 15.01.13 when Fenton was seen by WHV1. Kelly Emery told her the name of her substance misuse worker whom she said she saw every two weeks. She was taking 19 mls of methadone daily. Fenton’s father was said to be in prison and the child was reported to see him every fortnight. A development review was arranged for the 19.04.13. It had been almost one year since Fenton had been seen by a health visitor. 186. WHV1 completed the ‘Health Assessment Framework’ following the visit and Fenton was identified as ‘Vulnerable’. This required medium active intervention with the child being seen every three months by the health visitor and some extra parenting support being offered to his mother. The assessment did not include any consideration of potential risk to Fenton from his mother’s methadone treatment. WHV1 did not contact the substance misuse worker at the Dudley CRI to obtain his views on how Kelly Emery was progressing with her treatment plan or what the risks from that agency’s perspective might be to Fenton. WHV1 should have contacted the substance misuse worker and this omission marked a missed opportunity to obtain a better understanding of the potential risks to Fenton from his mother’s methadone use and substance misuse. 187. WHV1’s lack of perception of risk to Fenton was informed by her observations (over three contacts) of good presentation of Fenton and interaction between mother and child, seemingly credible excuses by Kelly Emery for her absences at appointments and her reported low methadone dose, relative to other clients. This last factor was not checked out with Dudley CRI. The combination of these conditions led to WHV1 making an assumption that Kelly Emery’s methadone Final Version 21.03.16 48 use was having a minimum impact on Fenton and did not result in her making fuller enquiries into his and SFH’s circumstances, albeit arrangements were in place for some parenting support in July 2013. 188. Worcestershire Safeguarding Children Board did at the time have a joint working protocol , ‘Safeguarding children and young people whose parents/carers use drugs/alcohol’ that was part of the ‘ Think Family’ initiative which had been signed up to by the Care Trust. However, WHV1 was not aware of the document and its encouragement of a more joined up approach between professionals. The Trust IMR noted that greater awareness of the document (which was/is available through the Trust internet) is needed which this Review would strongly endorse. 189. The relevant lessons learnt from this episode are set out at paragraph 380 below included. Birmingham Children’s Social Care 190. This agency had two episodes of involvement with Fenton and his family, these being, the anonymous referral from neighbours in late August 2012 to the Integrated Access Team and the child protection referral from West Midlands Police on the 22.04.13. Both were missed opportunities for Birmingham Children Social Care to effectively assess the needs of Fenton and his sister and establish whether they were at risk from their mother’s methadone use, substance misuse and other aspects of her parenting. 191. On neither occasion were any assessment tools used; beyond a very superficial consideration of nominal risk and protection factors in the April 2013 referral, to produce an accurate understanding of Kelly Emery’s capacity to safely parent her children in the light of her methadone and substance misuse. 192. The referral of 30.08.12 from a neighbour taken by the Referral and Advice Officer (RAA1) in the Integrated Access Team resulted in the referrer being wrongly advised to make direct contact with Children’s Social Care. Perhaps not surprisingly, the referrer became annoyed with the response and was not inclined to contact Children’s Social Care. Apart from recording the referral on Carefirst (the local authority’s electronic social care recording platform) and some cursory health checks, there was no evidence that any additional actions or enquiries were taken to ascertain the children’s safety and wellbeing. 193. The Integrated Access Team’s screening response fell below expected standards and demonstrated inadequate practice. The safeguarding referral should have been accepted, entered on the system and been subject to one of four outcomes as set out in the agency IMR. These were, Final Version 21.03.16 49 • Referral to Children’s Social Care First Response Team to undertake a Level 4 child protection enquiry. • Referral to an Integrated Family Support Team for a Level 2/3 response • Advise that a Common Assessment within a Level 1 universal service setting should be offered • Advice and signposting to universal services for Level 1 referrals. 194. None of these options were taken and there was no sign that the decision for no further action was discussed with and approved by a duty screening manager. Moreover, the decision was made without any reference to the safeguarding concerns of the referral regarding suggestions of mother’s substance abuse, involvement in sex working and exposure of the children to undesirable adults. 195. Given the nature of the safeguarding concerns this Review suggests that there should have been a Level 4 safeguarding response from Children’s Social Care to determine whether there were any grounds to believe that the children were suffering or likely to suffer significant harm. RAA1 and the team manager were not available to be interviewed about the reasons not to send the referral to Children’s Social Care. By way of explanation for this unsafe practice that left Fenton and his sister at risk, the agency IMR cites two recent Ofsted reports (2012, 2014) that throw some light on the situation at the time of the referral. These identified, poor management oversight, lack of staffing capacity, the absence of qualified social workers in the Integrated Assessment and Advice teams, a lack of understanding and implementation of thresholds and a lack of focus on outcomes for children and young people, as factors. 196. In regard to the ‘ Front door’ service of the Integrated Access Team the 2012 Ofsted report commented that, ‘ A review of contacts made to children’s services shows that some that met the threshold for services were not progressed to referrals for action, which left children at risk’. (page 9. Paragraph 25). This seemed to be the case with the August 2012 referral. 197. In the case of the April 2013 Police referral the newly introduced Integrated Advice Support Service (IASS) correctly passed it on to the Children’s Social Care ‘First Response’ team where it was allocated to a senior social worker (SW1) for an initial assessment. The initial assessment was undertaken in a very cursory manner, was significantly flawed and did not complete all of the very relevant actions set out in Carefirst by the team manager of the IASS. SFH was not seen or spoken to by SW1; there was a naïve acceptance of the mother’s denial that she was involved in substance abuse and sex working and a minimisation of the risks to the children around her admission of weekend binge drinking of alcohol. Final Version 21.03.16 50 198. There were insufficient lateral enquiries with partner agencies, especially the Police and the drugs worker at Dudley CRI when it was known by SW1 that the mother had a long history of heroin abuse and was currently subject to a methadone programme. There were no discussions with the extended family, or neighbours, who were in receipt of a great deal of information about the wellbeing of the children. Finally, the assessment lacked sufficient child focus as evidenced by the failure to ascertain SFH’s wishes, feelings and experiences of being parented by her mother. 199. Had all of these actions been carried out it is likely that they would have led to the convening of a strategy meeting/discussion with the Police, Dudley CRI and the health visitor, followed by an in-depth core assessment and/or section 47 child protection enquiry, when SFH’s previous episode of being on a child protection plan in Sandwell would have emerged. Given the knowledge of the full spectrum of information it is not unreasonable to think that Fenton and SFH would have become subject to child protection plans, or at the very least, Children in Need plans under section 17 of the Children Act 1989. 200. Instead, a decision was made by the team manager (a different one from the manager who had overseen the initial response to the referral and who had set out a number of clear tasks to be completed) to close the case. This was based on a recommendation from SW1 whose flawed initial assessment concluded that, ‘ The mother is supporting the children appropriately and there are no concerns regarding the care provided to them by those professionals already involved with the family in respect of the five outcomes for children. I recommend closure of the case on the basis that there is no evidence of harm to the children and mother engages well with professionals’. (Birmingham CSC IMR page 15) 201. An additional contextual factor of some significance (revealed at the learning event) was the, then, agency edict, of a ten day time limit in completing and closing referrals and assessments. It may have been the case that the over-optimistic, superficial and inadequate assessment and the decision to close the case were subject to a degree of organisational pressure to close cases within the ten day target. In short, corners may have been cut at the expense of an effective consideration of Fenton and SFH’s safety and wellbeing. 202. A further factor was the well documented (Ofsted, 2014) high threshold of child protection intervention by Children’s Social Care. This was indicated in the Le Grand, (2014) report which noted that there were 31/10,000 children on a child protection plan in Birmingham in November 2013, a much lower figure than comparative statistical neighbours and similar core cities. Final Version 21.03.16 51 203. In conclusion, the omission by SW1 to gather all of the known intelligence and information on the family from other agencies led to a flawed risk assessment and a decision to prematurely close the case without properly considering the risks to the children from Kelly Emery’s substance abuse and methadone use. This episode was a significant missed opportunity by Birmingham Children’s Social Care to have taken steps to intervene to safeguard the children and promote their wellbeing. 204. Both SW1 and the team manager have since left the employ of Birmingham City Council. Despite enquiries as to their current whereabouts they have not been available for interviews with the agency IMR author. Therefore it has not been possible to ask them why actions were taken and decisions made that were patently not in the interests of Fenton and SFH. 205. In relation to any wider organisational and systemic factors that might have influenced the sub-standard practice of SW1 and her manager, the agency IMR alludes to Birmingham Children’s Social Care having been served with an improvement notice in 2010 , following an Ofsted inspection which found the service to be ‘ inadequate’. 206. Following major changes in senior management within the service, the local authority responded by introducing four Integrated Access teams in 2011 and in Birmingham South, a pilot Multi-agency Safeguarding Hub (MASH), in October 2011. The overall organisational context was therefore marked by close external scrutiny, key changes in senior personnel, the introduction of structural changes, low staff morale, poor retention and lack of staff capacity10. In short, less than favourable circumstances in which to introduce significant operational changes. 207. Despite, or perhaps because of these structural changes to contact, referral and assessment arrangements, the Ofsted inspections of 2012 and 2014 continued to identify major weaknesses in the operation and practice of ‘Front Door’ Children’s Social Care. The Ofsted inspection report of 2014 found that, ‘When children and young people need statutory social work intervention, they do not experience good help and support from the Information and Advice Support Service (IASS). There is a lack of clarity and understanding about the threshold for referral to children’s social care. The absence of a qualified social worker in the IASS team means that children do not benefit from a timely response from children’s services. When children’s cases need to be progressed from the IASS to safeguarding teams, arrangements to do this are not always timely or effective. Some 10 See the Le Grand (et al) report, February 2014. Final Version 21.03.16 52 contacts were closed when further action was required, and others were not acted on by safeguarding teams, because safeguarding team managers overturned original IASS decisions. There is a lack of trust and confidence between managers about thresholds and the decision making process and this means that some children do not receive a service. (Ofsted Report, 2014, paragraphs 45 and 47) 208. Other identified factors accounting for unsafe practice at the ‘Front Door’ of Children’s Social Care were the recognition by the local authority that thresholds for starting child protection enquiries were too high, due in part to a lack of staffing capacity (Ibid, paragraph 49). Moreover, there was a lack of robust management oversight in the IASS of which contacts had been screened. Thus managers were not always aware of the screening status and progress of contacts which resulted in a lack of an effective system to monitor and track the work and check that appropriate decisions had been made about referrals. 209. In sum, this analysis concludes that the actions and decisions taken by Birmingham Children Social Care staff in their handling of the two referrals, seems to have been a function, at an individual level, of inadequate practice and poor management oversight. This was set within a wider organisational context of systemic and long entrenched problems in ensuring an effective and safe delivery of services to children, particularly (but not confined to) the ‘Front Door’ (see paragraph 4.10 of Le Grande Report February 2014). In this respect, there are several parallels between this case and the earlier SCR involving Keanu Williams which criticised front-line practice and management decision making at the time of the child’s death in 2011. Dudley CRI 210. All of the aspects of inadequate practice and service delivery to Kelly Emery and the lack of consideration around the safeguarding of Fenton and SFH identified in the earlier section (whilst the family were resident in Sandwell) continued during their time in Birmingham. The reasons for the inadequate service have already been set out previously. 211. Once it had become known that the family had moved to the Birmingham address there should have been a timely transfer of Kelly Emery’s treatment programme to the Birmingham Drug Service and the allocation of a new key worker. This did not happen because local protocols had not been developed, making information sharing and partnership working difficult. 212. Kelly Emery was allowed to continue her sporadic involvement with the Dudley CRI. She was not drug tested in accordance with agency policy and did not attend planned medical reviews. She was not given a methadone Safe Storage Final Version 21.03.16 53 Box although it was noted that she kept her prescription in a high cupboard out of the reach of the children. Her disengagement from the service meant that she was not consistently receiving the individual psycho-social support that should have underpinned the methadone programme. Moreover, there was minimal observation of her interaction with the children and oversight of the impact of her parenting on them. In short, there was no consideration given to the safeguarding and wellbeing needs of Fenton and SFH. 213. The lack of liaison between the prescribing GP at Dudley CRI and the family GP in Birmingham and the pharmacists continued the previous pattern from when Kelly Emery was in Sandwell. Given that she was being prescribed a course of anti-depressants by the family GP in the months leading up to Fenton’s death, whilst also receiving methadone, there should have been inter GP communication ( and with the pharmacist) on this matter. 214. DW1’s failure to challenge SW1 on 29.04.13 in response to her telephone enquiry of the 24.04.13 in pursuance of the initial assessment was a significant omission in safeguarding the children. It is reasonable to think that had there been some dialogue between SW1 and DW1, concerns around Kelly Emery’s poor involvement with the CRI would have come to light. This may have better informed the perception of risk by Birmingham Children Social Care leading to a form of intervention (possibly a Child in Need Plan or even a Child Protection Plan) that could have safeguarded and promoted the children’s welfare. 215. The quality of supervision of DW1 during this period was sub-standard with no evidence that there was any professional follow up of practice regarding Kelly Emery’s poor engagement; no annual review of the Parental Capacity Assessments, and minimal monitoring, factual checking and auditing of the case. No action was evident from the team leader in ensuring the timely transfer of the case to the Birmingham Drug Service. 216. In addition to the previously identified factors accounting for the inadequate safeguarding practice the CRI IMR also highlighted the tendency for the methadone treatment to over-focus on Kelly Emery as an individual rather than see her as a parent with dependent children. In essence, the treatment intervention was too adult focused and did not consider the safeguarding and welfare needs of Fenton and SFH. 217. A key learning point from this episode thus highlights the need for adult focusing agencies ( in particular, substance misusing support services) to work within a more holistic, ‘Think Family’, approach that also takes into account the impact of client behaviour on children and vulnerable others. Final Version 21.03.16 54 West Midlands Police 218. In relation to the first two contacts with the family in January and November 2012, regarding reports that Kelly Emery was dealing in drugs from her home and engaging in prostitution whilst the children were there, no effective analysis of the intelligence was made to determine whether the children were at risk. The November episode resulted in a police visit to the home and a finding that, “All parties were safe and well, no issues”. 219. Suspicions and professional curiosity should have been aroused when the adult female left by Kelly Emery to look after the children referred to her as ‘Michelle’ and claimed not to know her surname. FLINT intelligence checks to confirm the details of the children were not completed, the identity of the babysitter was not established, no referral was made to the Police Public Protection Unit (the specialist unit that dealt with child protection cases) and a child abuse non-crime number was not generated. The episode was closed by the two police constables. 220. As the Police IMR makes clear, there was a lack of professional curiosity from the investigating officers. The family details and identification (including the babysitter) should have been ascertained and arrangements should have been made to speak directly to Kelly Emery in due course. There was no assessment done on the potential risks to the children in regard to the information received from the public. Moreover, neither child was seen or spoken with. 221. The commonplace and colloquial use of the term, ‘Safe and well’ has been criticised in the IMR and also by the SCR Panel as an imprecise and, ‘non-specific phrase which leaves it unclear what actions officers actually took to determine that a child was in fact unharmed’. What is needed is for officers to pro-actively ensure the safety of the child by physically seeing them, speaking to the parents, following up any intelligence checks and fully documenting their actions before closing a case. The IMR and a previous SCR (Khyra Ishaq; 2010) recommends that the term ‘Safe and well’ should not be used and there has, in fact, been training given to officers over the last twelve months to use more qualitative language. 222. The intelligence record of the 17 January 2013 was very similar in content and nature to the previous November 2012 referral. ‘Sanitised ‘ (i.e. the process of anonymizing and evaluating intelligence) intelligence reports were sent to the Personnel Notification List’s ( PNL) of several officers although there was no evidence that they had logged into their Intelligence Management Systems and therefore would not have received them. This dissemination system has been discontinued and since April 2014, all officers are now directly notified through e- mail of any intelligence reports which need their attention. According to the Police Final Version 21.03.16 55 IMR, this is a much more effective means of disseminating intelligence and alerting officers to the fact. 223. In any event, partly as a result of the internal communication difficulties the intelligence report was not actioned by the Police. There was no child abuse non-crime report or sharing of intelligence with other agencies or attempt at determining the safety and wellbeing of Fenton and his sister. Nor was there any evidence to suggest that the relevant officers appreciated the potential adverse effects on the children from their mother’s substance misuse and chaotic lifestyle. 224. Both this incident and the previous November 2012 episode marked missed opportunities for the Police to have directly intervened in the lives of Fenton and SFH and ascertained their safety and wellbeing. 225. The decision to make a referral on the 22.04.13 by the police officer from the local burglary team to Birmingham Children’s Social Care was correctly based on an appreciation of the possible risks (albeit not informed by a formal risk assessment tool) to the children from observations of probable drug paraphernalia (namely, silver foil and spoons) and previous known intelligence. However, the standard operating procedure within the Police was for a referral to have been directly made to the Public Protection Unit (PPU) rather than, as in this case, to Birmingham Children’s Social Care (CSC). Had this been done a child abuse non -crime number would have been generated and action taken by the PPU to hold a strategy discussion with Birmingham CSC. 226. In the event, no strategy discussion ( a joint responsibility of both CSC and the PPU) was held and SW1 did not avail herself of the full range of Police intelligence on Kelly Emery which could have increased the perceived level of risk presented by her to the children and resulted in some form of multi-agency intervention. School 227. SFH attended Academy 1 where she was described as a bright, articulate child; a model pupil who always presented as immaculate, hardworking, popular and outspoken. Her attendance was registered at 98% with no issues around punctuality or unauthorised absences; nor were there any concerns around parenting. 228. A teaching assistant (TA) at the school, who was a neighbour of the family, had seen several incidents concerning anti-social behaviour and problematic parenting around loud music played at night, cars regularly coming to and from the house and a suspicion that the mother was paying for drugs. These concerns, including allegations of drug and alcohol abuse, were said to have been communicated to the school’s attendance manager (AM, who was the school’s Final Version 21.03.16 56 designated safeguarding lead) at the end of April/early May 2013. Unfortunately, no records were kept by the AM of the conversation or their dates, which breached existing safeguarding procedures and practice. 229. The TA was aware of previous concerns from another neighbour about Kelly Emery’s alleged anti-social behaviour which had been reported to the Police and the Housing department. The latter agency had taken action against Kelly Emery (the Police were said to be ‘watching ‘the house) who had confronted the TA in an angry exchange and threatened her, leaving the TA feeling vulnerable. 230. AM advised the TA to make a referral to Children’s Social Care. The TA was reluctant to do so because she was fearful of being identified by Kelly Emery and suffering repercussions, given her previous experiences. The AM therefore advised that she refer to the NSPCC. This was done on an informal basis and none of the conversations were recorded or dated. Being ‘petrified’ of making a referral to the NSPCC herself, the TA asked a friend to do so anonymously. The NSPCC had no record of any referral in late April/early May 2013 on the children or their mother. 231. The School’s and Settings Improvement Service IMR highlighted a number of deficiencies and significant breaches of basic safeguarding procedures and practice. Firstly, the AM’s advice to the TA was not compliant with the school’s (and Birmingham Safeguarding Children Board) existing safeguarding procedures and practice. The AM, as the school’s designated safeguarding lead should have made a referral to Birmingham Children Social Care. Secondly, SFH’s file was not checked. Had it been, it would have revealed that she had been subject to a child protection plan in Sandwell in 2009 (for concerns around her mother’s substance misuse), in addition to previous records from her primary school of drawings made by her of Kelly Emery’s drug use. Knowledge of the previous episode of being on a child protection plan could have been passed to SW1 at Birmingham Children’s Social Care and informed the initial assessment. The AM made some checks with SFH’s head of year and from tutor regarding the concerns but none were identified. 232. Thirdly, SFH was never spoken with about her experiences at home by any school staff. Thus, her voice was not heard in the process and there was a general lack of a child focus in this case. Finally, the recordings of the episode and decision making were minimal and sub-standard. 233. The agency IMR identifies several reasons why safeguarding procedures were not followed. These included, Final Version 21.03.16 57 • Capacity issues of the AM having a very high case load of over ninety cases where she was ‘fire- fighting’, in addition to having responsibility for addressing issues around school attendance. • An increase in workload resulting from reduction in the Education Social Work service. • Over reliance on the actions of other agencies such as the Police and Birmingham Children Social Care, where the latter agency had told the school that the case was closed after having done an assessment. The Police had stated that they were going to challenge this decision. • Over-optimism and a lack of professional curiosity about SFH’s safety and wellbeing given reports she was a ‘model’ pupil with an excellent attendance record. The TA’s concerns were rationalised and reframed as being about anti-social behaviour and ‘neighbour nuisance’ rather than the possible impact of the concerns on the children and issues around appropriate parenting. • A lack of any basic assessment that included looking at SFH’s school file and speaking to her. • Concerns for the TA about possible repercussions from Kelly Emery. • Lack of any regular and structured line management supervision for the AM and others with designated safeguarding responsibilities. 234. Overall, this analysis suggests that sub-standard safeguarding practice and poor decision making happened within an organisational context of insufficient resources and lack of line management oversight and supervision. These conditions led to corners being cut and non-compliance with basic safeguarding practice which did not promote the safety and welfare of SFH or Fenton. Moreover, there was minimal recognition or awareness of the potential risks of Kelly Emery’s substance misuse and lifestyle on the children and no evidence of any reference to the existing Birmingham Safeguarding Children Board substance misuse guidance. 235. See paragraph 403 for lessons learnt. South Central Birmingham Clinical Commissioning Group (GP Service) 236. See paragraphs 167-178 above. ToR 2 To what extent did practitioners understand and investigate the risks to the children and act on them, in particular considering maternal alcohol and substance misuse and the presence of males in the home? Final Version 21.03.16 58 237. Many aspects of this question have already been addressed in the previous term of reference and paragraphs from that part of the report will be cited to inform the ensuing analysis of this section. 238. The analysis and supporting evidence of ToR 1 have shown that, with the exception of the Probation Service and to some extent the West Midlands Police in regard to the April 2013 referral by the burglary team; practitioners did not understand and investigate the risks to the children from their mother’s behaviour in general and substance and alcohol misuse in particular. Nor was there sufficient appreciation of the presence of males in the home and its implications for the children. Consequently, no effective action was taken by any of the relevant agencies (save those already mentioned above) to safeguard and promote the welfare of Fenton and his sister. 239. This Review has identified that there should have been a pre-birth review undertaken jointly by the Dudley CRI and the specialist midwife in line with Dudley Safeguarding Children Board guidance (see above at paragraph 126). Indeed, this was one of the Key Practice Episodes (KPE1) analysed at the Learning Event. Why was not a pre-birth assessment held? 240. The process leading up to a review should have started with Dudley CRI undertaking an effective Parent Capacity Assessment. This should have accurately identified any risks to the unborn child and SFH from Kelly Emery’s methadone use and substance misuse. The known risk factors (i.e. SFH’s child protection plan of 2009, Kelly’s sporadic engagement with CRI, evidence of ongoing substance abuse when arrested by the Police in May 2011, no drug tests, Kelly Emery’s community order with the Probation Service) should have raised questions and prompted, ‘professional curiosity’, for the safety and wellbeing of the unborn child and SFH. These should have been shared with the specialist substance misuse midwife who attended Dudley CRI for a fortnightly ante-natal clinic which at the time did not involve a joint meeting with the CRI prescribing doctor and allocated drugs worker. 241. Formal channels of communication in 2011 between the specialist substance misuse midwifery service and Dudley CRI professionals were thus not in place. Currently, the Specialist Midwife conducts a fortnightly antenatal clinic for women accessing services at Atlantic house (Dudley CRI). Joint substance misuse/antenatal clinics are also conducted by the Specialist Midwife and Consultant in Specialist Addictions on a six weekly basis at Atlantic House. The woman’s drug worker is also present at this appointment. 242. Regarding Dudley CRI, the reasons for the lack of an effective Parenting Capacity Assessment have been previously set out above at paragraphs 116 and 118. A key factor was the ‘silo’ approach on ‘harm reduction’ intervention that Final Version 21.03.16 59 was entirely adult focused on Kelly Emery. This was not holistic and did not ‘Think Family’ and consider the safeguarding needs of and risks to the children of Kelly Emery’s methadone use and substance misuse. 243. The inaccurate view communicated to the specialist midwife by CRI Dudley was that Kelly Emery was stable on her methadone programme with no current safeguarding concerns. A drug test on Kelly Emery done by the hospital on the 21.06.11 indicated that she was positive for methadone and did not detect any banned substances. This may have reinforced the midwife’s thinking that there were minimal concerns around evidence of any substance misuse by Kelly Emery. Moreover, there was no evidence of Fenton suffering from neo-natal abstinence syndrome on discharge from hospital. The specialist midwife’s positive perception developed into a mind-set and dominant narrative of Kelly Emery who claimed to be co-operating with Dudley CRI and receiving support from her mother and male partner, neither of which were true. This narrative described Kelly Emery as adequately managing the care of Fenton and SFH. Arguably, there was a degree of naivety on the part of the specialist midwife in not seeking any third party corroboration of Kelly Emery’s self-reported accounts of her drug use and lifestyle. 244. A Review of cases (Adfam, 2014) involving intentional administration of Opiate Substitutes (methadone) to children by their parents has identified a common feature to be the omission or minimisation of risk factors by professionals. Professionals working with adults, understandably, often adopt a ‘Positive regard’ attitude towards their clients/patients/service users which rules out the ‘unthinkable’ of deliberate administration of methadone as a pacifier to children by their parents. 245. This SCR agrees with the observations in the Adfam Review that a ‘cultural shift’ by agencies and practitioners is needed towards adopting a more robust and challenging approach to substance misusing parents. Whilst respecting the adult, practitioners should have an open mind on circumstances and maintain a degree of ‘healthy scepticism and respectful uncertainty’ in their work with parental substance misusers. 11 In short, practitioners should not automatically take the word of clients who substance misuse. Rather, in the interests of children’s welfare they need to seek corroboration from other professional sources. The approach would be applicable to all practitioners (both adult and children’s services) working with substance misusing parents and not just specialist substance misuse midwifes. 11 These terms are taken from the Victoria Climbie Inquiry Report authored by Lord Laming in 2003. See also ‘Medications in Drug Treatment: Tackling the Risks to Children’ (Adfam: 2014, pp54-55). Final Version 21.03.16 60 246. In any event, informed by an overly optimistic understanding of Fenton’s family situation no assessment of need/risk was undertaken by the specialist midwife; nor were any safeguarding issues identified. Moreover, even if any concerns had been recognised, the specialist was not aware of a formal threshold document (The ‘Right Services, Right Time, Right Place’ threshold document was only introduced in September 2011), or a risk assessment tool that considered the impact of parental substance misuse on children. There was also no structured ‘pathway’ process for adult substance misuse services working with parents in place at the time. One was subsequently later produced by Public Health England in 2013 (see appendix 7) which this Review would commend the use of to all of the agencies involved in this Serious Case Review. This Review submits that the presence of these systems and processes in 2011 would have greatly facilitated a joint review by the Dudley CRI and the specialist midwife into the needs and risks of the children. 247. However, notwithstanding the lack of the above guidance, the overly optimistic narrative needed to be set against the known evidence of a number of significant risk factors as set out above in paragraph 128. On this basis, the lead reviewer and Panel are of the opinion that there were sufficient grounds for the specialist midwife to have requested a joint review with Dudley CRI of Fenton, SFH and Kelly Emery’s circumstances. Such action would have been consistent with both the Dudley and Sandwell SCBs extant guidance on maternal substance misuse as set out in paragraphs 126 and 146 above. Had this happened it is probable that a decision to make a referral to Sandwell Children’s Social Care for a pre-birth assessment on Fenton would have followed. At the very least a Common Assessment/Early Help offer may have resulted or, depending on the circumstances at the time, perhaps a child in need plan or even recourse to child protection measures might have ensued. 248. In any event, this was a missed, early opportunity for a pre-birth, multi-agency intervention to have been started which could have sought to safeguard and promote the children’s welfare and got them on the Sandwell Children’s Services ‘radar’. 249. The key learning points are set out at paragraph 345. Post Birth Assessments in Sandwell 250. As previously mentioned, Staffordshire and West Midlands Probation Trust understood the risks to Fenton and SFH from Kelly Emery’s methadone use and substance misuse by classifying her as a ‘medium risk to children’, following the OASYS offender assessment. In the lead reviewer’s opinion the risk classification Final Version 21.03.16 61 would have been increased to ‘high risk’ had the Probation Service Officer (PSO1) spoken with the drugs worker from Dudley CRI and learnt that Kelly Emery’s engagement with the agency for her methadone treatment was sporadic and that she was not being drug tested. Adherence to the methadone programme and regular drug testing were two key conditions of the twelve month community order and risk management plan. 251. As pointed out in the agency IMR, action should have been taken to identify Kelly Emery’s partner (FFH) and establish whether he was known to the Probation Service. The agency had evidence suggesting that FFH was misusing substances and enquiries should have been done to ascertain any potential risk to Kelly Emery and the children. Whilst acknowledging the concerning omission PSO1 was not able to explain why she had missed this matter, save that there had been an overreliance on information given by Kelly Emery. This was a feature in all agency contacts throughout this case. 252. The IMR identified that although the risk to the children was identified as medium which resulted in a late referral to Sandwell Children Social Care, the case should have been flagged as a, ‘Child concern’, on the agency’s internal recording system. The absence of flagging meant that the case was not identified as one needing escalation to management oversight by a senior probation officer. This gap in practice, according to the IMR, was not unique to this case and an implementation circular was issued to clarify the practice in December 2012. 253. See paragraph 355 for the key learning point. 254. In relation to the Sandwell and West Birmingham Hospital’s Trust health visiting service the evidence suggests that the risks to the children from Kelly Emery’s substance misuse were not well understood or investigated. Although the proposed Universal Plus/Active Intervention support package recognised Kelly Emery’s methadone use there was no effective consideration of the potential risks to Fenton and SFH. 255. Reasons for this included the health visitor’s untested assumptions, based, partly on Kelly Emery’s self-reporting that her methadone and substance abuse risks were being mitigated by positive engagement with the Dudley CRI and that consistent support was being given by the maternal grandmother. Both of these accounts were untrue. 256. HV2 should have spoken directly with the drugs worker at Dudley CRI to find out the extent to which Kelly Emery was co-operating in her methadone treatment. Moreover, there should have been a phone call to Sandwell Children’s Social Care to enquire about that agency’s previous involvement with the family in relation to SFH’s child protection plan of 2009, given the reference to the agency Final Version 21.03.16 62 in the health visiting card. Fenton’s defaulted hospital neo-natal appointments should also have been followed up in a timely way and given rise to some concerns. 257. Here, the rule of optimism, untested assumptions based on untruthful accounts from Kelly Emery; and a lack of lateral enquiries with other involved agencies, seemed to have contributed to a health visiting perception that Kelly Emery was adequately managing the care of Fenton. His development was therefore not identified as requiring further follow up. 258. Also, there was no appreciation of the presence of males in the household and the potential risks presented to the children. The ‘invisibility’ of males would appear to be a common phenomenon amongst child welfare practitioners. 259. See paragraph 357 for key learning points. 260. The child protection referral and request for an assessment made by the Probation service to Sandwell Children’s Social Care on the 20.07.11, some two days after Fenton’s birth and whilst he and Kelly Emery were in Russells Hall Hospital, was responded to in a very inadequate manner. It breached the Sandwell Safeguarding Children Board procedures which stated very clearly that, “Where a referral is made in relation to a child where the parents have a substance dependency, Children’s Social Care Services will undertake an Initial Assessment and if necessary a Core Assessment’. 261. As previously analysed and concluded in ToR 1 at paragraphs 162-166, there should have been an Initial Assessment informed by rigorous lateral enquiries with all of the agencies involved with Kelly Emery and both children. Instead, only limited and partial checks were made with the Probation Service (and not with PSO1) and the community midwife, who, “appeared to reassure the duty worker that there was sufficient support from professionals and family not to warrant a further assessment”, (Agency IMR, page 6). Indeed, given the array of risk factors present at the time, it is reasonable to suppose that a core assessment would have followed, resulting in a Child in Need Plan or possibly a Child Protection Plan. 262. In addition, no reference was made to the presence of males in the home or any associated potential risks to the children. 263. In conclusion, the inadequate enquiry by Sandwell Children’s Social Care into the concerns for the children by the Probation service, the lack of an Initial Assessment and poor management challenge and oversight, evidenced minimal Final Version 21.03.16 63 understanding of the risks to them and marked a very significant lost opportunity to safeguard and promote their welfare. 264. The poor practice response and inadequate management challenge and oversight can be seen as a function of the wider organisational context of systemic problems within Sandwell Children’s Services and in particular the referral and assessment team in July 2011, as referenced by the agency’s IMR. 265. Additional contextual insight into organisational issues has been provided by the 2010 Ofsted inspection report of safeguarding and looked after children services. Then, Sandwell Children’s Services were subject to an improvement notice which was overseen by an Improvement Board. The inspection found the overall effectiveness of safeguarding services in Sandwell to be ‘Inadequate’. Of some significance in regard to this practice episode, the report noted that the Referral and Assessment team had, 266. “Been under considerable staffing pressures and several posts have been filled by a succession of short term agency staff. As a result, thresholds for intervention remain too high and assessments are not routinely completed and lack detailed analyses of risk and need. Assessment and planning processes are inadequate. The use of CAF (Common Assessment Framework) is not yet fully embedded across the borough”. (page 7, paragraph 18) 267. The local authority was required within three months to, “Review staff workloads and pressures in referral and assessment services and take action to ensure these are consistently delivered to the required standards and are supported by regular supervision and managerial oversight”. (paragraph 16) 268. Three years on, things had not improved. The Ofsted Inspection report of 2013 judged the overall effectiveness of child protection in Sandwell to be inadequate and that, “Significant, systemic failures in arrangements for the protection of children mean that the council and its partners cannot be assured that all children and young people in Sandwell are being appropriately protected from harm”. (Page 6, paragraph 14) 269. Ofsted required that the local authority, • “Ensure that all Section 47 enquiries are compliant with child protection procedures and statutory guidance. Final Version 21.03.16 64 • Introduce a formal risk assessment process to improve management oversight of child protection work and ensure that decisions are based on robust written evaluations of risk. • Improve the quality and consistency of assessments so that full account is taken of risks, protective factors and historical information and that where appropriate, fathers are fully engaged in the process” 270. See paragraphs 361-362 for learning points. Assessments in Birmingham 271. In regard to the Worcestershire Health and Care NHS Trust health visiting service, WHV1 knew of the risks associated with parental substance misuse and possible accidental ingestion of methadone by children. WHV1 said in interview that normally she covered these aspects with substance misusing parents and could not explain why she had not done so with Kelly Emery. 272. By way of partial explanation, WHV1 said that Kelly Emery was ‘very welcoming’ and seemed very open with her. In these circumstances when faced with a welcoming and likable mother it was difficult to ‘Think the unthinkable’. Hence, she had not considered the possibility that a mother might purposely administer the substance to a child to keep them quiet. There may have been an element of ‘false or disguised compliance’ from Kelly Emery. 273. For further analysis, reference has previously been made (at paragraphs 188-190) to WHV1’s lack of consideration of potential risk to Fenton from Kelly Emery’s substance and alcohol misuse and the reasons for this. 274. WHV1 was aware that Fenton’s father was in prison; she said that there had been discussions with Kelly Emery about contact with the father and where he planned to live on release. 275. As observed by the agency IMR, the bruise noted on Fenton at the final visit should have been referred onto Birmingham Children’s Social Care, particularly given the earlier assessment completed in late April 2013 and the discussion had between WHV1 and the duty social worker. 276. Key lessons are set out at paragraph 380. Final Version 21.03.16 65 277. Regarding Birmingham Children’s Social Care the evidence and analyses presented in ToR 1 at paragraphs 190-209 have shown that the practitioners involved in the two referrals of August 2012 and April 2013 did not sufficiently understand or adequately investigate the risks to the children from their mother’s substance misuse and methadone use. The reasons for this are set out in the above mentioned paragraphs of this report and it is not intended to repeat them here. 278. These episodes were very significant missed opportunities to intervene in the lives of Fenton and his sister and promote their safety and welfare. 279. See paragraph 385 for key learning points. 280. Regarding the West Midlands Police, its IMR found that all (save one) of the officers who had involvement with the family between 2011 and July 2013 did not recognise the risks to the two children. Hence, no referral was made to the Public Protection Unit/Child Abuse Investigation Unit for an assessment and possible investigation. This included the custody staff who dealt with Kelly Emery in May 2011. Moreover, even when the risk was recognised by DC2 in March 2013, staff did not follow proper procedure and make an internal referral to the Police Protection Unit (PPU). 281. In the event, the referral to Children’s Social Care on the 22 April 2013 by DC2 was a month after the episode and should have been made contemporaneously to the PPU. The reason for the delay was that DC2 was unclear of the correct pathway for making a referral, which as noted below (at paragraph 221) is not uncommon amongst front line (non PPU) officers. If the referral had been made in March, standard practice should have resulted in the generation of a child abuse non-crime number and the probability of a strategy discussion between the PPU and SW1 from Birmingham Children’s Social Care. The very significant intelligence held on Kelly Emery by the Police could have been shared with SW1 and her manager and a section 47 enquiry duly initiated. Moreover, according to the Police IMR, (at page 19), a strategy discussion would have ‘afforded the opportunity for suitably trained officers to make a joint visit with the assessing social worker’, possibly leading to a more rigorous and fuller initial assessment and follow up child protection response. 282. A further issue was the inter-agency escalation process not being used by the police in response to SW1 and her manager’s decision to take no further action and close the case on the 26.04.13. DC2 was uncomfortable with this response and discussed his concerns with a PPU officer (DC1) who directly challenged SW1’s assessment that there were no safeguarding concerns. The lack of Final Version 21.03.16 66 recording by DC1 and her supervisor (ADS) not to formally escalate a challenge to Birmingham CSC was not compliant with agency practice. Police standard operating procedure provides that a decision and rationale, not to challenge (or conversely, to challenge) another agency’s actions would be recorded on the CRIMES (crime recording system) portal. The result in this case was that the decision went unchallenged despite the legitimate reservations of the two DCs. 283. Clearly, DC1 and ADS should have recorded any discussions held regarding challenging Birmingham CSC’s decision to close the case, along with a rationale for any decisions (entered on the CRIMES portal) relating to accepting, or not, the course of action. 284. Passing reference only was made in a Police log in May 2011 to FFH as being the temporary partner to Kelly Emery. There was no effort made to find out more about him and any potential risk implications for the children. 285. The above findings need to be set within the wider context of the Police role in safeguarding children. This can be found in the October 2014 HMIC12 inspection report of the West Midlands Police Child Protection service; the specific police roles as set out in the guidance13are: • The identification of children who might be at risk from abuse and neglect. • The investigation of alleged offences against children • Their work with other agencies, particularly the requirement to share information that is relevant to child protection issues 286. Moreover, ‘Every officer and member of police staff should understand their duty to protect children as part of their day-to-day business. It is essential that officers going into people’s homes regarding any policing matter recognise the needs of children they may encounter’ (HMIC, October 2014, 9) 287. As previously mentioned, there were several missed occasions when the Police could have intervened in the children’s lives and liaised with Sandwell and Birmingham Children’s Social Care, respectively; to safeguard and promote their welfare. These included the four times she was in custody between May to July 2011 (see paragraphs 183-184 above) and the two occasions in November 2012 and January 2013 (see paragraphs 220-226) regarding the allegations of drug 12 Her Majesty’s Inspectorate of Constabulary 13 Working Together To Safeguard Children: HM Government, March 2013. Final Version 21.03.16 67 taking and sex working. Non-abuse crime reports/numbers should have been submitted and referrals made to the Public Protection Unit/Child Abuse Investigation Units (CAIU). Why were risks not recognised, interventions not made and non-abuse crime reports not submitted? 288. Several reasons have been identified both in the IMR and from the learning event. These include; • Officers being too ‘crime focused’ and not sufficiently attuned to the circumstances of the children. • Intelligence officers not always being conversant with their responsibilities regarding safeguarding and child protection. • Confusion with front line officers around correct referral pathways to the PPU. • Not seeing and speaking to the children (SFH). • A tendency towards ‘Silo’ department working. • Interoperability difficulties around internal Police IT systems. • Internal and external information sharing/inconsistent use of flags on IT systems. • General lack of awareness by some front line officers of the risks to the children from their mother’s substance misuse. • Lack of a risk analysis. • Lack of building intelligence and joining ‘The jigsaw’ to see the ‘bigger picture’ of the children’s situation. • Lack of supervision • Over-reliance on ‘Safe and Well’ checks when investigatory follow up actions should have been undertaken. 289. Several of these factors are reflected in the HMIC inspection report, which whilst not confined just to practice in Birmingham, did identify (at page 20) ‘a lack of understanding (from officers) about, and guidance for recording information that had come to the attention of the police……..they should initiate an electronic non-crime incident form’. The report highlights the importance of the form, which outlines an incident, risks to the children and any action taken; and crucially, its use. In the case of any further incidents with a child, a cumulative record of a pattern of abuse can be identified leading to a much richer and more comprehensive intelligence picture that can be shared with other agencies when needed. 290. There was also a general lack of awareness of child protection issues and inconsistent supervisory oversight in some frontline teams which may have accounted for the poor recording and quality of information in some cases. These observations in the HMIC report (at page 20) resonated with the findings of this SCR. Final Version 21.03.16 68 291. See paragraphs 365-373 for key lessons. 292. The contacts with the GP services in Sandwell and Birmingham have already been set out previously in paragraphs 167-178 above. The evidence and analysis of these paragraphs demonstrates that the GP services in Sandwell and in particular, Birmingham (Frankley) did not recognise any safeguarding issues in respect of Fenton and SFH, when, patently, there were. Kelly Emery’s methadone programme and mental health issues were not seen by the Frankley GP in a wider context as presenting a possible risk to the children’s welfare and safety. This included no discussion of safe methadone storage. The absence of a holistic, ‘Think Family’ approach to Kelly Emery precluded any exploration of the presence of males in the home. 293. As identified by the IMR, a good opportunity to have made some enquiries about the impact of Kelly Emery’s parenting on the children was during the consultations in December 2012 and early 2013 when she was being treated for depression. In particular, her written ‘cry for help’ to the GP at the December consultation should have prompted action to seek to understand and investigate the risks to the children. As previously mentioned there were no lateral communications with the Dudley CRI or the practice health visitor. The reasons for this have been previously set out in paragraphs 172 to 174 above. 294. Reasons for the lack of action by the GP practice to make some enquiries on the children included the absence of a holistic approach with an overly narrow professional adult focus on Kelly Emery’s depression. This medical model approach confined itself to diagnosis and medication with no wider reference to liaison with the Dudley CRI or the relevant practice health visitor. This was an example of ‘Silo’ practice which is a recurrent theme amongst other agencies in this review. The GP should have followed the GMC and Birmingham Safeguarding Children Board guidance in regard to parental substance misuse and mental health and considered the impact of Kelly Emery’s parenting on the children. Analysis as to why this did not happen is provided in paragraphs 172-178. 295. Key lessons and current practice are set out at paragraphs 398-400. 296. Regarding SFH’s school (Academy 1), the previous analysis in Term of Reference One (see paragraphs 231-233) concluded that there was minimal recognition or awareness of the potential risks of Kelly Emery’s substance/alcohol misuse on the children and no evidence of any reference to the existing Birmingham Safeguarding Children Board substance misuse guidance. Final Version 21.03.16 69 Moreover, there was also no awareness of the potential dangers presence of males in the home. 297. The principal reason for these deficiencies was the lack of adherence by the school safeguarding lead to the Birmingham Safeguarding Children Board to the published guidance and the absence of senior staff oversight. The contributory causal factors for this are set out in paragraphs 233-234. 298. Key lessons can be found at paragraph 403 below. ToR 3 To what degree were both children’s wishes and feelings, the voice of the child and needs for protection recognised and acted upon by practitioners? 299. The foregoing analyses and accompanying underpinning evidence, set out in the preceding ToRs, suggests that there were very few occasions when the voices of Fenton and his sister were heard by practitioners and their wishes and feelings noted and acknowledged. Exceptions, to some extent, were those occasions when the Probation service PSO1 and the local burglary team police officer recognised the children’s needs for protection and made referrals to Sandwell and Birmingham Children’s Services respectively. 300. However, apart from these two instances, none of the other involved practitioners or their managers; in particular those from Sandwell and Birmingham Children’s Social Care and SFH’s secondary school, sought to talk with SFH in an attempt to understand her experience of living with and being parented by Kelly Emery. Regarding Fenton, none of the relevant child care agencies, GP services and Dudley CRI effectively documented the interaction with his mother, considered his lived experience with her or attempted to get a sense of his ‘voice’. Significant emphasis is given in Government guidance (‘Working Together’ 2013, 2015 and previous editions) and in the Children Act 1989 to establishing the wishes and feelings of children and young people. Why was this not done in this case? 301. Likely reasons include; • Silo working within agencies and within agency departments such as the West Midlands Police (crime focused and offence specific) which omitted consideration of the welfare of the children. • An overly adult focus on Kelly Emery by adult services such as GPs (patient and symptom focus), Dudley CRI (methadone programme, harm reduction focus) which did not recognise the presence of the children Final Version 21.03.16 70 • Professional assumptions and an unchallenged ‘narrative’ that the mother was being supported by her extended family and other agencies, leading to a low perception of risk for the children. • Lack of a holistic,’ Think Family, Whole Family’, 14interactional approach by adult service providers that considered the impact of Kelly Emery’s behaviour and actions on her children and vice versa.15 • Pressure on Birmingham Children’s Social Care practitioners to close assessments in ten working days and ‘cut corners’ by not seeing the child. • In the case of Sandwell Children Social Care, the workload demand and its effect on staff and over reliance on agency staff, and pressures to address a significant workload. 302. Ofsted (2010), in a study of the importance of professionals listening to the voice of the child and learning lessons from Serious Case Reviews, found that, • “The child was not seen frequently enough by the professionals involved, or was not asked about their view and feelings. • Agencies did not listen to adults who tried to speak on behalf of the child and who had important information to contribute • Parents and carers prevented professionals from seeing and listening to the child • Practitioners focused too much on the needs of the parents, especially on vulnerable parents, and overlooked the implications for the child. • Agencies did not interpret their findings well enough to protect the child.” All five of these findings resonate with this case and can be identified as factors in how the agencies interacted with Fenton, his sister and Kelly Emery. The key lessons are set out at paragraphs 412-414. ToR 4 14 See the ‘Think Family Protocol’ (based on original work by the Social Care Institute for Excellence in 2009) from Warwickshire Safeguarding Children Board for principles. 15 This approach is not the same as the ‘Think Family’ initiative (which comes under the ‘Troubled Families’ programme of the Department for Communities and Local Government (DCLG)) currently being implemented by Birmingham City Council. See the Birmingham Safeguarding Children Board website for more information. Final Version 21.03.16 71 Did agencies undertake formal interventions to safeguard the children appropriately? If they did, were they effective? If not, why did they not happen? 303. As previously noted, there were several missed opportunities for agencies to have taken action, both before and after Fenton’s birth whilst he was living in Sandwell; and then after the family’s move to Birmingham, which could have contributed towards safeguarding and promoting the welfare of the two children. The reasons and analyses why this did not happen have been set out in the earlier sections of this report. 304. In regard to formal interventions to safeguard the children there were three occasions when this should have taken place. Firstly, following the referral from the Probation service to Sandwell Children’s Social Care consequent to Fenton’s birth in July 2011. Secondly, in August 2012 consequent to the anonymous referral to Birmingham Integrated access team and thirdly, in April 2013 when Birmingham Children’s Social Care received a referral from the West Midlands Police. The referral from the TA at SFH’s school to the Attendance Manager/Safeguarding Lead was not passed to Birmingham Children’s Services, as Child Protection Procedures required. Had it been, Children’s Services would have been alerted to the serious situation in which Fenton and his sister were living. The failure to deal properly with this was a significant lost opportunity to protect the children. Possibly the last one before Fentons’ death. 305. On no occasion did these referrals lead to the instigation of formal safeguarding interventions by way of strategy discussions, Section 47 enquiries, initial child protection conferences and possible formal child protection plans or child in need plans. 306. As previously noted, the referral to Sandwell Children’s Social Care led to no further action, rather than the completion of an initial assessment and if necessary a core assessment, in line with existing standard safeguarding procedures. An analysis and reasoning for this has been provided above at paragraphs 260-269.. 307. Regarding the two Birmingham referrals and why they did not result in action to safeguard Fenton and his sister, the analytical reasoning is given at paragraphs 190-209 above. Final Version 21.03.16 72 Family Views 308. Both sets of grandparents and Fenton’s father were seen in separate meetings by the SCR Panel Chair and the lead reviewer in July 2015. The purpose of the meetings was to hear their views about the way that agencies handled the situation with Fenton, his sister and Kelly Emery. All family members were aware of what had happened from their attendance at Kelly Emery’s trial in March 2015. SFH declined to be interviewed. The accounts below are summaries from the written notes of the Panel Chair which have been seen by the family members and agreed as being an accurate version of what was said. Fenton’s Paternal Grandparents and Father 309. Fenton’s father (FFH) had been in prison during the lifetime of his son but had seen him on prison visits and had formed a deep attachment with him. FFH was aware of Kelly Emery’s drug use and was very concerned about the response to it from the drug agency based at Atlantic House. He considered it unacceptable and a dangerous practice that Kelly Emery’s methadone script was posted out to her when she had not been drug tested. He felt that there were clear indications that Kelly Emery was using other none prescribed drugs and to presume that she was not using, in the absence of proof by drug testing, was an unsafe response. 310. The paternal grandparents (PGFH) had the care of Fenton on most weekends. They said that they were not welcome by Kelly Emery to collect Fenton and there was an arrangement whereby the maternal grandmother would bring him to them. Alternatively, Kelly Emery would meet them away from the home and pass Fenton to them. They now consider this was to prevent them seeing the unacceptable home conditions, which were described during the trial. 311. The PGFH and FFH felt that the referrals to Birmingham Children Social Care had not been thoroughly investigated. FFH stated that SFH’s teacher had phoned Social Care several times about concerns around lack of parental care. They understood that a social work visit had taken place some ten days before the death of Fenton and questioned why no action on the children’s situation had been taken. They had a copy of a section 47 report giving details which would be sent to the lead reviewer. 312. FFH also highlighted concerns that the Police saw unsatisfactory home conditions and felt that they could have removed the children on an emergency basis to ensure their safety. FFH and PGFH understood that Social Care had carried out a home visit in June 2013 when home conditions were alleged to be poor. They considered that (Birmingham) Social Care had failed to assess the risk to the children and act appropriately. They also felt that the incidents at Kelly Emery’s home involving parties and disturbances were well known. Agencies did Final Version 21.03.16 73 not consider the risks to the children, in particular Fenton being so young and vulnerable. They felt if appropriate action had been taken his life could have been saved. The Maternal Grandparents 313. The maternal grandparents described many years of trying to support their daughter Kelly Emery in numerous difficult situations caused by her drug misuse. In 1999 they had sold their home to move to another area, in an attempt to separate Kelly Emery from the drug dealing/using fraternity she was involved with. These problems predated SFH’s birth but had progressively become more serious and worrying for the maternal grandparents once SFH and then Fenton were born. 314. They complained of a lack of support from Children’s Social Care both from Sandwell and Birmingham. When SFH had been subject to a CP Plan the maternal grandmother (MGM) had initiated the intervention by reporting concerns relating to SFH’s safety and wellbeing due to neglect on the part of Kelly Emery. MGM felt that throughout the intervention Kelly Emery “managed” the social workers, complaining about any who challenged her and having them replaced. MGM tried to tell the social workers how manipulative Kelly Emery was but felt she was not listened to. Both maternal grandparents felt all social workers involved should have made unannounced visits. They then would have gained a more accurate picture of the lifestyle of Kelly Emery and the neglect the children were suffering. As a result of MGM’s referral Kelly Emery refused her access to SFH for a year. This caused great distress to MGM resulting in her feeling unable to report further concerns regarding SFH and later Fenton, as she feared losing her contact with them again. In effect Kelly Emery was controlling her mother by this threat. 315. The maternal grandparents described a deteriorating series of events in the lives of Kelly Emery and her children. These included frequent house moves, damage to her homes windows being smashed and a car, being used by Kelly Emery, being “petrol bombed’. These events they understood to be related to drug use and dealing. The MGPs frequently heard of the noisy parties and frequency of male visitors to Kelly Emery’s home from her neighbours and friends who had witnessed or heard accounts of these. They were aware Kelly Emery was involved in prostitution and had tried to dissuade her from this. They described Kelly Emery’s care of Fenton to be good during his first year, however once she moved to Rednal in Birmingham, the situation deteriorated markedly. The lack of any unannounced visits to Kelly Emery’s home by social workers and other professionals was again a feature of concern. They felt this contrasted keenly with the frequent inspections of their home prior to SFH’s permanent placement with them being agreed. Final Version 21.03.16 74 316. SFH’s life experience was described as living with the home conditions described above; in addition Kelly Emery sold SFH’s possessions to purchase drugs. Her grandparents tried to keep any valuable items owned by SFH at their home but often Kelly Emery would insist on taking these to her home, she would then sell them. MGM described trying to improve Kelly Emery’s home for the sake of the children, buying replacement carpet and furniture and decorating the houses. SFH spent almost all weekends with her grandparents. MGM described both of them being in tears when the time came for SFH to be taken home. On one occasion a friend witnessed their distress and had made an anonymous call to Social Care giving information about the concerns, including concerns that the children were inadequately fed. MGM believes the Social Care did not check their records fully when evaluating this referral. 317. The MGPs were also concerned that the drug agencies were not sufficiently robust in monitoring Kelly Emery’s drug use while issuing her with prescriptions for methadone. Kelly Emery was able to obtain prescriptions through the post so avoiding clinic appointments and any testing for her use of other drugs. On occasions SFH told her grandparents Kelly Emery had used SFH’s urine to submit as a sample in place of her own, in order that her use of non-prescribed drugs would not be identified. The MGPs felt Kelly Emery manipulated her key drugs worker DW1 and had him, “wrapped around her little finger”. Both Grandparents said methadone containers were everywhere in the house. They had not considered Kelly Emery would administer drugs to her children. Following Fenton’s death, a neighbour of Kelly’s, told of a conversation she had with Kelly Emery in 2013 prior to Fenton’s death in which Kelly Emery had spoken of the dangers of methadone and she would not give it to a child. The MGM had reported this to the police investigating the circumstances of Fenton’s death.16 Kelly Emery 318. Kelly Emery agreed to be interviewed as she hoped the Serious Case Review Reports findings would contribute to a safer environment for children whose parents abuse substances. She felt that overall the professionals who visited her were too trusting and accepted her assurances regarding her situation and her ability to care for her children. Kelly Emery felt they placed too much weight on the good appearance of her home and the fact that FH’s sister attended school regularly and without problems. She was untruthful about her drug use and those visiting her accepted what she said without question. She thought professionals should be aware that drug users may be untruthful. 16 This information was passed on to the West Midlands Police by the lead reviewer shortly after the interview in July 2015. Final Version 21.03.16 75 319. Specifically she highlighted; • The repeated issuing of prescriptions for her methadone, by the agency, without drug testing her, this allowed her on occasion to store the methadone, as she was additionally using other drugs. • The professionals visiting accepted her account of her compliance with the methadone programme, without seeking any verification. 320. Kelly Emery said as she was using other drugs in addition to the methadone she was able to store quantities of the methadone in the house. She was not supplied with a secure box to store the methadone. She was not told in detail about the dangers of methadone to children or that a small amount could kill a child. 321. She would have expected professionals to seek some verification, of her accounts of her drug taking and lifestyle; she knew that her mother was concerned and would have voiced those concerns had she been seen without Kelly Emery being present. One worker who called to assess home circumstances following a Police referral stayed no longer than 10 minutes. Key Learning and Findings from Similar Serious Case Reviews 322. All but one of the SCRs have involved the deaths of young children from methadone ingestion whilst in the care of their parents/carers. The Child Daniel, Wolverhampton SCR concerned the death of a young child (23 months) from heroin ingestion. Birmingham SCB; Child 2007-8/3 323. The child (2 years and 5 months) died in 2008 as a result of drinking methadone. His older sibling also drank methadone but survived. The SCR Overview Report was completed in June 2009. Key relevant findings and learning points were, • Professionals were overly focused on the needs of the adults and not sufficiently aware of the neglect suffered by the two children. • The mother’s drug abuse was not fully recognised and the impact of two drug abusing parents on the children was missed. • The BSCB and Birmingham Drug and Alcohol Action Team to commission training for professionals in recognising drug abuse by parents and the impact on their children • Agencies were working in isolation with poor information sharing between them. Final Version 21.03.16 76 • A general lack of professional curiosity and failure to challenge the parents who showed apparent compliance • A willingness for professionals to accept the reassurances and excuses of the parents despite chronic neglect and inadequate parenting • A lack of a holistic view of the family • Professionals did not follow basic procedures, failed to intervene appropriately and did not respond to the obvious risks to the children. Wolverhampton Safeguarding Children Board; Child Daniel 324. Daniel (aged 23 months) died after ingesting heroin in May 2011 whilst in the care of his parents who were on methadone programmes. The SCR report was published in 2013. Key relevant findings and learning points were, • Insufficient child focus; practitioners did not understand the day to day experience of the child. • Missed opportunities to address safety issues with the parents around safe storage and use of substances. • Missed opportunities to undertake effective assessments around the impact on the child of parental substance misuse. • Lack of challenging but supportive management oversight • The need to guard against professional ‘ over-optimism’ and fixed thinking and maintain a child focus. • WSCB to develop an inter-agency pathway and protocol for assessing the needs of unborn babies in all circumstances where there is the likelihood of compromised parenting. • The need for professionals to have in mind the ‘Think Family’ approach when working with adults who have children. Derbyshire Safeguarding Children Board; Child BDS (Published November 2013) 325. BDS, a two year old boy died in March 2012 from ingesting his mother’s methadone from his beaker. Key relevant findings and learning points were; • The failure of drug treatment professionals to prioritise the safety of the child over the needs of the mother. • Robustly risk assess the mother regarding her suitability for having methadone in the home where she had the care of her young son and to review this as circumstances changed and incidents occurred, sharing information with other professionals as necessary. • An over-reliance on mother’s ‘ Engagement’ with services as evidence of compliance and a lack of professional challenge and cynicism Final Version 21.03.16 77 • Lack of a referral to Children’s Social Care which could have led to a comprehensive assessment being made and the likelihood of the child being subject to a child protection plan. • The need for a ‘Think Family’ approach. Blackpool Safeguarding Children Board; Child BT (Published May 2015) 326. The young child BT died in 2014 from methadone poisoning after drinking the substance from a feeding cup whilst in the care of both parents. Key findings and relevant learning points were, • A whole-family approach was lacking which did not include the father. There were no parenting assessments done. • Despite knowing about the mother’s illicit drug use the substance misuse service did not make a referral to Children’s Social Care. • Specialist drug services were aware of the child’s mother not complying with OST treatment by using illicit drugs whilst on a methadone prescription and providing ‘false’ urine samples. • Non-compliance should result in immediate action to bring multi-agency professionals together to discuss the case. • It was recommended that all drug using parents are tested via swab tests if this provides a more accurate and reliable test result. Key Findings, Learning and Desired Outcomes 327. Formerly, it has been accepted practice for Birmingham Safeguarding Children Board (BSCB) to be presented with a set of SMART17 recommendations resulting from the conclusions and key learning points from commissioned Serious Case Reviews. The agreed recommendations would be operationalised into an action plan and duly implemented. However, recent thinking on achieving effective change in safeguarding policy and practice has challenged this practice. Arguably, there has been a tendency to focus on relatively minor changes such as revisions to policies and procedures whose outcomes (or more accurately, outputs) can be easily measured; and which rarely produce effective improvements to safeguarding practice and substantive positive outcomes for children. 328. After consultation with the Board, through the Business Manager, it has been agreed not to produce a list of recommendations but rather to set out the key findings, identified learning and desired outcomes for children. These will aim to offer challenge and reflection to a ‘Strategic Panel’ from the BSCB that is familiar with the current complexities and context of the local safeguarding scene. The 17 Specific, Measurable, Attainable, Relevant, Timely (SMART) Final Version 21.03.16 78 lead reviewer will converse with the Strategic Panel with the aim of converting the findings and learning into relevant and tangible actions, through an Action Plan that complements and informs the current on-going development of services (‘the Birmingham improvement journey’). The Action Plan will be implemented by the BSCB to ensure that the required changes are widely disseminated and embedded across the full spectrum of front line practice in Birmingham (and elsewhere). Finding 1-Fenton’s Death 329. Fenton died on the 01.07.13 after being given a lethal dose of methadone by Kelly Emery in the belief that it would pacify him so that she could take illicit drugs. The finding of manslaughter at the trial of Kelly Emery by definition established that she did not intend to kill her son. The evidence of this SCR and the criminal trial suggests that his death was not predictable. Finding 2-Was the Death Preventable? 330. There were many agencies and professionals involved with Fenton and his family during his short life that between them could and should have taken steps to have better promoted him and his sister’s (SFH) safety and wellbeing. Tragically, this was not done. There were significant shortcomings in the way that agencies, both individually and collectively, responded to the safeguarding needs of Fenton and his sister. 331. It was not possible to conclude with any causal certainty that Fenton’s tragic death could have definitely been prevented had there been effective multi-agency intervention, given his death was manslaughter and that Kelly Emery did not intend to kill him. However, the Review concludes that the likelihood of his death could have been reduced had effective inter-agency action been taken to recognise and assess the known risks to him and his sister from Kelly Emery’s substance misuse, methadone use and lifestyle; and based upon this recognition, implement an effective inter-agency response. Finding 3 Pre-Birth Recognition and Risk Assessment of Parental Substance Misuse/Methadone Use regarding Fenton and his sister. 332. There was no evidence to show that any consideration had been given by medical or non-medical practitioners associated with Kelly Emery’s drug support agency (Dudley CRI) to the potential risks to Fenton and his sister of Kelly Emery’s inconsistent involvement with her methadone treatment. The focus and Final Version 21.03.16 79 approach to treatment ‘did not take into account the wider needs of Kelly Emery and the impact and risks associated with substance misuse on the family unit as a whole’. (CRI IMR, p.10). No account was taken by CRI personnel in their decision-making regarding Kelly Emery’s treatment, of her ability or motivation to parent her children safely. 333. The lack of awareness of risk to Fenton and his sister by the Dudley CRI resonates at a wider, national level with adult substance misuse services. Recent research from serious case reviews on the deaths of children from opiate substitution ingestion found that,’ the evidence presented shows that practitioners do not consistently recognise the possible risks to children post by OST ( Opiate Substitute Treatment), despite NICE and the Department of Health stating this requirement explicitly’ ( Adfam, 2014, p.8). 334. There was no recognition or assessment by the midwifery service to the potential risks of Kelly Emery’s methadone use to the unborn child (Fenton) and his sister. The midwifery service did not liaise with the drug support agency despite the known risk factors; Kelly Emery’s inconsistent engagement with her treatment regime, and the lack of any drug testing. 335. There should have been a joint review of risk to the unborn child (Fenton) by the Dudley CRI and the specialist midwife and a referral on to Sandwell Children’s Social Care for an assessment of risk and need. The omission was an early missed opportunity for a pre-birth multi-agency assessment that could have informed a plan to have safeguarded the children’s safety and welfare and placed them at an early stage on the Sandwell Children’s Services ‘Radar’. 336. A factor in the lack of a pre-birth joint review of risk to the unborn child (Fenton) was the lack of a structured ‘pathway’ for midwifery and adult drug support services to use in consideration of whether to refer onto Social Care for a pre-birth assessment. This SCR would suggest that the pathway developed by Public Health England (2013) should be incorporated into local multi-agency policy and practice (see appendix 7). Key Lessons and Learning 337. Knowing what went wrong and why, what now would be done differently and what are the key learning points? 338. Firstly, Dudley CRI (and indeed, all substance misuse support services) needs to be working within an effective safeguarding policy. This should contain a set of effective safeguarding systems and processes informed by a holistic, ‘Think Final Version 21.03.16 80 Family’ approach18; where practitioners (both medical and non- medical) routinely consider any potential safeguarding issues, especially in relation to the potential impact of a client’s methadone use and substance misuse on any children and vulnerable adults in the service user’s family. In this regard, this Review would urge the CRI to adopt ‘The Protocol for Provider Services Working with Parents who misuse substances, HM Government, 2013 (see Appendix 7). 339. Secondly, practitioners and their supervisors need be trained and confident in competently carrying out Parenting/Risk assessments that are compliant with Local Safeguarding Children Board guidance. Thirdly, practitioners require manageable caseloads and the opportunity for regular, reflective and challenging supervision. Fourthly, there needs to be a rigorous quality assurance and audit framework that, amongst other things, ensures that agency practice keeps children (and vulnerable adults) safe. 340. Thirdly, there needs to be a fully integrated service delivery system with prescribing GPs working within the CRI structure and liaising closely with the drug support workers, dispensing pharmacists, midwifes, health visitors and social workers, in addition to also communicating with clients’ own GPs. Sixthly, sporadic client engagement and failure to attend medical reviews needs to be followed up and addressed robustly, especially with those service users who have children. Lack of engagement should be seen as a significant risk factor in regard to children; and serious consideration should be given to the suspension of prescribing and a return to supervised consumption of methadone. Seventhly, there should be regular drug testing of clients and where appropriate (and with the client’s consent) the sharing of results with other relevant professionals such as midwifes health visitors, GPs and social workers. Eighthly, there should be a quick and timely transfer of service to the new district when a client moves into a different catchment area. 341. Fourthly, methadone needs to be kept in safe storage by the client with a record of this by the agency. The risks to children of ingesting even small amounts of illegal substances, including methadone, should be clearly explained, as should the absolute requirement that children are never to be given these substances as a sedative or pain reliever. Documented rationale should be made as to why prescribed supervised consumption is not used for parents whose engagement or compliance to treatment is poor. Finally, CRI professionals need to work co-operatively and effectively communicate with other professionals; particularly, as in this case, specialist midwifes, who should be present at all client reviews held by the CRI agency. 18 Not to be confused with the ‘Troubled Families’ initiative which in some areas (such as Birmingham) is referred to as ‘Think Family’. Final Version 21.03.16 81 Changes Made since 2013 and Current Practice 342. The CRI’s Individual Management Review (IMR) states that the key lessons from the case have been identified and are being addressed through an action plan that purports to remedy the previous deficiencies. However, it was the view of the lead reviewer and the Overview Panel that the IMR lacked sufficient rigour in its analysis of why the risks to Fenton (and his sister) were not recognised and acted upon by a referral to Sandwell Children Social Care. The action plan was thought to be reactive, vague and a reflection of the weak analysis. 343. Indeed, the evidence of serious systemic and structural flaws accounting for the causes of a lack of recognition of the risks to Fenton and his sister raised wider concerns for the Panel and the lead reviewer about the current effectiveness of Dudley CRI practice regarding the safeguarding of children (and for that matter, all vulnerable individuals). The Panel was also aware that as of the 1 March 2015 the CRI is the current sole supplier of drug and alcohol services to Birmingham City Council. 344. Such were the concerns about the safeguarding processes and practice of Dudley CRI that the Panel took the view (in October 2014) that Dudley Safeguarding Children Board should undertake an audit of the effectiveness of the agency’s safeguarding practice. This was done. No concerns were identified by Dudley in terms of safeguarding or clinical practice. CRI Dudley now conduct a rigorous annual S11 self assessment and report it to the Dudley LSCB. The Panel also requested (in February and July 2015) that the Birmingham Safeguarding Children Board (BSCB) be assured by the CRI that its current practice is safe. A letter was received from the Chair of the BSCB on the 26 August 2015 informing the SCR Panel Chair that the concerns regarding the local substance misuse service had been passed on to the service commissioners to look into to the issues raised. Consideration was to be given to an audit of safeguarding practice by the BSCB multi-agency audit pool if necessary. 19 345. Regarding the midwifery service (Dudley Group NHS Foundation Trust), changes in practice and procedures are required based upon the following identified learning, namely; 19 The Chair of the Birmingham Safeguarding Children Board, in a letter from the Birmingham Director of Public Health (dated 11 September 2015), has been informed that the CRI designated Quality and Governance Lead has completed an internal safeguarding governance audit. There is also to be a Section 11 audit focusing on the specific issues identified in this SCR. Birmingham has also put itself forward as a pilot site for Adfam’s Year +Project. Final Version 21.03.16 82 • That the service should comply with the current Local Safeguarding Children Board guidance on ‘Maternal substance abuse during pregnancy’. • That the service should adopt a ‘Think Family’ approach that includes working within a structured pathway (e.g. the ‘Protocol for Provider Services Working with Parents who misuse substances’, see Public Health England, HM Government, 2013). • The adoption, effective implementation and embedding into practice of the threshold document ‘ Right Service, Right Time, Right Place’ and a specific risk assessment tool regarding the potential impact of substance misusing (and methadone using) parenting on children. • Close joint working between the specialist midwifery service and the CRI (both the CRI prescribing doctor and the drugs support worker) that would include regular attendance at joint reviews on service users with children. 20 • Recording of all discussions and contacts to be made in hospital clinical notes in addition to the women’s handheld notes. • Where drug testing (with informed consent of the mother) is not done by the substance misuse service (i.e. Dudley CRI) this should be done by the specialist midwifery service/Hospital. • The need for Professional curiosity (‘Healthy scepticism’ and Respectful uncertainty’) and not to take everything on face value from the parent’s self-reporting. 21 • Regarding the above learning point, agencies should provide staff learning and development opportunities that build confidence and competencies around child safety, whilst maintaining an open, direct and positive relationship with the client. • Effective liaison and communication with the community midwife, allocated health visitor, family GP service, maternity service and (where appropriate), local authority Children Social Care service. Changes Made since July 2013 and Current Practice 346. The Head of Midwifery services for the Dudley Group Foundation Trust (Russells Hall Hospital) reported to the Panel in March 2015 the following changes to practice. 20 ‘There should be liaison between maternity and drug treatment services to review the management of the mother’s drug use and impact on the baby before and after pregnancy. If there is a concern about the parent’s child care abilities , a referral should be made to Children’s Social Care under these procedures’ ( Current Dudley Safeguarding Children Board safeguarding procedures; Maternal Substance Misuse during Pregnancy’) 21 This learning point and the one immediately below would apply to all agencies and practitioners working with parents who substance misuse. Final Version 21.03.16 83 347. Regarding closer joint working with the CRI, the specialist midwife holds a fortnightly clinic for women accessing services at Atlantic House (Dudley CRI). Joint substance misuse/ antenatal clinics are also held by the specialist midwife and consultant in specialist addictions every six weeks at Atlantic House, with the woman’s substance misuse worker also present. 348. All non-face to face contact is recorded in the hospital held clinical notes and if the woman brings her handheld pregnancy/postnatal notes a record is also documented in these. If any information, gained by face to face contact, is needed to be shared in writing, this will be by secure email. Notes are taken at the joint clinics and the Consultant management plan is shared with the Specialist Midwife who files this in the woman’s hospital held clinical notes on receipt (this comes by secure email). A copy is also provided by the Consultant to the GP. Following birth the Specialist Midwife also documents in the parent held record (red book), as a form of communication with all other care providers. 349. In relation to drug testing, at each antenatal contact attendance at the hospital a urine sample is requested and drug testing performed with consent. The results are sent from the Path Lab to the Specialist Midwife via internal post within 7-10 days. If the result was of ‘immediate concern’ the Path Lab contacts the Specialist via phone or secure email. The Specialist Midwife would then communicate with the Drug Team at Atlantic House to review/revise the woman’s management plan as required. This is documented in the woman’s hospital held clinical notes; the same applies post -natally. 350. Regarding shared care with the woman’s GP, The Drug Worker’s role is to meet with the GP and liaise regarding the monitoring of the prescription. Pregnant women who are prescribed by their GP are requested to attend the Joint substance misuse/antenatal clinics conducted by the Specialist Midwife and Consultant in Specialist Addictions in the presence of the woman’s drug worker, to review the woman’s management plan including the prescribed medication. The GP is informed of outcomes by the Consultant Outcomes as detailed above. 351. The points above describe the expected communication/ involvement of the GP. The Specialist Midwife role does not have any expected regular communication with GPs, this is performed by the woman’s named community midwife, however, if the woman’s care has multiple complexities, ante-natally or post-natally, the Specialist Midwife would ensure direct communication with the GP as required, completing documentation as described above. 352. Regarding liaison with other relevant professionals, all women who are substance misusers are notified to the Health Visitor/Family Nurse Practitioner directly by the Specialist Midwife via phone and discussed at the monthly unborn baby Final Version 21.03.16 84 network meetings. All women who require a CAF have the involvement of the Health Visitor/Family Nurse Practitioner as part of this process and these professionals are also invited to attend any ‘core group’/safeguarding meetings by Children’s Social Care which are also attended by the Specialist Midwife. Any additional ‘ad hoc’ communication is recorded and documented as described above. Desired Outcome for Children 353. The desired outcome from the learning aims to ensure that, when appropriate, a timely pre-birth assessment of risk to unborn children of parents who misuse substances/ are subject to methadone programmes, is undertaken to safeguard and promote the unborn child’s welfare. Finding 4 Post Birth Recognition and Risk Assessment of Parental Substance Misuse/Methadone Use regarding Fenton and his sister and intervention whilst in Sandwell 354. The Probation Service was the only agency to have assessed Kelly Emery’s risk to her children in regard to her methadone use and substance misuse whilst the family were living in Sandwell. The assessment of ‘Medium Risk’ informed the agency’s decision to make a referral to Sandwell Children’s Social Care. Lessons 355. The key lessons are firstly for the Probation Service to communicate directly with substance misuse services to clarify and confirm that clients are actually adhering to treatment programmes and undergoing drug testing when stipulated. Secondly for there to be an accurate recording of all family members of probation clients, especially children and partners, so as to obtain an accurate and full assessment of risk to relevant vulnerable individuals. The Probation Trust states in its IMR that this omission has been remedied through the implementation of a circular issued in December 2012. 356. The Health Visiting service of Sandwell and West Birmingham Hospitals’ Trust did not understand and investigate the risks to the children from Kelly Emery’s substance misuse/methadone use. Although the proposed Universal Plus/Active Intervention support package recognised Kelly Emery’s methadone use there was no effective consideration of the potential risks to Fenton and SFH. Final Version 21.03.16 85 357. The rule of optimism, untested assumptions based on untruthful accounts from Kelly Emery; and a lack of lateral enquiries with other involved agencies, seemed to have contributed to a health visiting perception that Kelly Emery was adequately managing the care of Fenton. His development was therefore not identified as requiring further follow up. Lessons • Health visitors should adopt a ‘Professional curiosity’ approach to parents who substance misuse/ are on OST programmes. • There should be direct lateral follow up enquiries with substance misuse services, Children’s social care and other involved agencies when it is known that parents are substance misusers/ methadone users. • There should be adherence to the defaulted appointments procedures. • There should be inclusion of all significant household members, including relevant males, in health visiting assessments. 358. The response by Sandwell Children’s Services duty and assessment team to the safeguarding referral from the Probation Service was sub-standard and poor practice. The safeguarding referral should have resulted in the duty officer carrying out an initial assessment in line with existing agency and Sandwell Safeguarding Children Board safeguarding procedures. 359. The handling of the referral sought to ‘cut corners’, partly in response to existing organisational pressures (see paragraphs 164-165) and needs to be set within this wider agency context. 360. Sandwell Children’s Social Care duty team’s decision not to take any further action on the referral was not informed by an initial assessment or any understanding of the potential impact of Kelly Emery’s methadone use and substance abuse on her children. There was also poor management challenge and oversight of the case. This episode was a significant missed opportunity to carry out an assessment into the potential risks to Fenton and Robyn and their needs; and take appropriate multi-agency action to safeguard them and promote their wellbeing. Lessons 361. Sandwell Children’s Services were inspected in January 2015 and were given a rating of ‘Inadequate’ by Ofsted. In regard to children who need help and protection the Ofsted report noted that, ‘Management oversight of frontline practice is failing to ensure that children and families are receiving services at the Final Version 21.03.16 86 right level based on need and risk and taking account of the requirements of ‘Working Together to safeguard children’ (Ofsted report, June 2015, page3). The Report ( at page 4) required the agency to, ‘Improve the management oversight of social work practice to ensure that assessments, plans and interventions are at the right level to address need and risk and that appropriate action is taken to safeguard children’. 362. The findings of inadequate and superficial assessments and poor management oversight from this practice episode would reflect, emphasise and support the recent (2013 and 2015) Ofsted findings and improvement requirements regarding the referral and assessment team. West Midlands Police 363. The lack of a referral to the (Police) Child Protection Unit and Sandwell Children’s Social Care from police custody staff in May 2011(following Kelly Emery’s arrest for shoplifting offences in May 2011prior to Fenton’s birth) was a very significant lost opportunity for multi-agency intervention to safeguard and promote the wellbeing of Fenton and his sister. 364. The impact of Kelly Emery’s substance misuse and criminal behaviour, whilst being heavily pregnant and the mother of a ten year old child should have been considered by the Police custody officers and a referral made. Had there been a referral it is likely that a Section 47 enquiry would have been undertaken, followed by the holding of an Initial Child Protection Conference, resulting in both children made the subjects of child protection plans. Lessons 365. Front line officers, custody personnel, intelligence analysts and supervisors, whilst necessarily having a crime focus to their work, also need to develop a more holistic, less, ‘Silo’, approach to recognising the potential impact of individual’s (alleged or actual) criminal behaviour on children, young people and vulnerable adults within the household. 366. In this regard, as identified by the Police IMR (at page 29), a duty of care was owed towards the unborn child (Fenton) by the Police when Kelly Emery was in custody in May 2011 for the shoplifting offences. In addition to compromising her unborn child’s welfare through her criminal activities she was also known to be misusing cocaine and heroin whilst pregnant. This Review agrees with the Police IMR view (at page 29/30) that, ‘It would have been appropriate for (the) custody Final Version 21.03.16 87 sergeant to instruct investigating officers to make a child protection referral by way of generating a child abuse non-crime number’. 367. Had this been done, Fenton and SFH’s circumstances would have been considered by specialist safeguarding officers in the PPU, resulting in a greater likelihood of West Midlands Police gaining an effective appreciation of the family dynamics and risks that their mother’s criminal behaviour presented to the children. Moreover, as stated in the IMR, the procedures would have led to a strategy discussion with Sandwell Children’s Social Care and in all probability, a pre-birth child protection plan for Fenton; in addition to SFH also being subject to formal child protection measures. In short, the children would likely have been placed on the inter-agency ‘radar’ in the summer of 2011. 368. In addressing the matter of a more holistic, child focused approach, the IMR identifies that safeguarding issues may exist in regard to the unborn child where there are concerns for a pregnant woman in relation to domestic abuse.22 In this eventuality, the Police policy is very clear; namely for a child abuse non-crime report to be filed to both the domestic abuse and child abuse investigation teams respectively. The IMR therefore correctly identifies that there is a need to widen out the recognition amongst the Police service of the potential risks to the unborn child (and existing children) in pregnancy, other than in domestic abuse contexts. 369. Thus the lesson here is for the production of clear guidance where pregnant women (and their partners) are engaging in lifestyle behaviours (such as acquisitive criminality, substance misuse) that place the safety and wellbeing of children (including the unborn) at risk of harm. This is addressed by Recommendation One and the ensuing actions of the IMR Action Plan which addresses the need for both custody staff and front line officers to recognise the risk and make an internal referral to specialist officers or third party agencies. 370. All front line staff, intelligence analysts and supervisors need to be knowledgeable about the signs of child abuse, recognise and consider risk in child protection and take appropriate action to address risks; including recording, referring on to specialist sections and clarity around initiating non-crime (child abuse) reports. This learning is partially covered by Recommendation Two of the Police Action Plan contained in the IMR which takes steps to train intelligence officers to analyse risk to children and know the appropriate referral pathway to specialist officers in the PPU/CAIT. The wider aspects of this lesson, including recording and, where appropriate, initiating a non-crime incident form, are included in the HMIC ( 2014) recommendation to the West Midlands Police at page 21, namely to; 22 West Midlands Police Child Abuse Policy and Guidance ( September 2012) Final Version 21.03.16 88 • “Ensure that police officers and staff understand the significance of drawing together all available information from police systems to improve their risk assessments; • Ensure that all relevant information is properly recorded and readily accessible in all cases where there are concerns about the welfare of children and, as a minimum, provide guidance to staff on: � What information (and in what form) should be recorded on systems to enable good quality decisions; � The importance of sending the information to the correct police department and/or relevant partner agency; � The value and relevance of ensuring that records are made promptly and kept up to date; and • Ensure that managers carry out quality assurance checks on records and provide feedback to police officers and staff. “ 371. An obvious lesson was that officers should always (as far as possible) see and speak to any child or young person who is a subject of concern. If not already in existing procedures this learning point should be included in the agency action plan. 372. Two further lessons of note were; • The need for effective, high quality supervision of front line officers in regard to decision making around child protection practice. • Adherence to Police policies around the use of challenge (that is recorded) to other agencies’ decision making, the recording of the rationale for any outcomes and the use of intra and inter-agency (LSCB) escalation measures when appropriate. 373. This SCR would suggest that the Police IMR action plan includes and operationalise these lessons in order to disseminate them widely and embed thoroughly into practice. Reported Improvements made since 2014 374. This SCR notes that the HMIC inspection required the West Midlands Police to take immediate steps ( as of the published date of October 2014) to implement the recommendation at paragraph 318 and would therefore anticipate and expect that the above actions have been completed, or are at least well on the way to Final Version 21.03.16 89 completion. Some evidence of this has been provided by West Midlands Police and can be found at appendix 6. 375. The SCR Panel was encouraged to see the developmental progress made by the West Midlands Police as set out in its commentary. It looks forward to clear and tangible evidence of improved outcomes for children as a result of the ongoing work and would suggest that the Birmingham Safeguarding Children Board receives regular audit data that demonstrates the improvements. Desired Outcome for Children 376. The desired outcome of the above lessons aims to ensure that timely recognition and assessment by professionals of risk to children of parents who misuse substances/ are subject to methadone programmes, is undertaken to safeguard and promote the child’s welfare. Finding 5 Post Birth Recognition and Risk Assessment of Parental Substance Misuse/Methadone Use regarding Fenton and his sister; and intervention whilst in Birmingham 377. None of the agencies in Birmingham, either individually or collectively, sufficiently recognised or assessed the potential risks to Fenton and his sister from Kelly Emery’s methadone use and substance misuse. This resulted in there being no effective agency intervention to safeguard and promote the children’s welfare. 378. The ‘Health Assessment Framework’ completed by the Worcestershire Health and Care NHS Trust, health visiting service, identified Fenton as being ‘Vulnerable’. This required medium active intervention with the child being seen every three months by the health visitor and some extra parenting support being offered to his mother. 379. The assessment did not include any contact with Kelly Emery’s drug misuse support service or consideration of potential risk to Fenton from his mother’s methadone treatment. This omission marked a missed opportunity to obtain a better understanding of the potential risks to Fenton from his mother’s methadone use and substance misuse. Final Version 21.03.16 90 Lessons 380. These include; • Health visitors (and all other practitioners) should adopt an attitude of respectful uncertainty and healthy scepticism in taking at face value what they are told by parental substance misusers. • Professionals should consider whether parents are engaging in ‘false and /or disguised compliance’. • Professionals should not work on the basis of untested assumptions. Information should be checked out directly with other agencies and professionals, particularly substance misuse agencies (including GPs) to ascertain the facts. • Parents should be informed of the dangers of children ingesting methadone or being given it in a misguided attempt to pacify them. • Health visitors (and other practitioners) should work within an agreed pathway of risk (see appendix 7 parental substance misuse pathway protocol)), be child focused and ‘Think Family’. The IMR reference to considering adopting a risk assessment tool such as the ‘Substance Misuse Family Matrix ‘would seem a sensible move. • That the service should comply with the current Local Safeguarding Children Board guidance on ‘Maternal substance abuse during pregnancy’. 381. Birmingham Children’s Social Care in its handling of the two referrals of August 2012 and April 2013 did not sufficiently understand or adequately investigate the risks to the children from Kelly Emery’s substance misuse and methadone use. 382. The omission by the social worker to gather all of the known intelligence and information on the family from other agencies led to a flawed risk assessment and a decision to prematurely close the case without properly considering the risks to the children from their mother’s substance abuse and methadone use. 383. These episodes were very significant missed opportunities to intervene in the lives of Fenton and his sister and promote their safety and welfare. 384. The actions and decisions taken by Birmingham Children Social Care staff in their handling of the two referrals, seems to have been a function, at an individual level, of inadequate practice and poor management oversight. This was set within a wider organisational context of systemic and long entrenched problems in ensuring an effective and safe delivery of services to children, particularly (but not exclusively confined to) the ‘Front Door’ service. Final Version 21.03.16 91 Lessons 385. Key lessons include; • Birmingham Children’s Social Care need to complete and successfully embed the structural changes regarding the development of the locality Hubs (co-located Multi-Agency Safeguarding Hubs) with the child protection and family support teams all co-located, ensuring consistency of practice city-wide. 23 • Evidence of sustained improvement in the effectiveness and safety of the agency’s, ‘Front Door’, service needs to be provided, with particular reference to child protection enquiries, quality of assessment and inclusion of the voice of the child, in compliance with the Birmingham City Council Children Social Care Improvement Plan 2014-2017. • In compliance with the Ofsted 2014 report, priority action 31; ensure that the system to manage contacts and referrals is secure and provides the professional basis to support social workers in keeping children and young people safe and protected. • In compliance with the Ofsted 2014 report, priority actions 29 and 30, ensure that the delayed Early Help strategy is implemented urgently and that partners are fully engaged in the work to achieve this; and, for the local authority and partners to re-launch the threshold document, ‘Right Service, Right Time’. • In compliance with the Ofsted 2014 report, priority action 25, to ensure that strategic and operational oversight is effective, including supervision and that case file audit arrangements are robust in order for workers to deliver services of consistently high standards. • Develop the confidence and practice competencies of social workers in the referral and assessment teams to undertake child focused risk assessments that include, properly analysed impact assessments on children of parents who substance misuse and/or use methadone. • Adopt a more ‘Professionally curious’ approach to assessing parental substance abuse which respectfully challenges what parents say and conducts the full range of robust lateral enquiries, especially with adult substance misuse services. In short, be aware of the rule of optimism, parental disguised compliance and be prepared to ‘Think the unthinkable’. 23 See ‘Integrated Transformation; Our Strategy for Improving Services for Children and Young People in Birmingham’. ( Birmingham City Council:2013) Final Version 21.03.16 92 • Maintain a child focused approach and speak to all of the siblings and extended family members in conducting the assessment. Such an approach should seek to understand the ‘lived experience’ of children and young people. Reported Improvements made since 2014 386. Birmingham Children Social Care has been operating to an Improvement Plan (2014-2017) since June 2014 which includes many of the above issues. The following commentary has been provided regarding progress being made with the ‘Front Door’ services. The reader is referred to Appendix 5 387. The SCR Panel was encouraged to note the extensive work that has been undertaken by Birmingham Children’s Social Care over the last eighteen months, particularly in respect of the ‘Front Door’ services. However, clear and tangible quality assurance and audit evidence of high quality outcomes for children, in relation to high quality risk and need single assessments, child protection enquiries and the inclusion of the voice of the child are needed to demonstrate consistent and sustained service improvement. The SCR Panel would expect the Birmingham Safeguarding Children Board (in addition to the Improvement Board and Ofsted) to be assured of outcome improvements for children through the provision of regular audit data as part of its learning and improvement agenda. 388. Regarding Dudley CRI the previous inadequate and unsafe service with respect to Kelly Emery’s methadone programme and the lack of any consideration of potential risk to her children, whilst in Sandwell, continued during the family’s time in Birmingham and up to Fenton’s death. 389. There was a tendency for the methadone treatment to over-focus on Kelly Emery as an individual rather than see her as a parent with dependent children. In essence, the treatment intervention was too adult focused and did not consider the safeguarding and welfare needs of Fenton and SFH. 390. The quality of supervision of the drugs worker (DW1) during this period was sub-standard with no evidence that there was any professional challenge regarding Kelly Emery’s poor engagement; no annual review of the Parental Capacity Assessments, and minimal monitoring, factual checking and auditing of the case. No action was evident from the team leader in ensuring the timely transfer of the case to the Birmingham CRI. Final Version 21.03.16 93 Lessons 391. Drug support agencies should work within a more holistic,’ Think Family’ approach that considers the impact of adult client behaviour on children and vulnerable others. 392. There needs to be a challenging and rigorous approach to management supervision and oversight that includes case auditing both of the effectiveness of the OST treatment and any safeguarding risks to children. 393. West Midlands Police in its involvement with the family between 2011 and July 2013 did not recognise the risks to the two children. Hence, no referral was made to the (Police) Public Protection Unit/Child Abuse Investigation Unit for an assessment and possible investigation. This included the custody staff who dealt with Kelly Emery in May 2011. Moreover, even when the risk was recognised by DC2 in March 2013, staff did not follow proper procedure and make an internal referral to the Police Protection Unit (PPU). Lessons 394. See paragraphs 365-373 395. Regarding the GP service; apart from the specific use of the HAD tool to diagnose the extent of Kelly Emery’s depression there was no evidence to show that any consideration was given to evaluating her parenting capacity in the light of her alcohol and substance abuse and mental health issues. Thus, no account was taken of these matters by the GP in relation to the potential for abuse or neglect of Fenton and SFH. 396. Decision making was solely confined to treating and managing Kelly Emery’s depression through medication and did not include any wider considerations for the safety and welfare of the children. The absence of a holistic, ‘Think Family’ approach to Kelly Emery precluded any exploration of the presence of males in the home. 397. There was no liaison with the prescribing doctor or drugs worker at the Dudley CRI or any discussion of safe methadone storage. Lessons 398. The learning from this episode highlights the need for GPs to firstly, be knowledgeable about their duties and responsibilities regarding the safeguarding Final Version 21.03.16 94 of children and young people. Secondly, to think about the children of parents who may present risks, in this case in relation to mental health and substance misuse issues. Thirdly, to discuss any concerns about the children of parents in the context of the ‘toxic trio’ (or any wider safeguarding concerns) with their practice safeguarding group/ safeguarding lead, which needs to meet regularly. Fourthly, the imperative for effective communication between GPs and drug support agency professionals. 399. The IMR states that the Frankley practice has since, ‘embedded’ the discussion of parents with mental health and substance misuse issues at practice safeguarding meetings. These mechanisms need to be a systemic feature of all GP practices in the four areas (Birmingham, Sandwell, Dudley and Worcestershire) subject to this Review and should be monitored by the respective LSCBs and Clinical Commissioning Groups. 400. Key learning points are, • That GPs and prescribing substance misuse agencies must communicate with each other regarding progress of the patient with the OST programme, medication from the GP and consideration of any risks to children. • GPs must take a holistic (‘Think Family’) view and consider the impact on children, by the use of their Local Safeguarding Children Board guidance, when treating parents for mental health and substance misuse issues. • GPs must discuss any concerns about children with their primary care colleagues, including health visitors and school nurses. • GP Safeguarding leads must regularly participate in their safeguarding practice team meetings. 401. In regard to SFH’s school, no referral was made to Birmingham Children’s Social Care in April/May 2013 regarding concerns of drug and alcohol misuse in the family home. This was a serious breach of local authority and Birmingham Safeguarding Children Board safeguarding procedures. 402. There was minimal recognition or awareness of the potential risks of Kelly Emery’s substance/alcohol misuse on the children and no evidence of any reference to the existing Birmingham Safeguarding Children Board substance misuse guidance. Moreover, there was also no awareness of the potential dangers of males in the home. Final Version 21.03.16 95 Lessons 403. These include, • The school safeguarding lead having sufficient capacity to discharge their duties effectively and not having to ‘cut corners’. • Compliance to the Birmingham Safeguarding Children Board safeguarding guidance including referral on to the Children Social Care when appropriate and not other agencies such as the Police or the NSPCC. • Adherence to strict recording policies, including written reasons for decision making. • Not putting the responsibility on to the TA to make a referral. • Speaking to the child. • Not assuming that because a child is a ‘Model pupil’ all is necessarily well at home. Sometimes school can be a ‘safe haven’ for abused and neglected children and young people. • Effective senior line management and oversight of the safeguarding lead by the head teacher; and regular scrutiny from a safeguarding governor lead and sub-group. 404. Both the lead reviewer and the Overview Panel were very concerned in regard to the evidence from the IMR of such poor safeguarding practice from the school. The Panel requested that a safeguarding review of the school under section 175 of the Education Act 2002 be carried out in order to assure itself that children were safe in the school. This was done in July 2014 although the Panel has (of August 2015) not yet seen the report to the Schools and Settings Improvement team. It is therefore not yet reassured that safeguarding practice has improved. It is suggested that the Panel is provided with the report. 405. Regarding GP intervention, apart from the specific use of the HAD tool to diagnose the extent of Kelly Emery’s depression there was no evidence to show that any consideration was given to evaluating her parenting capacity in the light of her alcohol and substance abuse and mental health issues. It therefore follows that no account was taken of these matters by the GP in relation to the potential for abuse or neglect of Fenton and his sister. Decision making was solely confined to treating and managing Kelly Emery’s depression through medication and did not include any wider considerations for the safety and welfare of the children. 406. The learning from this episode highlights the need for GPs to firstly, be knowledgeable about their duties and responsibilities regarding the safeguarding of children and young people. Secondly, to think about the children of parents who may present risks, in this case in relation to mental health and substance Final Version 21.03.16 96 misuse issues. Thirdly, to discuss any concerns about the children of parents in the context of the ‘toxic trio’ (or any wider safeguarding concerns) with their practice safeguarding group/ safeguarding lead, which needs to meet regularly. 407. The IMR states that this is now done (and ‘embedded’) within the Frankley practice. This begs the question as to whether practice safeguarding team meetings involving GPs are systemically embedded and operating effectively within the practices overseen by the Clinical Commissioning Groups in Birmingham, Sandwell, Dudley and Worcestershire? 408. Key learning points are, • That GPs and prescribing substance misuse agencies must communicate with each other regarding progress of the patient with the OST programme, medication from the GP and consideration of any risks to children. • GPs must take a holistic (‘Think Family’) view and consider the impact on children, by the use of their Local Safeguarding Children Board guidance, when treating parents for mental health and substance misuse issues. • GPs must discuss any concerns about children with their primary care colleagues, including health visitors and school nurses. • GP Safeguarding leads must regularly participate in their safeguarding practice team meetings. Desired Outcome for Children 409. The desired outcome of the above lessons aims to ensure that timely recognition and assessment by professionals of risk to children of parents who misuse substances/ are subject to methadone programmes, is undertaken to safeguard and promote the child’s welfare. Finding 6 The Wishes and Feelings and Voices of the Children 410. There were very few occasions when the voices of Fenton and his sister were heard by practitioners and their wishes and feelings noted and acknowledged. Exceptions, to some extent, were those occasions when the Probation service and the local burglary team police officer recognised the children’s needs for protection and made referrals to Sandwell and Birmingham Children’s Services respectively. Final Version 21.03.16 97 411. Apart from these two instances, none of the other involved practitioners or their managers; in particular those from Sandwell and Birmingham Children’s Social Care and SFH’s secondary school, sought to talk with SFH in an attempt to understand her experience of living with and being parented by her mother. Regarding Fenton, none of the relevant child care agencies, GP services and Dudley CRI effectively documented the interaction with his mother, considered his lived experience with her or attempted to get a sense of his ‘voice’. Lessons 412. All agencies, in particular those delivering services to adults, need to be aware of the potential dangers of ‘Silo working’ where there may be an overly narrow focus on specific aspects of an adult’s behaviour or condition. Agencies should adopt a holistic, ‘Think Family’ approach which includes appropriate consideration of the impact of parenting on children. This is especially the case when children are living in a family environment where parental mental ill health, substance misuse and/or domestic abuse are present. 413. In compliance with law and statutory guidance, subject children and their siblings must be seen and when developmentally mature enough, their views elicited and recorded. In this case SFH had spoken back in 2009 to social workers of her Kelly Emery’s drug use and its impact on her. Evidence from the Birmingham Children Social Care IMR stated that SFH, after Fenton’s death, spoke about him being left unattended by Kelly Emery until 2 pm whilst she slept. Babies and young children’s interaction with their carers should be observed and recorded. Observations need to be made sense of in the context of any risk factors such as substance misuse, adult behaviour and poor parenting. 414. When appropriate, practitioners must speak to and elicit the views of significant figures in the child’s life such as, in this case, grandparents and adult males. According to the Birmingham Children’s Social Care IMR, the maternal grandmother had several very significant concerns about aspects of her daughter’s parenting of Fenton and SFH. Arguably, had she been spoken to on her own in April 2013 by the social worker the emerging evidence of concern could have been assessed (e.g. SFH allegedly being forced by Kelly Emery to shoplift, intending to be used as a drugs mule on a forthcoming holiday, Kelly Emery being an active sex worker and having sex with ‘clients’ whilst SFH babysat Fenton downstairs). This may have led to formal child protection intervention such as a Section 47 enquiry, an Initial Child Protection Conference and a child protection plan. Final Version 21.03.16 98 Desired Outcome for Children 415. For the voice of vulnerable children to be heard by professionals in order to better understand their lived experience and include their wishes and feelings in all planning aimed at safeguarding and promoting their welfare. Finding 7 Formal Safeguarding Interventions and Their Effectiveness 416. There were three occasions when formal agency safeguarding interventions should have happened, namely, the Probation Service referral to Sandwell Children’s Social Care on the 20 July 2011, the anonymous referral in August 2012 to Birmingham Children’s Service and the Police referral in April 2013 to Birmingham Children’s Service. 417. On no occasion did these referrals lead to the instigation of formal safeguarding interventions by way of strategy discussions, Section 47 enquiries, initial child protection conferences and possible formal child protection plans or child in need plans. Lessons 418. See previous sections Finding 8 The Six Key Findings from the Similar SCRs 419. These are, • Professionals need to ‘Think Family’, be aware of the needs and risks to children from parental substance misuse, not be overly adult focused and beware of ‘Silo’ working. • Professionals should beware of accepting at face value the accounts of substance misusing parents and avoid adopting a fixed over-optimistic view of parenting in the face of evidence to the contrary. Parental non- compliance with treatment plan should result in immediate action to arrange a multi-agency meeting to discuss case Final Version 21.03.16 99 • Professionals should adopt a ‘Respectful uncertainty/Professional curiosity’ approach to parental substance misuse which, when necessary, challenges parents’ behaviour. • Agencies not referring to Children’s Social Care for assessment. • Lack of challenging but supportive management oversight • The need for an inter-agency pathway and protocol for assessing the needs of unborn children in all cases where there is the likelihood of compromised (including parental substance misuse) parenting. Seven Overarching Lessons 420. Finally, many lessons and learning points have been identified by this SCR. Here are seven key overarching lessons. 1. Agencies, particularly adult service providers, need to think holistically ('Think Family') and consider the effects of parental substance misuse on children. 2. In families where there is parental substance misuse there needs to be early intervention, including an initial assessment of need/risk by substance misuse and midwifery services, and where indicated, early help or child protection measures when necessary. 3. Agencies, especially adult service providers, should be aware of the dangers of 'Silo' working in relation to being too crime focused (Police), symptom focused (GPs), treatment focused (drug support agencies). 4. When working with parental substance misusers Professionals should maintain a degree of 'Respectful uncertainty' and not accept at face value what they are told; seek corroboration. Beware of parental disguised compliance. 5. When working with parental substance misusers Professionals should always make wider lateral enquiries with other agencies and not make assumptions about the support given to parents and how they are coping. Where possible, always speak to the wider family to gain a fuller picture of what is going on for the child. 6. The voice of the child must be included in all interventions with parental substance misusers. 7. 'Stick to the knitting'. Do the basics well and follow agreed procedures and practice. Final Version 21.03.16 100 Glossary of Terms Family Members FFH - Father of Fenton SFH - Sister of Fenton Kelly Emery - Fenton’s mother MGP-Maternal Grandparents MGM-Maternal Grandmother PGP-Paternal Grandparents Terms IMR - Individual Management Reviews SCR - Serious Case Review Hospital 1 - Russells Hall Hospital Dudley CRI - Crime Reduction Initiative WMP - West Midlands Police BCSC - Birmingham Children’s Social Care SCSC - Sandwell Children’s Social Care CM1 - Community Midwife1 DW1 – Kelly Emery’s Drugs Worker from Dudley CRI BDW - Birmingham Drugs Worker HV1 - Health Visitor 1(Sandwell) HV2 - Health Visitor 2 (Sandwell) HV3 - Health Visitor 3 (Sandwell) WHV1 - Worcestershire Health Visitor Dr1 - The Prescribing Doctor PSO1 - Probation Service Officer 1 PSO2 - Probation Service Officer 2 PPU - West Midlands Police Public Protection Unit Final Version 21.03.16 101 USS - Ultra sound scan PCSO - Police Community Support Officer TL1 - Team Leader (Dudley CRI) GP - General Practitioner CAF - Common Assessment Framework HAD: Hospital, Anxiety and Depression Scale BCH – Birmingham Children’s Hospital NSPCC - National Society for the Prevention of Cruelty to Children SW1 - Birmingham Social Worker (senior) OST - Opioid Substitution Treatment NICE - National Institute for Clinical Excellence SPMW1 - Specialist Midwife 1 SPMW2 - Specialist Midwife2 OASYS - Offender Assessment System (Probation) ICS - Integrated Children’s System (electronic social care system) (RAA1): Referral and Advice Officer; (Birmingham) IASS: Integrated Advice Support Service (Birmingham) MASH – Multi Agency Safeguarding Hub (Birmingham) Academy 1-SFH’s school TA –Teaching Assistant (at Academy 1) AM - Attendance Manager (at Academy 1) DC2 - Detective Constable 2 (West Midlands Police, burglary squad) DC1 - Detective Constable 1(West Midlands Police, Public Protection Unit) ADS - Acting Detective Sergeant (West Midlands Police, Public Protection Unit) CAIU - Child Abuse Investigation Unit (West Midlands Police) HMIC: Her Majesty’s Inspectorate of Constabulary SMART - Specific, Measurable, Achievable, Relevant, Timely Final Version 21.03.16 102 References Department for Education (2013) : ‘Working Together to Safeguard Children’ Department for Education (2015) : ‘Working Together to Safeguard Children’ Advisory Council on the Misuse of Drugs (2003): ‘Hidden Harm’ Adfam (2014): ‘Medications in Drug Treatment-Tackling the Risks to Children’ Social Care Institute for Excellence (SCIE): (2008): ‘Learning together to safeguard children, developing a multi-agency systems approach for case reviews’. A Preston: ‘The Methadone Handbook’ (11th Edition); Exchange Supplies.org NHS Lothian (2003): ‘Substance Misuse in Pregnancy: A Resource Pack for Professionals in Lothian’ Dudley Safeguarding Children Board: (2007): Maternal Substance Misuse During Pregnancy Sandwell Safeguarding Children Board: Guidance: ‘Children of Drug Misusing Parents Department of Health; (2007): Drug Misuse and Dependence; UK guidelines on clinical management General Medical Council (2012): ‘Protecting Children and Young People’ Ofsted (2012): Birmingham City Council, ‘Inspection of services for children in need of help and protection, children looked after and care leavers’ Ofsted (2014): Birmingham City Council, ‘Inspection of services for children in need of help and protection, children looked after and care leavers’ Ofsted (2010): Sandwell Metropolitan Borough Council, ‘Inspection of services for children in need of help and protection, children looked after and care leavers’. Ofsted (2013): Sandwell Metropolitan Borough Council, ‘Inspection of services for children in need of help and protection, children looked after and care leavers’. Ofsted (2015): Sandwell Metropolitan Borough Council, ‘Inspection of services for children in need of help and protection, children looked after and care leavers’. Ofsted (2010): ‘The Voice of the Child: Learning Lessons From Serious Case Reviews’ Le Grand. J et al: (2014): ‘Report to the Secretary of State for Education and the Minister for Children and Families on Ways Forward for Children’s Social Care Services in Birmingham’. Final Version 21.03.16 103 Birmingham City Council; Children Social Care Improvement Plan 2014-2017. Birmingham City Council (2013): ‘Integrated Transformation; Our Strategy for Improving Services for Children and Young People in Birmingham’. HMIC (2014): ‘National Child Protection Inspections: West Midlands Police 2-13 June 2014’ Final Version 21.03.16 104 Appendix 1 Scope of the SCR and Terms of Reference Key Issues 1. The Review will consider each agency’s contact with Subject Child, half sibling, Mother, Father, Maternal and Paternal Grandparents and any other known adults living in the household and the nature of that contact in terms of how well FH’s needs were identified and recognised 2. The Overview Report will consider relevant research and previous Serious Case Reviews, based on a West Midlands wide learning event and the outcomes of previous West Midlands SCRs related to the ingestion of methadone where circumstances were similar and make recommendations if appropriate in relation to this for Birmingham and the Region. 3. The Panel will consider how and when the most appropriate method of securing family members involvement with the SCR process whilst adhering to BSCB’s guidance on the involvement of family members and being mindful of the criminal investigation. The Panel Chair will be responsible for arranging liaison with the family with the support of West Midlands Police Family Liaison Officer. Consideration should be given to whether it is possible to talk in particular the Subject child’s half-sister taking into account the potentially traumatic nature of such a conversation. 4. Consideration has been give to the racial, cultural, linguistic and religious background to this case and there does not appear at this stage to be any factors that impact on immigration status. 5. BSCB will obtain legal advice as necessary. Current BSCB legal advice relating to SCRs and other publication will be adhered to. 6. The CCG will notify the Local Area Team of NHS England of the Serious Case Review through the Sudden Untoward Incident system. 7. Relevant information to emerge from criminal proceedings will be taken into account by SCR Panel. The police representative on the panel will be responsible for liaising with the CPS. 8. The social care representative will be responsible for provision of information from family proceedings. 9. Public and media enquiries will be handled by the Chair of BSCB. 10. Agencies will implement the learning from this case prior to publication 11. Health Forum to review emerging findings for Health Organisations and advise on the most effective way the learning can be taken forward. Final Version 21.03.16 105 At the conclusion of the Serious Case Review agencies will debrief those staff involved in the case, BSCB will disseminate the key learning from the case through a series of targeted seminars and Senior Managers in each agency will be asked to audit the impact of applying relevant learning within a year of finalising the draft report. Learning Events Following the panel’s deliberations and draft hypotheses and the production of a draft overview report the panel should organise two learning events, to 1. Work with middle managers in each agency to consider the implications of the overview report for their services 2. Work with representatives of each West Midlands regional LSCB’s to look at the learning from similar SCR’s over a 5 year period in the region and identify regional learning and recommendations Case Specific Terms of Reference (ToR) ToR 1 What tools were used by practitioners to evaluate and assess the mother’s capacity to parent safely in the light of her alcohol and substance abuse? Was the degree to which that abuse could compromise her ability to parent safely taking into account in decision making? ToR 2 To what extent did practitioners understand and investigate the risks to the children and act on them, in particular considering maternal alcohol and substance misuse and the presence of males in the home? ToR 3 To what degree were both children’s wishes and feelings, the voice of the child and needs for protection recognised and acted upon by practitioners? ToR4 Did agencies undertake formal interventions to safeguard the children appropriately? If they did, were they effective? If not, why did they not happen? Final Version 21.03.16 106 Appendix 2- SCR Panel Membership This comprised of senior representatives from the following agencies, • The Independent SCR Panel Chair • Birmingham Children’s Social Care • Birmingham South Central Clinical Commissioning Group (CCG) • Birmingham and Solihull Mental Health Trust • Birmingham Clinical Commissioning- Public Health-Substance Abuse Service • Birmingham General Practice Service • West Midlands Police • Consultant Paediatrician • Birmingham Early Years’ Service • Dudley Safeguarding Children Board Representatives from Sandwell and Worcestershire Safeguarding Children Boards were invited to be part of the SCR Panel but declined. Administrative support was provided by the Birmingham Safeguarding Children Board business unit. Final Version 21.03.16 107 Appendix 3 List of Agency Individual Management Reviews 1. Crime Reduction Initiative (Substance Misuse Service) - CRI-Dudley Adult Integrated Recovery Services 2. Dudley Group NHS Foundation Trust-Specialist Midwifery - Substance Abuse and Drug Liaison service 3. Sandwell and West Birmingham Hospitals Trust (Primary midwifery) 4. Sandwell and West Birmingham Hospitals Trust (Health Visiting) 5. South Central Birmingham Clinical Commissioning Group (GP services) 6. Staffordshire and West Midlands Probation Trust 7. Sandwell Children’s Social Care 8. Worcestershire Health and Care NHS Trust (Health visiting) 9. Birmingham People Directorate-Children’s Social Care 10. West Midlands Police 11. Academy 1 (Secondary school) Final Version 21.03.16 108 Appendix 4- Key Practice Episodes 1. Why was there no pre-birth assessment of risk and need undertaken on FH (and SFH) during the ante-natal period, given Kelly Emery’s methadone use and substance abuse? (Kelly Emery, during the ante-natal period, was in contact with the specialist midwifery service, the GP, the Probation service, the Police, Russells Hall Hospital and Atlantic House: SFH had been on a child protection plan to Sandwell CSC in 2009 and this agency was aware of his birth to Kelly Emery). Analyse this KPE from a multi-agency perspective in terms of what individual agencies knew about Kelly Emery and family and what they could have done. 2. Why was there no post-birth assessment of risk and need undertaken on FH (and SFH), given Kelly Emery’s methadone use and substance abuse? (The family had involvement with the Probation service, Sandwell CSC, the health visitor, community midwifery, Atlantic House, School. Probation made a referral to Sandwell CSC on 20.07.11 regarding concerns about Kelly Emery and her partner’s methadone use.) Analyse this KPE from a multi-agency perspective. 3. Why was the referral to Birmingham CSC in August 2012 not followed through for action to an assessment? Why was the second referral of the 22.04.13 and the subsequent Initial Assessment unsatisfactory and prematurely closed? Why was it not effective? (Were these missed opportunities to safeguard and promote the children’s welfare? Why wasn’t SFH seen and her voice heard? Why weren’t other sources of corroboration of concerns explored-neighbours, family? Why wasn’t the professional making the referral (the Police officer) spoken to? The need for professional curiosity and the danger of an overly adult focused approach despite knowledge of Kelly Emery’s parenting status. Also, consider the earlier NSPCC referral in March to Birmingham CSC.) 4. Why did Fenton’s GP not share information about Kelly Emery’s methadone use when referring the child to BCH on the 26.04.13? 5. Why wasn’t a holistic and up to date awareness of Kelly Emery’s overall progress in addressing her substance misuse (drug addiction) maintained? (Maintaining timely reviews of Kelly Emery’s engagement with the drug services-including her voluntary drug testing, via the drugs agency rather than solely dependent on her self-reporting. Ensuring the right questions are being asked of other key professionals. For example, is the mother undertaking voluntary drug testing? How often is this taking place, what are the results? Are there any particular issues that can be addressed by agencies jointly? The need to ‘Think Family’.) Final Version 21.03.16 109 6. Why did the police intelligence reports of January and November 2012 and January 2013 on Kelly Emery not generate child abuse non-crime numbers and referrals to the Public Protection Unit and Birmingham CSC? (Analyse what happened and why? What systems changes have been made to assess intelligence and communicate it back to police officers to take action to protect vulnerable children? Issue of ‘Safe and Well’ checks?) Final Version 21.03.16 110 Appendix 5 Birmingham Children’s Social Care Improvements made to the ‘Front Door’ Services ‘Since the introduction of MASH (Multi-agency Safeguarding Hub) in July 2014 there has been a marked increase in partner confidence that the local authority will respond to safeguarding concerns as expressed by partners. This is evidenced by a 60% increase in contacts and increased referrals. Children on Child Protection Plans have increased and are now comparable to National and statistical neighbour averages. Work has been undertaken internally and with partners agencies in understanding thresholds by holding MASH/Right Service RightTime roadshows. Monthly Independent multi-agency auditing of the front door takes place which report consecutive improvements. Threshold consistency is a constant theme for practitioner workshops and the service proclaims that Birmingham is “Safer but not yet safe” The voice of the child is well understood by practitioners and a recent Ofsted improvement visit reported that the voice of the child is evident in our work. A new quality assurance framework has been introduced which has the voice of the child as a measure in every audit undertaken. Quality of assessments have improved in some large part by reducing and capping caseloads, currently at 23 children to reduce to 21. We have implemented Voice of the Child Project which includes (that) managers will not sign off assessments unless the voice of the child is evident, this includes tools of observation and behaviours of parents with pre-birth and none verbal children. Dip sampling would suggest performance is much better although still not evident in all cases. Managers undertake five audits a week and we are currently producing learning themes. We have also developed an audit for monitoring outcomes from strategy meetings’. Final Version 21.03.16 111 Appendix 6 West Midlands Police –Practice Improvement Actions The agency states that, ‘A substantial amount of improvement work has already taken place within WMP, since the death of Fenton and following on from the requirements, following the HMIC inspection in June 2014. . 1. Improving West Midlands Police Service to Children (See paragraphs 298-305 in SCR Report) WMP Public Protection Unit (PPU) have delivered a presentation entitled ‘Improving our services to children’, to all officers and staff across all departments within WMP. This presentation has been complimented by the issuing of an Aide Memoire, which reinforces the referral steps that all employees should take if they encounter a scenario where a vulnerable child is apparent. Current additional developments include significant work with colleagues in ensuring WMP have a definition of vulnerability against which the service can operate and be held accountable for. Linking to this has been significant work regarding developing the THRIVE model for dissemination into WMP and staff psyche. This model is aimed at encouraging officers and staff, regardless of rank or role, to consider what additional and wider Threat, Harm and Risk may be apparent to help Identify Vulnerabilities that necessitate partnership intervention and Engagement, aside from the job that they are actually faced with. (Clearly in this case WMP had a pregnant mother coming in and out of custody with a drug dependency, who was shoplifting and turning to prostitution, with children in her care that the service failed to pick up). This then all links with the flowchart that the author has discovered, which was referred to at the last panel, which the NHS National Treatment Agency have developed. This could be adapted to incorporate the THRIVE approach? WMP currently have key leads in force under the prevention strands of work and partners have been consulted regarding the approach THRIVE brings and currently a unanimous agreement in utilising this approach has been recorded. The force Learning and Development department has then been consulted and subsequently commissioned to develop and design a THRIVE approach in all training – focussing especially on courses around Sentinel (See explanatory notes attached) and the key themes identified within this scope. This was trialled initially in June 2015 and it has been identified that there needs to be some further development of the material to influence behaviours/thinking as well as how WMP influence partnerships in terms of early intervention, referral and any intervention/engagement. Final Version 21.03.16 112 This work is also factored into a key development and training approach in Force Contact, the department that handles all calls/face-to-face contact with the public at the police stations along with our control room staff. The WMP approach to ‘risk frameworks’ is a key part of the 60 day accelerator programme under WMP’s 2020 programme with Accenture. Therefore whilst work will continue to be developed around the THRIVE model it has to blend into the structured delivery under the 2020 work streams. It is recognised that there is a need for cultural and behavioural changes in our approach to, recognition of and action to mitigate prevent, reduce risk/vulnerability and potentially for THRIVE becoming part of WMP psyche in this approach. The work to formally bring THRIVE (or an appropriate alternative framework) into WMP actually starts Mon 6 July and will gather momentum. 2. Early Help (EH) & MASH In essence, most local authorities across the West Midlands now seem to be moving towards a MASH/EH approach within social care change programmes. The “PVVP” document attached contains current assessments of where each LA area is currently at. An Assistant Chief Constable (WMP) now chairs an internal governance group covering WMP responses to both concepts. A Chief Inspector has been asked to co-Chair the Birmingham Early Help Partnership which meets for the first time on the 20th July and he will work through developing a city wide offer across the partnership. It is anticipated that this approach, once agreed for Birmingham will be shared with the other 6 local authorities across the Midlands for consideration and possible adoption 3. Criminal Justice /Safer Custodial Detention A substantial amount of work around Safer Detention and vulnerability has been completed over the past 12 months within WMP focusing on the detention and treatment of juveniles whilst they themselves are in custody. In this instance, Kelly Emery was in and out of police custody both during and post her pregnancy for drugs/shoplifting offences. As an organisation, WMP dealt with her for the matters in hand but failed to notice the child suffering from harm in the background. Final Version 21.03.16 113 In the below scenario the emphasis very much currently sits with the Officer in Charge (OIC) to ensure that there were no issues with dependents whilst the detainee was in custody, although the question would be asked of the detainee by the custody staff whilst delivering their rights and entitlements and conducting the risk assessment/necessity test. As part of the risk assessment process any detainee with a Class A substance abuse problem should also have been referred to the Drug Intervention programme. However, I believe that there is a necessity for the force to strengthen its approach and learn lessons from the Fenton Hogan case in this regard. 4. Encourage officers and staff to have the confidence to escalate a challenge when a partnership response to a concern does not feel right (as per paragraph 305) The West Midlands regional escalation process is currently out for consultation across all seven local safeguarding children’s boards 5. Requirement to further strengthen National Intelligence Model (NIM) processes and the knowledge management side of things (capturing/developing/sharing/disseminating to ensure effective use of organisational knowledge and engender a multi-disciplined approach. WMP have been on this journey around CSE but I think that there is still opportunity for WMP to develop capturing the wider risk implications around vulnerability that is not overtly obvious and subject of a crime/non-crime number.i.e. the custody scenario surrounding Fenton’s mother with Fenton slipping through the cracks in the background. Clearly one of the issues highlighted within the SCR is the interoperability difficulties around internal IT systems (see paragraph 295). Although there is no overnight fix for this, work is already in hand to bring wholesale change in enhancing WMP’s approach towards protecting children in the guise of the WMP2020 project, a fundamental change programme delivered in partnership between WMP and Accenture, which was launched in early 2015. A Blueprint has been developed which is a target for how West Midlands Police will operate by 2020. The Blueprint gives an indication of what policing within the West Midlands will look and feel like. It also describes how the organisation, services, processes and technology will all work together. The development of the Blueprint has involved extensive internal and external consultation and has drawn upon Accenture’s experience with other police services as well as with other public and private sector organisations. Final Version 21.03.16 114 Three main areas WMP2020 is focusing on are: 1. A programme of work to deliver wholesale change. 2. Business change – preparing the workforce to get ready for the changes coming over the next five years 3. ICT – ensuring WMP have the right technological infrastructure to be able to deliver a new service Underpinning all of this is a communications and engagement plan’. Final Version 21.03.16 115 Appendix 7 Protocol for Adult Substance Misuse Services Working with Parents Adapted from Public Health England, 2013 Final Version 21.03.16 116 |
NC51199 | Death of a 5-year-old child in July 2016. Child E's step-father pleaded guilty to manslaughter and no inquest was carried out. Family had contact with children's services over 14-month period prior to Child E's death, with fluctuating concerns by professionals about care being provided by Step-father and home environment. Step-father was judged as medium risk to the children concerning domestic abuse, alcohol use, driving without a license, and sexual offending. Concerns over contact with unknown men who posed risks to the children. Mother had some level of learning difficulty. Significant incident in May 2015 when children were pulled from the family car by Step-father and left on the pavement. Learning includes: focus on the physical care of the children and home conditions diverted attention from other serious issues, including risk of being in contact with people who presented risks to the children; professional challenge and escalation is important in effective intra and inter-agency work; agencies that saw signs of concern dealt with them appropriately most of the time but some intra and inter-agency communication and information sharing could have been better. Ethnicity and nationality not stated. Recommendations include: more training on neglect and its impact on children, more understanding of legal processes and what local authorities must evidence to secure statutory orders; raise awareness of the Escalation Procedure and the importance of robust, respectful professional challenge between and within agencies; consider the introduction of a panel, chaired by a different professional to take a fresh look at cases that are making insufficient progress.
| Title: Serious case review overview report in respect of: Child E 2016. LSCB: Staffordshire Local Safeguarding Children Board Author: Glenys Johnston Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Local Safeguarding Children Board Serious Case Review Overview Report in respect of: Child E 2016 Glenys Johnston OBE Director Octavia Associates Ltd 2 Contents Title Page 1. Introduction 3 2. Summary 6 3. Case management 6 4. Information sharing 10 5. Assessments 11 6. Neglect 12 7. The views of the family 14 8. The views of practitioners and managers 14 9. What was life like for the children? 15 10. Conclusion 16 11. Recommendations 17 3 1.0 Introduction The Serious Case Review Process 1.1 On 27th July 2016 a notification for consideration of a Serious Case Review was made to the Local Safeguarding Children Board by Children’s Social Care and the Independent Chair of the Board agreed that a Serious Case Review should be undertaken, in accordance with Chapter 4 of the statutory guidance ‘Working Together to Safeguard Children’ (HM Government 2015) and the Local Safeguarding Children Board’s Learning and Improvement Framework; Ofsted were notified in accordance with procedures on 16th March 2017. 1.2 A multi-agency Review Panel was established by the Local Safeguarding Children Board to conduct the Serious Case Review and report progress to the Board through the Serious Case Review Subgroup Chair. Membership included an Independent Lead Reviewer and Overview Report Author, together with representatives from key agencies who were involved with the child and/or their family. The Panel met regularly, was well attended; Panel members provided important information and were constructively challenging, minutes were distributed promptly, and all follow up actions were completed. The Local Safeguarding Children Board’s Interim Manager and administrators provided excellent support. 1.3 The following agencies were members of the review panel and provided an Individual Management Review: Agency Acute Hospital NHS Foundation Trust Birmingham Community Healthcare NHS Foundation Trust District Borough Council Heart of England NHS Foundation trust National Probation Service (NPS) Pre-school Primary School Staffordshire Clinical Commissioning Groups Staffordshire County Council Families First Staffordshire Police Staffordshire and West Midlands Community Rehabilitation Company (CRC) 1.4 I, Glenys Johnston OBE was appointed as the Independent Overview Author, I have extensive experience of undertaking SCRs, chairing Local Safeguarding Children Boards, service reviews and government inspections of child protection. I 4 have previously undertaken consultancy work for the local authority, but I have not had any involvement in this case. Links with parallel processes 1.5 Consideration was given to parallel processes, it was identified that 2 police forces were investigating Child E’s death, and this meant that the Serious Case Review was paused to allow time for this to be completed, before meeting managers, practitioners, or the family to seek their views. Once the prosecutions were completed, the review continued without further delay. 1.6 As SF pleaded guilty to Child E’s death by manslaughter there was no inquest. 1.7 Following the completion of the Serious Case Review, the report has been presented to the neighbouring Local Safeguarding Children Board and their Child Death Overview Panel for consideration. Period covered by the Review 1.8 The review covers the period from 1st December 2014 to the time of Child E’s death on the 23rd July 2016. Any significant incident relevant to the case but prior to the start of the period was included in a contextual summary completed by each agency as part of their Individual Management Review report. Subject(s) of the Review Mother M Step-Father SF Child subject of the review Child E Child E’s eldest sibling Sibling 1 Child E’s youngest sibling Sibling 2 Purpose of the Review 1.9 The purpose of Serious Case Reviews is to identify learning that will improve the practice of agencies, locally and potentially nationally, it is not to apportion blame. 1.10 The full terms of reference for this review are attached at Appendix 2, the key areas to be addressed were: • Determine whether decisions and actions in the case complied with the policy and procedures of named services and the SSCB. • The knowledge of professionals about neglect. 5 • The effectiveness of supervision and the quality of management decisions. • Examine inter-agency working and service provision, including quality of assessments including risk, for the child and management oversight. • The quality effectiveness and monitoring/revision of plans and the contribution of agencies. • Where necessary were concerns, for example about drift and delay or decisions made, escalated? • Determine the extent to which decisions and actions were child focussed and the extent to which the child’s voice was listened to and contributed to plans. In relation to the above key questions: • Identify any organisational issues that affected practice. • Identify the reasons for any practice that fell below expected standards or in relation to good practice. Methodology 1.11 The Review Panel considered the most appropriate methodology for the review and agreed that this would be in accordance with ‘Working Together 2015’ but include events for practitioners and managers to gather their views, as included in ‘Protecting Children in Wales: Guidance for Arrangements for Multi-Agency Child Practice Reviews’ 2013. Opportunities for the family to make their views known to the Independent Overview Author were also seen as particularly important. 1.12 Each agency that had been involved with the family produced an Individual Management Review report, written by a manager with no previous involvement in the case. The Individual Management Reviews used the Local Safeguarding Children Board’s template and guidance; they were of a good standard, completed on time, approved by a senior manager and where necessary, were updated with some minor revisions, following the second Review Panel meeting. The authors set out clearly their experience, qualifications, and independence from the case; the methodology they used and their sources of evidence, together with recommendations for improvements. 1.13 This is an overview report based on the Individual Management Reviews and meetings with managers, practitioners, and M and SF, it does not repeat all the information or single agency learning contained in the Individual Management 6 Reviews but draws these together with additional comments, analysis, and recommendations. 1.14 The names of family members and professionals have been anonymised to protect their identities. 2.0 Summary 2.1 The above key events indicate the persistent and periodically growing concerns about the family over the 14 months before Child E’s death. It is evident that there was a significant amount of contact with the family by professionals (the Social Worker hereafter referred to as SW, family support worker, health visitor and school staff) and the conditions at home changed rapidly from acceptable to unacceptable and acceptable again. There were intermittent concerns about the inappropriate (personal) care being provided by SF and a clear under-lying frustration about the time taken to complete risk and parenting capacity assessments of M and SF expressed by partner agencies, together with concerns about the lack of effectiveness of the core group. The situation appeared to deteriorate following the birth of sibling 2 in October 2015. 2.2 Over the 19-month period between the 5th December 2014 and the 20th July 2016 the children were very young; sibling 1 was between 6 years and 10 months and 8 years and three months old; Child E was between 4 years and three months and 5 years and 9 months old; and sibling 2 was between 0 and 9 months old. In reviewing the chronology, it is evident that the number of occasions when the situation was not acceptable far outweighed the number of occasions when they were. • There were 67 occasions when the home conditions were seen to be extremely poor or school were expressing concerns about the care of the children (dirty bodies, dirty clothes, Child E not wearing spectacles, insufficient clothes for weather conditions, lack of food, being hungry and head lice) which lasted over an extensive period and caused sibling 1 great distress. • There were also 29 occasions when concern was expressed about the children’s contact with inappropriate adults or about the adults driving uninsured, children being pulled from a car (one occasion) and being out late at night with their parents, who were delivering take away food. • 18 occasions when the home conditions and the care of the children had improved and were adequate, although on several of these occasions, there were still some concerns. 3.0 Case Management 3.1 From April 2012 this case was managed through several different processes; early help, child in need and child protection. 3.2 Children’s Social Care’s Individual Management Review highlights that the period before that covered by this review was not effective with poor quality assessments, 7 drift and delay, weak management oversight and an over optimistic view by some professionals about M’s ability to change and a lack of a clear understanding of her over reliance on her new partner. 3.3 The second period of involvement (covered by this review) showed some improved practice though the previous problems remained within the family. 3.4 A Family Dysfunction Referral was received on 28th July 2014, reporting several male visitors to the family home. M was by this time in a new relationship with SF who was known to be a person presenting a risk to children. Concerns continued in relation to the home conditions and parenting capacity, it was also reported that the couple were using alcohol excessively; empty bottles of alcohol were regularly seen in the house and sibling 1 told the SW about their concerns. 3.5 CSC made an initial visit to the family home within the correct time-frame on the 30th July 2014 and found conditions to be inadequate and indicative of chronic neglect. The record of the visit focusses on the narrow issue of poor home conditions, demonstrates an over reliance on M’s view of things and an over optimistic view that the situation would improve. The issue of SF’s risk status is dealt with by the SW stating that he must not stay overnight at the family home and he should not have unsupervised access to the children without the SW assessing M’s capacity to support this. 3.6 CSC took the decision to undertake a Child Social Work Assessment to be completed in twenty days and to implement a Child in Need Plan. The decision making did not adequately consider the known history of concerns, intervention and family functioning. It makes no reference to SF’s history of domestic violence with a previous partner and does not report or risk assess his risk status or use of alcohol. A Child in Need Plan was however, an opportunity to assess his role within the family, the risk he presented, his previous behaviours with particular reference to his risk status and to seek the views of the children. 3.7 It is considered good practice to allocate a re-referral to the SW that has previously worked with the family, it can be beneficial to the family who already know the SW and enables the worker to build on the knowledge they already have in relation to the children’s needs and family functioning. This was the decision made in this case however the additional context and consideration of the previous level of concern for Child E, the performance/practice of the SW during the previous period of involvement and the lack of sustained improvement should have led to a decision to allocate the family to a different worker. 3.8 The Child Social Work Assessment was not concluded until 11th February 2015, some seven months after it commenced and outside the forty-day target, this drift within the process was not addressed by the Team Manager. 8 3.9 The first risk assessment of SF was undertaken by the National Probation Service at court, it described him as being of “medium risk”, and this was later confirmed by the Staffordshire and West Midlands Community Rehabilitation Company, on the 30th of January 2015. The risk assessment was comprehensive and complemented by specific assessments in relation to risk of sexual offending and domestic abuse and judged that SF presented “medium risks to children and others”. 3.10 The recommendation from the Child Social Work Assessment was to refer the family for an Early Help Assessment, to help and support the family, as at that point progress had been made in the home conditions. The SW again formulated their view without the benefit of appropriate assessment tools and does not discuss the impact of continued neglect on the children, nor take account of the risk presented by SF and it is therefore an inadequate report. 3.11 A Child in Need Plan was not however, put in place until 29th April 2015 some eleven weeks later. Within the plan there were tasks for SF and M to improve the home conditions and the children’s presentation and development. It is evident from the plan that SF was part of the family unit, had responsibilities within the home and M was pregnant with his child. 3.12 From case records, escalating concerns included associates of SF who also presented risk to the children staying at or visiting the family home. It is also reported that the children were visiting the home of the same risky adults. Child E’s appearance continued to be poor, with holes in their shoes, recurring head lice, and lack of food. The children are at this stage also being included in delivering take away food with M and SF, returning late at night. Conditions at the family home continued to be unsafe, unsanitary, and malodorous. SF was reported to be driving M’s car, despite the fact he did not have a driving licence and therefore was also not insured. 3.13 The incident on the 8th May 2015 in which the children were pulled from a car resulted in SF being asked to stay away from the family home for the weekend. The Emergency Duty Service passed this information to the area team appropriately and promptly. 3.14 A strategy meeting was convened on 19th May 2015 which was too long after the incident, the police contributed to the discussion and agreed it met the Sec 47 threshold and that an Initial Child Protection Conference should be convened. The central issue remained the neglectful care of the children and the outcome was to return to an Initial Child Protection Conference with Child E being at risk of significant harm. This was the appropriate action. 3.15 On the 22nd May 2015 a written agreement was put in place and signed by the SW, Team Manager and M, the intention being to ensure that M was aware of the expectation to keep Child E safe until the Child Protection plan was in place. The SW 9 was aware that M had some level of learning difficulty and it was unlikely that she understood the agreement or what was expected of her, so it was of little value. In addition, SF was not asked to sign the agreement, which was a missed opportunity to engage his commitment. Serious Case Reviews frequently raise the issue of professionals not engaging men in care planning. 3.16 Despite the Community Rehabilitation Service attending and informing the Initial Child Protection Conference of the assessed risks presented by SF, there remained no risk analysis in relation to the domestic abuse, alcohol use, driving without a licence or his and others’ risk status, by the conference. The minutes of the meeting record that a cognitive assessment had previously been carried out with M. There is nothing in Child E’s records to suggest that this was the case. The Conference does, however, give clear direction in relation to the assessment of SF. 3.17 The SW report to the Conference used the Signs of Safety model to analyse risk appropriately, it had a good focus on the children’s quality of life and the inadequacy of their care although the home environment was still a significant focus. The author of the Children’s Social Care Individual Management Review is of the view that a greater level of respectful caution/challenge should have been applied to M’s account that SF was not living with her as the report also stipulates that she and the SF ‘are untruthful’ and I concur with this. 3.18 At that Review Child Protection Conference in September 2015, the risk assessment of SF remained outstanding, as does the recommended cognitive assessment of M. This is some three months from the Initial Child Protection Conference and leaves the children in a situation of unassessed risk or the risks being addressed in the Child Protection plan. The Team Manager does comment that the County Manager had agreed to fund a cognitive assessment of M. 3.19 In December 2015, concerns were such that the SW sought advice from a Legal Gateway Meeting. When concerns are escalating or not reducing for children, this is the correct meeting for SWs to seek advice from the County Manager and Legal Services. Decisions are made at these meetings that might include making an application to the Family Court for approval and direction for complex ‘expert’ assessment and reporting to be made. 3.20 The following Review Child Protection Conference took place on 18th May 2016, cognitive testing of M (agreed in September 2015) had still not taken place and the risk assessment in relation to SF remained outstanding. The Team Manager recommended that the Public Law Outline process should be considered due to the children’s continued exposure to neglectful care. It follows therefore that the SW would attend a Legal Gateway Meeting to seek the advice of the County Manager. This was the last Review Child Protection Conference before Child E’s death. 10 4.0 Information sharing 4.1 The effective and appropriate sharing of safeguarding information about children and adults involved with them has been an ever-present issue identified in Serious Case Reviews. 4.2 As the Triennial Review- Pathways to Harm and Pathways to Protection DfE 2016 states; “The persistence of findings relating to communication and information sharing suggests a deep, systemic issue. That information sharing is highlighted repeatedly in reports and training suggests neither a lack of professional awareness nor a failure to appreciate the importance of information sharing that is at fault. Nor can the issues be blamed on lack of guidance or systems for sharing information. All national guidance and legislation on confidentiality and data protection supports sharing information to safeguard children and vulnerable people. Our reviews of Serious Case Reviews spanning more than ten years suggest that, despite national guidance and legislation, there are deep cultural barriers to effective information sharing among professionals. Data protection legislation is viewed as a set of constraints limiting information sharing rather than a facilitative too” 4.3 In this case there were some good examples of agencies making referrals, raising concerns with Children’s Social Care and sharing information within and between agencies. Some of which are included as follows. 4.4 The pre-school reported concerns about the incident of the 8th May 2015 to which Children’s Social Care responded appropriately by convening a strategy meeting and ultimately a Child Protection plan. The primary school regularly shared information with the SW and at core groups, strategy meetings and child protection conferences and were alert to the indicators of abuse and acted appropriately when they had safeguarding concerns. Through this Serious Case Review the pre-school has identified that they did not share a full written safeguarding chronology with the primary school when Child E transferred there, although information was shared verbally. 4.5 The police appropriately informed Children’s Social Care in December 2014 when they had reason to check SF’s offending history. 4.6 Invitations for the GP to attend the Child Protection Conferences appear inconsistently in Child E’s and sibling 1 records. It is evident in Child E’s record that the GP was not invited to the Review Child Protection Conference on 1st December 2015 and for sibling 1 the invitation to conference was received on the 23rd May 2016 when the conference was held on the 18th May 2016. There is evidence of some invitations to conferences and minutes from conferences are available to view in all three children’s records. Notification of death is provided on the same day Child E died. There is no evidence of GP attendance at any of the Child Protection Conferences or contribution towards the health information required in the form of a report or telephone conversation. However, GPs are currently using a new report 11 template designed to enable them to share their information and professional views appropriately, if they cannot attend a Child Protection Conference. 4.7 Although the GP did not attend any Child Protection conferences due to capacity and availability, information was shared with the GP by the health visitor and the GP was fully aware that there were safeguarding concerns about the children from conference minutes. The sharing of information within health was one-way i.e. to, rather than from the GP, however, in relation to the older children as the GP rarely saw them the family did not ‘stand out’ as being of significant concern. Contact with M and the baby sibling 2 was more frequent and there could have been more liaison with the community midwife as the GP was involved in M’s asthma care and could have explored with her, the child protection concerns. 4.8 However, at the Practitioners’ Event in February 2018 professionals commented on the poor performance of the core groups with information not always being shared by the SW, (who did not always attend) for example the midwife did not know that SF was a PPRC before sibling 2 was born which had implications for the management of the birth. Minutes of core groups were not always produced so attendees had to rely on their own notes and there was insufficient consideration or monitoring of the Child Protection Plan at each core group meeting. 4.9 The SSCB Multi-Agency Neglect Strategy Nov 2016 states: Effective information-sharing within and between agencies. Each area should have a cross sector information-sharing protocol. All relevant agencies and services should be signatories and it should clearly state what information should be shared, by whom and the process for doing this. This information should inform assessments and decisions about risk. It is also paramount when reviewing information that all agencies consider historical information and the potential impact of this on a child’s presenting circumstances; this will help to identify families at risk of inter-generational neglect. In addition, all frontline practitioners should have significant regard to be the overlap between neglect and other forms of child maltreatment, such as parental domestic abuse, substance misuse and mental ill-health. 5.0 Assessments of M and SF 5.1 The Individual Management Reviews and chronology provided for the review identifies a running thread of frustration, delays and drift in the completion of a cognitive assessment of M and a risk assessment of SF; this was an action agreed in the Child Protection Plan of September 2015 and raised by the health visitor, the school and the Child Protection Conference chair on several occasions but by the time Child E died these had not been completed. 5.2 Although professionals have the skills to assess observed behaviour, they are not clinical experts. Identifying parents with cognitive limitations is an essential first step for SWs and other partners and there was a shared view that M may indeed have a learning difficulty or impairment. Without formal psychological, expert assessments it 12 was difficult to ‘un-pick’ whether M was able (had the capacity) to understand the concerns of professionals and whether she agreed with them, comply with plans, and whether she had the willingness to do so and if not whether she was affected by SF’s manner and dominance and if so why she accepted this. The Children’s Social Care Individual Management Review mentions a written agreement but does not evaluate its accessibility. M was not referred to Adult Services for assessment and should have been although the referral may not have been accepted if the service determined that the threshold was not met. 5.5 SF’s angry outbursts, mentioned above together with his dominant personality was known but never specifically assessed in relation to these children. 5.6 Without the assessments it is difficult to see that measures to safeguard and protect the children could be informed by clinical expertise, nor could the concerns about SF be clearly explained to M. 6.0 Neglect 6.1 Throughout the period the children were known to Children’s Social Care and at times, other agencies, there were concerns, identified above, about neglect, the physical care of the children, the chaotic state of the home, physical chastisement, alcohol use by adults, domestic abuse, sexual offenders having contact with the children and risky adults visiting the home. At times, these concerns reduced but overall, the care of the children continued to be of concern to professionals. 6.2 Neglect is the most common form of child maltreatment. For example, Brandon et al 2014 1 notes, “During 2013 in England almost half of child protection plans occurred as a response to it and it also featured in 60% of serious case reviews. However, a number of high profile child deaths in the UK have shown that it is extremely difficult for professionals with safeguarding responsibilities to identify indicators of neglect, to assess whether what they have seen is serious enough to take action and to decide on the most appropriate course of action.” ‘Working Together 2015’ defines neglect as: The persistent failure to meet a child’s physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to: • provide adequate food, clothing, and shelter (including exclusion from home or abandonment); • protect a child from physical and emotional harm or danger; • ensure adequate supervision (including the use of inadequate care givers); or • ensure access to appropriate medical care or treatment. 6.3 Further to this, the glossary to ‘Working Together 2015’ defines emotional abuse as: 13 • The persistent emotional maltreatment of a child such as to cause severe and persistent adverse effects on the child's emotional development. • It may involve conveying to a child that they are worthless or unloved, inadequate, or valued only as far as they meet the needs of another person. It may include not giving the child opportunities to express their views, deliberately silencing them or 'making fun' of what they say or how they communicate. • It may feature age or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond a child's developmental capability, as well as overprotection and limitation of exploration and learning, or preventing the child participating in normal social interaction • It may involve seeing or hearing the ill-treatment of another. It may involve serious bullying (including cyber bullying), causing children frequently to feel frightened or in danger, or the exploitation or corruption of children. • Some level of emotional abuse is involved in all types of maltreatment of a child, though it may occur alone. 6.4 Some of the characteristics and challenges of neglect contained in the Department for Education Research report of 2014, ‘Missed opportunities; indicators of neglect, what is ignored, why and what can be done’ are paraphrased below as they are relevant to this case: - neglect can in some cases be challenging to identify because of the need to look beyond individual parenting episodes and consider the persistence, frequency, enormity and pervasiveness of parenting behaviour which may make them harmful and abusive; - there is a reluctance to pass judgement on patterns of parental behaviour when associated with social disadvantages such as poverty. 6.5 Services in this case were not unresponsive to the family, many neglectful families like this one are extremely demanding of professional time with frequent crises and requests for assistance as happened in this family, but the focus can be, and was, on the presenting problem-the home conditions and physical care of the children rather than their being exposed to sexual harm and domestic abuse. As a result, plans were largely ineffective as was their monitoring, nor was there reflective pauses as to whether the care of the children was ‘good enough’ and what the cumulative impact of their neglect was. 14 7.0 The Views of the Family 7.1 The Local Safeguarding Children Business Manager spoke to Child E’s birth father on 20th July 2017, he shared that he had raised concerns about M’s care of the children in 2012 but had not seen his child for five years and had little to contribute. 7.2 In February 2018 I met M with the local authority’s Head of Partnership and Development. M explained that she had been born with physical difficulties and learning difficulties and had had difficult relationships with her first two partners which included domestic abuse. She described her contact with professionals as “feeling bullied all the time” which made her feel very anxious that her children would be removed from her care. To avoid contact with professionals she often spent the whole day driving around while the children were at school. She said she understood why professionals were concerned about the state of her house but not why they were concerned about the care of the children. 7.3 She did not receive copies of assessments or reports which were submitted to Child Protection Conferences, she did receive minutes and Child Protection Plans but struggled to understand them and despite pictures being included to help her understand she did not find the written agreement helpful either. She said that when she attended Child Protection Conferences she had to join professionals who were already in the room, which was intimidating. 7.4 She recognised the efforts made by the Family Support Worker in that she played with the children and talked to them. She said she would have found some instruction and assistance with how to run the house helpful. 7.5 In March 2017 I also met SF with the local authority’s Head of Partnership and Development. He recognised that M had difficulties in maintaining their home properly but felt he had played a significant part in improving it. He resented the involvement of the SWs but found most other agencies were helpful, he acknowledged that at times he became irate and professionals probably found him challenging. He was adamant he had not been responsible for CE’s death and had only pleaded guilty to charges to avoid M going to prison as she had no previous offences. 8.0 The Views of Practitioners and Managers 8.1 As part of the review, it was decided that two events, one for practitioners and one for managers involved in this case, would be held, facilitated by me. These took place in February 2018. 8.2 Practitioners found M’s lack of appreciation and criticism very difficult to accept as they felt they had all worked very hard to support the family. They did welcome the opportunity to meet to discuss the case although this was almost two years after CE died, a long time to contain their concerns about the outcome of the review. In summary the views of those who attended the events, which are not necessarily endorsed by me, were: 15 • Overall, there was good information sharing by agencies. • Core groups were poorly managed; there was no regular monitoring of the plan, poor attendance by some agencies, cancellations not always being notified to attendees and inadequate minutes which did not reflect changes or decisions. • Practitioners are aware of the need to professionally challenge and escalate concerns and are increasingly confident in doing so. However, in this case they felt the outcome was not positive, e.g. delays in assessments etc still did not reduce. There was information in the multi-agency chronology produced for this review that not all agencies were aware of, had they known it they may have escalated more frequently. • There were real problems to do with no timely assessment being completed of M’s cognitive abilities, which was regularly raised by professionals and the Child Protection Conference Chair. Children’s Social Care seem to have conveyed that parenting assessments by clinicians can only be funded when families are in proceedings. Some confusion about what single or multi-agency are parenting assessments and which are specialist assessments involving clinicians • What risk was posed by SF given his offending history? Why wasn’t this assessed especially given the risk. • Agencies lack a clear understanding of the legal processes which are open to CSC and the thresholds and evidence requirements at each stage. • Agencies would find it helpful to have sight of CSC’s assessment timetables for parenting assessments and the content as it progresses. • Overall, agencies were unfamiliar with the LSCB neglect assessment tool (The Graded Care Profile) and therefore had not used it, the benefit of using the same tools across agencies is that information and assessments can be easily shared, using the same language. 9.0 What was life like for the children? 9.1 From reading Children’s Social Care Individual Management Review and the chronology it can be gathered that life for these children was far from ‘good enough’ or that we would wish for our own children. As they had been the subject of two Child Protection Plans before the period covered by this review there had clearly been concerns since sibling 1 was four and Child E was two years of age. 9.2 There is evidence that professionals worked hard to seek the children’s views and envisage what their life was like and this is captured in the Children’s Social Care Individual Management Review and the last Child Social Work Assessment. 9.3 Child E was described in pre-school as a quiet, happy child who enjoyed staff attention, never appeared reluctant or scared to go home at the end of the school day and had a good emotional bond with M. However, concerns noted by the pre-school and school clearly evidence that all was not well; they constantly had to remind M about making sure they wore their spectacles, was clean i.e. not smelling of cat urine, 16 had a proper packed-lunch in a clean lunch-box. On the day of the car incident in May 2015, Child E said that they had ‘skin on their toes’ and on checking them, the staff saw that the toenails were so long they were bending over the edge of the child’s toes. 9.4 Sibling 1 suffered from head lice for most of the period covered by the review which made her embarrassed and led to her being bullied, she is described in the Children’s Social Care Individual Management Review as being proud to show the SW when her bedroom was tidy but was very conscious of the appalling state of the house and commented that M “did not help her tidy up”. The chronology clearly indicates that sibling 1 was visiting a property where there were several men who posed risks to children including SF. 9.5 The incident when the children were pulled from the family car by SF and left on the pavement while he and M drove away, was considered to be abusive by pre-school staff, they describe witnessing how the children ran after the car along a busy road and that they (especially sibling 1) were visibly frightened. SWs, the police and education professionals were united in their view that this situation was of serious concern and supported the convening of the Initial Child protection Conference. 9.6 The pre-school Individual Management Reviews also makes an important reflection, that SF could appear intimidating, that his large physique and at times, angry face, angry and overpowering behaviour and kicking doors and shouting must have made an impression on the children. The Children’s Social Care Individual Management Review also highlights that SF was a controlling individual who managed all elements of the family home and that M appeared content to accept this by following his wishes, rather than accepting responsibility. 10.0 Conclusion 10.1 From this Serious Case Review there is evidence that the three children who are considered in the review, suffered from neglectful abuse for at least the last four years and it is reasonable to assume that the neglect occurred before then. 10.2 The review has enabled us to gather a clear sense of the children and their experience of being cared for and it presents a worrying and unsatisfactory picture. 10.3 Most concerns were identified and largely shared through emails, verbally, referrals and at meetings although information was not always shared by children’s social care between and at core group meetings. Agencies that saw signs of concern, dealt with them appropriately on an individual basis most of the time. However, some intra and inter-agency communication, sharing information, could have been better, a finding of many Serious Case Reviews and the Department for Education Triennial Review of Serious Case Reviews. 10.4 Core groups are an important part of the child protection process, their role is set out in statutory procedures and is to develop and monitor the child protection plan, amending it as new information comes to light. They are an invaluable arrangement 17 to share information between professionals and the family. In this case they did not work well until the latter stages. 10.5 Services were not unresponsive, many neglectful families like this one are extremely demanding of professional time with frequent crises and requests for assistance but the focus can and was on the presenting problem-the home conditions and physical care of the children and there was the lack of a reflective pause on whether the care of the children was ‘good enough’ and what the cumulative impact of their neglect was. 10.6 The focus on the physical care of the children and the home conditions, diverted attention from other serious issues such as the risk of being in contact with people who presented risks to the children, despite relevant information being communicated by professionals from Staffordshire and West Midlands Community Rehabilitation Company. 10.7 Children’s Social Care openly accept that the social work support given to the family was not of the standard to which they aspire, this led to unusually poor communication and drift and delay in the case work and planning. This was highlighted by the Head Teacher of the primary school who has worked with the service for many years and described the practice in this case as not of the quality previously delivered. The problem was compounded by poor management at both levels above the SW, this practice was regrettable but has been robustly addressed by the service. 10.8 Professional challenge and escalation is of significant importance in effective intra and inter-agency work. There were occasions when concerns about delays and decisions were escalated but where they were not or not escalated further this would appear to be because professionals outside Children’s Social Care believed what they were told by the SW. They also felt that their concerns, when raised to the SW’s manager were unhelpful and they had little confidence that action would be taken, or decisions re-considered. Some also lacked confidence in and a full understanding of the escalation process, comments from the practitioners’ event indicated that they now have a better understanding and more confidence in doing so. 10.9 The agencies that contributed to the review undertook their work well and have identified and have or are implementing the recommendations for improvements in their own agencies. 11.0 Recommendations Local Safeguarding Children Board should: i. Reflect on the comments from the practitioners’ and managers’ events. These included: • the need for more training on neglect and its impact on children, • more understanding of legal processes and what the local authority must evidence to secure statutory orders; 18 • the changing role and landscape of children’s social work departments, given the impact of rising demands and reducing resources. ii. Assure itself that core groups are functioning effectively and in accordance with procedures. iii. Raise awareness of the Escalation Procedure and the importance of robust, respectful professional challenge between and within agencies iv. Highlight to agencies the value of using chronologies in supervision, core groups and case conferences to monitor progress in cases where neglect is of concern and consider the practicality of establishing combined (inter-agency) chronologies for child protection planning purposes. v. Consider the introduction of a panel, chaired by a different professional to take a “fresh look” at cases that are making insufficient progress. |
NC52530 | Teenage boy who stabbed his father in February 2021 in an apparent act of self-defence. Learning is embedded in the recommendations. Recommendations include: review what the barriers are to professionals using the escalation process and why it is so under used; develop systems and processes to identify those young people with highly complex needs and at the greatest risk so that service responses can be flexible and if necessary, fast tracked to respond effectively to unmet needs; explore opportunities for co-working in complex cases to help support transitioning between teams and enable young people to build a rapport and relationship with a new worker; adopt a flexible approach where the practitioner best placed to develop a relationship with the child and their family takes a lead in ensuring the child's voice is heard; monitor and evaluate the progress of actions to reduce waiting times for neuro development assessments; explore local provisions to provide more targeted levels of support to children with complex needs who have high levels of social, emotional and mental health needs; undertake a quality assurance process to assess the progress of the introduction of contextual safeguarding in assessments of young people at risk of exploitation; and evaluate the capacity of the Child Abuse Trafficking and Exploitation team for proactive work to develop assessment of risk of young people at risk of child exploitation.
| Title: Child safeguarding practice review: James. LSCB: Warwickshire Safeguarding Partnership Author: Lucy Young Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. V 9.0 Published 23.06 2022 1 Child Safeguarding Practice Review James Date: June 2022 Lucy Young V 9.0 Published 23.06 2022 2 TABLE OF CONTENTS Page no 1. Introduction • • 3 2. Organisational learning and improvement 4 3. Thematic appraisal of professional practice 5 4. Findings 14 5. Summary of findings and recommendations 19 6. Summary of single agency action plans 22 7. Appendices 24 V 9.0 Published 23.06 2022 3 James Local Child Safeguarding Practice Review Report 1. Introduction 1.1 Succinct summary of the case This Local Child Safeguarding Practice Review (LCSPR) concerns James who, in February 2021, stabbed his father at home in an apparent act of self-defence. James’s father was not seriously harmed but James and his family have been known to a wide range of services over a number of years. He is extremely vulnerable with several complex needs including risk of criminal exploitation1, mental health issues, self-harm and suicide attempts, a history of traumatic childhood experiences and frequent cannabis misuse. He has missed a significant part of his secondary education. James experienced chaotic early life experiences and instability in his care arrangements moving between his parents care throughout his childhood. He has been involved with Child and Adolescent Mental Health (CAMHS) since the age of nine and there is an extensive history of mental health issues including nine recorded episodes of overdose and/or suicidal ideation since. There are 37 recorded attendances at Accident and Emergency departments. James has been subject to a child in need plan and a child protection plan, and the family have been offered support from several agencies. 1.2 Scope of the review For this review to learn about current systems issues it focusses on the two years prior to the stabbing incident (February 2019 to February 2021). The agencies and organisations who worked with or had contact with James and his parents during that time were involved. Although the detailed focus is on the most recent two years the local review panel was mindful that previous years of childhood trauma, neglect and mental health issues have impacted significantly on James during his teenage years. The local review panel acknowledges that had different decisions or interventions been made earlier in James’s life the outcomes might have been different. The review endeavours to take into account earlier events in James’s life where they are seen to have impacted on more recent attempts to work with him and support his family2. The period in scope for the review took place against the backdrop of the covid 19 pandemic with three national lockdowns taking place over the two years. This gave an additional complexity to the case. 1 The Government definition of criminal exploitation of children is “where an individual or group takes advantage of an imbalance of power to coerce, control, manipulate or deceive a child under the age of 18. The victim may have been criminally exploited even if the activity appears consensual” Home Office Guidance 7 February 2020 HMO: London 2 “An issue with adolescent reviews is that they usually only focus on the recent past and consider at most the last 2-3 years. Much of the harm in adolescents relates to previous childhood trauma and neglect, so that it may be exceptionally difficult to change things for them by the time, for instance, they move into residential care. The key decisions for supporting families when effective preventive action could have been taken falls outside of the review, so we cannot learn from it. There needs to be consideration of how we can ensure full learning from adolescent reviews.” Annual Review of LSCPRs and Rapid Reviews May 2021 V 9.0 Published 23.06 2022 4 1.3 James’s family James, who is white/UK, was born in October 2004. His parents are separated and during the review period he was living with his mother until October 2019 when he moved to his father’s. James has an older brother and sister who both live independently. James and his father met separately with the reviewer at the end of the review and their perspectives are included in s.3.8. 1.4 Pen picture of James James’s social worker describes him as a likeable and kind young man with a good sense of humour. He likes cooking and playing computer games and is good at putting things together and fixing things. He has been interested in becoming a mechanic or an engineer. He’s just under 6 foot tall with a slim build. He takes pride in his appearance and likes to look smart. When he was younger James loved horse riding which he was very good at. Sadly, James’s struggles with his mental health can overshadow all his really good traits. He struggles with relationships and has not yet developed the skills required to make friends of his own age easily and he can sometimes show naivety and lack insight. James has strong views about cannabis use for medicinal purposes which he finds helps to calm him down and regulate his mood. He has researched this and can give a well thought out cohesive argument in favour of it. 2. Organisational learning and improvement A Rapid Review3 by Warwickshire Safeguarding Children Partnership found that there was evidence of systemic failure in this case which could have contributed to James’s deteriorating circumstances. The national Child Safeguarding Practice Review Panel decided there were significant issues and potential important learning from James’s case to merit an LCSPR. The Review Panel thought that this case could shed light on systems issues in the Warwickshire Safeguarding Partnership. It recognised that some children who are extremely vulnerable can have several complex needs such as risk of criminal exploitation, mental health issues including self-harm and suicide attempts, a history of traumatic childhood experiences including neglect and significant cannabis misuse. The local panel felt this case could help the Safeguarding Partnership learn more about how to enable a more effective safeguarding response to these children by looking at the following key lines of enquiry: 1. How are young people’s own views captured and recorded and how well does the partnership ensure that the child’s voice forms a key element of the decision-making process? 2. How does the partnership respond to children struggling with their mental health? 3. How well does the safeguarding system respond to children when they are at risk of criminal exploitation? 3 When a possible serious case is identified ‘the safeguarding partners should promptly undertake a rapid review of the case, in line with any guidance published by the Panel”. Working Together 2018 V 9.0 Published 23.06 2022 5 4. How does the education system respond to children who present challenges to schools due to their range of behaviours? 5. How did the covid pandemic effect the partnership involvement with GL and his family? 3. Thematic appraisal of professional practice The appraisal of practice provides an overview of what happened in this case, looking at professional responses and systems learning. It sets out the view of the local review panel of how effective agencies were in their contact with James and his family. It aims to outline what got in the way of professionals being as effective as they wanted to be and, where possible, to provide explanations for practice. At the heart of this case is a fragmented approach to supporting James and his family where agencies struggled to engage or maintain engagement with this young person with complex needs. There was a pattern of James’s risk-taking behaviour escalating and his mental health declining through the years with services dropping in and out of his life, often failing to engage either James or his parents. Practitioners described feeling a sense of paralysis and hopelessness when supports such as drug and alcohol services, education and mental health were not consistent or effective in engaging or supporting James. 3.1 James did not attend full time school throughout the review period James told professionals that he was worried about his education, he aspired to be an engineer and felt that by missing so much school he would not be able to achieve this. Despite being on the roll of School A until March 2021 he did not attend school for nearly all his secondary school career. The approach to meeting James’s educational needs was fragmented and ultimately the system failed James. His Education, Health and Care Plan (EHCP)4 finalised in November 2017 (when James was in year 8) stated that he should remain at School A which was responsible for meeting his needs until a special school was identified for him. During the time of this review two separate unregistered alternative education providers5 were commissioned either by the school or the local authority at different times. Regulation requires the named school to be accountable for all students on their roll and for James this should have involved School A setting outcomes with the provider, monitoring attendance and progress and addressing safeguarding issues. Best practice would be to monitor James at least weekly and to track his attendance through the Central Learning Monitoring system. It is expected that the school would maintain a relationship with James and his family. In this case, as time went on and the local authority failed to identify a special school, the lines of accountability became blurred. School A was frustrated by the lack of progress and felt it became 4 An Education, Health and Care plan (EHC plan) describes a child’s special educational needs (SEN) and the help they will get to meet them. An EHC plan also includes any health and care provision that is needed. It is a legal document written by the local authority and is used for children and young people with high support needs. (Warwickshire SENDIAS 2018) 5 Alternative Provision is education arranged by Local Authorities for learners who, because of exclusion, illness or other reasons would not otherwise receive suitable education; education arranged by schools for learners on a fixed period exclusion; and learners being directed by schools to off-site provision to improve their behaviour (DfE 2013). V 9.0 Published 23.06 2022 6 increasingly inappropriate for James to be on their roll. Other agencies felt the school disengaged from him. His EHCP was never reviewed6 and became very out of date. Not all schools in Warwickshire are effective at supporting children with EHCP who struggle in the mainstream setting and require more specialist provision. In September 2021 Ofsted found; “Schools have not accessed enough training to help school staff understand and provide for children and young people’s needs in mainstream settings. Leaders know this and have plans in place to address it. However, the plans are yet to be fully implemented, which means that some schools do not have enough qualified and experienced staff to support children and young people with SEND effectively.”7 School A maintained that James’s needs were so complex that it was not possible for him to attend school even on a part time basis. There were several obstacles to identifying a special school for James; he went to stay with his sister in Birmingham for a few months; his mother refused one school on grounds of distance from home; the family rejected residential school as an option and three schools did not offer places on the grounds of suitability or capacity. For a short time, the local authority amended the EHCP to name a special school but when the offer of a place was withdrawn School A was once again named as James’s school. This further blurred the lines of accountability and oversight of James. At the time Warwickshire was experiencing a high number (1800) pupils who were not on any school roll, in September 2018 there were 300 children placed in unregulated alternative provision in Warwickshire. The SENDAR team responsible for managing James’s case and identifying a special school for him was over stretched and under resourced. It is a serious failure of the system that having agreed in November 2017 that James’s needs would be best met in specialist provision it was not identified nor the EHCP reviewed until March 2021. There was an over reliance on part time unregistered alternative provision. The position of central government and the local authority is that alternative provision should be temporary and either enhancing registered provision or a short-term intervention to enable reintegration into registered provision. For a short time in 2019 he was attending an alternative provider full time, but this ceased as it was an illegal arrangement with an unregistered provider. To get around this regulation by 2020 James was being offered a combination of part time places at two different unregulated alternative providers. Alternative Provision 1 was commissioned by the local authority in February 2020 to work specifically with him on behaviour and relationships with a view to helping him back to school. Education input (English and Maths) was offered by Alternative Provision 2. It was unusual for the local authority to commission alternative provision for a child who is on a school roll, and this blurred the lines of accountability further. This meant that the alternative provision did not know that he was on school A’s roll and school A assumed that the local authority had assumed the lead role in coordinating James’s educational needs which contributed to their hands off approach. James engaged sporadically with the alternative provision and there was some evidence of progress for example developing a good relationship with one worker 6 The local authority must review the EHC plan at least once every 12 months. This must be done in partnership with you and your child or the young person, and must take account of your views, wishes and feelings. (Warwickshire SENDIS 2018) 7 Ofsted Joint local area SEND inspection in Warwickshire September 2021 V 9.0 Published 23.06 2022 7 and the opportunity to attend work experience as a car mechanic. However, these successes were short lived possibly because the alternative provision was short term and part time8 and there was a lack of monitoring and coordination. The covid 19 lockdown also had an impact on his attendance. A recent review of alternative provision in England concluded: “Children in Alternative Provision are some of our most vulnerable. The education available to them should be of equal if not better quality than for children in mainstream schools. An effective education system must support the most disadvantaged pupils to access the same broad curriculum and educational opportunities as their peers.”9 James was a victim of the dysfunctional relationship between the local authority and the school, and his needs remained unmet. Research10 has clearly and repeatedly shown that when children fall through the gaps in a system, such as attending an education provision, then they become more vulnerable. The lack of a full-time special school place for James and the absence of clear accountable oversight by School A or the local authority made him more vulnerable to risks from criminal exploitation, drugs and his mental health and it was harder to monitor his safety and wellbeing. Research11 into positive responses to support children with adverse childhood experiences identifies the involvement of a trusted adult who a child can talk to and gain support from as being pivotal to supporting these children. Attendance at school can provide children with a sense of belonging and structure as well as consistent and positive relationships with adults. This was not available to James. 3.2 James experienced suicidal ideation and he made a number of suicide attempts. James has a long-standing history of involvement with mental health services since he was nine years old. Interventions from the Child and Adolescent Mental Health Service (CAMHS) have included psychotherapy, medication for depression, crisis intervention in the form of emergency assessments and attempts to involve his parents. Troubled young people can respond well to relationship-based work when given the opportunity to establish a connection with a skilled practitioner. In James’s case there were few opportunities for this to happen due to a combination of difficulty in engaging the family and the fragmented nature of the services, for example the lack of a full-time school place which is often the place where very regular health and well-being conversations can take place with young people alongside input from CAMHS. Despite James making three suicide attempts in early 2019 CAMHS closed his case at his and his mother’s request. He felt therapy and medication were not helping him. James continued to be at significant risk from his mental health and his daily drug use and lack of engagement with school. With the withdrawal of CAMHS and non-involvement of school the social worker was left as the only professional with a role in supporting the family. With such a complex case it should be expected that key 8 It is illegal to place a child full time in an unregistered alternative provision 9 The Centre of Social Justice May 2020 10 Children’s Commissioner 2019 11 Addressing Adversity: Prioritising adversity and trauma – informed care for children and young people in England. Young Minds NHS England 2017 V 9.0 Published 23.06 2022 8 agencies would make decisions about withdrawing their services in the context of the multi-agency partnership, for example at a child in need review. In effect neither health nor education remained involved with James at that time. The local review panel thought that when key agencies close a child in need or child protection case this should happen with discussion with partners and include a risk assessment to decide the impact of withdrawing involvement. It is not uncommon for children and families with the most complex needs not to engage with key services like CAMHS or drug services, but these services can continue to have a role in supporting statutory partners. The social care team could have considered escalating the non-engagement of partners in such a complex case within the partnership. James’s case remained open to the Neuro Development team as he was on the waiting list for an Autistic Spectrum Disorder assessment. This assessment might have supported practitioners in developing an appropriate care, support, and treatment plan for James. In fact, the assessment did not take place, and, at the time of this review, it has still not happened. In Warwickshire “Area leaders acknowledge that the Neurodevelopmental Pathway (a specialist service responsible for the assessment of neurodevelopmental conditions such as autism spectrum disorder (ASD) and attention deficit hyperactivity disorder) has not worked well enough across agencies. Children and young people wait too long for an assessment. The plans to address the key issues, including waiting times for assessments, have been developed too slowly, are not specific enough and do not have clear targets.”12 This was another missed opportunity for James. The local review panel recognised this as a national issue with a shortage of skilled practitioners to do assessments. Warwickshire’s written statement of action in response to the Ofsted findings includes targets to bring the waiting times for assessments down from 5 years to 18 months over the next 2 years. The approach by CAMHS was at times fragmented and uncoordinated. For example, there was a lack of clarity about the coordination of James’s care for a period of five months in 2020 when James and his father only had contact with CAMHS though duty workers and there was a lack of coordination of information about him within CAMHS and with partner agencies. When James’s mental health deteriorated further in January 2021, and he was presenting with paranoia and psychosis he was assessed as being low risk to himself and others. A safety plan included a referral to drug services and he was prescribed medication. With hindsight the CAMHS professionals recognised that it would have been beneficial to provide home treatment for assistance with administering his medication given his history of reluctance in the past. This would also have provided more support for his father who was clearly struggling. Although James was not detainable under the Mental Health Act CAMHS considered referral for a tier 4 inpatient bed, but no bed was identified for him. This is a national issue and local providers are reliant on NHS England commissioning arrangements and the availability of appropriate facilities. 12 Ofsted Joint local area SEND inspection in Warwickshire September 2021 V 9.0 Published 23.06 2022 9 3.3 There was no holistic health needs assessment of James At various times during the review period James was the subject of an EHCP, s.1713 child in need plan and a child protection s.4714 assessment and plan all of which require a holistic health needs assessment as part of the multi-agency process. In James’s case this did not happen. There was no contact with school health or the GP when James was subject to a child in need plan possibly because School A were not engaged with this process either and the link with school health was not made. When he became subject to a child protection plan the school nursing service made various unsuccessful attempts to engage James in an assessment, but he was not attending school and his father appeared to block their attempts to see him. In many cases school health can coordinate and develop a plan to address a child’s health needs through the school. The GP was not able to engage with the child protection process because of very limited capacity and late notice of meetings. When the school nursing service closed the case due to lack of engagement no one was taking the lead role in coordinating James’s health care needs. The review found that in very complex cases where families are hard to engage the best coordinator for health care assessment and planning needs should be agreed on a case-by-case basis. It requires concerted efforts in communication and coordination between GP, school nursing service, school, and alternative providers to agree the best way to engage children and families. 3.4 James was using cannabis daily James had been using cannabis since his early teens. During the review period he was said to be using it daily which he said was to manage his anxiety and anger. CAMHS practitioners discussed James’s cannabis use with him and his father and talked about the impact of this on his mental health. There were offers of alternative medications to support him to reduce his use. However, James was reluctant to engage with Compass, the specialist drug and alcohol service, and the issue was not addressed. James’s cannabis use complicated mental health assessments in terms of the impact that it was having on his general mental health. Research15 has shown that people using high-potency cannabis every day were nearly five times more likely to be diagnosed with psychosis that those who did not use cannabis. Combined with other risk factors such as adverse childhood experiences (ACES)16 and attachment difficulties the likelihood of developing psychosis is higher. It was not well understood how James was funding his use of cannabis. Practitioners who were aware of James’s cannabis use did not express curiosity about this to James or his father. CAMHS could not effectively assess and support James while he was still using cannabis and there was no stability in his life. The issue of James using cannabis from a young age and the risks it presented raised questions for the local review panel as to whether there was a general resigned acceptance amongst professionals of his use. 13 Section 17 of the Children Act 1989 imposes a general duty on local authorities to safeguard and promote the welfare of children “in need” in their area. 14 A section 47 enquiry as defined in the Children Act 1989 means children social care must carry out an investigation when they have “reasonable cause to suspect that a child who lives in their area is suffering or is likely to suffer significant harm”. 15 Association of High-Potency Cannabis Use With Mental Health and Substance Use in Adolescence JAMA Psychiatry 2020 16 The term Adverse Childhood Experiences (ACEs) is used to describe a wide range of stressful or traumatic experiences that children can be exposed to whilst growing up. There are 10 recognised ACES; examples of ACE’s include physical abuse, parental substance misuse, parental criminal activity, neglect, parental mental health V 9.0 Published 23.06 2022 10 CAMHS have a clear pathway and an early intervention process, working with Compass, for young people from 14 years old at risk of drug induced psychosis James was not involved in this service and was not willing to engage with Compass. Although they make every effort to encourage engagement it is not a statutory provision and unless a young person is detainable under the Mental Health Act CAMHS cannot support young people who do not wish to engage with services. 3.5 There were concerns that James was involved in criminal exploitation In August 2019 information came to light indicating that James may be involved in criminal exploitation and linked to gangs. At that time there was a concern about gangs in the area and information was being shared about several young people, but James was not one of them although he was thought to be on the periphery. James was subject to a s.17 child in need plan at this time and there was discussion in the Strengthening Families17 team to consider how the issues of criminal exploitation were to be assessed and whether the child protection threshold was met. There was no assessment undertaken to try to develop a deeper understanding of his daily life, his peer group, how he spent his time, areas he was frequenting, how he got his drugs etc. There was no referral to the Child Exploitation team, and this was a missed opportunity for multi-agency intervention. Instead, the child exploitation tool was completed many months later at a more stable time and contained little of the detail of the previous concerns. The social worker submitted a National Referral Mechanism (NRM) referral to the Police in respect of James’s drug use, associations and potential for him being exploited or trafficked to supply drugs. The NRM is a tool for identifying and referring victims of modern slavery to the Single Competent Authority in the Home Office so that they can receive the appropriate support. The definition of modern slavery (which covers trafficking and exploitation) means that young people who are being criminally exploited are often referred to the NRM in the hope that it will give them protection. Research18 findings suggest that the NRM’s purpose does not always fit well with the circumstance of this group of children. The Home Office Single Competent Authority (SCA) made a decision that there was reasonable grounds that James was a victim of modern slavery. Despite this it is unclear whether a child exploitation assessment tool was completed, and no referral was made to the Child Exploitation team for consideration of additional support. Warwickshire Trafficking procedures were not followed, in that there was no multi-agency strategy discussion held with the police and other agencies to develop a plan of action. There was an over reliance on using the existing children in need process to manage this risk. In fact, the child in need plan and reviews at the time made little reference to these contextual19 risks and robust plans to address them, with only 17 The Warwickshire Strengthening Families Service incorporates Targeted Family Support and Child In Need. The service is for families with children and young people aged 0-18 years old who need support to improve their life chances or avoid issues escalating to child protection concerns. Depending on the level of need they will either receive targeted support or child in need support. 18 It was hard to escape: Safeguarding children at risk from criminal exploitation. The Child Safeguarding Practice Review Panel 2020 19 Contextual Safeguarding is a term developed by Carlene Firmin, University of Bedfordshire which describes an approach to understanding and responding to young people’s experiences of significant harm beyond their families. It recognises the different relationships young people form in their neighbourhoods. Parents and carers often have little influence over these contexts. V 9.0 Published 23.06 2022 11 surface level actions to keep James away from the potential harm. In April 2019 the Multi-Agency Sexual Exploitation (MASE) team and processes transitioned to include criminal exploitation as well as sexual exploitation (MACE).20 There were procedures in place for assessing and managing risk of criminal exploitation, but the MACE was not fully established within the workforce for another year, and they were not well understood. ‘The MACE process is implemented to effectively respond to concerns where a child/young person is groomed or targeted for exploitation. MACE is the established framework in Warwickshire for responding to the contextual challenges of exploitation in all forms.’21 Rather than having separate multi-agency meetings, the MACE process aims to integrate assessment and risk discussions regarding exploitation into existing meetings held for the child/young person. The MACE guidance says that section 47 and child protection procedures should only be initiated in exceptional circumstances. Where the risk is external to the family the focus must be clearly on the perpetrator(s) and other contextual spaces of concern rather than on a parent’s ability to protect or blame for their child’s vulnerability. The local review panel heard that Warwickshire Safeguarding Partnership is now working to embed these MACE processes and a contextual safeguarding approach into the system, but this was not well established during the time in scope of this review. A criminal exploitation assessment tool completed in May 2020 did not identify a risk at that time. However, it eventually resulted in allocation in July 2020 (delayed because of staff shortages within the team) because of the additional factors of a feud with another young person apparently causing James’s father to be stabbed and James driving a car at a young person. James and his father were not aware of this referral and had not been engaged in completing it which would have been best practice and may have helped pave the way to better engagement with the team. The referral to the Child Exploitation team was another lost opportunity, the mistiming of the referral, the considerable delay in the team allocating it and the non-involvement of James and his father were all likely contributors to the team not being able to work with James. The Child Exploitation team collates information and intelligence about individual young people. At this time the team was struggling with resources having recently added criminal exploitation to the child exploitation role and they were focussing on several high-level operations. In James’s case there was no new information or intelligence about him, and the police did not have the capacity for proactive gathering of information and intelligence on young people where, in their view, there was perceived low risk rather than a known risk. Essentially the police were not able to do lower-level proactive investigation work with child criminal exploitation. The police were involved with James on at least 11 occasions over the review period for significant incidents including: being found on a bridge threatening suicide, crashing his father’s car into a wall at speed (a few months prior to the review period), NRM referral, James’s father was stabbed at home by a young associate of James, James drove his father’s car trying to hit the young person who stabbed his father, James being attacked with a knife. 20 Multi-agency Child Exploitation Team MACE 21 Multi-agency Child Exploitation risk discussions guidance. Warwickshire Children’s Services 2020 V 9.0 Published 23.06 2022 12 The non-proactive police approach dealing with each incident on an individual basis meant that the element of criminality in James’s life was not fully known or understood. When it is recognised that a child is being exploited, the detail of their daily lives is difficult to establish and so ascertaining the level of risk and the management of that risk is more difficult. From a child’s perspective practitioner involvement might be characterised as being on the surface of their lives.22 3.6 James was subject of a child in need plan and a child protection plan Statutory child in need and child protection processes rely on an engaged multi-agency approach to be effective in improving children’s outcomes. In this case, where the family did not always engage with services offered or dipped in and out there were times when the children’s social care team felt unsupported by their partners. For example, social care took a role in trying to identify alternative provision for James because in their view School A was not supporting James. For most of the time the school was disengaged from the children in need process. Social care arranged for school meal vouchers for James’s father during covid lockdown although this should have been the school’s responsibility. For the social workers this was a very difficult case to be involved in, struggling to engage the family and find out what was happening for James in his daily life. They knew more was going on but felt stuck trying to manage a case with fragmented involvement of other services. In efforts to protect his son James’s father was perceived as resistant and anti-authority. Practitioners struggled to get into the house and engage with James. It was very difficult to have open and frank conversations. Despite multi-agency involvement with James from a very young age there was no robust chronology to contribute to good assessment. The MOSAIC23 information system did not have an effective chronology tool at that time. The system has since been upgraded and the local review panel heard that work is ongoing to embed new processes that aim for there to be a chronology in the form of the ‘child’s story’ on every child’s case file. James became subject of a child protection plan under the neglect category in June 2020 following a critical incident when James was in a car with his father and drove towards a young person crashing the car and assaulted a police officer on arrest. There was good attendance at child protection core group meetings by agencies and a clear plan for their involvement. James did not engage with the health needs assessment; the referral to the child exploitation team took months and eventually James did not engage with the worker; the neuro development assessment did not happen; police investigations were slow and the EHCP was not progressed. Practitioners talked about the sense of paralysis with not being able to progress the plan while seeing James’s mental health decline. 22 It was hard to escape: Safeguarding children at risk from criminal exploitation. The Child Safeguarding Practice Review Panel 2020 23 Warwickshire children’s information and recording system V 9.0 Published 23.06 2022 13 3.7 Critical moments in James’s life The National Panel Review24 explored the systems theory concept of how critical times in a child’s life are responded to in order to make a difference to their lived experiences. The National Panel explain that by adopting a flexible and responsive approach in the critical moment in a child’s life can have a powerful influence on the direction taken after the event and after conversations have happened. Leaving things, even by a day or two later may be too late to effect change. There were several critical and reachable moments throughout James’s story which could have been acted upon in a timelier way and possibly with a different outcome for him. For example, when James did share concerns about wanting to address his drug use the referral took several months which meant that the moment was lost, and the drug service was unable to engage James. The referral to the Child Exploitation team happened months after a critical time when he was found to be involved in drug debt and threats from other young people. “As agencies, we need to find ways of being flexible and responsive enough to be ready to engage in those moments in real time. Days after the event might be too late. Services have to be constructed to be nimble enough to respond in the right moment, in the crisis.25” The key learning point here is that organisations must be flexible enough to respond immediately to the critical moment when the child is more likely to be open to change. 3.8 Views of James and his father James continues to struggle with his mental health, and he is no longer living at home. The reviewer was very grateful to him that despite his current complex circumstances he agreed to meet with her (on a virtual Teams call) once the report was completed. James told the reviewer about how distressing and difficult he found it with the voices in his head, he said they made his life hell and he felt like someone was controlling him. He felt that smoking ‘weed’ made the voices calm down. James did not think that anyone understood what he was going through. He said he had spent a lot of time at home and would get very bored. He wished he could have gone back to school, he loved it when he did mechanics for a few months. He said it would have helped him if people had taken him out to do activities like paintballing or skateboarding, he thinks that it would have helped to ‘distract his mind’. He found the covid lockdowns very stressful and difficult and does not remember seeing anyone then. The reviewer also met with James’s father at the end of the review. He said that while James was living with him, he had a mortgage to pay and was working full time. He wishes now, with the benefit of hindsight, that he had stopped work, moved into council accommodation and claimed benefits. Caring for James, who was not attending school, required a full-time parent and he thinks that might have made a difference to the outcome. He could have made sure James spent less time alone, had a routine and got involved in more activities. James’s father feels that professionals should have asked him more about his own lived experience as a single parent to James. Practical advice about finance and benefits if he stopped 24 It was hard to escape: Safeguarding children at risk from criminal exploitation. The Child Safeguarding Practice Review Panel 2020 25 As above V 9.0 Published 23.06 2022 14 work would have been helpful. On at least two occasions when James was very unwell the assessments by CAMHS crisis teams took place once he had calmed down and his father felt they did not help to address James’s needs or support the family. This is explored in Findings 1 and 3. 4. Findings 4.1 Working together Finding 1 A fragmented and inconsistent approach to supporting James and his family led to a sense of professional paralysis amongst practitioners and James’s complex needs were not addressed A consistent theme through this review was the sense of paralysis felt by practitioners working with James and his family. This was particularly difficult for children’s social care when the fragmentation of the education response and James and his family’s disengagement from CAMHS at times left them as the only agency trying to engage, support and keep James safe. The review team questioned why escalation processes within the partnership are under used and what the barriers are to this. Services should consider escalating concerns about the non-engagement of partners though the partnership where services withdraw and there is only single agency involvement remaining. Children in need and child protection processes can only be effective with the engagement of a team around the child. Key agencies should only close cases or withdraw services in partnership with other agencies, for example at a child in need review, in order to agree how to address unmet need. The complexity of some children’s needs and circumstances means that the usual solutions are not effective and results in a great deal of harm for them. However, the absence of a mechanism for identifying who those young people are at a strategic level prevents the professionals responsible for them from having a mandate to think creatively and make bespoke proposals about how to achieve the outcomes required for these children. James’s case would have benefitted from an effective escalation process to senior leaders to resolve the paralysis in the process of identifying a special school place for James. A more flexible approach could have meant being able to achieve a very fast track response during the times when James showed a willingness to engage with drug services. Recommendation 1 Undertake a comprehensive review to understand what the barriers are to professionals using the escalation process and why it is so under used (Warwickshire Safeguarding Partnership) Recommendation 2 Develop systems and processes to identify those young people with highly complex needs and at the greatest risk so that service responses can be flexible and if necessary, fast tracked to respond effectively to unmet need (Warwickshire Safeguarding Partnership) V 9.0 Published 23.06 2022 15 4.2 How are young people’s own views captured and recorded and how well does the partnership ensure that the child’s voice forms a key element of the decision-making process? Finding 2 There is no evidence that any practitioner was able to get a clear understanding of James’s daily lived experience, if they did, it did not contribute to the multi-agency work with him Despite attempts by practitioners to develop a relationship with him it seems that practitioner involvement might be characterised as being on the surface of James’s life. Social workers often felt blocked by James’s father in their attempts to meet with James and the covid 19 lockdowns placed an additional barrier in their way. James has had social care involved with him from a very young age and is wary of professionals, his father had a mistrust of authority which made it difficult for practitioners to develop relationships with them. Parental engagement is nearly always a protective factor26 and parents need effective support in helping them manage risk. Skilled work is required to build good relationships with families. Since the review period James has become a child in care and the local review panel heard that he and his father had developed a good relationship with the social worker which enabled him to develop a deeper knowledge and understanding of James and his family. Unfortunately, more recently there has been another change of social worker when James was moved to the Leaving Care team, given James’s highly complex needs the local review panel was concerned for him at the loss of the relationship with his social worker. Recommendation 3 Explore opportunities for co-working in complex cases to help support transitioning between teams and enable young people to build a rapport and relationship with a new worker (Children’s Services) Recommendation 4 The multi-agency team around the child needs to adopt a flexible approach where the practitioner best placed to develop a relationship with the child and their family takes a lead in ensuring the child’s voice is heard (Warwickshire Safeguarding Partnership) 26 It was hard to escape: Safeguarding children at risk from criminal exploitation. The Child Safeguarding Practice Review Panel 2020 V 9.0 Published 23.06 2022 16 4.3 How does the partnership respond to children struggling with their mental health? Finding 3 There is a gap in service provision for those children with complex needs who do not have a diagnosed mental illness resulting in a fragmented and uncoordinated approach which did not address James’s mental health needs. CAMHS was involved with James for many years and offered different interventions and undertook several assessments although there is little evidence of any significant change or any greater understanding of his mental health issues. At times there was a lack of coordination of CAMHS services and despite the complexity and risk to James, involvement was withdrawn at James and his family’s request leaving statutory agencies feeling unsupported. There were differing views about how James’s cannabis use impacted on his mental health and no successful strategies were found to address this. There is a national shortage of CAMHS Tier 4 beds and although James was referred for assessment in Tier 4 provision none was available. During this time CAMHS acknowledges that he may well have benefitted from input from the Crisis and Home Intervention Treatment team. Crucially a neuro development assessment never took place which may have enabled a more helpful assessment of James’ overall mental health needs. It is recognised that in the UK a lack of capacity throughout the system is resulting in health agencies prioritising children with a diagnosable mental health condition over those with emotional or behavioural needs “to gatekeep access to rationed CAMHS”. In 2019 the ADCS recommended that “NHS England should instruct health partners to cease using the distinction between children with emotional and behavioural needs and those with a mental health condition as a means to gatekeep access to CAMHS services. Health partners must take more responsibility for co-commissioning appropriate services for children who have emotional and behavioural needs which affect their mental health.27” Recommendation 5 Monitor and evaluate the progress of actions to reduce waiting times for neuro development assessments (Warwickshire Safeguarding Partnership) Recommendation 6 Review the availability and use of the Crisis and Home Intervention Treatment team (Coventry and Warwickshire Partnership NHS Trust) Recommendation 7 Undertake a review of the coordination of James’s care during 2020 and to implement recommendations from this into processes and practices (Coventry and Warwickshire Partnership NHS Trust) _______________________ 27 ‘A health care system that works for all’ ADCS 2019 V 9.0 Published 23.06 2022 17 Recommendation 8 Explore local provision which enables a multi-agency team to provide more targeted levels of support to children with complex needs who have high levels of social, emotional and mental health needs (Warwickshire Safeguarding Partnership & Health & Wellbeing Board) 4.4 How well does the safeguarding system respond to children when they are at risk of criminal exploitation? Finding 4 MACE processes and contextual safeguarding were not well understood or embedded in practice at the time of this review so the risks of criminal exploitation to young people were not addressed effectively Finding 5 Warwickshire Police did not have the capacity to proactively gather intelligence about young people who may be at risk of exploitation There is no specific legislation or policies for child criminal exploitation and is therefore mainly supported under legislation including the Children Act 1989 and the Modern Slavery Act 2015. Working Together to Safeguard Children was revised in 2018 to include extra-familial risks as child protection issues. However local authorities have received very little guidance and the research is still somewhat limited to support and inform agencies as to the most effective ways of responding to such extra-familial risks. The impact of this means that most professionals working with children at risk of criminal exploitation did not and arguably still do not know how best to support children or reduce risk effectively in this complex area of practice. Police in Warwickshire lack capacity for proactive work to develop an assessment of the risk to a young person considered to be likely risk of exploitation. The Police responded to incidents on an individual basis, processes were generally followed with risk assessments based on what was happening at each moment in time placed on the record system. This did not allow for a more comprehensive assessment of risk to James to be developed using all accumulated information available. There was no contextual approach to assessing the risks to James. The review team heard that there has been a programme of training to try to embed the MACE approach to criminal exploitation since the time of this review. Children’s Services has initiated a project to implement a framework for Contextual Safeguarding and to develop a framework to address extra familial risk and harm experienced by children outside the home such as child sexual and criminal exploitation, peer-on-peer abuse and gang affiliation and violence. The challenge to the safeguarding partnership is to ensure that contextual safeguarding becomes embedded in practice across the partnership. Recommendation 9 Monitor and evaluate progress on embedding MACE processes throughout the partnership (Warwickshire Safeguarding Partnership) V 9.0 Published 23.06 2022 18 Recommendation 10 Undertake a quality assurance process to assess the progress of the introduction of contextual safeguarding in assessments of young people at risk of exploitation (Warwickshire Safeguarding Partnership) Recommendation 11 Evaluate the capacity of the Child Abuse Trafficking and Exploitation team (CATE) for proactive work to develop assessment of risk of young people at risk of child exploitation (Police) 4.5 How does the education system respond to children who present challenges to schools due to their range of behaviours? Finding 6 The local authority and the school failed to meet James’s educational needs which resulted in him missing his secondary education and being vulnerable to exploitation in the community The relationship between school A and the local authority is fractured and individual children fall through the net when neither appears willing to accept responsibility for meeting their needs. There is a need for restorative work to resolve the fragmented arrangements between schools and the local authority to ensure collective ownership of responsibility for the children with the most complex and challenging needs. There should be no gaps in the system for children to fall through. The review found that schools in Warwickshire have been using unregulated alternative provision inappropriately rather than meeting their needs within the school setting despite specific funding set aside for them to address this issue. There are insufficient places in special schools in Warwickshire for the children who need to be there because places are taken by children who should and could have their needs met within mainstream school. The local authority SENDAR team is under resourced resulting in very slow progress in identifying school places for individual young people and not reviewing EHCPs. The local review panel heard from the local authority that since the period of this review there has been an overhaul of processes and panels and the system is now more responsive to young people like James. As these systems are still embedding and given the serious safeguarding implications of children not being in school the review recommends that the Partnership Board request information about the provision and monitoring of education for the most vulnerable children with complex needs who are not receiving full time education. The functioning of the education panels in Warwickshire should be evaluated to ensure that there is no longer a possibility that children like James will be failed. Schools have a paramount role in keeping children safe and each child who may show challenging behaviours should have an education package in place to address their needs. V 9.0 Published 23.06 2022 19 Recommendation 12 To seek assurance from Warwickshire Education Services that children with EHCP who are not attending school full time either because they have been excluded or because they are only receiving part time alternative provision are identified and their safety and progress is robustly monitored (Warwickshire Safeguarding Partnership) Recommendation 13 To seek assurance from Warwickshire Education Services in respect of the effectiveness of the new local authority panels to provide timely responses to children in need or children with an EHCP who cannot attend mainstream school for any reason (Warwickshire Safeguarding Partnership) Recommendation 14 Undertake Restorative work with relevant schools and the local authority to improve the collective ownership of responsibility for the children with the most complex needs ensuring timely and appropriate review of EHCP plans (Warwickshire Education Services and Warwickshire Children’s Services) 4.6 How did the covid pandemic effect the partnership involvement with GL and his family? The working environment has changed hugely since March 2020. Use of digital virtual meetings has improved capacity to attend meetings and agency’s ability to maintain contact with practitioners. The negative side to this is that in James’s case he developed a paranoia of use of virtual meetings and would not engage via zoom which meant that he was even less reachable during covid. James and his father were very anxious about Covid and were even more reluctant to engage with services during this time. During the covid pandemic lockdowns James remained at home and did not receive in-home support from School A which continued to have a responsibility for James as for any other student on roll. Alternative providers continued to offer support to James throughout the lockdowns when his father agreed to accept it. 5. Summary of findings and recommendations Finding 1 A fragmented and inconsistent approach to supporting James and his family led to a sense of professional paralysis amongst practitioners and James’s complex needs were not addressed Recommendation 1 Undertake a comprehensive review to understand what the barriers are to professionals using the escalation process and why it is so under used (Warwickshire Safeguarding Partnership) Recommendation 2 V 9.0 Published 23.06 2022 20 Develop systems and processes to identify those young people with highly complex needs and at the greatest risk so that service responses can be flexible and if necessary, fast tracked to respond effectively to unmet need (Warwickshire Safeguarding Partnership) Finding 2 There is no evidence that any practitioner was able to get a clear understanding of James’s daily lived experience, if they did, it did not contribute to the multi-agency work with him Recommendation 3 Explore opportunities for co-working in complex cases to help support transitioning between teams and enable young people to build a rapport and relationship with a new worker (Children’s Services) Recommendation 4 The multi-agency team around the child needs to adopt a flexible approach where the practitioner best placed to develop a relationship with the child and their family takes a lead in ensuring the child’s voice is heard (Warwickshire Safeguarding Partnership) Finding 3 There is a gap in service provision for those children with complex needs who do not have a diagnosed mental illness resulting in a fragmented and uncoordinated approach which did not address James’s mental health needs. Recommendation 5 Monitor and evaluate the progress of actions to reduce waiting times for neuro development assessments (Warwickshire Safeguarding Partnership) Recommendation 6 Review the availability and use of the Crisis and Home Intervention Treatment team (Coventry and Warwickshire Partnership NHS Trust) Recommendation 7 Undertake a review of the coordination of James’s care during 2020 and to implement recommendations from this into processes and practices (Coventry and Warwickshire Partnership NHS Trust) Recommendation 8 Explore local provision which enables a multi-agency team to provide more targeted levels of support to children with complex needs who have high levels of social, emotional and mental health needs (Warwickshire Safeguarding Partnership & Health & Wellbeing Board) V 9.0 Published 23.06 2022 21 Finding 4 MACE processes and contextual safeguarding were not well understood or embedded in practice at the time of this review so the risks of criminal exploitation to young people were not addressed effectively Recommendation 9 Monitor and evaluate progress on embedding MACE processes throughout the partnership (Warwickshire Safeguarding Partnership) Recommendation 10 Undertake a quality assurance process to assess the progress of the introduction of contextual safeguarding in assessments of young people at risk of exploitation (Warwickshire Safeguarding Partnership) Finding 5 Warwickshire Police did not have the capacity to proactively gather intelligence about young people who may be at risk of exploitation Recommendation 11 Evaluate the capacity of the Child Abuse Trafficking and Exploitation team (CATE) for proactive work to develop assessment of risk of young people at risk of child exploitation (Police) Finding 6 The local authority and the school failed to meet James’s educational needs which resulted in him missing his secondary education and being vulnerable to exploitation in the community Recommendation 12 To seek assurance from Warwickshire Education Services that children with EHCP who are not attending school full time either because they have been excluded or because they are only receiving part time alternative provision are identified and their safety and progress is robustly monitored (Warwickshire Safeguarding Partnership) Recommendation 13 To seek assurance from Warwickshire Education Services in respect of the effectiveness of the new local authority panels to provide timely responses to children in need or children with an EHCP who cannot attend mainstream school for any reason (Warwickshire Safeguarding Partnership) Recommendation 14 Undertake Restorative work with schools and the local authority to improve the collective ownership of responsibility for the children with the most complex needs ensuring timely and appropriate review of EHCP plans (Warwickshire Education Services and Warwickshire Children’s Services) V 9.0 Published 23.06 2022 22 6. Summary of single agency action plans Agencies submitted their individual action plans to the review, and these are summarised below. The review recommends that the Safeguarding Partnership Board requests updates on progress of these plans. 6.1 Coventry and Warwickshire Partnership NHS Trust (CAMHS) If there is a child awaiting a tier 4 bed assessment consideration should be given to input from the CAMHS Crisis and Home Treatment Team CWPT acknowledges that there is a lack of clarity over the coordination of James’s care during a set period. This will be subject to an internal review, which we will consider and implement any of the recommendations 6.2 Warwickshire Education Service Monitoring of children and young people attending alternative provision as the main part of their education for more than 10 weeks. That education placement decisions are made in a timely manner and not deferred Expanding specialist education provision for children and young people with SEMH needs New school opened March 2022 Monitoring of annual reviews and action where this has not taken place Reforming the annual review process within SENDAR Finding ways to engage with hard to reach and disengaging families 6.3 Warwickshire Police To highlight to the wider workforce on the importance of reflecting the risk to children from missing episodes Raise awareness of the work of the HAU in conjunction with MASH Awareness and training of the process in respect of the National Referral Mechanism (NRM) Athena- raise the standards of investigation reports and ensure that there is relevant content on investigation logs inputted in a timely manner with rationale documented for key decisions 6.4 Children’s Services Remind staff to have open conversations with alternative education providers when attempting to engage with hard-to-reach young people Ensure Social Workers are aware of what the educational entitlement for children and young people is Ensure social workers are aware of the updated escalation procedure, which includes details of all key agencies and the key practitioners to speak to. All plans should be formulated with families All attempts to contact children and Families to be recorded even if they are unsuccessful and clarity in these records as to whether they are planned or unplanned contacts V 9.0 Published 23.06 2022 23 Ensure all social workers completed relevant mental health awareness training Ensure all social workers and family support workers have an understanding of the MACE policies and procedures, including early help and children in need Children’s Services to undertake Trauma Informed Practice training 6.5 University Hospitals Coventry and Warwickshire NHS Trust Professionals should be encouraged to adopt an investigative, questioning and professionally curious approach when considering the history of a case Professionals to be aware of the specialist services available in relation to substance misuse for appropriate sign posting 6.6 Coventry and Warwickshire CCG All individuals with a history of overdose should be offered a GP follow up appointment within 2 weeks of being closed to CAMHS All individuals should be offered a GP follow up appointment within 2 weeks after discharge from A&E/Hospital for mental health issues The Practice should review their policy of ensuring that children and young people are pro-actively offered to be seen alone in the Practice (where appropriate) 6.7 School A Link member of staff to make weekly contact with each Alternative Provider that is being used SENCO / DSL meet with SENDAR monthly 6.8 COMPASS School Nursing Service To remind staff to have open conversations with alternative education providers when attempting to engage with a hard-to-reach young people If COMPASS is unable to complete a child protection or LAC health assessment, they should inform the GP V 9.0 Published 23.06 2022 24 Appendix 1 Methodology The independent lead reviewer28 worked closely with a local review panel which comprised of the following: Agency Role Independent Safeguarding Consultant LSPR Author and Lead Reviewer Education Strategic Lead for Alternative Provision Warwickshire Police Police Staff Manager, Statutory & Major Crime Review Unit (SMCRU) NHS Coventry and Warwickshire Clinical Commissioning Group Head of Safeguarding Warwickshire County Council Legal Services Warwickshire Children’s Services Practice Improvement Manager Warwickshire Safeguarding Partnership Board Quality, Learning and Improvement Officer Coventry and Warwickshire Partnership NHS Trust (CAMHS) Head of Safeguarding All meetings including the practitioner reflective workshop were conducted virtually using Microsoft Teams. The review drew on information and analysis provided by each agency in individual information reports and chronologies. These reports are designed for an agency to analyse their involvement with the child and family. The information was followed up at a Reflective Learning Event. Agencies also provided additional data including assessments and case records where appropriate. Data from reports to the rapid review was also available. Agencies that provided Information Reports and chronologies School A Alternative Provision 1 Alternative Provision 2 Warwickshire Children’s Services including Safeguarding Team, Strengthening Families Team, Child Exploitation Team and Special Educational Needs (SENDAR) Hospital Coventry and Warwickshire Partnership NHS Trust (CAMHS) Warwickshire Police School Health COMPASS NHS Coventry and Warwickshire Clinical Commissioning Group _______________________________ 28 Lucy Young is an independent safeguarding consultant with an extensive background in children’s social care and safeguarding. V 9.0 Published 23.06 2022 25 This review has used a systems approach drawing on the Social Care Institute of Excellence (SCIE) Learning Together Systems model29. This approach endeavours to understand professional practice in context, identifying the factors in the system that influence the nature and quality of work with families, and make it more or less likely that the quality of practice will be good or poor30. _______________________ 29https://www.scie.org.uk/children/learningtogether/ 30‘The purpose of reviews of serious child safeguarding cases, at both local and national level, is to identify improvements to be made to safeguard and promote the welfare of children. Learning is relevant locally, but it has a wider importance for all practitioners working with children and families and for the government and V 9.0 Published 23.06 2022 26 policymakers. Understanding whether there are systemic issues, and whether and how policy and practice need to change, is critical to the system being dynamic and self-improving.’ (Working Together 2018) |
NC043377 | Death of a 7-year-old boy (Child U) and his 6-year-old sister (Child V) on 30th September 2012. Children were found on a bridleway with their Father who was also deceased. Police evidence later revealed that Father stabbed both children before taking his own life. Mother had disclosed domestic abuse (verbal/emotional) to GP in October 2011 and had reported deterioration in the marriage in the months preceding the incident. Mother left father following what she claimed was a first instance of physical abuse several weeks prior to the incident. A contact agreement had been reached and it was during a contact visit that the incident took place. Lessons learned, include: domestic abuse is a child protection issue; children should be actively spoken to, engaged with and observed by professionals; and violent acts that lead to the death of children can occur without any prior indication. Makes various single agency and multiagency recommendations for: children's services, health services, police and education services.
| Title: Overview report on the serious case review relating to Children U and V. LSCB: Surrey Safeguarding Children Board Author: Ron Lock Date of publication: 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Overview report on the SERIOUS CASE REVIEW relating to Children U and V Independent Chair of Serious Case Review Panel - Helen Davies Independent Overview Report Author - Ron Lock May 2013 2 CONTENT Introduction Paragraphs 1.1 – 1.5 Page 3 Serious Case Review Process 2.1 – 2.9 Page 4 The Facts 3.1 – 3.24 Page 10 The Children’s Experience 4.1 – 4.6 Page 14 Analysis: - Appropriateness of Agency Involvement 5.1 – 5.19 Page 16 - Inter-agency Communication 6.1 – 6.3 Page 20 - Domestic Abuse/Child Focus 7.1 – 7.5 Page 21 - Parental Physical & Mental Health 8.1 – 8.5 Page 23 - Race, Religion, Language, Culture and Disability 9.1 Page 24 - Organisational Resource Issues 10.1 Page 24 Predictability and Preventability 11.1 – 11.6 Page 25 Lessons Learned 12.1 – 12.8 Page 27 Recommendations 13.1 – 13. 4 Page 28 Appendix 1 - Individual Management Review Recommendations Page 29 3 1. INTRODUCTION 1.1 This Serious Case Review (SCR) has been undertaken following the tragic deaths of two children, who will be referred to as Child U and Child V within this report, who were found dead on a bridleway in Area 2 with their Father who was also deceased. Their deaths occurred in late September 2012. The subsequent Police investigation came to the view that both children had been stabbed by their father who then took his own life. Child U was almost 8 years old and Child V just over 6 years old when they died. The parents had been recently separated, and it was during a contact visit for the Father that the deaths occurred away from the family home. 1.2 If “abuse or neglect is known or suspected to be a factor in the death” of a child, this requires that the Local Safeguarding Children Board should “always conduct a SCR into the involvement of organisations and professionals in the lives of the child and the family”1, and therefore in response to this guidance, and because the death of both children was believed to have been perpetrated by their father, then Surrey Safeguarding Children Board (SSCB) commissioned this SCR. 1.3 The purposes of this SCR reflect the relevant government guidance at that time to: - - Establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; - Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and - Improve intra and inter-agency working to better safeguard and promote the welfare of children.2 1.4 Each agency that had some direct involvement with the children and their family was required to undertake an Individual Management Review (IMR) to look openly and critically at its practice in relation to their involvement with them. In undertaking this, each agency was also required to produce a chronology of its contact with the family. The managers/officers conducting the IMRs did not at the time immediately line-manage the practitioners involved and were not directly concerned with the services provided for the children or their family. 1.5 Senior representatives from relevant agencies in Surrey were brought together to form a SCR Panel in order to review and analyse the material from the IMRs. The role of Independent Chair of the SCR Panel was undertaken by Helen Davies, and the Overview Report author was Ron Lock, both being independent consultants who were independent of all agencies in Surrey and had extensive experience in safeguarding children and young people. 1 Paragraph 8.9 – Working Together to Safeguard Children – A guide to inter agency working to safeguard and promote the welfare of children – Dept. for Children, Schools and Families – March 2010 (NB: This guidance was reissued in March 2013 although very similar criteria for conducting a SCR is included) 2 Paragraph 8.5, Working Together to Safeguard Children – Dept. for Children, Schools and Families, March 2010 4 2 THE SERIOUS CASE REVIEW PROCESS 2.1 The period of time to be covered by this SCR was from the birth of the eldest Child “U” in November 2004 up until his and his sister’s deaths on the 30th September 2012. Agencies conducting IMRs were also invited to include any information known to them which was outside of this timeframe but which may have had relevance to understanding the family history or to the analysis of later professional interventions. 2.2 The following agencies were commissioned to complete the IMRs: Surrey County Council (CC) Children’s Services Ashford and St. Peter’s Hospitals NHS Foundation Trust NHS Surrey GP Practice Mid Cheshire Hospitals NHS Foundation Trust Virgin Care Surrey Police Schools and Learning, Surrey County Council Surrey and Borders Partnership NHS Foundation Trust Additional information was also received from Royal Surrey County Hospital NHS Foundation Trust, who because of their limited involvement, were not asked to undertake a full IMR. 2.3 The SCR Panel members were: Group Manager - Surrey County Council Legal & Democratic Services Designated Nurse Safeguarding Children – Surrey PCT Detective Inspector – Public Protection Investigation Unit - Surrey Police Head of Performance and Support – Surrey CC Children’s Safeguarding Services Area Education Officer - Surrey CC Schools and Learning Consultant Child and Adolescent Psychiatrist, Named Doctor for Child Protection - Surrey and Borders Partnership Trust 2.4 All SCR Panel meetings were chaired by Helen Davies, Independent Safeguarding Consultant Also in attendance at Panel meetings: Ron Lock – Overview Report Author Quality Assurance Officer – Surrey Safeguarding Children Board Safeguarding Board Administrator - Surrey Safeguarding Children Board 2.5 Specific Issues to be considered for analysis were: a) Was the level and extent of agency engagement and involvement with the family appropriate? b) Were any safeguarding issues recognised by agencies and how these were addressed? 5 c) Did the agencies communicate effectively and work together to safeguard the children’s welfare? d) Was the level and extent of domestic abuse known and was the impact/risk to U and V adequately assessed and responded to? e) Were there any parental physical or mental health issues or issues of substance misuse which may have impacted on parenting capacity? f) Whether there are any factors in the history of any adults that indicated that they may pose a risk to children. g) Whether race, religion, language, disability or culture was a factor in this case and had been considered fully. h) Were the children’s wishes and views known and taken into account in assessments and planning? i) Were there any organisational or resource factors which may have impacted on practice? Additionally, consideration should be given to the areas identified in Working Together 2010 Page 245 for analysis of involvement that is not covered by the above specific issues. 2.6 Methodology/SCR Process 2.6.1 The circumstances of the deaths of these children was first considered by the Serious Case Review sub group of the SSCB on the 16th October 2012, which led to the recommendation to the SSCB Independent Chair that a SCR needed to be commissioned. The SSCB Chair wrote to involved agencies on the 25th October 2012, informing them of the decision to undertake a SCR. Members of the SCR Panel were selected and the Independent Chair and Independent Overview Report author were commissioned. The SCR Panel had its first meeting on the 9th November 2012. 2.6.2 In total there were five SCR Panel meetings, the first on the 9th November 2012 and the final one on the 19th March 2013. As part of the process, the IMRs were separately presented to the SCR Panel on the 8th January 2013, with revisions completed in time for SCR Panel to consider them at the next meeting on the 1st February 2013. Overall the IMRs were completed within deadlines with limited additions or revisions being required for their final versions. Because of a considerable delay in accessing the Father’s former medical records from the Army, this delayed the completion of the SCR. The final Overview Report was presented to the SSCB Executive Committee on the 23rd May 2013. 2.7 Parallel Processes 2.7.1 The only relevant parallel process is that to that of the Coroner’s inquest, which was held on the 5th December 2012 and which concluded that the two children were unlawfully killed and that the Father took his own life through a deliberate act. The inquest took the view that the Father had planned the deaths of his children but that there was no prior indication that this was going to happen. 6 2.8 Contributions by the Family 2.8.1 The Mother agreed to meet with the Independent Overview Author and was able to give information in respect of her experiences of work with the various professionals who were involved in providing support and advice to her and her family. The Mother’s contributions have been included within the body of the report where appropriate. 2.8.2 Contact was also made with one of the Father’s brothers who was keen to provide some input into the SCR process. Although he had no direct experience of the support services provided to the family, he was able to provide some context via his understanding of the family circumstances. 2.9 Individual Agency Involvement/Individual Management Reviews (IMR) The GP Practice 2.9.1 The GP practice had the most continuous involvement with the family, dating back to 1996, and both children were registered with the practice since their births. The practice was also the first service to become aware of family difficulties when the Mother expressed concern about domestic abuse in October 2011, and then was instrumental in supporting her to report an incident of alleged domestic abuse by the Father in the late summer of 2012. The Father had also consulted the GP at this time. 2.9.2 The IMR provides detailed accounts of the GP practice’s involvement with the family and within its analysis, recognises the supportive approach taken by the GP, but that there was nevertheless a need for greater understanding by the GP of what services for domestic abuse were available and to whom the GP could have made appropriate referrals on behalf of the Mother. The IMR finds that opportunities for referral to other agencies and assessment were missed and has made recommendations to ensure that the remit for the safeguarding lead in GP practices is fully understood and utilised. 2.9.3 Following a formal request by the SCR Panel, the GP IMR author made enquiries about the ability to access the Father’s previous army health records (He had a career in the Army up until mid-1990s) There was no automatic transfer of such records to a civilian GP. The SCR Panel decided that useful information, however old, could be potentially useful in understanding whether there were any previous mental health issues for the Father, particularly as he was a casualty in the Hyde Park bombing in 1982, and so a formal request for the records was made. These eventually arrived very late in the SCR process, but the GP IMR was redrafted to include this information and related analysis. A recommendation in this Overview Report has been made in respect of access to former Army medical records. Mid Cheshire Hospitals NHS Foundation Trust 2.9.4 The reason for the need for this IMR was that the one alleged domestic abuse incident that was recorded in respect of the parents, and in which the Mother received injuries, occurred in late August 2012 in the Midlands whilst the family were away at a friend’s, and the 7 Mother attended a local hospital there with her injuries the following day. Because there was no disclosure at the time by the Mother of any domestic abuse, and because her presentation in the company of the Father did not raise any concerns, then no related action was identified by hospital staff at the time. 2.9.5 The IMR considered that in the context of the Mother’s presentation, that hospital staff were conscientious and responded appropriately in the circumstances and that there was nothing to suggest that the injury was anything other than an accident, as described to them by both parents. Records were however not made about whether the Mother was seen alone whilst at the hospital or of the Father’s identity who attended with her. The IMR author understood that taking the opportunity to speak with patients in confidence was now being undertaken by practitioners. Recommendations have been made regarding improved training in respect of safeguarding children and vulnerable adults in relation to domestic abuse, backed up by an audit of its impact upon practice, including the need to ensure that the next of kin and accompanying adults are documented appropriately. Surrey Police 2.9.6 Surrey Police’s main involvement was in respect of the alleged domestic abuse incident which although it occurred outside Surrey, was reported to Surrey Police by the Mother a few days later, which they then investigated. As part of that investigation, both the Mother and Father were seen and Children’s Services were notified of the alleged incident. 2.9.7 The IMR gives clear detail of Police involvement with the family during this investigation and whilst there were some minor administrative issues with the criming/ownership of the assault allegation, overall it was considered that the Police response to the domestic abuse allegation reported to them was appropriate. It is however a reminder of how processes can be complicated or compromised when incidents occur across county borders. The outcome of the analysis within the IMR appropriately reflected the need to remind officers of their safeguarding responsibilities with particular reference to always consider the needs of children when responding to incidents. Surrey County Council Children’s Services 2.9.8 Similarly to other agencies, Children’s Services had just one period of involvement, again in response to the domestic abuse allegation in late August 2012, and the IMR considered that this response was appropriate in the context of how the Mother was presenting at the time. However the IMR recognises that there could have been greater attempts to ascertain the wishes and feelings of the children at the time, and recommendations are made as a result. Surrey County Council Schools and Learning 2.9.9 This IMR reflects the time that both children had in the local playgroup and primary school, which they were both attending in September 2012, which was the time of their deaths. The IMR identifies how the school were appropriately attentive to the needs of the children at the time when it was apparent that there was marital discord, and when the parents had separated by the time the children had returned to school in September 2012 after the summer holidays. The IMR contained useful information about the children’s personalities and how they presented at school. 8 2.9.10 One key area for analysis for this IMR related to the way in which the school responded to legal information provided by the Mother that the Father was not to have contact with the children following their return to school in September 2012. The IMR considers that this is a difficult issue for schools to deal with and that in this case, it was apparent that the “order” which the Mother had presented was not fully studied in that in reality it did not prevent the Father having contact. It also emerged later that this was an application to the court rather than the order itself. Subsequently recommendations have been made within the IMR in relation to this issue. Ashford and St. Peter’s Hospital 2.9.11 The hospital was involved in terms of maternity services re the birth of both the children, as well as involvement via some limited attendance by them at A&E Dept., but more particularly had contact with the Mother when her physical injuries were assessed from the alleged domestic abuse incident in late summer 2012. 2.9.12 The IMR recognises that the mother’s presentation at the fracture clinic was a missed opportunity to understand the dynamics of the family relationships and risks, with the focus being on the medical model in relation to reviewing and repairing the injuries but little attention to aspects of her situation and the domestic abuse disclosure. Recommendations therefore relate to the need to strengthen knowledge and adherence to safeguarding procedures as well as to progress the implementation of a single patient electronic record. Virgin Care 2.9.13 This IMR relates to the services provided by the health visitors, school nurse and speech and language service. Overall it was considered that these services were appropriately delivered and met the presenting needs of the children and family. Concerns were however identified in respect of the size of the caseload of the school nurse and the lack of clarity about expectations upon them when in receipt of domestic abuse notifications. The issue about the caseload was subsequently addressed by extra support being put into that particular school nurse team. Recommendations are appropriately made to improve understanding and expectations when responding to information about domestic abuse. Surrey and Borders Partnership Trust 2.9.14 This IMR relates solely to services provided to another member of the family and therefore understandably whilst it is no doubt useful to the Trust in terms of its analysis, it has not been necessary or appropriate to include this within the overall analysis within this Overview Report. The IMR has appropriately not made any recommendations for changes to services as a result of its analysis of practice. Home Start 2.9.15 Whilst Home Start did provide some support services, primarily to the Mother when the children were younger, records were not retained for that period of time and so no IMR could be requested. Because of the earlier timeframe of their involvement, the SCR Panel did not consider that the lack of information from them compromised the overall analysis of professional interventions with the family. 9 Royal Surrey County Hospital 2.9.16 The hospital only had limited involvement in the treatment of the Mother’s injuries from the alleged domestic abuse incident, following a referral for specialist outpatient care from the Ashford and St Peter’s Hospital. Therefore an IMR was not requested although the letter requested from the Royal Surrey County Hospital gave sufficient information to explain the minimal involvement which they had had. Health Overview Report 2.9.17 The Health Overview Report helpfully sets the context of the provision of health services in Surrey and additionally comments on the individual Health IMRs which were produced for this SCR. The learning identified for health organisations includes the need for greater enquiry about domestic abuse and to consider its impact upon children within the family. Additional learning relates to the need to be alert to silo working and for health practitioners to be more rigorous in the need to gather information about significant males/fathers. The Health Overview Author rightly points out that these areas of learning are reflected in a number of SCRs on a national basis. 2.9.18 The Health Overview Report makes two additional recommendations to those already contained within the Health IMRs, and these reflect the need for the process of current health reorganisation to be able to continue to monitor how health agencies are embedding lessons learned from this SCR. _____________________________________________________ 10 3 THE FACTS Family Background 3.1 The Father was formerly a soldier who left the Army in the mid-nineties. During his time in the Army he received injuries at the Hyde Park bombing in 1982. Both the Father and the Mother had previous marriages which had ended in divorce, with the Father needing to be prescribed anti-depressants by his GP at that time in order to help him manage any associated stress. He was again treated with anti -depressants from December 2003 – February 2004 during a period of marital difficulties. ___________________________________________________ 3.2 Their first child, (Child U), was born in November 2004 and the couple’s second child (Child V) was born in July 2006. 3.3 Generally the care of the two children was good and uneventful in that professional involvement was primarily limited to universal services only. During Child U and V’s early childhood there were no safeguarding concerns identified by the health practitioners involved with the children. Both children had fairly normal patterns of attendance at the GP surgery. Whilst in total there were four A&E attendances by the children, none of these raised any safeguarding concerns. 3.4 There was involvement by Home Start for the period February 2008 to June 2009 in order to provide some additional support to the Mother. 3.5 In Autumn 2011, the Mother presented to her GP with issues relating to domestic abuse, which she reported primarily related to verbal abuse and control by the Father. She stated that the abuse had been going on for more than two years. Anti-depressants were re-commenced and the GP advised the Mother to seek legal advice. The GP’s records at the time identified that the Mother was “aware of the domestic violence unit”. 3.6 The Mother again attended the GP surgery in Spring 2012 when she reported that the situation had become worse and was concerned about the effect this was having on the children, and that she was unsure how much longer she could cope. 3.7 In late August 2012, on the morning following a party that the Mother and Father were attending at a friend’s home outside of Surrey, the Mother presented to the local A&E Dept. saying that she had slipped the previous evening, sustaining an injury to her shoulder and arm, along with some facial injuries. It was confirmed that the arm was fractured. She also had a broken tooth, some of which was embedded in her lip. The Father was present at the A&E attendance and hospital staff considered that they were comfortable in each other’s presence. No safeguarding concerns were identified and no indicators were apparent or identified by 11 hospital practitioners that the cause of the Mother’s injuries were anything other than accidental. 3.8 Following the family’s return to Surrey, the Mother visited her GP a few days later when she reported that although she had originally said her injury had been caused by her falling, that in fact following an argument, she said the Father had pushed her to cause her to fall forward onto a kerb stone. The Mother was clear that the Father had never been physically violent before, but that since the incident, had been feeling very threatened by him. The GP advised that she must contact the Police who in turn would contact Children’s Social Care. 3.9 Later that day, the Mother attended the local police station where she reported the incident, again saying that this time was the first occasion that the Father had been physically aggressive towards her. She stated that the children had witnessed the incident and were currently staying with a friend. Later Police inquiries with potential adult witnesses identified that no one had witnessed an assault – the Mother had told people at the time that she had fallen. 3.10 Also on the same day, the Father voluntarily attended the police station where he was arrested and interviewed. He denied any assault and claimed that the Mother had fallen because she had been drinking and because the ground was muddy. He acknowledged that immediately prior to this he had become angry because of what he considered was inappropriate behaviour by his wife. The Father was released from custody on conditional bail until 22nd October 2012, and was not to contact the Mother in the meantime. 3.11 On the following day, the Father attended the GP surgery and presented to his GP as very upset that he had been arrested and been told to leave the family home. (At this time he was still living there, whilst the Mother and the children were living with a friend). Although the GP advised supportive counselling, the Father wished to be prescribed anti-depressants, and the GP agreed to prescribe a month’s supply. 3.12 The Mother contacted the Police again on the 1st September 2012 to say that the Father was breaching the bail conditions as he had apparently tried through a mutual friend to arrange contact with the children. The Mother and the two children were currently staying at a friend’s home. The Mother told the Police that she was seeking to take out an injunction against her husband and was going to seek a divorce. On the next day, the Mother again expressed concern to the Police about the Father breaching the bail conditions in that she said she had seen his car outside where she was staying. She was advised to seek legal advice. Police officers also visited the Father and gave him “strong words of advice” as there had been no breach of bail, and he was advised to sort out child contact arrangements via a solicitor. 3.13 The Father had telephone contact with the GP practice on the 3rd September 2012, when he made reference to his involvement in the Hyde Park bombing and saying that he thinks that he may have post-traumatic stress disorder as a result. Arrangements were made for the GP to review the Father at the end of the month. 12 3.14 Police notifications of the reported domestic abuse incident were forwarded to Children’s Social Care and the health safeguarding team, (forwarded on to the school nurse) on the 3rd September 2012. 3.15 As a result of the Police notification, the duty social worker made telephone contact with the Mother on the 4th September 2012, who explained that as a result of the domestic abuse incident, she had ended her relationship with the Father. She also gave full details of all that had happened at the party and of subsequent events. She said that today she had visited a solicitor to seek advice regarding obtaining an occupancy order so as she could return to the family home with the children, and the matter was to be heard in court later in the week. She also said that she had details of the domestic abuse outreach service which she was considering accessing. Although the Mother said that she had no concerns that the Father would be abusive to the children and that she wanted them to retain a relationship with him, she was concerned he may try to abduct them as he would know that this would distress her. She however had no direct evidence of any threats by the Father of this nature. The social worker advised that she seek legal advice on this matter, and potentially gain a Prohibited Steps Order3. The Mother was also advised to ensure the children were safe and protected at all times, which she confirmed she understood and it was arranged that the Mother would call back if future advice or support was needed. 3.16 On the 5th September 2012 the Mother advised the school that she and the children had left the family home and gave the head teacher a copy of a non-molestation order imposed on the Father. (It later transpired that this was likely to have been the Mother’s application for the order). The Mother told the school that the Father was not to collect the children from school, and the head teacher duly informed school staff of this. 3.17 The Mother obtained a non-molestation and occupancy order at the Magistrates Court on the 6th September 2012 which forbade the Father not to threaten, intimidate, pester or harass his wife, and not to damage, or threaten to damage any of her property. He could also not do this via any other person. The Mother explained via her later contribution to this SCR that arrangements were agreed in the court for the Father’s contact with the children to be after school on Thursdays and from 10am to 5pm on Sundays, and that these took place as agreed over the coming weeks, (with four separate contacts ultimately taking place). Whilst these contact arrangements were agreed and recorded in court, there was no specific order made in respect of them. 3.18 The GP was contacted by the Police on the 10th September 2012 to confirm that the Police and the GP had the same information about the alleged domestic abuse incident. Although the Police were seeking a medical view about how the Mother’s injuries might have been caused, the GP said that it was not possible medically to say whether the Mother had been pushed or fell. 3 “An order that no step which could be taken by a parent in meeting his parental responsibilities for a child, and which is of a kind specified in the order, shall be taken by any person without the consent of the court” Section 8 (1) of the Children Act 1989. 13 3.19 It is understood that the Mother and the two children returned to live at the family home on the 12th September 2012 by which time the Father had moved out. On the 14th September 2012, the Mother spoke with the teacher in the playground and said that things were not too bad and that she was getting on with her life, adding that the children were fine. At a hospital appointment to remove a small piece of tooth from her lip on the 13th September 2012, the Mother confirmed to the doctor that she had contacted all relevant agencies in respect of dealing with the domestic abuse and that “It’s been sorted out”. 3.20 Although the Mother reported on the 17th September 2012 that she had received two “unpleasant” letters from the Father, which she believed meant that he was breaching his bail conditions/non molestation order, the Police did not consider that the letters themselves constituted a breach – neither letter was threatening but were claiming that he was not responsible for her injuries. It was at about this time that Child U told his school teacher that he would be seeing his Father for a coming weekend and that they were going fishing. 3.21 On the 26th September 2012 the Father wrote a letter to the GP (received either the next or following day) in which he stated that the allegations of assault by his wife were unfounded and that this had been an “annihilation of his stature”. The purpose of the letter was to request confirmation regarding whether it was his wife who had instigated the allegations or whether it was the doctor who said that the incident at the party was no accident and that she had been assaulted. 3.22 On the 30th September 2012 the Mother reported to the Police at 7.24pm that the Father was supposed to bring the children home by 5.00pm, after having contact with them, but that he had not returned. She said he was not answering his phone and had been acting strangely recently and that “she had a bad feeling” about it. 3.23 It was at 6.16 pm that a member of the public contacted the Police and in response, Police Force 2 discovered the bodies of the Father and both children in his car. Surrey Police were informed; who later made the connection with the concerns raised by the Mother and duly informed her of the deaths. In the car, some letters were found that the Father had written to the Mother, and other family/friends, including to “The Police etc” which made it clear that he had taken his own life and that of his children. 3.24 Later evidence identified that there was no indication from his behaviour at lunch earlier that day at a local hotel with paternal family members and the children, that the Father wanted to harm himself or the children. It would appear that the deaths were planned insofar as knives recovered from the scene were taken there by the Father and were likely to have been kitchen knives that he had removed from the family home when he had previously left there, before the Mother and the children moved back in. 14 4 THE CHILDREN’S EXPERIENCE 4.1 Despite their tragic and traumatic deaths, it was nevertheless apparent that both of the children experienced fairly normal childhoods and that they had good attachments to their parents. The evidence from health visitor records was of two children who developed well physically and emotionally and at school they were well liked by teachers and their peers. However it appeared that over the last two years of their lives that they did inevitably experience some of the conflict and disharmony that existed for some of that time between their parents. 4.2 Child U was described by his school as being “delightful, kind, considerate and thoughtful” and was also sometimes a “day dreamer” but who was very protective of his younger sister. In respect of Child V, the description of her at school was of her being “delightful, lively and very bubbly – she skipped everywhere, was giggly and very chatty”. Both children were well liked in their peer group. In her contribution to the SCR, the Mother agreed that these were accurate descriptions of her children. 4.3 To what extent the two children experienced either directly or indirectly, some of the domestic abuse and marital arguments that took place between their parents is not clear. Certainly the Mother expressed concern to the GP that the children were becoming affected by the verbal abuse from the Father towards her and of his controlling behaviours. This was when Child U was aged from 7 years old and Child U was aged from 5 ½ years old. The Mother later told the social worker that the children had asked her “why is Daddy being horrible?” Additionally as part of her contribution to this SCR, the Mother said that she considered that the children were affected by the Father’s controlling behaviour and that as part of the domestic abuse he shouted a lot, with neighbours sometimes expressing concerns about this. She considered that the children therefore became anxious in his presence and were not always keen to be left in his care when she went to work. 4.4 Within school, it was considered that both children were quite open, although nothing significant or untoward was noticed about the children’s demeanour and behaviour. However when Child U returned to school from the summer holidays in 2012 the head teacher noticed that he was “subdued as if he had the weight of the world on his shoulders”, and that he seemed “half asleep” at times. This was the period when the children were living with their mother with friends, though once they returned to live in the family home later in September, Child U was said to be noticeably more relaxed and happy, and more positive about his work. Although Child V was very often open with her teachers and often spoke her mind, she did not express any concerns or behave in any way to indicate that there were difficulties at home. 4.5 The children were said to have witnessed the incident when the Mother was injured at the party although there were conflicting accounts of what parts, if any of the incident they directly witnessed. They clearly experienced the tension between the parents from late August throughout the month of September 2012, when their day to day lives were disrupted by the parental separation. For example on one occasion, Child U told the school teacher that 15 his mummy was picking him up “as his daddy was not allowed to”. However there was never any concern expressed by the children about their Father’s care of them and they had previously been just as happy for him to pick them up from school as they were for their Mother. Child U also had spoken positively about spending time with his Father once the contact arrangements had been set up. 4.6 Whereas “Children’s symptoms of depression, anxiety, dysphoria (a state of unease or mental discomfort) and withdrawal have been shown to be adversely affected by exposure to inter-parental conflict” it is also commented that “Teachers who are not familiar with the circumstances behind a child’s individual symptoms may be less likely to see such symptoms as a particular problem for that child” 4 For example this may mean viewing a child as a quiet child rather than a depressed child. It therefore remains unclear the extent to which the children internalised the parental conflict problems and to what degree their well-being was adversely affected by the home circumstances. How the parents separately managed the impact on the children would of course have been important in terms of how the children were able to manage what was happening around them, and there was one example when the Mother declined to discuss the marital problems over the phone with a social worker because of the presence of the children. This reflected that the children were therefore afforded a level of protection by their Mother of the traumas and details of the parental conflict. _________________________________________________ 4 Children living with domestic violence – Martin C Calder, Russell House Publishing, 2004 16 5 ANALYSIS The appropriateness and extent of agency engagement and involvement with the family, particularly in respect of any safeguarding issues Health Visiting Service 5.1 Generally within this case, the level of individual agency involvement with the children and the parents was delivered at an appropriate level and within the context of the needs that the family had at the time. In terms of the universal services of health visiting, hospitals and education, then the children’s circumstances did not reach a level that would have warranted more targeted interventions. The family were however appropriately placed at an enhanced level of health visiting service for a brief period in 2008. The health visitor’s referral to Home Start at the same time reflected that the mother needed some additional support during this period. Education 5.2 As the two children presented well in school and had no worrying behaviours within school, it was understandable that this did not lead the school to provide any additional oversight or support of them, despite it being understood that the parents had separated at the time when the children returned to school after the summer holiday in 2012. 5.3 It was nevertheless apparent that school staff were alert to any possible impact on the children at this time, and on one occasion Child U was asked how he felt about what was happening at home. More particularly however, the head teacher reported being shown a “court order” by the Mother, who claimed that this meant that the Father could not have contact with the children and was not allowed to collect them from school. In response to this the head teacher ensured that the rest of the school staff were aware, so as they could enforce the Mother’s request. This appeared to have been managed well in the circumstances and there were no reported incidents of the Father attempting to collect the children. 5.4 It became apparent from later enquiries via the SCR process that the Mother did not obtain the non-molestation order until the following day and that the head teacher had likely been shown the Mother’s application for a non-molestation and occupancy order. The bail conditions already meant that the Father could not contact the Mother directly or indirectly and the non-molestation order forbade the Father from threatening or harassing his wife, but neither made any reference to the children, nor that he could not have contact with them. It was not therefore apparent that the head teacher had read the detail of the order that was referred to by the Mother or understood that it was the application rather than the order itself. In essence this made little difference to the actions by the school who chose to accept the formal request from the Mother that the children were not to be picked up by the Father, and he did not arrive at the school to challenge this arrangement. Nevertheless, the experience clearly suggests that when court orders are presented to school staff to support an action required by the school, that such an order should be read in detail to check the legal requirements. Whilst the IMR suggests that it was implicit in the detail of the document shown to them, meant that the Father could have had no contact with the children (because he would have needed to make contact with the Mother to do so), this was not the case. For example he could have arranged via a third person to make contact 17 with the children – which he in fact tried to do on one occasion. It was agreed within the court the next day that the Father could have regular contact and this was what eventually took place, with another person acting as the go-between, with the children being collected from them. Hospital Services 5.5 The contact which the two 2 local hospitals had with the family in terms of the births of the children and in relation to a small number of A&E attendances was not significant in any way. Although it was apparent that no contact with the family raised any safeguarding concerns, there was one occasion when Child U was aged 2 ½ years, that he suffered an injury to his elbow apparently being caused by being pulled up by the hand from the floor. Although it was apparent that this injury and the explanation given, raised little additional questioning about the home circumstances and did not lead to any safeguarding concerns being raised at the time or via any report to the health visitor or Children’s Social Care to request any follow up, potentially the description of how the injury was caused should have generated further enquiries. When the health visitor did eventually receive notification of the A&E attendance a week later, she followed this up with a telephone call to the mother, who now reported that Child U was fine. Similarly there was apparently no consideration by the health visitor that there was any safeguarding concern in relation to the incident, and therefore no further questioning made as a result. 5.6 There was just the one incident which led to the involvement of the hospital in Cheshire who needed to respond to the A&E attendance by the Mother following her being injured at the party held locally. The service which was delivered from a medical perspective was thorough and met all of the Mother’s needs in respect of the injuries she had suffered. The respective IMR author was confident that “No safeguarding concerns, vulnerable adult triggers or domestic abuse indicators were identified by practitioners in the care of the Mother from the point of admission until the time of her discharge.” It was clear that the Mother made no allegation of domestic abuse and was consistent in her story of an accident, and the hospital reported that she and the Father, who accompanied her to the hospital, appeared comfortable in each other’s company. The hospital however did not confirm that it was in fact the Father who was accompanying her. Although it was not recorded, the doctor thought that she had a conversation with the Mother on her own during her attendance at the hospital. This would have been good practice in these circumstances. 5.7 In her contribution to this SCR, the Mother confirmed that it was the Father who accompanied her to the Hospital and that she did not disclose any abuse to the hospital staff. She said that she felt she was a long way from home, felt very vulnerable at this time, the children were not with her in the hospital and she was concerned about how she would get home if she told anyone about the truth of how she received her injuries. She said that the Father was being very controlling at the time and would not leave her on her own. She could not understand why the hospital staff thought that she and the Father were comfortable in each other’s company, as she felt that there was evidence in their behaviours in the hospital of the tension that existed between them. The Mother confirmed that she was not seen alone apart from a very brief time when having x-rays undertaken. 5.8 The Mother acknowledged that it would have been difficult for staff to have picked up that her injuries were the result of a domestic abuse incident and therefore have questioned her about this, but she was nevertheless surprised about the lack of enquiry and that staff had 18 not picked up on the tension in their relationship. Whilst in this scenario, it could not necessarily be expected that the hospital’s suspicions would be raised that domestic abuse was the cause of the injuries, if the Mother had been seen alone and more probing questions asked, there would have been a greater chance of this being revealed. General Practitioner 5.9 Similarly to other local health services, the family’s involvement with the GP surgery was primarily related to ordinary day to day medical issues, although these did include some short episodes of depression separately for the parents. These were dealt with in a standard way by prescription of anti-depressants, and the episodes themselves were not long term. The Father also presented with depression following the final separation from his wife. 5.10 However the major difference from other health services was that it was only the GP practice which was contacted by the Mother about domestic abuse issues. In fact it was the Mother who chose, in October 2011, to disclose verbal abuse and controlling behaviour by the Father and of the adverse effect this was having on the children, and then six months later, that it was deteriorating. Whilst the GP had no doubt been a helpful “sounding board” for the Mother on these occasions, the GP did not follow up with any further advice or make enquiries with any other agency about what more specialist help could be offered to the family, and especially to address any needs that the children might have in the situation. Whilst the presentation by the Mother of the home situation could not be said to have represented a significant level of risk to her or the children on this occasion, or that it required a child protection referral to be made, some follow up with further advice to the Mother by the GP would have been helpful and the GP could potentially, with the Mother’s agreement, discussed the situation with Children’s Social Care or the school nurse and agree the most appropriate response. As a minimum this should have been formally considered. The Mother explained in her contribution to the SCR that the GP had been supportive but that she nevertheless felt very isolated at this time and didn’t know how to resolve the situation or whether to leave her husband. Greater information and advice at this time from the GP therefore may have been helpful. 5.11 The situation was much more concerning on the occasion when the Mother presented at the GP surgery with injuries following her return home after receiving hospital attention in Cheshire. Not only did the Mother say that the injuries had been caused by her husband pushing her, but also because since then she said he had been threatening and that she was feeling threatened. She also said that he was shouting at the children. When interviewed for her contribution to the SCR, the Mother said that she had not initially intended to disclose to the GP about the cause of her injuries, but that the doctor quickly “got it out of her”. The GP then recognised the greater seriousness of the matter and therefore urged the Mother to immediately make contact with the Police. This clearly had an impact, as the Mother then went to the Police station later that day to register her allegation. This GP consultation also clearly raised safeguarding concerns about the children, and the GP dealt with this by saying that the Police would involve Children’s Social Care. 5.12 Whilst the Mother followed the GP’s advice, and the Police did then later involve Children’s Social Care, the GP had relied on the Mother to take the appropriate actions and not confirmed by way of information sharing or referral, that the Mother’s concerns were going to be fully investigated. The Police later made contact with the GP to confirm the surgery’s understanding of the concerns and to potentially gain more information – however ideally there should have been communication from the surgery to the Police at the time that the 19 Mother raised the concerns. It was clear however that the GP was reassured that the Mother would take her advice, but there was no guarantee that she would eventually do so. Clearly if she hadn’t, then there was the potential that the children could have been left exposed to some risk. 5.13 The Father had sought help from the GP surgery very soon after his arrest by the police for the domestic abuse allegation. He saw a different GP than the Mother, and he wished to be prescribed anti-depressant medication to manage his upset. It was appropriate for the GP to have advised the Father to receive counselling, though understandable that the Father’s request and preference for medication was ultimately agreed. Even if the two GPs who had seen the Mother and Father had spoken or liaised over what was happening in their relationship, it probably would have had little impact on how they were separately dealt with. The fact the Father’s GP offered to review the anti-depressant medication in a month’s time was a reasonable response in the circumstances. The Police 5.14 Police involvement in Surrey related first of all to their response to the Mother’s allegation of the domestic abuse incident, following her disclosure to the GP. This investigation presented some challenges in that it had been reported to the Police five days after it had taken place, and that it had occurred in the North Midlands. There was a delay in identifying and making contact with potential witnesses, and some were spoken to on the phone which did not have corresponding statements recorded. Statements were however obtained from the hosts of the party. 5.15 Whilst the normal agreed procedure in this sort of situation would be for the Police force in the area where the alleged crime was committed, to conduct the investigation of the incident, this did not happen on this occasion, with Surrey Police taking on this role. It was therefore because of the geographical factors that Surrey’s attempt to investigate the incident was compromised. The reason for the investigation being conducted this way was that the victim (i.e. the Mother) was local and the on-going domestic situation could be monitored locally. In this scenario it could be seen why the investigation was conducted from Surrey and, ultimately it was not apparent that the outcome would have been any different. However, formal agreed procedures should have been followed, although the Police IMR considered that what happened on this occasion was not reflective of wider practice across Surrey. 5.16 When the Mother later contacted the Police re concerns on more than one occasion that the Father was breaching the bail arrangements or non-molestation order, she was appropriately advised and the Father seen by police officers as a consequence, to remind him of what was expected of him in relation to the orders in force. Whilst the Mother explained that she was generally very appreciative of the response and support by the Police, especially regarding her initial allegations, she later said as part of her contributions to the SCR, that she felt they could have been more responsive on the occasion in mid-September 2012 to her concerns that the Father was breaking the bail conditions. From an objective perspective however, it would appear that the Police’s response was appropriate in the circumstances. 5.17 Because at the time of the deaths of the children, they were found in Area 2, then there was a delay by Surrey Police in notifying the Mother of the deaths, which was said to be due in part to the different practices of deployment of Family Liaison Officers. Once again, it was 20 the issue of cross border working which generated some difficulties in achieving prompt effective practice. Children’s Services 5.18 The involvement by Children’s Services related to their response to the one domestic abuse notification that they received from the Police, and in essence their response was prompt and appropriate in the circumstances. It was acceptable practice for the Mother to be contacted by phone in the first instance by Children’s Services, and it was apparent that there was a detailed discussion about her concerns, including the safety of the children. Whilst direct contact with the family would have been an ideal and more efficient response to understand the situation, a telephone call was realistic in the circumstances as a process to identify whether this situation was a priority over others. Within the telephone contact, the Mother gave a clear indication that she felt she was in control of the situation and had made an informed decision to end her relationship with the Father, and was putting arrangements in place to support that decision. The Mother was also clear that there had been no pattern of physical abuse or violence from the Father in the past. She had also shown her sensitivity to the children by not discussing the problems in their presence and there was discussion about how she would manage contact arrangements, including via seeking legal advice. It was therefore understandable in context, that with the reassuring response by the Mother generally, the fact that she had been to a solicitor, and was content to make further contact with Children’s Services in the future if necessary, that “no further action” was the decision by Children’s Services at this time. _______________________________________ 5.19 Following the range of interventions identified above, particularly those in early September 2012, soon after the alleged domestic abuse incident a few days earlier, there was a gap in agency involvement for much of the rest of September as no incidents arose or were reported by the family, to warrant any formal intervention. Therefore there was no record of any build-up of tension within the home that would have suggested that the situation had worsened or was moving to a crisis. Despite the Mother stating on her application for the non-molestation order on the 3rd September 2012 that she feared “for the safety both of herself and the children”, in her conversations with the head teacher at a similar time said that she did not want the marital difficulties to impact on the children and that she had no concern for their safety in their Father’s hands. Whilst this appears contradictory, in effect no concerns arose at this time. In fact it was apparent that the Mother had settled on arrangements to enable the children to have contact with the Father, and so outwardly, as she had later described to the school, she considered that they were “getting on with their lives”. The effectiveness of inter-agency communications in safeguarding the children 6.1 The key issue about inter agency communication in this case was whether the information about domestic abuse within the family was appropriately shared and that this was done with the safeguarding needs of the children in mind. As part of agreed procedures, the Police informed the Contact Centre for Children Services about the domestic abuse incident alleged by the Mother. The same report was also received by the school nurse on the same day. There was no automatic expectation that the school nurse would share the details of the concerns with the school, and there was no record that this was done. Helpfully, the Mother had already done this of her own volition. The school nurse did however check with the Contact Centre what action had been taken and she was told that the Mother had been 21 contacted and advice given to her. The Contact Centre did not however have a record of this communication from the school nurse. At that stage, no decision had been made about any follow up action but according to the school nurse, there was agreement that the Contact Centre would let the school nurse know of the eventual decision – however there was no record that this took place or that the school nurse chased up a response. It was considered by the SCR Panel that it was likely that the contact from the school nurse did take place and there was probably a failure to record this by the Contact Centre. The reason for this lack of follow up by either professional may well have been that by this time the domestic abuse situation was not seen as critical and actions were therefore potentially downgraded. This should not however distract from the importance of recording telephone conversations, and confirming the outcomes of interventions or responses to concerns. 6.2 It was acknowledged in the GP’s IMR that the GP who tried to advise the Mother about how to manage her domestic abuse situation, firstly in relation to the disclosures of verbal abuse the previous year, did not know who or where to seek appropriate advice from on such matters. As happened in this case, a GP surgery may often be the first point of contact for a victim of domestic abuse, and so it is imperative that they are aware of the related signs and symptoms, but more importantly of its clear links to the protection of children. Additionally, there is the need to know how and where to access the correct form of help. Potentially if access to more specialist services had taken place at the time of the Mother’s concerns about escalating verbal abuse in March 2012, then the circumstances may have reached the threshold for an assessment to be undertaken by Children’s Services. 6.3 It was reassuring to the GP when the Police made contact following the Mother’s allegation of assault by the Father, to confirm that action was being taken but also to clarify the GP’s understanding of what had transpired and the GP’s opinion of the possible cause of the Mother’s injuries. Despite it being reassuring to the GP, it would have been more appropriate if the GP had initiated the communication with the Police. The GP however usefully told the Police of the earlier concerns about verbal abuse and threatening behaviour by the Father in the home. The Children’s Services IMR suggests that in the knowledge of the GP’s early involvement in respect of the domestic abuse, that it would have been expected for the GP to notify the Contact Centre of their assessment of the Mother’s ability to protect the children. If this was a realistic expectation, then in the absence of contact from the GP, the Contact Centre should have communicated with the GP practice to seek this information, in the anticipation that it would inform the decision about the necessity regarding any future interventions. This is another example of how communication is not viewed as a two way process, with responsibilities on both communicator and recipient of information. Was the level and extent of domestic abuse known and was the impact/risk to U and V adequately assessed and responded to. Were the children’s wishes and feelings taken into account? 7.1 It was apparent that all agencies that were directly involved or informed of the domestic abuse incident in late summer 2012, were fully aware of its extent and of the intended actions by the Mother to address these problems. There was less evidence however that the impact or risks to the two children were simultaneously addressed. For example, the Police did not have any direct contact with the children and the description of the events did not raise any immediate issues about possible safeguarding concerns for the children. In this context it was understandable that the Police did not take any additional action to address the needs of the children, as this was not an occasion when the Police attended an address 22 where a domestic abuse incident had occurred. The fact that the Mother went to the Police directly to report her concerns and reported that the children were staying at a friend’s home, meant that the Police would have needed to take a purposeful stance to see the children. Nevertheless, no matter how much a domestic abuse incident does not appear to directly involve the children, there is nevertheless always an impact upon them and domestic abuse is always a child protection matter. It was not apparent on this occasion that the lack of seeing the children was identified as a possible shortcoming of the Police enquiry, and that as a result this would be confirmed in the notification to Children’s Services that this was outstanding. 7.2 It was also not apparent that the needs of the children were given priority within the GP surgery and the risks to them identified or discussed with the Mother and the Father. This potentially related to a lack of appropriate training in respect of the impact of domestic abuse upon the children. Nevertheless it needs to be acknowledged that it was the GP’s robust response to the Mother in late August 2012 which led her to ultimately report her concerns to the Police who in turn involved Children’s Services. 7.3 When the Contact Centre engaged in the telephone conversation with the Mother about the domestic abuse incident, the Mother was encouraged to ensure the safety of the children and the issue of contact was discussed. In this way the possible needs and risks to the children were appropriately raised. However it would have been additionally useful if there had been dialogue about how specifically the children were being affected and how the Mother could address this and potentially discuss with the school any additional needs they would have at this time. 7.4 In this respect therefore the children’s wishes and feelings were not ascertained or taken into account, to help inform the best way forward. There appeared to be an understanding that the Mother was taking the correct protective action and that there was therefore less need to explore the impact and feelings of the children. In fact there was evidence to suggest that this was the case, but to specifically ask the questions and probe about the circumstances and reactions of the children, would in itself confirm to the Mother that they are the priority in the situation. Also it is the outcome of those particular enquiries which should be the main determinant of how or whether Children’s Services should proceed with further interventions. 7.5 Generally the school focused on keeping the school environment normal for the children and there was some attention given to the children’s behaviour and demeanour to make sure that there were no adverse signs that that they were experiencing difficulties. Staff did not actively encourage either child to talk to anyone about their parent’s separation, and the IMR reported that the school “took the lead from the child in such situations”. This may well have been the most appropriate strategy overall and was understandable in the circumstances – certainly the children did not present any worrying behaviours. The school had a policy of encouraging children to confide in three trusted adults to whom they could tell of any worries which they might have – this was meant to apply to children who may be particularly vulnerable, although it was not apparent that this was utilized in respect of these two siblings. The respective IMR identifies that this policy needs greater clarity about its purpose and application. 23 Were there any parental physical or mental health issues or issues of substance misuse which may have impacted on parenting capacity or that could pose a risk to the children? 8.1 There was certainly no history in respect of either parent that they could pose a risk to children. Additionally there were no physical health or substance misuse concerns about the parents. In respect of mental health, then both parents suffered with periods of depression but none of these episodes suggested that this impacted on their parenting ability. 8.2 Whilst the Father attended the GP surgery soon after the marital separation and said he was feeling depressed, there was no connection with his parenting ability or that this had been adversely affected in any way. In fact he did not have the care of the children at this time. Interestingly however, he did tell the GP that he felt he may have suffered post-traumatic stress disorder as a result of his experiences at the Hyde Park bombing incident. It is not clear what motivated the Father to make this link at this time. His army medical records were not available to the GP to check if this was the case or not – in fact the GP was not aware of the Father’s previous army career. 8.3 As part of the SCR process, the GP IMR author was asked to explore the situation in respect of an ex-soldier’s army medical history. It was confirmed that when a soldier leaves the service for whatever reason, he gets a final medical and at that medical he is provided with a full print off of his service medical records that he can take to a civilian GP in order to register. He is also provided with the address and details of who the civilian GP needs to write to (Army Personnel Centre in Glasgow) in order to obtain the actual medical records. The service person himself must give consent for the Medical records to be released to the GP for data protection reasons. The Civilian GP has no automatic right to that information. Potentially the reference to post traumatic stress disorder (PTSD) could have prompted curiosity from a GP about his army health history, but the Father died shortly after he made this reference to the impact of his army experiences. 8.4 Eventually the Father’s army records were obtained following formal requests for the SCR process to have access to them. These were studied by the author of the GP IMR. Whilst these records identified the physical injuries he sustained at the Hyde Park bombing, there was little reference of any psychological impact upon the Father. One letter by a plastic surgeon in 1984 referred to the Father suffering a “systemised neurosis relating to this fiendish event”, but no referral was made to assess or treat this. Similarly, as part of a criminal injuries compensation report at the same time, it was stated that the Father “obviously underwent a severe emotional experience …..there is no doubt that there are deeply seated emotional scars”. Once again there was no evidence of any related diagnosis, assessment or treatment of any emotional problems as a result of these comments. Upon discharge from the army, the summary of his medical history transferred to the NHS in 1994, stated “none relevant”. 8.5 In her contribution to the SCR, the Mother was very sceptical that the Father had suffered from PTSD as a result of the bombing incident in London. She said that his injuries were minor and that the incident was something he was able to speak of openly and tell people about, and that there was never any evidence to her that he was in any way affected by what happened in any emotional way. However, as part of the contribution by one of the Father’s brothers, he stated that the Father suffered from deafness as a result of the bombing incident and that in his view the incident had had a continual emotional impact upon him and how he presented. Whilst this brother posed the question whether the treatment of the Father’s depression would have been greater if the army records had been 24 available for the GP to consult, the review of these records which has now been possible, suggests that they added no additional issues of concern to warrant greater monitoring or different treatment. Whether race, religion, language, disability or culture was a factor in this case and had been considered fully 9.1 For the short periods of time that most of the professional agencies were involved with the family, there was no evidence that the family as White British, presented with any factors which would suggest that issues such as race, religion, disability or culture had any impact either on the services which were being offered to the family or upon the sorts of problems being presented. Were there any organisational or resource factors which may have impacted on practice? 10.1 Within all of the IMRs, the only one which identifies that organisational factors may have had an impact on practice, was that of the school nurse team, which at the time of the domestic abuse allegations were holding a safeguarding caseload of double that in other teams. There were also some staff vacancies. Nevertheless, the school nurse had made enquiries with Children’s Services about the domestic abuse notification and so in this culture had taken an initial proactive approach to understanding any initial possible risks associated with the domestic abuse incident. 25 6 PREDICTABILITY AND PREVENTABILITY 11.1 Overall, it is clear within the work that was undertaken by professionals with this family, that this was generally done so appropriately and effectively within the particular circumstances presented at the time. Whilst there have been some lessons which have been learned, overall these did not reflect any significant issue that would have impacted on the final tragic outcome. 11.2 It needs to be recognised that up until the incident of extreme violence which resulted in the deaths of the two children, that this family presented as very normal in many respects. The children were well cared for and were popular in school. Whilst domestic abuse is always an issue of child protection concern, there was only one incident which had an element of physical violence within it (according to the Mother) and there was no previous pattern of violence within the marriage. Whilst the verbal abuse, reported earlier, was of a concern, once again in comparison with the issues of domestic abuse and violence that the Police and Children’s Services deal with on a day to day basis, the circumstances presented by this family, whilst of concern and in need of attention, would not have led to high levels of safeguarding concerns. This made the later shocking events even less understandable. Therefore in this way there was no way that any professional could have predicted the eventual outcome or could have prevented it. 11.3 There is a body of research that has considered the issue of filicide, (the act of the murder of a child by a parent), and one of the most influential pieces of research has classified six different set of characteristics of child murder5. Of these characteristics, two could potentially apply to the acts by this Father; the first would be in relation to “Altruistic Filicide - where the parent kills the child because it is perceived to be in the best interests of the child”, and the second would be “Spouse Revenge Filicide - where the parent kills the child as a means of exacting revenge upon the spouse, perhaps secondary to infidelity or abandonment”6. In fact the most common motive found in the original research was that of altruistic filicide and the least common that of spousal revenge. By the content of the letters written by the Father at the time of the deaths, where he was stating that he and the children were “going to a better place” and also blaming his wife for what he was doing, his actions appeared to reflect these two particular characteristics. 11.4 Whilst the presence of psychosis or psychiatric problems has often been found to exist in those adults who commit filicide, there was no such evidence of this in respect of the Father. However, “The presence of significant life stressors has been reported by filicidal fathers, including financial difficulties, impending marital breakup and fear of separation. Some paternal filicides reportedly have occurred in the aftermath of arguments concerning marital infidelity, and being separated at the time of the offence has been noted to be an important precipitating factor”7. 5 Resnick, PJ, “Child Murder by Parents: a psychiatric review of Filicide. American Journal of Psychiatry 1969 6 Sara G West, “An Overview of Filicide” – Psychiatry MMC – February 2007 7 Bourget, D et al ; A Review of Maternal and Paternal Filicide –, Journal of the American Academy of Psychiatry and Law – March 2007. 26 11.5 Whilst this might generate some understanding that the Father took the lives of his children and his own life in circumstances that research has shown to previously exist in similar deaths, it in no way helps in consideration of whether there was any level of predictability or preventability. In fact one piece of research identified that the act of murder of the child occurred impulsively and that “such an act of violence was out of character and totally incongruous with how they lived their lives up to the time of the crime”8. Furthermore, “Whilst suggestions have been made for the prevention of certain types of filicide, little is known about prevention of filicide-suicide”9. 11.6 Recent research10 has identified that men are at a greater risk of suicide in the aftermath of a relationship breakdown and that men are less likely to enjoy the network of friends to support them at such times. In fact as part of her contribution to the SCR, the Mother felt that the Father might have benefited from greater support and advice at the time of the parental separation. Additionally his brother also contributed that the Father was in need of greater support and advice at this difficult time for him. Unfortunately the Father did not specifically seek this, other than one consultation with his GP. Additionally this particular research has also identified that “services designed to support the relationship needs of individuals and couples are not “male –friendly” enough”. 8 Pappietro, DJ and Barbo, E; “Towards a psychiatric understanding of Fillicide”, Journal of the American Academy of Psychiatry and Law – Dec 2005. 9 Freedman, S et al, “Fillicide-Suicide; common factors in parents who kill their children and themselves” – ”, Journal of the American Academy of Psychiatry and Law –2005 10 “Try to see it my way: Improving relationship support for men”, Relate report - February 25th 2013 27 7 LESSONS LEARNED 12.1 It would be good practice for a professional to confirm with a parent that they have taken agreed actions to address domestic abuse within the home by their own contact with an appropriate agency, and if not to make an appropriate referral on the parent’s behalf. In this way, meeting the safeguarding needs of a child would not be potentially compromised or delayed. Research is clear that numerous incidents of domestic abuse usually take place before a victim feels able to report it, so there might always be reluctance for the victim to take their concerns further. For the professional to make the referral on the victim’s behalf or to directly support them to do so, would be the most productive in safeguarding terms. 12.2 It is an important principle for professionals to confirm to their colleagues, when it has been agreed to do so, that certain actions or interventions have been undertaken in respect of addressing safeguarding issues. There is a responsibility to chase up the professional if the required communication is not forthcoming. 12.3 It needs to be recognised that greater care is required by professionals when cross-border issues exist within the process of addressing safeguarding concerns. In such circumstances, information sharing can be compromised as well as the application of relevant procedures. 12.4 Domestic abuse is very much a child protection issue, and if professionals who regularly work with families have limited knowledge or understanding of this as a problem, and of the resources available to address it, then it would be likely that the safeguarding needs of children will be overlooked. 12.5 Unless children are actively spoken to, engaged and observed by professionals when there are safeguarding concerns, it would not be possible to accurately assess or understand their needs, wishes and feelings. 12.6 When legal orders are presented by parents in order to advise and request professionals to act in a particular way in order to protect their children or prevent contact by another parent or adult, then it is incumbent on that professional to confirm the exact requirements and conditions of the legal order being presented. This could be done either by the use of specialist advice or checking back with the parent how their expectations match what is contained within any order. 12.7 Within domestic abusive relationships, research has indicated that is at the time when the adults separate, that the greatest physical risk exists for the partner victim and potentially to the children. 12.8 Violent acts which lead to the death of children can occur without any prior indication, predisposing factors or known intentions, and that on such occasions there would be nothing that a professional could do to prevent such a tragedy. 28 8 RECOMMENDATIONS NB: These recommendations are made to primarily address multi agency safeguarding issues and have not repeated or replicated those made within the IMRs, which are listed as an appendix. 13.1 The Surrey Safeguarding Children Board to make a recommendation to the relevant national body to request that army medical records of former army personnel can be accessed when there are concerns about the person’s presenting health which could have an impact on the safeguarding of children. 13.2 The dissemination of learning to professionals of the findings from this Serious Case Review will need to include the “lessons learned” section of this report but also should provide information about the study of Filicide and of the associated research. 13.3 At times of transition and reorganisation within the Health service, the SSCB must be assured that relevant Health organisations are held to account for the implementation of relevant IMR recommendations. Ron Lock 30.5.13 29 APPENDIX 1 Individual Management Review Recommendations Mid Cheshire Hospitals NHS Foundation Trust NB: The vulnerable adult agenda is gaining increased significance and organisational responses are developing and evolving at a fast pace within the Cheshire and North West locality. 1. Mid Cheshire Hospitals NHS Foundation Trust are responding to this progression within the mandatory training agenda. From April 2013, all staff within the organisation will receive an initial induction session and then regular update sessions around Safeguarding in the widest sense. 2. The sessions will be delivered by the safeguarding Team and will not only include safeguarding children; but also vulnerable adult triggers and professional responses to the recognition of domestic abuse. 3. It is hoped that this new training approach will build upon staff knowledge and increase staff confidence and competence in supporting vulnerable families. 4. Anecdotal evidence from staff evaluation of safeguarding children sessions has revealed that the discussion of case studies can effectively reinforce the practicalities of addressing safeguarding concerns. 5. The IMR author is aware that this approach will also be employed to the vulnerable adult / domestic abuse training agenda. The IMR author will therefore be recommending and ensuring that the reinforcement of who is attending with a patient is included and why it is of importance – using this Serious Case Review as an example. 6. To demonstrate the effectiveness of the training and it’s key messages; the IMR author proposes for the Safeguarding Committee to conduct a random audit of Casualty Cards in April 2013; to verify if next of kin and accompanying adults are documented appropriately. The audit should then be repeated in April 2014; after the first year of the revised safeguarding training has been delivered. The audit results, trends and recommendations can be reported through the Safeguarding Committee, governance structure and annual report. Surrey Police 1. The Head of Public Protection should remind all staff via a communication on the Surrey Police intranet of their safeguarding responsibilities. There should be specific emphasis on the need for officers / staff to consider the potential for children to be at risk when responding to incidents and to make sure that any children are seen (preferably at the home). Surrey County Council Children’s Services 1. For Contact Centre Duty Managers when outlining the task to be undertaken to always state that the views and wishes of the child should be sought. 30 2. For Managers in the Central referral unit when outlining the task to be undertaken to always state that the views and wishes of the child should be sought. 3. For Contact Centre Managers to record the reasons for their decisions referencing the impact/level of risk of the incident to the child. Schools and Learning, Surrey County Council 1. All CPLOs to be provided training on court orders and their impact, including roles and responsibilities of all staff. 2. All Head Teachers to receive a briefing note on good practice in relation to understanding, monitoring and escalating issues where a child is known to be subject to a Court Order. 3. The Child Protection policy at Ashford CofE School to be reviewed and updated in line with the findings of this IMR. 4. All schools to be issued with the learning summary of this case once published. Ashford and St Peter’s Hospitals NHS Foundation Trust NB: The key recommendation from this report is that there needs to be compliance in practice with safeguarding policy, procedure and training. 1. Ensure that all staff attend on-going training in Safeguarding Children and Domestic Abuse at Level 3 and the training uses relevant case material for discussion. All temporary staff must have safeguarding awareness training as part of their local induction and supplier agencies must provide assurance that temporary staff have received safeguarding training at the appropriate level. 2. A & E weekly Safeguarding meetings to be multi-disciplinary and shared with Social Care. There must be a culture of child first and professional curiosity regarding other family members in adult services. 3. A & E to devise and implement a trigger list for Safeguarding Adults to be reviewed at every A & E attendance. A & E need to provide assurance to the Trust that they have a robust/consistent approach when undertaking initial assessment of all patients. . 4. The Trust must identify the approach to implementation of a single patient electronic record. 5. In the meantime a procedure is required to ensure that previous records of attendances in A & E are reviewed at each attendance. 6. Share lessons learned with all staff in A & E, Paediatrics & through Safeguarding Children Training across the Trust. 31 Virgin Care 1. The role of the school nurse in receiving police reports needs to be made clearer and this also needs to be reflected in their 0-19 policies and procedures regarding their role and responsibility on receipt of police reports. 2. Other agencies need to be made aware of the role and responsibility of the school nurse which clarifies their expectation. 3. That a practitioner from Virgin Care to be present on the multi-agency pilot scheme in Woking for triaging police reports. 4. The health needs assessment needs to be updated to included information learnt from serious case reviews as key questions asked at first contact. Health Overview Report 1. NHS Surrey need to ensure that lessons from this review and provider action plans developed in response to this review are included in the hand over process to new commissioners from 1.4.13 to ensure monitoring that lessons are being embedded into practice 2. Commissioners need to be assured that practice within commissioned services acknowledges and responds to the impact of domestic abuse on children ____________________________________________________ |
NC52213 | Injuries to an 8-week-old girl in 2019. Beatrice was taken to a walk-in centre concerning a rash and was found to have unexplained bruising. An ambulance was called and Beatrice was taken to hospital where scans showed 13 fractures to ribs and legs of differing ages. Beatrice's parents did not live together. Father suffered from depression, had anger issues and was diagnosed as having Asperger's Syndrome. Mother had made allegations of sexual abuse against her father, and had a history of self-harm and suicidal ideation. Father had attempted suicide previously and Mother had a history of risk taking. Concerns over both parents not taking prescription medication. Family proceedings and criminal investigation were in progress at the time of writing the review. Ethnicity and nationality not stated. Learning includes: local authorities should liaise around support to care leavers living across boundaries; where there is a history as a care leaver, background information should be sought from the responsible authority; police should take a more holistic view of a person's circumstances and consider information sharing to protect a child, even in cases where the child is not yet born. Recommendations include: agencies working with care leavers must be aware of the right for care leavers for service provision up to the age of 25-years-old; request guidance on information sharing between local authorities where care leavers are not living in the area of the responsible authority; ensure information sharing policies are in place and include all cases, not just those managed under formal child protection procedures.
| Sefton Local Safeguarding Children Board (LSCB) Serious Case Review (Beatrice) January 2020 Jane Booth Independent Author 2 Contents: Page 1. Introduction 3 2. The review 3 3. Views of the family 5 4. Background 6 5. Childhood histories and transitions from child to adult services 6 6. Significant information prior to the timeframe of the review 8 7. Significant events/practice episodes during the period covered by the review 9 8. Analysis and learning 15 9. Good Practice 20 10. Conclusions 21 11. Recommendations 22 3 1. Introduction 1.1 This review arises from concern about injuries to a child to be known as Beatrice was taken by her mother and paternal grandmother to the walk-in centre as they were concerned about a rash. Beatrice, at this point was eight weeks old, and was found to have unexplained bruising and an ambulance was called to take her to the hospital. 1.2 Over the next few hours more bruising became apparent. Subsequent examination and scans showed thirteen fractures to ribs and legs of differing ages. Parents said Beatrice had been unwell for the last couple of days but could offer no explanation for her injuries. 1.3 The parents stated that they did not live together. Beatrice lived with her mother. Father was said to live with paternal grandmother but spent much of his time at mother’s home. Paternal grandmother offered support and was the only other person to have taken part in Beatrice’s care. 1.4 At the time of writing this report, both family proceedings and a criminal investigation were in process. 2 The Review 2.1 Sefton Local Safeguarding Children Board (LSCB) Practice Review Panel (PRP) considered whether the case met the criteria for a Serious Case Review. In accordance with paragraph (1) (e) of Working Together 20151 a serious case is one where; a) abuse or neglect of a child is known or suspected; and b) Either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 2.2 The PRP concluded that the criteria for a Serious Case Review had been met and recommended a review be undertaken. Jane Booth was appointed as the independent author to complete the work and a Serious Case Review Panel established to support the work and ensure timely completion. The independent author has never worked for any of the agencies involved in this case, has considerable experience in the field of social care and has previously authored reviews for other Safeguarding Boards in the North of England. 2.3 The report generally refers to family members using their relationship to the child e.g. paternal grandmother. Professionals are referred to by the role they fulfilled. 2.4 The PRP set the following terms of reference for the serious case review; 1 Although Working Together 2018 had been issued prior to the commissioning of this review, the review was commissioned prior to the move to new arrangements and therefore under the 2015 requirements. 4 o Establish lessons to be learnt from the case regarding the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children. o Identify clearly what those lessons are, both within and between agencies. The review will consider the following issues: o Transitional arrangements from children’s services to adult services o Understanding the known and unknown vulnerabilities of Mum o Understanding the known and unknown vulnerabilities of Dad o Multi-agency working in assessment, risk management, safety planning and permanence o Connectivity with health services. 2.5 The following agencies contributed to this review: o National Probation Service o Merseyside Community Rehabilitation Company o Merseyside Police o North West Borough Healthcare NHS Foundation Trust o Mersey Care NHS Foundation Trust o Southport and Ormskirk Hospital NHS Trust; o Alder Hey NHS Foundation Trust; o Liverpool Women's Hospital NHS Foundation Trust o GP surgery o Sefton Children’s Social Care o Sefton Early Help Service o Sefton IRO Service o One Vision Housing 2.6 Access has also been provided to records held by Children’s Social Care Service from a neighbouring local authority who were responsible for mother’s care as a child. Father lived in another local authority area up to 2012 but attempts to identify records have been unsuccessful and it seems likely there was no social care involvement. 2.7 The timespan considered by the review was set as 01.08.18 to 03.06.19 2.8 The methodology used for the review involved the development of single agency chronologies which were then integrated into a single timeline of agency involvement. Practitioners, and some managers, who had worked with the family were invited to a practitioners’ learning event where key issues arising from the chronology were considered alongside the terms of reference for the review. 5 3 Views of the Family 3.1 The parents and paternal grandmother were invited to make a contribution to the review. It was initially agreed that father and paternal grandmother would meet with the reviewer after the completion of the fact finding hearing2 in care proceedings. Mother was initially unsure. In the event paternal grandmother did meet with the reviewer but father did not, and mother made a contribution via telephone. 3.2 Paternal grandmother has always supported her son and was keen to support both parents with preparation for, and care of the baby. She knew that mother had support from what she thought was a psychiatric nurse, and knew she had been in care. She knew that parenting would be likely to present a challenge for both parents. 3.3 Paternal grandmother was contacted during the course of the pre-birth assessment. She stated this consisted of a 10-minute phone conversation with the social worker. During the court proceedings she says she heard a lot of background information that she did not know, some of which she believes her son also did not know. 3.4 Paternal grandmother encouraged the parents to engage with any help offered and they were both positive about this. She believed agencies were talking to each other. Her perspective on the extent to which the Asperger’s Service knew about the relationship and pregnancy is at variance with the information submitted for the review. Paternal grandmother states that she attended an appointment with father when the relationship was discussed and that on at least one occasion mother also attended when obviously pregnant. 3.5 Paternal grandmother feels she was identified as an important support but kept in the dark. She did not know the extent of mother’s vulnerabilities, or her risk-taking behaviours. She feels it is also possible that father did not know, almost certainly, about the risks arising from going to high places. 3.6 Mother states that she was open with professionals from the start about her history and her own anxieties about being a first-time parent. She states she was keen to accept all and any help offered, and even when she knew it would be difficult for her, e.g. the parenting group, she would have tried to take advantage if more support had been offered. 3.7 She says that she was frightened that her history would result in her child being taken into care but wanted to work with Children’s Social Care. She was anxious about the outcome of the pre-birth assessment and had to ring up to find out the outcome. She was surprised to be told the case had been closed. 3.8 Mother is angry with agencies and feels let down. She is aware that there were some issues about multi-agency communication and does not understand why this 2 Fact-finding hearings are used in Care proceedings (where the Local Authority has concerns about children) to decide important issues that are in dispute between the parties or to find out what happened on an occasion. They are generally used to decide on a factual issue, to inform an assessment or welfare report. 6 happened. She says she attended the Asperger’s Service with father when he was having difficulty dealing with feelings of anger, when she was clearly pregnant and recalls his medication being increased. 3.9 She says she would have welcomed early help and doesn’t know why this was not arranged before the baby was born. She says some professionals cancelled appointments with her and does not feel she was always listened to when she voiced concerns. She was however pleased that the support from the Personality Disorder Hub was extended beyond the usual 2-year period. 4 Background 4.1 Father and paternal grandmother were not known to local social care services. Father was receiving support from the local Asperger’s Team, and had a history of depression and suicidal ideation. 4.2 It was known that mother had been a looked after child in a neighbouring area and was residing in Sefton when still a care leaver. She was receiving support from mental health services in Sefton as an adult. On leaving care she had lived in supported accommodation prior to obtaining her own tenancy. She had a history of offending, linked to a mental health episode in 2017 – a single incident of assault on a health professional and police. 4.3 Mother had a significant history of self-harm and suicide ideation, was under the care of a psychiatrist and was being supported by the Personality Disorder Hub, via a two-year intensive programme. A Care Programme Approach Care Plan was in place. 4.4 A Pre-birth Assessment was undertaken by Children’s Social Care between August and November 2018 and did not identify the need for ongoing support/intervention from the service. 4.5 Mother accessed local community midwifery services in Sefton and opted for a hospital delivery at a hospital across the local boundaries. Midwifery services made appropriate referrals to Children’s Social Care. The hospital produced a care plan in consultation with the specialist mental health midwife and, post-birth, there were routine midwifery visits, visits from the 0-19 (health visiting) service and a referral was made to the Early Help Service. 4.6 Beatrice was presented to the GP on a number of occasions with minor health issues, all were appropriate concerns. 5 Childhood histories and transition from child to adult services 5.1 Mother is a member of a large family. Maternal grandmother (mother’s own mother) is recorded as having both a visual impairment and a learning disability. Concerns regarding neglectful care, physical abuse, domestic abuse and the home being” chaotic”, are recorded. 7 5.2 When mother was fourteen years old the school made a referral to their local Children’s Social Care (the family lived in another local authority area at the time) about a possible pregnancy, drinking and allegations that mother was having sex with an adult. It was established that she was not pregnant. There is no record of the outcome of the allegation regarding sex with an adult nor any reference to possible sexual exploitation. 5.3 Family relationships were highly conflicted. Maternal grandfather was alleged to have physically abused and controlled his wife, and to have physically abused the children. Mother was also recorded as a perpetrator of violence towards her siblings. 5.4 On 1 September 2009, when aged 14 years, mother alleged sexual abuse by her own father (maternal grandfather). She reports that she was not supported by her own mother (maternal grandmother) and was rejected by the family. She became a looked after child. As she moved towards adulthood she moved into supported housing and was provided with the support of a leaving care worker. She continued to receive this support until the age of 21 years. She had a number of placements but finally settled well in a residential unit where she made friends and had a good relationship with staff. She continued to receive support from the unit after she left. 5.5 Mother is said to have received support from the Child and Adolescent Mental Health Service (CAMHS) in a neighbouring area. This was outside the time frame for the review and has not been further explored. It is not known whether she ceased one service and later represented or whether formal transition arrangements were carried out. It is clear however that by the time mother was an adult she was known to adult mental health services due to significant self-harm and suicide ideation resulting in presentation at emergency services. She was diagnosed as having an unstable Emotional Unstable Personality Disorder and has been in receipt of specialist services. Mother herself has been open with professionals about her childhood so these issues were known to the Personality Disorder Hub. 5.6 Father is one of three children and little is known about his childhood experiences. He was not known to local Children’s Social Care and attempts to identify any information held in neighbouring authorities has been unsuccessful. 5.7 It is known that he was electively home educated from around the age of 13 years and GP records state he self-reported that he was referred to the Child and Adolescent Mental Health Service but did not attend. The Asperger’s Service have been entirely reliant on self-reporting from father regarding his history Analysis and learning re transitions 5.8 Mother’s transition to adulthood was supported via a neighbouring authority’s leaving care service up to the age of 21 years and she continued to receive emotional support from staff at her last placement beyond this point, on an informal 8 basis. Despite her significant mental health problems, she appeared to cope well in practical terms, making her own arrangements to move on from supported housing and managing her finances well. It is not clear whether extending the care leaver support beyond 21 year was considered but the presenting problems at this time were all associated with her mental health and by the time the leaving care support ceased, she was being supported by adult mental health services. In the event, Children’s Social Care in Sefton were not informed that another authority were supporting a care leaver in their area. Learning point 1: In general, it would be good practice for local authorities to liaise around support to care leavers living across boundaries. (In this case it is unlikely that this would have resulted in any additional active support being offered to mother.) 5.9 It has not proved possible to trace records of father’s childhood history. What is clear is that there is no record of engagement with children’s social care, either in Sefton or in neighbouring areas. His last involvement in formal education appears to have been in Lancashire in 2005 at which point he became home educated but it has not been possible to trace any records. 5.10 The only specialist service working with father was the Asperger’s Service and they have no information regarding father’s history other than that which he provided himself. He was referred to them by the GP. It would appear there were no arrangements or plans developed to ensure smooth transition from child to adult services. 6 Significant information prior to the time period of the review 6.1 During 2015, prior to the period under review, mother had two episodes of compulsory admission to mental health settings. During 2016-18 she had 26 Accident & Emergency Department (AED) attendances resulting in 13 admissions linked to her mental health and in 2017 she was convicted for an assault on hospital staff and police – linked to a mental health admission. There is one reference to cannabis use in MASH3 records but drug use was not noted as an issue in recent times. 6.2 During the period immediately prior to the review, father is recorded as having made a suicide attempt after a breakdown of a previous relationship. GP notes reference drug and alcohol use but no agencies record serious concerns regarding this. He is recorded as suffering from depression and was diagnosed as having Asperger’s Syndrome in June 2018. 6.3 It is understood by some agencies that the parents met online. It is not clear whether they actually lived together as father maintained that he was living with his mother (paternal grandmother) whereas mother’s conversation with professionals suggested he was with her much of the time. Whilst services supporting mother 3 MASH refers to the Multi-agency Safeguarding Hub which is the gateway for incoming referrals to Children’s Social Care 9 knew about her relationship with father and that he also had mental health problems, he too disclosed his relationship with the mother to the Asperger’s Service. 6.4 Both parents were known to be unreliable in terms of taking their medication. 7 Significant events/practice episodes during time covered by the review 7.1 In March 2018 mother became pregnant but in April 2018 records indicate that there was a miscarriage and reference to this having been “a molar pregnancy”4. There is no note of any significant response from agencies or any work done with mother around this. 7.2 In July 2018 father was assessed at the “single point of access”, an entry point for mental health services. He said he was struggling with anger. He made no mention of being in a relationship, the impact of the miscarriage, or the possibility of being a parent in the near future. He said his outbursts could be set off by the smallest thing (giving an example of having run out of milk) and that his anger was generally directed towards his immediate family. He was referred back to the Asperger’s Service. He was not explicitly asked about caring responsibilities. 7.3 Three weeks later mother attended the early pregnancy assessment unit where a scan confirmed a 6-week pregnancy. She stated that both she and her partner were feeling positive about the pregnancy. 7.4 Later in August 2018 a student social worker commenced a pre-birth assessment (referral having been made by the local midwifery service). Although father was known to have Asperger’s Syndrome, there appears to have been no discussion with him about how this manifests, and what impact it might have on parenting nor any contact with the Asperger’s Service. There is no record of discussion about their relationship or about the recent miscarriage. The MASH5 enquiry generated on 20 August 2018, when the referral was made, had indicated that mother had been a cannabis user, but this also was not discussed. There does not appear to have been any discussion about the recent miscarriage and its impact on the parents. 7.5 At this time mother’s period of support from the Personality Disorder Hub was due to come to an end due to the natural conclusion of a two-year programme of work. Mother was expressing concern about this. 7.6 On 28 August 2018, the police responded to a report from a member of the public that mother was on the railway bridge and maybe about to jump. She had left by the time they arrived, but they located her nearby. They obtained good information 4 A molar pregnancy is where a foetus doesn't form properly in the womb and a baby doesn't develop. A lump of abnormal cells grows in the womb instead of a healthy foetus. 10 from contact with mental health services, including the possibility that she was pregnant (not yet confirmed). Mother herself denied this and denied being suicidal. A common pattern of behaviour for her has been to go to high places, bridges or car park roofs usually resulting in an emergency service call-out. She generally has said this was to “let off steam” and not part of a suicide attempt. She has not generally acknowledged the inherent dangers. 7.7 The police dropped mother off at AED on a voluntary basis so she could access the mental health crisis service. Information about this event was shared with mental health services for mother but does not appear to have been known to either midwifery or children’s social care. 7.8 Early September 2018 both parents attended the booking appointment at a local hospital. Both were present for most of the appointment but routine screening for domestic abuse took place without father there. A referral was made by the midwife to the perinatal mental health at the local hospital. Mother declined this referral although she was seen at a later date by the perinatal mental health midwife. Additionally, a second referral was made to Children’s Social Care. 7.9 Comprehensive histories were taken for both parents and they disclosed their mental health histories. Both were said to be smokers and a smoking cessation referral was made for mother. The parents stated they did not live together but that father would be spending more time with mother after the birth. 7.10 The Care Coordinator from the Personality Disorder Hub continued to give weekly support and made additional visits jointly with the social worker doing the pre-birth assessment. The Care Coordinator is recorded as giving considerable support and re-assurance to mother and described the coming baby as a “protective factor” for mother. Father had disclosed that he had Asperger’s Syndrome, but no detailed information was sought and no supporting services identified or contacted. The Asperger’s Service remained ignorant of his relationship and the pregnancy. 7.11 As part of the completion of the pre-birth assessment the social worker contacted the psychotherapist at the Personality Disorder Hub. The psychotherapist stated that mother did not attend very often. The social worker recorded the psychiatrist as saying “…. the birth of the baby will be a great event for mother as she is a very capable person and will make a good mother with the right support around her”. There is no record of a risk assessment re parenting having been completed by the Personality Disorder Hub at any point. Maternity Services at local hospital were not consulted regarding the pre-birth assessment. 7.12 At the end of September 2018 there was a second joint visit by the Care Coordinator from the Personality Disorder Hub and the social worker. At this time mother’s support from the Personality Disorder Hub was due to come to an end and the record states “…. she was looking forward to moving away from services and for case management to come to an end”. Shortly afterwards the Children’s Social Care record notes that her mental health support will continue until November 2018. It quotes the practitioner from the Personality Disorder Hub as 11 saying that mother has the ability to manage risks to her unborn child, has a good understanding of child development and the importance of taking her medication. 7.13 From the beginning of October 2018, the “enhanced” team midwife6 visited at home every two weeks. At the local hospital information is documented in hand-held records and on an electronic maternity information system. Mother was seen in the antenatal period and post-natal period by local maternity hospital so any documentation written in hand-held records would not be duplicated on local hospital electronic records. Mother retained these hand-held notes and they have not been available for review. Mother was referred to a parenting class “Mellow Bumps” but she did not attend. Practitioners from the Personality Disorder Hub indicated at the practitioner event that her condition makes group activities very difficult for her. The parents were still said to be living separately. 7.14 At the end of October 2018 mother telephoned the Personality Disorder Hub and expressed concerns about whether she will be a good mum. She had left the house and said she was going somewhere to “clear her head”. She said she had her medication with her and feared she might take an overdose. There is no evidence that this information was shared with Children’s Social Care or with the midwife who was not aware of mother’s risk-taking behaviours. 7.15 Around the same time the social worker received an email from the consultant psychiatrist who described mother (also not aware of the recent incident) as doing well, calm, and with no episodes of self-harm or suicidal ideation. On this basis he said she was to be discharged from the service. However, support continued to be provided by the Personality Disorder Hub throughout the pregnancy and beyond although there is no recorded decision about his. At the end of October 2018 in a telephone conversation with a practitioner at the Personality Disorder Hub, mother stated she was struggling and feeling more isolated. She said she had been thinking about self-harm but would not take action due to the baby. 7.16 On the 2 November 2018 mother made a telephone call to the Personality Disorder Hub. She reported having “low mood”. She was sitting on top of a car park she was observed by CCTV and the police were alerted. She is described as “very fearful”. She said that father was at his mother’s and was not being supportive at present. During the conversation the police arrived and talked mother down. She agreed to go to the Personality Disorder Hub. Once there, she reiterated her concerns and agreed strategies to keep her safe overnight. Arrangements were made for the “safe and day” service to visit overnight and at the weekend. Mother was described as “chronic risk of self-harm and suicidal ideation but no evidence of acute risk”. Information about this incident was not shared with Children’s Social Care or midwifery. 7.17 On the 5 November 2018 mother was still feeling low and stated she was thinking about going to a car park but denied being suicidal. Possible admission to hospital was discussed but she declined this. Her medication was subsequently increased. 6 This term is used to refer to a midwife with specialist skills in respect of mental health. 12 Her GP was notified of the medication increase but no details were shared with any other agencies. 7.18 On 13 November 2018 the Pre-birth Assessment was signed off as completed by Children’s Social Care. It stated: “Mother has mental health issues which can be triggered by stress and if medication is incorrectly managed. Having a new born baby will increase stress levels therefore having additional support available for mother is essential to safeguard the health and well-being of the baby, mother, however has engaged well with the assessment and is currently presenting as stable. She is able to identify her low moods and address it appropriately. She has good rapport with her psychiatrist who monitors her medication and mood regularly. Mother has family support from paternal family and knows where to access support from external services. Mother does not feel she needs a Social Worker and currently there is no role for Children’s Social Care. Case to close, however health services will be monitored closely and if concern arises in the future the case will be referred to Children’s Social Care”. It is not clear which part of the health economy this refers to. At this time the local hospital, who were providing antenatal care, were not aware of the assessment. 7.19 In December 2018 there are two entries in the mental health record which described mother’s mood as “fluctuating”. This did not prompt contact with Children’s Social Care. 7.20 There are two references in January 2019 to appointments with a family therapist from the Personality Disorder Hub in respect of a “parent-infant assessment” which are shown as not attended by mother and in February 2019 mother cancelled her appointment with her mental health worker. These cancellations do not appear to have been explored further. 7.21 Records of a conversation between a health visitor and the Care Coordinator in the Personality Disorder Hub state that the Care Coordinator had indicated that they had no concerns about mother’s potential ability to bond with her child although mother herself was expressing concern in view of her own childhood experiences. The practitioners agreed there was a need for an early help assessment but concluded this best be done after birth of baby. 7.22 As the due date for the baby neared, the local hospital, where she was to give birth, developed a birth plan. Mother was advised that she should remain in hospital for 72 hours after the birth of the baby. The plan included a comment from mother about the importance of sleep deprivation as a factor in her mental health. There is no further reference to this. 7.23 In March 2019 father is recorded by the Asperger’s Service as reporting feeling angry. He stated he had not been taking his medication (baby due in 3 weeks). 13 7.24 On 15 March 2019 mother was increasingly suffering with pelvic pain. She reported to the antenatal midwife that she continued to have thoughts of self-harming. Children’s Social Care were contacted in respect of the midwifery plan of care but reported that the case was closed. In the plan of care mother’s own words were quoted and she acknowledged the risk that her health might deteriorate following the birth. She referenced the support from the Personality Disorder Hub and denied any risk-taking activity during her pregnancy. 7.25 On 25 March 2019 mother was admitted to hospital. The midwife made a second call to Children’s Social Care to check the information about the case being closed. This was confirmed. 7.26 Beatrice was born in the early hours of the 27 March 2019. It was a difficult delivery and mother was quite unwell. She received one unit of blood but subsequently refused a second unit – against medical advice. Despite the discharge plan for 72 hours in hospital mother discharged herself. 7.27 During the next eight weeks Beatrice was seen by a number of professionals. The midwifery and health visitor contacts were in line with expected practice. The contacts that the parents initiated with GP or emergency/urgent care services were considered to be appropriate contacts generally in response to an identifiable concern. 7.28 On 29 March 2019 the “enhanced” midwife visited as did the practitioner from the Personality Disorder Hub who recorded mother’s mental health as good but noted she had been forgetting to take her medication. 7.29 On 1 April 2019 parents made a 111 call and were advised to go to GP which they did. They described Beatrice’s feet as going blue. The GP examined the baby and recorded “Mum concerned about clicky knees; no abnormalities found”. The enhanced midwife also records a visit on this date. 7.30 On 3 April mother had a telephone consultation with the GP who reduced her medication, recording that that she was to reduce antidepressants by one and continue taking the Fluoxetine. Regular visits continued from the Care Coordinator in the Personality Disorder Hub. 7.31 On 5 April 2019 the enhanced health visitor made a joint visit with the Care Coordinator from Personality Disorder Hub. The Health Visitor’s record reflects good practice with all relevant areas discussed. The Care Coordinator reports that she was visiting three times a week and has no concerns. Mother is recorded as now only taking her anti-depressants. The property is described as very untidy, particularly the bedroom. The Health Visitor noted that an early help assessment is required. The parents agreed to an early help assessment and the referral was made. 7.32 On 8 April 2019 parents brought Beatrice to the GP. The GP recorded a small mobile lump on cheek and re-assured the parents. On 12 April 2019 the health visitor made a home visit and recorded that the baby was distressed and seeming 14 to be hungry. There were no sterilised bottles. The Health Visitor recorded positive interaction between both parents and the baby. 7.33 On 13 April 2019 the parents made a 111 call re reduced feeding and fewer wet nappies. They were advised to go to AED where the baby was observed with low temperature and kept in overnight. The baby was subject of a full medical examination. 7.34 On 24 April 2019 there was a home visit by the health visitor – again thoroughly recorded and reflecting good practice. Oral thrush was noted and a prescription given. It was noted that the family had moved house though father was still living with paternal grandmother but staying over some of the time. 7.35 On 30 April 2019 mother is recorded as having a “new patient check” presumably changing GP following the house move. She is recorded at this point as only taking Fluoxetine. 7.36 On 8 May 2019 the Health Visitor and Personality Disorder Hub Care Coordinator made separate visits and Beatrice was taken to the GP who recorded oral thrush. This was the 3rd visit from the health visitor and she made a thorough recording of a visit which reflected good practice. She noted the house as “very untidy”. Mother reported that she was taking her medication. The record from the Personality Disorder Hub notes no concerns 7.37 On 9 May 2019 parents brought Beatrice to GP – with concern re bleeding from rectum and on 11 May 2019 went to AED via ambulance re bleeding per rectum - query anal fissure due to constipation. This was followed up in phone call with the Health Visitor the next day and advice was given re feeding regime as mother had put Beatrice on “hungry baby milk”. 7.38 On 15 May 2019 the Early Help Service made a first visit jointly with the Health Visitor. Father was described as quiet throughout. The referral had been made by the health visitor. The full extent of the mental health information was not known by the health visitor so this was not passed to the Early Help Worker and, as she did not know about mother’s risk-taking behaviours or lapses in medication taking during pregnancy, these were not communicated. 7.39 On 20 May 2019 mother attended the GP surgery, who recommended a type of antidepressant. Her mood was described as low and poor sleep and lack of motivation were noted. The next day the Health Visitor made a visit – Beatrice’s weight had reduced on centile chart. Mother indicated that, despite previous assurances to the contrary she had not in fact been taking her medication and found it hard to motivate herself to do routine things. The family were struggling with accommodation issues and mother was having some difficulty with her benefit payments. 7.40 On the 22 May 2019 the Personality Disorder Hub Care Coordinator visited and mother again indicated she had not been taking her medication. The record states 15 that on the surface she appeared upbeat and in good spirits and no acute risk was noted. 7.41 On 22 May 2019 Beatrice was taken to the GP and the 6-week baby check was completed. The was baby examined and the notes record no abnormalities and no concerns. 7.42 On 23 May 2019 Mother telephoned the Health Visitor reporting teething problems and reduced feeding. She was given advice and told to take Beatrice to the GP if she continued to refuse feeds. Later that day Beatrice was taken to the walk-in-centre where injuries were observed and she was transferred to local children’s hospital. 8 Analysis and learning Understanding the known and unknown vulnerabilities of mother 8.1 Mother informed midwifery and other professionals of her history and of her Emotional Unstable Personality Disorder and depression herself. This was not checked out with the area where she had been in care and some potentially important information was missing. Midwifery services made appropriate referrals to Children’s Social Care for a pre-birth assessment to be completed. 8.2 The pre-birth assessment was completed by a student social worker and contained relevant information provided by mother about her childhood history. Again, the allegation of possible abuse of her siblings was not disclosed. 8.3 The assessment drew on information provided by other local services, but this was incomplete, and factually inaccurate due to lack of communication between services. Whilst the nature of mother’s history and her vulnerabilities were recorded, their potential significance does not appear to have been recognised. 8.4 The incident the police attended on 2 November was not notified to Children’s Social Care. This may be because mother did not at that time have children, but this meant an opportunity was missed – the pre-birth assessment was signed off only a couple of weeks later in ignorance of this event. 8.5 Mother’s history of a neglectful and abusive childhood was known to the Personality Disorder Hub and mental health services. These experiences are known to create an increased risk of compromised parenting and mother herself had expressed concern. 8.6 While those with a Emotional Unstable Personality Disorder can and often do make good and committed parents research clearly highlights the issues which they might face7. Parental Emotional Unstable Personality Disorder is identified as a risk factor for impaired parenting behaviours and disturbed parent-child relationships. This risk was not referenced in the care plan in place in the Personality Disorder Hub and this 7 The link between personality disorder and parenting behaviours: A systematic review; Sarah Laulik, Shinning Chou, Kevin Browne, Jayne Allam 2013 16 plan did not appear to have been updated to include the information about the pregnancy until after Beatrice’s injuries had been identified and care proceedings initiated. 8.7 Throughout the pregnancy the Personality Disorder Hub Care Coordinator provided re-assurance to mother that she would make a good parent but there is no evidence of any kind of assessment. She had been involved with mother for around two years and perceived her to have made good progress during that time. It is possible that the “rule of optimism”8 was a factor influencing her judgement. This is a well-documented phenomenon, often referenced in Serious Case Reviews. Caution should be exercised however in seeing this in over-simplistic terms which lay blame at the door of the practitioner, and more modern research emphasises the importance of seeing this within the context of the organisational frameworks supporting good practice such as the provision of reflective supervision. 8.8 The Personality Disorder Hub Care Coordinator did refer mother to a family therapist from within the service, but mother did not follow this up. She was also offered access to parenting preparation classes via the midwifery service but these were group activities which her Emotional Unstable Personality Disorder prevented her from taking part in and no alternative options appear to have been considered. 8.9 Mother also suffered from depression. Sefton’s own practice guide in respect of mental health points out that 25% of children subject of a child protection plan have a parent with a mental health problem and that it is a factor in a third of cases considered under a Serious Case Review. 8.10 Mother’s need for general parenting support were referenced in records, and father (and paternal grand-mother) seen as a source of support. The nature of their relationship does not appear however to have been fully explored and it might have been anticipated that their individual needs would have made forming and sustaining relationships more difficult for both of them than might be the norm, but there is no record of this being assessed. The relationship was less than a year’s duration and they had had to deal with an unplanned pregnancy resulting in the loss of the baby followed very shortly by the pregnancy with Beatrice. Mother had moved house into what turned out to be less than satisfactory premises and was having problems with her benefits. There is no evidence that there was recognition of the potential impact of these cumulative difficulties. 8.11 On at least one occasion mother left the home distressed following some sort of difficulty with the relationship and on another expressed concern that father was not giving her enough support. Mother shared concerns with midwifery about her need for post-natal support and in particular a worry that lack of sleep might impact on her mental health but the extent to which father would actually be there was not explored – he did always seem to be there when visits were made but both maintained he was continuing to live with his mother. 8 Revisiting the Rule of Optimism Martin Kettle, Sharon Jackson 2017 17 8.12 Mother had been alleged to have abused siblings while still herself a child and had been convicted of a violent offence associated with a mental health admission to hospital. There is no evidence that she was prone to general violent outbursts but this was not explored. Learning Point 2: Where risk factors are evident the importance of full information cannot be over-emphasised. While the self-disclosure of information is positive it cannot be assumed that this is complete, and confirmation should be sought where possible. Specifically, where there is a history as a care leaver background information should be sought form the responsible authority. Learning Point 3: It is important for the police to take a more holistic view of a persons’ circumstances and, although not yet a parent, to consider information sharing to protect a child, albeit not yet born. Learning Point 4: Mother’s parenting capacity needed to be specifically assessed taking account of relevant research re parenting and Emotional Unstable Personality Disorders. Learning Point 5: Little information was obtained in respect of father – this is commonly reflecting in reviews where the male partner is almost the invisible male. The absence of more professional curiosity resulted in a lost opportunity. Understanding the known and unknown vulnerabilities of Dad. 8.13 Father’s childhood history was not explored in any detail by any of the services involved. It is now known that he was electively home educated from around the age of thirteen but the circumstances leading to this and the impact upon him were not known or explored. 8.14 He had a history of depression and had attempted suicide following the breakdown of a previous relationship. There is no evidence that this had been considered in terms of any future breakdown of relationship and any protective action plans developed. 8.15 Father was being supported by the Asperger’s Service, but he had not told them about his current relationship or the pregnancy. They believed he was living with and being supported by his mother. They had no reason to carry out any kind of parenting assessment and were not informed of nor involved in the pre-birth assessment. Had father been routinely specifically asked about relationships he may well-have disclosed the information. 8.16 Although he disclosed his mental health issues to Children’s Social Care when the pre-birth assessment was being done – both Asperger’s and depression - these were not taken full account of in terms of potential impact on parenting capacity. The student social worker did not contact either mental health or the Asperger’s Service in respect of father. His recent contact regarding angry outbursts was therefore not known or addressed in the assessment. 18 8.17 Research clearly indicates that a pre-birth/parenting assessment would have been appropriate and that some of the features associated with Asperger’s can make parenting a significant challenge.9 Parents often have to deal with fast moving situations, and factors which can be seen as overstimulating in cognitive terms, leading to stress and the possibility of being overwhelmed. These are described as having “organic” neurological components and require specific and focussed assessment. 8.18 Some records do contain historical reference to use of drugs and smoking. There were no indications that these were current issues, but they were not explored in the assessment. At the booking appointment at local maternity hospital, it is documented that both mother and father smoked one cigarette a day and mother’s CO reading was 0ppm. She stated never used substances and did not drink alcohol. Learning point 6: It cannot be assumed that all services hold all relevant information so particular care should be taken to check this out and adopt a “think family”10 approach. Multi-agency working in assessment, risk management, safety planning and permanence. 8.19 Mother had a long-standing involvement with the Personality Disorder Hub and there was good contact between the service and Children’s Social Care during the completion of the pre-birth assessment, including joint visits. A student social worker sought information from other agencies, but Children’s Social Care undertook the analysis and decided the outcome on single agency basis. Although the pre-birth assessment should not have been finalised until after the baby was born, the conclusion was to close the case. This meant that there was no under-pinning framework to support multi-agency working. Had the risks been more thoroughly assessed then a multi-agency meeting, such as a Child Protection conference, was likely to have been the outcome and would have facilitated both a multi-agency assessment of risk and the development of a joint safety plan. 8.20 The decision by Children’s Social Care to close the case, and the expectation that mother’s needs (both as an individual and as someone about to become a parent) could all be met by her continuing involvement with the Personality Disorder Hub, were not jointly agreed with the Personality Disorder Hub. However, there is no evidence that this expectation was challenged once known. Mental health practitioners at the learning event said that their experience was that it was not uncommon for other services to “back away” from cases with mental health 9 The Aspergers Comprehensive Handbook - Mark Hutten 10 SCIE: At a glance 9: Think child, think parent, think family - Published: May 2012; Key messages Think child, think parent, think family in order to develop new solutions to improve outcomes for parents with mental health problems and their families. Take a multi-agency approach, with senior level commitment to implement a think family strategy. 19 components. They felt it reflected a poor understanding of the needs of people with mental health problems and mirrored the responses often found within the community. 8.21 The possible impact of the Emotional Unstable Personality Disorder as a potential parenting risk was not acknowledged and so no risk management plan was put in place within the Personality Disorder Hub. In fact, the pregnancy and birth of the baby were seen as potentially protective factors for mother and likely to reduce mother’s risk-taking behaviours, though the evidence that this happened is dubious. There was no evidence of a focus on the baby’s needs from within the Personality Disorder Hub. 8.22 The midwifery service had made referrals for the pre-birth assessment and checked back with Children’s Social Care regarding the outcome. They had been told the case had been closed but made a further check suggesting that they had not expected this outcome. They did not however have full information and did not challenge the outcome formally. A discharge plan was agreed with mother and this identified where she would get her support but was not shared beyond midwifery services. Learning point 7: An effective pre-birth assessment is key to the development of an appropriate plan to support and safeguarded the well-being of children. Where this is allocated to a student social worker it is important that they are fully supported and supervised and that there are good quality control mechanisms in place. Learning point 8: Where a number of agencies are involved, it is important that there is good information sharing. This may be via the Child Protection planning processes, Child in Need frameworks or via an Early Help offer. It is important that a lead professional is identified and that they take on the responsibility of coordination and information sharing. Learning point 9: Decision making about the outcome of an assessment should be communicated to all relevant parties and should be subject of professional challenge if not agreed or seen as inappropriate. (Sefton now has a new pre-birth protocol that states all agencies involved should take part in decision making). Connectivity within health services 8.23 A single recording system supports practice across the mental health services so those in contact with mother in the Accident & Emergency Department (AED)/Urgent Care setting, crisis response and Personality Disorder Hub teams all had access to information held on record. All were able to access the care plan and it informed their responses, for example staff in AED knew that it was felt to be unhelpful for mother to be admitted to hospital and generally acted in accordance. 8.24 It is not clear whether the psychiatrist accessed this joint record before responding to the request from Children’s Social Care for information. A positive response which did not appear to take account of recent events was submitted. 20 8.25 There was no communication between the Asperger’s Service and the Personality Disorder Hub. The Asperger’s Service do have access to the joint record but did not know about father’ relationship with mother and so had no reason to make contact with the Personality Disorder Hub themselves. Conversely, the Personality Disorder Hub did know father was involved with the Asperger’s Service but appear not to have made any contact or shared information. 8.26 Support from midwifery and health visitors came from three different sources – two separate hospital trusts and a separate community midwifery service. Each service operated within the expected practice guidelines and there is evidence of good practice in the collection and assessment of information from the mother. This resulted in the referral for a pre-birth assessment and the involvement of the specialist mental health midwife. However, they do not have shared recording systems and although some joint visits with other professionals were made, there were issues with information sharing. 8.27 In particular the community-based midwife did not know that mother’s risk-taking behaviour was continuing and reported that this would have made a difference to her response. Similarly, the early help worker was not aware of these issues and again reported that her response would have been very different had she had access to more complete information. Learning Point: see learning point 8. 9 Good practice: 9.1 Midwifery services, both in the community and at the hospital showed good practice: • Safe sleep advice given and reiterated; • Smoking cessation addressed. 9.2 The recording in the health visiting service was of a high standard; 9.3 Local Walk in Centre reacted swiftly in a calling an ambulance and in transparent communication with the parents on the reasons for action; 9.4 Safety for the baby was well-managed on arrival at local children’s hospital; 9.5 Verbal agreement of parents re medical photographs was appropriately accepted at local children’s hospital in an urgent situation. 9.6 Mother’s support from the Personality Disorder Hub was extended beyond the normal time-span to continue support after the birth of the child. 10 Conclusions 10.1 Individually both parents had childhood and mental health histories which had potential implications for their parenting capacity and needed exploration and comprehensive assessment. They lived with mental health conditions which 21 impacted on the development and management of relationships and effected their ability to engage in community-based support such as parenting groups. They had been together a relatively short period of time and their living arrangements were not clearly understood. Mother had had to deal with the loss of a previous baby, had become pregnant very quickly thereafter, had moved house very soon after the baby’s birth, into unsatisfactory accommodation, and was having temporary problems with her benefits. Their only family support appeared to be from paternal grandmother. 10.2 There is clear guidance on the Sefton Local Safeguarding Children Board website about working with parents with mental health disorders or illnesses which indicates the likely complexity involved. When the referral for a pre-birth assessment was made it was clear this was a complex case. The pre-birth assessment was allocated to a student social worker and was based on incomplete information. It did identify vulnerabilities and the need for ongoing support, but the outcome is not reflective of the findings and the case was closed. It is not clear what management oversight there was of this process. 10.3 Closure of the case resulted in a significant missed opportunity and in there being no multi-agency meetings. It reduced information sharing and meant there was no shared risk management plan. The “hand-off” from Children’s Social Care to the Personality Disorder Hub was not challenged despite practitioners reporting that they feel this is a common occurrence reflecting poor understanding of mental health issues in other agencies. 10.4 The Personality Disorder Hub did recognise mother’s own vulnerability and extended the service beyond the usual two -year term but the service did not focus on the baby’s needs and the baby was inappropriately seen in terms of impact on mother – as a protective factor. The care plan was not updated to take account of the pregnancy. There was no formal assessment in respect of parenting in the Personality Disorder Hub, but considerable optimism was recorded and expressed to other agencies. Issues of professional bias and the rule of optimism may well have been a factor in this. 10.5 During the pregnancy and after Beatrice’s birth there was (with the exception of Children’s Social Care) no lack of service engagement. There were frequent visits from the Personality Disorder Hub, and both parents initiated contact with other parts of the mental health services at points of crisis but the crises did not cease. 10.6 There were several opportunities to re-open the multi-agency discussions on a more formal basis, for example in response to mother’s risk-taking behaviours, but these were not seen in terms of possible implications for the safety of the baby and this was not done. 10.7 Midwifery and health visiting contacts were also frequent. Individual visits and case records reflect good practice, but the quality of the interventions was undermined by the absence of full information. Practitioners acknowledge that they would have likely tailored the service differently had they been fully aware. 22 10.8 The absence of an appropriate assessment of father is striking and has been highlighted as a common issue in Serious Case Reviews. In this case, Father did disclose his relationship and the pregnancy to the Asperger’s Service and despite relationship difficulties being a known feature of Asperger’s syndrome, this does not appear to have been thoroughly explored. 11. Recommendations 1. All agencies working with care leavers must be cognisant of the right for care leavers for service provision up to the age of 25. 2. The LSCB to write to the Department for Education (DFE) and the Child Safeguarding Practice Review Panel to request consideration for issuing guidance specifically in relation to information sharing between Local Authorities where care leavers are not living in the area of the responsible authority. 3. The LSCB to provide practice guidance around multi-agency assessments which will make specific reference to: a) Risks in over-reliance on self-disclosure b) Importance of checking with all agencies who may hold relevant information c) Ensuring the (male) partner is fully considered within any assessment d) Highlights the importance of an informed specialist assessment where parental emotional well-being, ill health or neurological conditions are known or suspected; and e) Requiring the referrer to be informed of the outcome 4. The LSCB to promote the ‘think family’ approach by: a) Promoting the use of genograms to capture family composition b) Issuing a 7-minute briefing on the subject c) Building a bank of family assessment tools as a resource for the partnership 5. Children’s Social Care to assure themselves that the Student Social Worker Policy is being adhered to in all cases. 6. The LSCB to seek assurance from agencies that their information sharing policies are in place and include all cases, not just those that are managed under formal Child Protection procedures. 7. The LSCB to seek assurance from Children’s Social Care that decisions made about the outcome of an assessment is being communicated to all relevant parties. 8. All agencies to undertake an internal training analysis to assure themselves that staff are adequately trained (or there are plans in place for this) in their understanding of emotional health and well-being and mental health considerations and their relevance to parenting. 9. Mersey Care NHS Trust, as providers of the Personality Disorder Hub and Asperger’s Service, should assure themselves that staff give appropriate consideration to issues of safeguarding children. NOTE: No recommendation is made in relation to escalation of professional concerns as this has been recognised in an earlier review and work is already underway. |
NC046014 | Death of a 6-7-week-old-girl in May 2012. Subject child was found by mother with her face pressed up against the back of the settee at home where she had earlier fallen asleep. Mother had just woken from sleep after having drunk alcohol earlier in the day. Subject child was living with mother and half-brother at the time of the incident. History of domestic abuse, alcohol misuse and referrals to children's services concerning the care of half-brother. Mother was arrested in 2011 for being drunk in charge of a child, leading to half-brother being placed in foster care. Half-brother was returned to mother's care following assessments that recommended that there was no role for a social worker. Mother has a chronic abdominal condition, requiring abstinence from alcohol use to avoid the condition worsening and leading to hospitalisation. Identifies lessons learned, including: assessment of the impact of chronic alcohol misuse usually takes place when the parent is no longer intoxicated, leading to insufficient understanding of potential risks to the child; lack of professional knowledge of parents' persistent or long term medical conditions compromising understanding of the impact on parenting capacity; and professional response to incidents without consideration of previous concerns, leading to missed patterns and possibility of continued ineffective responses. Makes various multi-agency recommendations.
| Serious Case Review No: 2015-C5641 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. Serious Case Review OVERVIEW REPORT (Redacted) Independent Overview Author: Ron Lock December 31st 2012 Re Subject Child Born February 12 Died May 12 1 Contents Introduction 1.1 – 1.6 Page 3 Serious Case Review Process 2.1 – 2.8 Page 4 Summary of The Facts 3.1 – 3.17 Page 10 Analysis: The Identification of Risk Factors 4.1 – 4.18 Page 13 Assessment Practice 5.1– 5.10 Page 18 Decision Making/Missed Opportunities 6.1 – 6.20 Page 21 Policies and Procedures 7.1 – 7.3 Page 25 Communication and Information Sharing 8.1 – 8.20 Page 26 The Views, Wishes and Feelings of the Children 9.1 – 9.9 Page 31 Race and Culture 10.1 – 10.2 Page 34 Organisational Factors 11.1 – 11.6 Page 34 Immediate or Long Term Changes 12.1 – 12.4 Page 35 Actions following the Death 13.1 – 13.3 Page 36 Summary 14.1 – 14.6 Page 37 Lessons Learned 15.1 – 15.10 Page 38 Recommendations 16.1 – 16.7 Page 39 2 1. Introduction 1.1 This Serious Case Review (SCR) was undertaken following the death of a baby, whom for the purposes of this report will be referred to simply as the Subject Child. At the time of the death, this child lived with her Mother and an older brother. He was of school age at the time of his sibling’s death and he will be referred to as the Half-Brother in this report. For the vast majority of the time, the Mother cared for the children as a single parent. 1.2 The circumstances of the Subject Child’s death during one evening in the Spring of 2012 was that the baby was found by her Mother to be lifeless, with the baby’s face pressed up against the back of the settee in their home. This was where the baby had earlier gone to sleep. The Mother had herself just woken from sleep after having drunk alcohol earlier in the day. 1.3 If “abuse or neglect is known or suspected to be a factor in the death” of a child, this requires that the Local Safeguarding Children Board (LSCB) should “always conduct a SCR into the involvement of organisations and professionals in the lives of the child and the family”1, and therefore in response to this guidance, and because the Subject Child’s death was potentially due to neglectful care, then The area LSCB commissioned this SCR. At the time of completion of this SCR the Coroner gave a verdict regarding the cause of death as “unascertained” and that it occurred “in an unsafe sleeping environment”. 1.4 The purposes of this SCR reflect the relevant government guidance to: - - Establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; - Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and - Improve intra and inter-agency working to better safeguard and promote the welfare of children.2 1.5 Each agency that had some direct involvement with the children and their family was required to undertake an Individual Management Review (IMR) to look openly and critically at its practice in relation to their involvement with them. In undertaking this, each agency was also required to produce a chronology of its contact with the family. The managers/officers conducting the IMRs did not at the time immediately line-manage the practitioners involved and were not directly concerned with the services provided for the children or their family. 1.6 Senior representatives from relevant agencies in the area were brought together to form a SCR Panel in order to review and analyse the material from the IMRs. The Independent Chair of The area LSCB, undertook the role of Independent Chair of the SCR Panel and Ron Lock, a safeguarding consultant who was independent of all agencies in the area and with extensive 1 Paragraph 8.9 – Working Together to Safeguard Children – A guide to inter agency working to safeguard and promote the welfare of children – Dept. for Children, Schools and Families – March 2010 2 Paragraph 8.5, Working Together to Safeguard Children – Dept. for Children, Schools and Families, March 2010 3 experience in safeguarding children and young people, was commissioned to write the Overview Report. 2. The Serious Case Review Process 2.1 The period to be covered by this SCR is from 19th January 2006 (which was the date that the mother presented with her first pregnancy with the Half Brother) up until the 29th May 2012, which was the date of the Initial Child Protection Conference following the death of the Subject Child just over three weeks earlier. Although it was the death of the Subject Child as a baby which led to this SCR being initiated, because the time frame for analysis covers a period of more than six years, then the major focus has inevitably been upon the care which the older Half Brother received and of the services delivered to him and his Mother during that time. The SCR Panel considered that the eventual death of the Subject Child needed to be viewed and understood within the context of this background. 2.2 The following agencies were commissioned to complete Individual Management Reviews: • Family Services – Social Care (to include information from Preventative and Enhanced Services (Localities) • Family Services – Education (including Schools and Early Years) re Half Brother • The Constabulary • GP • The area Community Services: Health Visiting and School Nursing • The Hospital– to include Midwifery service, and any department that the mother may have been referred to or received services from during the period under review. • Additionally, the Ambulance Service and the Probation Trust were contacted and asked to provide relevant information in respect of any involvement they had with the family, including the extended family. A brief report was received from Probation. The limited extent of the involvement of both agencies did not warrant the completion of an IMR. 2.3 The SCR Panel members were: - Head of Early Years and Childcare, Family Services - Head of Safeguarding and Standards, Family Services - Designated Doctor, CP - Head of Community Services Law, CD - Head of Safeguarding, CCS - Public Protection Department, Constabulary - Associate Director for Safeguarding Children and Vulnerable Adults, NHS - Named Nurse Safeguarding Children, Hospital Also in attendance: - The area LSCB Business Manager - Overview Report Author Administrative staff of the LSCB 2.4 Specific Issues for the SCR to consider 4 a. To identify any risk factors and indicators of potential abuse and neglect in the family history known from point of pregnancy onwards with the half-brother (eldest child), including in the wider family network. and establish whether these risk factors were appropriately identified and taken account of in any work with the mother, the subject child and the half-brother b. To establish if appropriate assessments were undertaken, and the quality of these assessments and of the recording of work with the children and the family. c. To establish if decisions, plans and interventions made for the subject child and the half-brother were appropriate to the identified risk factors. d. To establish if there was appropriate communication and information sharing within and between agencies and, if not, why not. e. To establish how well individual agency and multi-agency policies and procedures to effectively protect the children, including those concerned with parental alcohol misuse and domestic violence, were understood and implemented by those working in all agencies f. To establish how well issues of parental alcohol misuse were communicated, assessed, evaluated, and managed and in the planning for the children within and between agencies g. To establish how well issues of domestic/ family violence were communicated, assessed, evaluated, and managed by agencies working with the mother and in the planning for the children. h. To establish how well issues of parental mental health were communicated, assessed, evaluated, and managed and in the planning for the children. i. To establish how effectively agencies sought and took in to account the views of the children, and the extent to which services took these into account in the provision of services. j. To establish if any racial, cultural, linguistic and religious diversity needs of and economic and social disadvantages to the children and family were identified, taken into account, and responded to. k. To establish if there were any difficulties with housing and accommodation and the impact of this upon the family. l. To establish if services for the family were limited or enhanced by any organisational factors within or between agencies, e.g. workforce capacity, re-organisation. m. To establish if staff involved were appropriately trained to achieve the level of competency required for their role. 5 n. To establish if supervisors and managers at all levels were appropriately involved in supervision and were accountable for decision-making. o. To establish how well agencies were able to engage with parenting figures and other adults living with or close to the family and how any barriers to effective engagement were dealt with. p. To establish if there were any missed opportunities to protect the children and what, if any, the identifiable contributory factors were to this. q. To identify any immediate or long term changes that must take place as to how agencies work to safeguard children and whether they have implemented. 2.5 Methodology/SCR Process 2.5.1 The decision to undertake the SCR was made on the 12th June 2012 when the draft Terms of Reference were drawn up and the panel members were agreed. The arrangements were also confirmed for the SCR in term of who would be the Independent Chair, followed by the appointment of the independent Overview Report author. 2.5.2 There were five SCR Panel meetings in all, from 3rd July 2012 through until 4th December 2012, following which the SCR Overview Report was presented to the area LSCB on the 11th December 2012. The IMRs were presented to the SCR Panel on 17th September and to varying degrees each required some changes or additions to be made, and to complete a second version of their reports. These were received during the period mid to late October 2012. 2.5.3 The first draft of the Overview Report was presented to the SCR Panel on the 16th October with a second draft completed for discussion at the 6th November meeting. Because the Health Overview Report’s first draft was completed for the same deadline, further changes needed to be incorporated into the main Overview Report, with a final draft completed by the 28th November 2012. This was ratified by the LCSB on the 4th December with some minor changes requested for the final versions, all of which were completed by 31st December 2012. 2.5.4 It was decided from the outset of the SCR process that there would be an opportunity for the practitioners and first line managers directly involved in the case to be able to contribute to the collation of factual information and to the analysis of the professional practice in the case. A half day meeting took place on the 10th October 2012, led by the Overview Report author, when the practitioners were presented with a summary of the key incidents and events in the case, for which they were asked to add or confirm their agreement to these. There was representation in the meeting from all the agencies who were involved with the family. Overall there was no disagreement with the main details which had been provided to the SCR process via the integrated multi-agency chronology. By this stage of the SCR process, some key themes for analysis had been identified and these were summarised as: - • The response and management of parental alcohol misuse/domestic abuse • The impact of a chaotic lifestyle on the children • Challenging parents – showing respectful uncertainty 6 • Identifying patterns of events/lifestyle – undertaking holistic assessments • Understanding and working with cultural and extended family influences • Professional communication - And the group were asked to use their direct experience of the case to consider each theme and identify: o How significant was this particular theme in the case? o Were there any challenges or issues about how this was able to be addressed in the case? o What was the context of professional interventions at the time – e.g.; Organisational issues, workload, support systems 2.5.5 The outcome from this practitioner workshop has been used throughout the case to inform the analysis of professional practice and is included within the body of the report. 2.6 Parallel Processes 2.6.1 As the death of the Subject Child did not lead to any criminal convictions and the Half Brother was not made subject to Care Proceedings. Therefore there were no parallel proceedings to consider alongside the SCR process. 2.7 Contributions by the Family 2.7.1 The Mother was visited by the Overview Author and the LSCB Business Manager for her to make a contribution to the SCR which she was able to do. Her comments and contributions have been identified and included in the body of the report at relevant stages. 2.8 Individual Management Reviews FAMILY SERVICES 2.8.1 This is a comprehensive review of social work practice with this family and highlights relevant practice issues in respect of the assessment work undertaken with the family, and identifies that even when some intuitive assessment practice was undertaken, these were not used to inform any later assessments or follow up work with the family. The IMR identifies a lack of challenge to the Mother’s disguised compliance and her denial of alcohol misuse as key areas of learning. The IMR helpfully provides useful contextual information to explain the significant pressures which family services staff were under during the period of this SCR and additionally how new major organisational changes are already beginning to have a positive impact to improving services 2.8.2 The IMR’s recommendations appropriately reflect the learning from the case and focus on the need to utilise chronologies and to strengthen assessment practice, although much of this should be integral to the expected level of practice in assessment activity. It was helpful to make particular reference in one recommendation to the area of parental alcohol misuse. Family Services – Education (including Schools and Early Years) 7 2.8.3 This IMR not only covers the work of the Primary School and Nursery which the Half Brother attended, but also that of the Children’s Centre which provided a range of early services to the Mother and Half Brother. It gives a good explanation and analysis of the work undertaken with the Half Brother and his Mother, but recognises that these services were generally unaware of any on-going domestic abuse or maternal alcohol misuse problems. Whilst the IMR specifically raises issues of concern about the apparent lack of notification to their services of domestic abuse incidents, in reality these incidents primarily occurred prior to their direct involvement. 2.8.4 The recommendations appropriately address the findings which the IMR made and raises the issue of the need for training for staff in terms of parental strategies of disguised compliance and how to address issues of absent fathers in their work with families. The Constabulary 2.8.5 This is a very detailed IMR which provides concise and objective analysis of Police practice in this case, identifying specific occasions when practice was very good, but also when alternative actions could or should have been undertaken to address the safeguarding needs of the Half Brother. He was the only child who was present at the time of Police involvement in addressing domestic abuse incidents or those relating to maternal alcohol misuse. The IMR is very clear in terms of lessons learned and how these can be transposed into current practice. 2.8.6 The IMR also helpfully identifies how current changes in multi-agency practice arrangements will assist and support the Police in their operational work with families and improve communication between key professionals. The recommendations are not very specific in nature and some relate to multi-agency initiatives rather than the sole responsibility of the Police. The IMR however overall reflects a very thorough understanding of the case from a Police perspective and of the learning it has generated. The GP Practice 2.8.7 This IMR explains how the GP Surgery in this situation had a pivotal role in its work with the family and clearly sets out what took place and the analysis of the interventions undertaken. Whilst it highlights the extent to which the Surgery appropriately raised concerns with family services about the Mother’s alcohol misuse when caring for the Half Brother, it recognises that communication systems did not work well in respect of identification of risks to the Subject Child. The IMR, like other health IMRs raises the question about the need to improve communication processes and for the need for more effective shared computer systems to achieve this. There is one main recommendation made which attempts to address the many factors involved in information sharing and how to ensure it is more effective and efficient in the future. Whilst the recommendation is appropriately made for the GP service to address, it will inevitably require input and cooperation from other agencies in order to achieve its outcomes. The Community Services: Health Visiting and School Nursing 8 2.8.8 This IMR recognises that the health visitor was in a key position in working with this family and that concerns about the Mother’s alcohol misuse were raised with family services when appropriate, but that there was never any clear understanding of the extent of the alcohol use and so no effective assessment followed. Good practice by the health visitor is identified when appropriate and there is some helpful analysis of practice overall. This IMR also identifies communication problems between the health visitors, community and hospital midwives and gives a useful insight into the complexities of working with the database recording process and how the case recording by community health practitioners was sometimes inadequate. The IMR also identifies how the Mother’s overall positive presentation generated an over optimistic view of her parenting and that there was evidence of disguised compliance. 2.8.9 The recommendations appropriately reflect the findings identified in the analysis from the IMR, which have a particular focus on improving communication, recording and the development of a team ethic among health visitors. Hospital 2.8.10 This IMR reflects the work that was undertaken in the hospital which had extensive involvement with the Mother in terms of her having a chronic abdominal condition and in respect of the ante and post natal periods in respect of both children. The IMR recognises that there was not a consistent response to potential incidents of alcohol misuse by the mother, in terms of recognising the possible impact on parenting ability. Information sharing and record keeping are identified as areas which need concerted improvements. 2.8.11 Recommendations are therefore made to try to improve record keeping processes as well as information sharing both within the hospital via Safeguarding Management meetings to discuss cases, and externally with the community midwives. Health Overview Report 2.8.12 This report succinctly draws together the learning from the community and hospital based health IMRs, recognising some of the difficulties of ensuring effective internal and external communication systems for sharing safeguarding information between health practitioners. Some other concerns in relation to insufficient understanding of the implications of parental alcohol misuse are also highlighted. It highlights that some lapses in practice could be attributed to organisational changes and capacity issues. 2.8.13 It is considered that the learning from the Rapid Response process was very useful and that these could have been more widely circulated - in this respect an additional recommendation has been made to reflect this issue in this Overview Report. 9 The Facts Prior to the birth of the first child (Half Brother) 3.1 It was recognised by health professionals, that prior to the birth of the Half Brother, that the Mother had a complex medical history in terms of a chronic abdominal condition which had required surgery on more than one occasion. This type of condition meant that the Mother needed to abstain from alcohol use, and if not that her condition could worsen and require hospitalisation. Three year period from birth of Half Brother 3.2 When the Half Brother was born in 2006, there were no concerns about his care or his weight and he was discharged home with his Mother the following day. His six-eight week developmental check was later recorded as satisfactory. The Half Brother’s father was not part of the family home and although there was a male partner in evidence for the first year of this three year period, the Mother primarily cared for this child as a single parent. 3.3 During this three year period, there were five reported domestic abuse incidents involving the Mother, some of which led the Police to make child protection referrals to family services. In fact in total, there were six separate incidents of concern about the care of the Half Brother referred to family services. Additionally, there were nine occasions when the Mother needed some form of hospital attention, some including stays of two – four days. All of these were related to flare ups of her chronic abdominal problems. 3.4 Apart from the involvement of the Police and family services at particular times of crisis, there was support provided by the health visitor, the GP surgery and for the year from the summer of 2008, regular involvement and support provided by the local Children’s Centre. Whilst in 2007 when most of the domestic violence occurred, there had been an offer of support from a domestic violence advocate, the Mother said that she did not want this help. The next 18 months 3.5 The Half Brother commenced at Nursery and at this three-year development assessment at about the same time, he was initially reported to have appropriate behaviour and play. However he was later placed on the Special Education Needs register and later designated as “School Action Plus”3 and was given an Individual Education Plan. 3 School Action Plus ("SA+") is used where SA has not been able to help the child make adequate progress. At SA+ the school will seek external advice from the Educational support services, the local Health Authority or from Children’s Social Care. For example, this may be advice from a Speech and Language Therapist, an Occupational Therapist or Specialist Advisory Services dealing with autism, Behavioural Needs etc. SA+ may also include one-to-one support and the involvement of an Educational Psychologist. As well as the use of external services, SA+ requires more detailed planning of interventions for children whose progress has been limited. A child's progress at SA+ stage should also be reviewed regularly (i.e. at least twice a year) and an IEP should also be written to assist the child. – www.specialeducationalneeds.co.uk 10 3.6 Overall, during this further period of time, it was apparent that the Mother’s alcohol use was continuing despite her often claiming she had ceased drinking. It remained difficult however on all occasions to make the direct link between some continued hospital attendances because of her abdominal problems and alcohol misuse. In mid-2010 the Mother was seen by a specialist in substance misuse when she said that she had not drank alcohol for the past 5 months. The assessment considered that the Mother had no mental illness and no arrangements were made for the specialist to see the Mother again. In late 2010, on one occasions when the Mother was found to be intoxicated at a friend’s house, both the Mother and the Half Brother were asleep on the settee and the Half Brother had turned his face to be pressed up against the back of the settee. He was 4 years 4 months old at this time. 3.7 The domestic abuse incidents decreased which was no doubt due to the fact that there was no male partner living in the household although it was clear that there was the propensity for violence from within the Mother’s extended family, in which the Mother had become the victim on at least one occasion. 2011 3.8 In early 2011 the Mother was arrested for being drunk in charge of a child. As a result, the Half Brother was taken into Police Protection and family services placed him in foster care. Following an Initial Assessment and Strategy Meeting, the Half Brother was returned to his Mother and a Core Assessment followed which recommended that although the incident had been high risk, its recurrence was low because the Mother had explained that her reaction was related to a family tragedy. The assessment recommended that there was no role for a social worker and the case was closed by family services. 3.9 There were further reported concerns about the Mother’s drinking over the following twelve months. These were: - - A physical assault occurred between adult members of the extended family in the presence of the Half Brother – the Mother had been drinking alcohol at the time. - The Mother was intoxicated and reported that the Half Brother had been left in a taxi and had driven off. He was later found safe where the Mother had left him. - A member of the public reported to family services that the Mother was in the street drinking three bottles of wine whilst the Half Brother was running around 3.10 Of the above incidents, the concerns reported in Spring 2011 led to family services undertaking an Initial Assessment and a Core assessment which eventually led to the setting up of Child in Need (CIN) meetings, the first of which took place in the Summer of 2011. This meeting identified that the Mother was pregnant but understood that she had stopped drinking. Some of the plans from the meeting included for the Mother to attend a parenting course and to have counselling via the GP. There was an arrangement for a further CIN 11 meeting in September 2011 which was attended by family services and school staff. The case was closed by family services two months later. 3.11 The Probation Service made a referral to family services when they stated that the Half Brother was on occasions in a household with a person who had offences, which meant that he could pose a risk to a child. The Mother told the social worker over the phone that she was aware of the individual and that he did not have any unsupervised access to the Half Brother. 3.12 In summary, during 2011, despite being pregnant for half of the year, the Mother had not managed to completely cease drinking. There were however no hospital attendances during this year although she sometimes attended the GP with abdominal pains. There was just one domestic abuse incident, this time again involving the extended family rather than part of any one to one relationship of her own. 3.13 During this period of time, there was some evidence of the Half Brother’s behaviour deteriorating within the school environment. He was seen by a community paediatrician in the Summer of 2011, following a very delayed referral from the GP, although the paediatric assessment did not identify any concerns, and as a consequence no follow up was planned. This was at a similar time to concerns being expressed within the CIN meetings about his behaviours. There were also some occasions when the Half Brother was noted to have some physical injuries, although none of these appeared to raise professional concerns as to their cause. 2012 3.14 Early in 2012, it was reported to family services that the Mother had smelt of alcohol during a particular week, although at this time she was in the late stages of the pregnancy in respect of the Subject Child. This had been told to the school. Family services made telephone contact with the Mother who said she had not drunk alcohol through her current pregnancy. Family services advised the school to report any further concerns immediately. 3.15 A day after the birth of the Subject Child when the Mother left the ward for a cigarette, the ward staff reported that she returned smelling strongly of alcohol. Contact was made with the community midwife and the health visitor to enquire if there were any concerns about previous parenting that would prevent the Mother being sent home with the Subject Child. Both community health practitioners were new to the family and knew nothing of the background and the response back to the hospital was that they had no concerns within the community. The Subject Child was therefore discharged home. 3.16 The primary birth visit was undertaken although this health visitor knew nothing of the family background. At the visit, the Mother reported having no concerns. The father of the baby was reported by the Mother to live more than 50 miles away and that he had regular contact with his child. A little later, the Subject Child failed to attend her 6 week check up with the GP and it was approximately a week later that the Mother called the ambulance to the home because the Subject Child was lifeless after apparently having fallen asleep with 12 her face pressed up against the back of the settee. The Mother acknowledged that she had been drinking alcohol earlier in the day following an argument and domestic violence incident with the Subject Child’s father who had visited earlier that day. She did not however contact the Police in respect of this. The Subject Child was taken to hospital where she was pronounced dead. 3.17 The Rapid Response process to deal with unexpected child death4 took place and the Mother was interviewed by the Rapid Response team and relevant information collected about the circumstances of the death. A joint Sec 47 child protection investigation began and this eventually led to an Initial Child Protection Conference being held when there was a unanimous decision to make the Half Brother subject to a Child Protection Plan under the category of Neglect. By this time, he was still living elsewhere under a voluntary care arrangement which had been instigated immediately following the death of the Subject Child. _________________________________________________________________________________ Analysis 4. The Identification of Risk Factors 4.1 Throughout the 6 years that this SCR covers, there were a range of risk factors in relation to the care and safety of the children which were identified by professionals at different times, although the level of concern associated with the risk was reflected in the responses which were made to address them. 4.2 Overall there were fourteen occasions when the Police were called to the home to respond to domestic abuse instances or of the Mother being intoxicated. Many of these were passed to family services and in total over the 6 year period there were eighteen referrals or expressions of concern made known to family services. These clearly represented formal identifications of risk factors although their frequency and the concerns behind the particular incidents tended to change over time, for example with regular early incidents of domestic abuse, but with concerns about the Mother’s alcohol misuse assuming prominence as the Half Brother grew older. 4.3 It was good practice that the maternity services identified, based on the number of worrying factors from the Mother’s background, and her circumstances at that time of being homeless, that her first pregnancy constituted a risk factor. The resultant referral to family services led to the appropriate action of an Initial Assessment being undertaken prior to the birth of the child. It was similarly good practice when the health visitor made a referral to the local Children’s Centre in 2008 in recognition that the Mother may be socially isolated 4 The responsibilities of a Rapid Response Team are to make enquiries into and evaluate the reasons for and circumstances of the death as well as to collect relevant information and to provide support to the bereaved family – summary from Para 7.50 Working Together to safeguard Children – DSF – March 2010 13 and that she was in need of support as a parent (the Half Brother was approximately 20 months old at this time). Both of these examples represented risk factors being recognised at early stages so as some support could be provided prior to difficulties escalating. Certainly it appeared as though the Children’s Centre, who became involved following the risks being identified, provided some effective and consistent support for the Mother in her early care of the Half Brother. 4.4 It was significant that later on, the Children’s Centre, the Nursery School and the Primary School did not individually identify any risk factors, despite them having the greatest day to day contact with the family during the time period of the SCR. In fact it was not until early 2012 that the school formally expressed some concern and identified the Mother’s possible alcohol misuse as a risk factor, and informed family services. Therefore, whilst there were numerous earlier concerns about domestic abuse and of the Mother’s alcohol misuse for much of this time, little of it was evident by any presenting behaviours or incidents witnessed by the Children’s Centre and schools. With the benefit of hindsight, some of the behaviour difficulties presented by the Half Brother were likely to have been linked with these family experiences. The Mother presented as being a caring mother to the Children’s Centre and the schools, and showed evidence of her commitment to the Half Brother, for example by her attendances at play sessions and then by her attendance at meetings at the Nursery or the School to improve the Half Brother’s education and behaviour. Additionally it was quite a long journey from her home to the Children’s Centre although she was committed to this sufficiently to attend regularly. Although the GP practice recognised risk factors in relation to the alcohol misuse, it was noted that whenever she was actually seen at the GP surgery, the Mother presented well and did not appear to be suffering from the effects of alcohol and so it was not immediately evident that she had any current alcohol related problems. 4.5 The risks which were identified to the Police and family services were either in relation to domestic abuse or alcohol misuse. In the majority of the domestic abuse incidents, the Police recognised the risk factors and consequently notified family services of these. Although the initial incidents related to the Mother’s partner at the time, once he left, the incidents related to the wider family. Although during these incidents, the Half Brother was also usually present and alcohol was a feature of the incident, these were not so readily identified as risk factors and an onward referral accordingly made to family services. In this way, because the incidents featured the extended family rather than the immediate family relationships, then it might have been that the risks to the Half Brother were not viewed as so clear cut. His presence however on these occasions should have meant that the risks were just as significant. The Police IMR does not give this as a reason for the lack of identification of risk to the child on these occasions, but more related to workload and likely human error. The IMR nevertheless is clear that under arrangements now, appropriate referrals to family services would be made even if the incident related to the extended family only. 4.6 There were five domestic abuse incidents reported during the Half Brother’s first year, although this only led to one Initial Assessment being undertaken by family services during 14 that time, which decided that there was no need for further action. What was missing here in terms of identifying the overall risk factors was the need to view these incidents more holistically in that a pattern of recurring domestic abuse was likely to provide greater risk to a child than a one-off event. 4.7 More generally, family services’ response to the domestic abuse incidents as well as those related to expressions of concern about maternal alcohol misuse, were incident focussed and failed to create a coherent pattern of family life and how its chaotic nature was likely to generate increasing risks to the Half Brother and to the Subject Child if the concerns went unaddressed. 4.8 The health visitor, GP and the hospital were aware of some of the particular incidents and concerns in relation to alcohol misuse. Certainly the Mother’s history of alcohol misuse was known and then links made with her hospital admissions which were thought to reflect a return to alcohol use by the mother. There were numerous examples of the Mother down playing her alcohol use or denying it, even in the face of evidence to the contrary, and this no doubt delayed recognition by the professionals that her behaviours were potentially presenting accumulated risk factors to the children. 4.9 The Mother was very well known to the Hospital as she had been a frequent attender there from the age of 16 years. Her difficult background as a child and young person was well known, as well as her recurring problem with alcohol as she got older and then became a parent. When there was direct concern for the care of the Half Brother from the Mother’s alcohol misuse, appropriate referrals were made, but these did not happen on every occasion of her needing hospital treatment for her medical problems. One difficulty was actually making the link between the flare up of her chronic condition with excessive alcohol use. On occasions there was evidence of a clear link, but the Mother would sometimes say that the episode was caused by eating spicy food, and in fact in her contribution to the SCR, stated that this was often the reason for her condition needing hospital attention. Specific concerns may not therefore have been obvious on each occasion in the hospital, but it might have been the case that the fact that she was so well known, led to some complacency about her situation in that she was not presenting with anything differently. Taking a more inquisitive approach to understanding the degree to which alcohol was involved could have helped confirm or otherwise the direct cause of the recurrence of her condition and challenged the Mother accordingly about the dangers of continued alcohol use. It was not apparent that the Hospital staff had a sufficient understanding of the social consequences and the effect that alcohol abuse would have in everyday living, particularly in respect of the impact on the children. 4.10 The health visitor alongside the nursery nurse provided support and advice to the Mother and were able to monitor the development of the Half Brother. It was clear that there were some positive views held about the Mother’s parenting and they, like other professionals, were often reassured by the Mother that she was not drinking. However as early as May 2007, the health visitor told the duty social worker of family services that whilst the Half Brother was thriving, she was concerned about the vulnerability of the Mother and the 15 impact of her drinking upon his care. Also in June 2008 the health visitor discussed the dangers of drinking with the Mother in relation to her own health and parenting, and by the summer of 2009, with the Half Brother approaching 3 years old, the health visitor expressed concern to family services about their decision not to allocate a social worker to the case despite the Mother’s continued drinking at that time, and in the health visitor’s view, the Mother’s corresponding inability to be protective towards the Half Brother. 4.11 Whilst the GP practice was similarly often reassured by the Mother on several occasions that she had stopped or was managing her alcohol intake, the GP practice generally recognised the risk factors and spoke to the Mother about them, although these were primarily related to the Mother’s own health which was being seriously affected by her apparent continued alcohol use. A referral to the counsellor within the GP Practice was evidence of their concerns. The link with her parenting ability and the associated risks to the Half Brother was not as evident although it was when he was approximately 2 ½ years old that the GP made a referral to family services in this respect. By this time it was apparent that the GP practice recognised that the Mother’s behaviours were not changing and required the input of family services to address the needs of the child. In effect however the Mother reassured the social worker that she had stopped drinking and once again no further action was taken. 4.12 Therefore both the health visiting service and the GP surgery recognised the accumulation of concerns in relation to the Mother’s alcohol misuse which in turn heightened the risk factors and then led to those concerns being expressed to family services. The Police similarly identified this when at the time of the incident in mid-2011 the Mother left the Half Brother alone in a taxi and then claimed he was missing; the assessing officer reported that the Mother “does not appear to be learning from her mistakes”. In effect however, the Police response could only warn the Mother or continue to advise her about the need to get help from other support agencies, and on occasions she would reassure them that she would do so. Overall it was the family services who were in the best position to act upon accumulating concerns, and the Police recognised this by advising family services on this occasion to “take a more robust approach” with the Mother. This could have been done by providing longer term and more focussed interventions, with the support and involvement of the health practitioners, although in reality, family services’ involvement did not progress pass the assessment stage. 4.13 What was apparent with this family was that if they were not seen in the middle of a crisis such as a domestic abuse incident or when the Mother was intoxicated and unable to care for her child, then it was difficult to identify risk factors and to respond in effective ways. It was clear that the Mother could be plausible and reassuring to professionals in normal everyday situations and could reassure them that any crisis was over and would not recur. One example of this was when following a particularly worrying occasion when the Mother had been drinking all day and was arrested by the Police, the eventual Core Assessment by family services rightly identified the incident as high risk but that the chance of its recurrence was low, as she had convinced the worker that a family tragedy had led to her excessive alcohol intake. However, this was too readily seen as an acceptable reason for the Mother’s behaviour. Whilst reaction to grief can take many forms, the Mother’s high 16 level of alcohol use and intoxication at this time led to her being unable to care for her child. This should not have been minimised or explained away as a one-off occurrence as it reflected the way in which the Mother responded to stressful circumstances. 4.14 This particular incident was a missed opportunity for more robust interventions by family services particularly as the incident itself led to the Police placing the Half Brother in Police Protection. The Police’s response was appropriate to a very worrying situation and reflected their recognition of a high risk situation, which FAMILY SERVICES could then have built on by providing social work input to enable the Mother to recognise the chronicity of events and why professionals were concerned about the accumulation of risks to the Half Brother. In effect the Core Assessment and case closure which followed, and the acceptance of the Mother’s explanation for her behaviour, meant that the risk factors went unaddressed. This was evidenced by two further episodes of the Mother’s alcohol misuse reported to family services via the Police occurring just three months since the completion of the assessment. On both occasions she had the care of the Half Brother. 4.15 There was potentially another occasion when Police Protection could have been used and this took place just a month earlier in late 2010 when the Mother was found to be drunk in charge of the Half Brother and of concern at this time was the description of the Half Brother as being unwell and as expressionless and distressed. The police officer however considered that the Half Brother was not in any immediate danger or likely to suffer significant harm. The Police IMR considered that on this particular occasion there was another woman on the premises who was also intoxicated and that she may have been the focus of Police activity, as she was arrested regarding an unrelated offence. Even if the Police did not take immediate protective action in respect of the Half Brother, potentially family services could have been asked to make an urgent visit to the home to assess the risk to the child although it was not until the following day before the incident was reported to family services. 4.16 Prior to the death of the Subject Child, only one Strategy Meeting was held in response to incidents of concern, when in reality the continuation of worrying incidents of the Mother’s alcohol misuse placing the Half Brother at risk, as occurred during a concentrated time between late 2010 and Spring of 2011, should have led to a further Strategy Meeting at that time and a Sec. 47 child protection investigation being undertaken. In fact during the Half Brother’s first year (up to the summer of 2007) there were sufficient incidents of domestic abuse, some linked to alcohol misuse, to warrant Sec 47 child protection enquiries being conducted. This was an early example of the continuing tendency of family services to separately focus on single incidents and fail to recognise when a pattern of risk factors required them to raise their response to the child protection threshold. 4.17 The pregnancy and the eventual birth of the Subject Child was in itself a risk factor and this vulnerability should have been recognised and the family circumstances re-assessed as a result. Although there was a Child in Need meeting in September 2011, and it was known at that time that the Mother was pregnant, this was not considered as an additional risk factor, with the focus at that time still on the Half Brother at which time the concerns were 17 not high. Local procedures state that where there is “knowledge of parental risk factors including substance misuse, mental illness, domestic violence” that a referral to family services should be “considered” and that all pre-birth referrals should be subject to a Common Assessment Framework.5 However there was no record of any agency considering a pre-birth assessment referral to family services at this time. Whether the fact that family services were undertaking a Core Assessment at this time in relation to earlier concerns led to a referral not being taken, is not known, but even though the Mother informed the social worker that she was pregnant, this was still not given any attention within the assessment. There was also an opportunity to arrange for a follow on CIN meeting for the latter period of the pregnancy to reassess the situation at that time although again this option was not taken up. The reasons for this would appear to be that the main focus remained on the Half Brother and there was no high level of concern about the Mother’s alcohol use from a multi-agency perspective, believing that she had ceased drinking, which then led to family services closing the case. 4.18 When the school passed on concerns to family services of the Mother smelling of alcohol, this was just a month before the Subject Child was born, and considering the background, needed to have elicited a response from family services, and in fact whilst contact was made with the midwife the family services IMR stated that “it was not followed through”. In fact on the last occasion when family services were involved, they had closed the case because they had accepted that the Mother was not drinking because of her pregnancy – from the school’s information, this was however apparently not the case. According to family services, information was gained from the Mother at this time who said that after contact with the midwife the previous day, all was well – (there was no corresponding record of midwifery contact at this time). The Mother said that she had not drunk alcohol during this pregnancy and that she had regular blood tests and transfusions due to her chronic medical condition, although this was not checked and no contact made with the midwife. Additionally the Mother said that the Half Brother’s behaviour was deteriorating. It was therefore of concern that the decision was made by a senior social worker that the circumstances did not meet their thresholds for intervention and the school were asked to monitor. 5. The Appropriateness and Quality of Assessment Practice 5.1 Overall, during the 6 year period of involvement covered by this SCR, there were nine occasions when formal assessments were undertaken by family services and yet there was no continuation of intervention in terms of a social worker being allocated to the case as a result of any of the assessments. Whilst the assessments were fairly spread out, with none occurring during 2008, in contrast there were two Initial and two Core Assessments over an eight month period during 2011. Overall, to have so many assessments in itself should suggest that there were continuing concerns which were not being addressed. It was not apparent that sufficient learning from one assessment was fully considered in the context of the next assessment in order to give a more informed understanding of the pattern of family life and of any resultant or build-up of risks to the Half Brother and then to the Subject Child. 5 Chapter 2.29 Pre Birth Multi Agency Procedures and Practice Guidance – The area LSCB – July 2011 18 5.2 On occasions the assessments gained useful historical information and occasionally the assessments identified the vulnerabilities of the Mother in terms of her alcohol misuse and of the impact on the Half Brother. However, for example, despite this being highlighted at the time of the second assessment in July 2007, the Initial Assessment still led to “no further action”. Some of the assessments as individual pieces of work appropriately identified the risks and need for future support for the Mother, but none of them ultimately led to any coordinated or focussed interventions to address potential safeguarding concerns for the Half Brother. The fact that the Half Brother needed an Individual Education Plan during his pre-school experience meant that he clearly had some behavioural and learning issues identified at an early stage which was then taken through into his Primary School. There should have been some links made between these issues and some of the incidents and concerns which led to assessment activity. In this way there was an insufficient connection between the incidents of concern and the Mother’s alcohol misuse, with some of the Half Brother’s presenting behaviours and to what extent these may have reflected any impact upon him in respect of his developmental progress. 5.3 In general some of the shortcomings of the assessment practice by family services were that information given by the Mother was generally accepted at face value without any objective information being sought to support or challenge what the Mother had said. In this way it was clear that she was quite plausible in her explanations to social workers. The social workers no doubt encountered difficulty in establishing with the Mother the existence or extent of any alcohol misuse, but her denial of any such problem was often accepted without much question or challenge. This issue warranted greater exploration within the relevant assessments. “On an emotional level, for those who have experienced long histories of using substances or where the use has provided significant emotional support, facing the possibility of examining their pattern of substance misuse can be particularly stressful”6. It was clearly therefore going to require a level of persistence and a greater opportunity to build a trusting relationship with the Mother before there was likely to be any acknowledgement of any alcohol problem by her. The short term assessment activities were not however the means by which this could be realistically achieved. 5.4 None of the assessments led to any identification that the child protection threshold had been reached although if incidents and concerns had been linked and a focus maintained on the potential impact upon the Half Brother of this lifestyle, then in reality it could be argued that such a threshold had been reached. This was particularly so at the end of 2009 after a number of reported incidents and concerns over the previous eight months, and again in the Spring of 2011 after a similar pattern of concerns re alcohol misuse over the preceding five months. 5.5 Another shortcoming of the assessments was the failure to clearly identify to what extent the Half Brother’s care had been shared with members of the extended family or friends. At the time of the death of the Subject Child, it was apparent that much of the care of the Half Brother, and then the Subject Child, had been shared with another couple who were family friends. The details of this family should have been collected and any information in respect 6 Parental Substance Misuse and Child Welfare - Kroll, B and Taylor, A – Jessica Kingsley 2003 19 of them sought at earlier stages. Similarly the extended family were often referred to as providing support or care for the Half Brother and yet their details were never clarified or information sought in sufficient detail in respect of them. This was particularly important as two members of the extended family had offences recorded against them which could have posed risk to a child in their care. Additionally, on some occasions the extended family were the source of tension and conflict. In this way the paucity of the knowledge of extended family compromised the quality of any assessment undertaken. 5.6 In essence therefore, whilst the family services assessments occasionally collected useful information and were able to identify risks to the Half Brother, they collectively had little impact on the family lifestyle or in getting the Mother to change her behaviours and to consider the impact on her child care abilities. 5.7 The ante natal and post natal assessments in respect of the Half Brother were however thoroughly undertaken by the health visitors, and information was gained upon which to base later interventions by the health visitor and nursery nurse, who was involved for a three month period during 2008. Assessments and follow up interventions tended however to be based on information given by the mother and she did not generally divulge information that may have been seen as concerning in terms of her parenting and for example only spoke of her wider family when they had been supportive. Whilst some useful work was undertaken by the nursery nurse to support the Mother with parenting issues associated with diet (presumably of the Half Brother) and behaviour, there was no record of how it was assessed that the Mother needed this type of support. 5.8 The Half Brother’s developmental review was carried out when he was just over 3 years old with the outcome that his development was age appropriate and nothing of concern was noted. Once again however this was based on the Mother reporting this. 5.9 It was when the Half Brother was just over 4 years old that the school informed the GP of some of the Half Brother’s behavioural difficulties and requested an assessment. After first seeing the Mother and the Half Brother at the surgery, the GP made a referral to the community paediatric service. Unfortunately this referral, according to the GP IMR “went astray” and was not resurrected for another four months, when the referral was re-made. It then took a further four months for the Half Brother to be seen for a paediatric assessment. These delays reflected inefficient practice without any real understanding of why the delays occurred. Also as the time between the referral and the appointment was eight months, there was likely to be a change in the presenting concerns in respect of the Half Brother. In event the assessment appointment did not generate any new initiatives, with the Mother claiming that there were no problems, and no further appointments being offered. Whilst the original referral had referred to the Mother’s health problems, there was no specific mention of the Mother’s alcohol issues, or any instability in the family, meaning that unless the Mother mentioned these, any assessment was likely to be compromised by the lack of this knowledge. It would however have been reasonable to expect the assessment to have explored the family background by asking pertinent questions of any past or recent problems in an attempt to understand the behavioural problems that the Half Brother was said to be presenting. In effect the assessment did not add anything to the professional 20 understanding of the Half Brother’s circumstances or in terms of his behaviours or to what extent they may have been linked to the Mother’s possible drinking and the overall family lifestyle. The assessment in fact took place just over a week after the incident in which the Mother had left the Half Brother in the taxi so it was most unfortunate that the assessment was not able to consider this context. Overall, this reflected a missed opportunity to gain a greater understanding of the family circumstances and of the potential impact upon the Half Brother. 5.10 In terms of assessments undertaken by the Police in their contact with the family, the respective IMR identified that there was a general improvement in the quality of the Police assessments from April 2011 based on the use of staff expertise in the Multi-Agency Referral Unit (MARU) which had been established from that time. These latter assessments were therefore more multi-agency based and had the potential for generating appropriate actions by the most relevant agency as a result. As part of many of the Police contacts, relevant assessments, especially prior to 2011, were hampered by the Mother’s lack of co-operation and corresponding limited information available to share with other agencies. 6. Decision Making, Plans and Interventions – Identification of Missed Opportunities 6.1 Whilst the Hospital had regular contact with the Mother in relation to admissions and attendances at the A&E Dept., particularly in the earlier periods of time, there was just one occasion when a referral was made to family services as a result. This was in the summer of 2009 when the Mother had a laceration to her hand following a fight in the home, and when it was identified by the doctor that the Half Brother was present; an immediate referral was made to family services. This was good practice by the Hospital. 6.2 The Police were unaware of the incident and it would have been useful for either the hospital or family services to have informed them as they could have assisted with enquiries about what actually transpired during the incident – potentially there were criminal acts involved. At the Practitioner Workshop, there was disagreement about whether it was expected practice or appropriate for the Hospital to have informed the Police of this incident, with the Police view that they should have been informed, whilst the Hospital view was that to report every injury which they see at A&E that might have had some criminal act involved, was unworkable in terms of the numbers that it would represent. In this instance the Mother was not claiming that she had been assaulted and it is not clear what difference, if any, Police involvement at this time would have, as it would presumably have been in respect of the two men involved in the fight. 6.3 However, whilst the referral to family services was entirely appropriate, in effect their response was slow and out of timescale in respect of the Initial Assessment which followed and used the opportunity to meet with the Mother and to observe the half Brother in his home circumstances and no concerns were noted about the parent/child interaction. The social worker accepted from the Mother that the Half Brother had been asleep during the altercation and that she had stopped drinking since then. Contact was made with the health visitor who said that she was not concerned about the day to day care of the Half Brother but nevertheless remained concerned about the Mother’s vulnerability and her use of alcohol. No action was taken by the social worker to establish the names of the other 21 people involved in the incident or checks made in respect of them. Police involvement would have helped in this respect. In summary, regarding this incident, whilst the Hospital had made a prompt referral, the delay and limited response by family services meant that the opportunity had been lost to respond effectively to this worrying incident and in particular to put them into the context of the previous incidents of concerns that had been raised. 6.4 For other hospital attendances by the Mother, generally these were responded to as medical problems, which whilst understandable in the context of the role of the Hospital, generally they accepted at face value that the Mother had now ceased drinking alcohol and therefore did not address any associated social problems by onward referral to other agencies. Similarly, potential risks were not identified in respect of the care of the Half Brother. Whilst it could not have been said with complete confidence that alcohol misuse was the cause of every hospital admission for the Mother’s chronic condition, these could have been explored more robustly by the hospital. This could also have been said of the consultation that the Mother had with the specialist in substance misuse, in that the background evidence of alcohol misuse should have led to greater challenge that it had now ceased. 6.5 To some extent, decision making based on background knowledge was compromised with the services provided in the Hospital, by the fact that the Mother had six volumes of medical notes, and most of the relevant risk factors were contained in volume two, when generally only the final volume was accessed to aid decision making. 6.6 With regard to the domestic abuse incidents, the lack of engagement by the Mother with the Police meant that this had an impact on decision making in respect of her as a victim. Despite some repeat episodes, her refusal to cooperate with attending police officers to take action against the perpetrators meant that she was not able to be offered any protection via the prosecution of offenders. In the Mother’s contribution to this SCR and to the Rapid Response team immediately following the Subject Child’s death, she spoke of a period of domestic abuse from the Subject Child’s father following the child’s birth and during the pregnancy, but more particularly on the day that the Subject Child died, which she claimed led her to consume alcohol. Overall the Mother said that she did not feel able to report any concerns to the Police or any other agency of any specific incident in relation to the Subject Child’s father. In this way the Mother again did not receive any service to help protect her or the children. She also described that when asked by the midwife about domestic abuse at this time that she replied that there was none. 6.7 The decision to provide Police Protection to the Half Brother at the time of the Mother being found drunk in charge of him in early 2011 was a sound decision and this intervention at the time showed relevant concern for the care and safety of the Half Brother. A strategy Meeting which was then held and there was a quick response to this referral and actions taken to ensure that the Mother and the Half Brother were seen separately and together in order to inform the assessment. However, the completed Core Assessment did not generate any further intervention when a different approach by family services could have been to provide a more in-depth intervention to consider her parenting capacity, and to address the 22 reasons for the Half Brother’s behaviour difficulties which she acknowledged at this time were of concern to her 6.8 In other respects, decision making following incidents or concerns reported to family services either generated a letter being sent to offer support, and then more regularly to either Initial or Core Assessments being undertaken. The lack of urgency attached to family services’ response to the referral from the Hospital about the Mother cutting her hand in 2011 in an altercation with knives in her home, was concerning and in fact the Mother was not contacted until five weeks after the incident. By this time the crisis had passed and the delay in family services making contact would no doubt have given the Mother the view that the incident was not considered as being serious by family services. In general where a decision was reached for family services to undertake a single agency response to a particular concern, there was no process for this to be reported back to any agency, particularly the Police who may have been involved in the decision in the first place. In this way there was no monitoring if intended actions were completed. 6.9 The only time when a pattern of interventions was decided upon following a family services assessment was when a CIN process was set up in the summer of 2011, with subsequent CIN meetings being held in July and September. The Core Assessment at this time had concluded that the Mother had ceased drinking but that she would need parenting support and that this would be accessed through the School and Children’s Centre. Whilst the assessment had identified that the Mother was again pregnant, no specific interventions or follow up appeared to be have been decided upon as a result. This should have been identified as a new risk factor which would need monitoring and more robust interventions with the Mother to support her at a time when alcohol use could have significant impact on her unborn child. By the time that the social worker shared the outcome of the Core Assessment with the Mother, a further anonymous referral had been received about her drinking, but her explanation that she had been drinking lemonade rather than wine was again accepted and so no further interventions were arranged and the case was closed. Although the case was held with the family services intake team, the need for a Team Around the Child meeting was identified to take place in November 2011, although there was no record of this happening. 6.10 In terms of health visiting practice, there were follow up contacts made with either the Mother or family services after notifications of hospital admissions and domestic abuse incidents. The health visitor made her concerns known to the Mother about the impact of alcohol misuse and domestic abuse on the care of her child, although generally the Mother denied or explained away such incidents as not reflecting concerns. The health visitor nevertheless was sufficiently experienced to recognise that the problems existed despite the maternal explanations, and carried out announced and unannounced visits to the home but did not ever witness the Mother’s drinking. To some extent this must have taken away the strength by which the Mother could be challenged. The health visitor nevertheless appropriately made her concerns known to family services. 6.11 There was an incident when the Half Brother had a physical injury to his nose, said to be the result of a fall against the wooden leg of a settee. The GP referred the matter to the hospital 23 and although the referral letter identified the child as previously being at risk, it was not suggestive that the cause of the injury was in itself suspicious. However in the circumstances it would have been prudent for the attending doctor in the hospital to have checked with the Safeguarding Children Team to ascertain any other relevant information. 6.12 Although the family services IMR refers to another occasion when the Half Brother had a bruise on his head, this is not mentioned in the records of other agencies so it is unclear when this occurred and where the information came from. What is concerning however is that the Half Brother apparently gave two versions of how he got the injury, one being that his mother hit him, so it would have required some form of follow up. However, there was no further information in respect of this and there is no reference to this in any other IMR. 6.13 In terms of the pregnancy and birth of the Subject Child, as explained previously, there were no interventions established to work with the Mother at this time to address any potential issues of risk. When the Mother presented with the pregnancy in respect of the Subject Child, the hospital records held scant information about the father and when she was questioned in a routine fashion about domestic abuse, she maintained that there was none. 6.14 As the pregnancy continued, the Hospital addressed medical issues in respect of the Mother, supported by information and concerns being presented by the GP at the time, but did not make specific links with past or recent alcohol misuse to inform any assessment of risks to the unborn child. Again there appeared to be a view at the Hospital that the Mother had ceased drinking. 6.15 Following the birth of the Subject Child, when the Mother smelt of alcohol on the ward, it was appropriate that the ward to sought advice from the Named Midwife. It was not however apparent that the Hospital medical records were accessed as these would surely have provided ample information to suggest that there were potential risk factors here, and lead to a referral to family services. Unfortunately the community midwife was new and knew nothing of the background and so no intervention followed. This was a missed opportunity at the beginning of the Mother’s care of the Subject Child to have addressed alcohol misuse in connection with the care of a new born baby and of all the concomitant risks that this could generate. Engagement with parents and other adult figures 6.16 Because of the amount of involvement that the Mother’s extended family and friends had in her life and their occasional care of the Half-Brother, then it should have been important to have gained information about them. As already stated, the family services assessments failed to do this in any consistent way, and often information about the details of family members was confusing. When concerns were expressed to family services by Probation in late 2011 about a member of the extended family, family service’s response was to ask the Mother about this over the telephone and accepted her response that there was no unsupervised contact with this individual, without any further checks being taken. Whilst this relative’s previous offence did not automatically place a child at risk in his presence, Probation were clearly sufficiently concerned to make the information known to family services. Contact by family services with the Half-Brother’s father would have been 24 appropriate in the circumstances in order to better understand the circumstances of the contact arrangements and to more clearly identify whether there were in fact any risks to the Half Brother, attached to these arrangements. Whilst family services did not make direct contact, Probation may well have further emphasised this concern to the relevant member of the extended family. 6.17 It was not until after the Subject Child’s death that there was any assessment of the involvement of the particular family friends who periodically cared for the Half Brother. At that time they were considered to be appropriate carers for the Half Brother which was sanctioned by family services. 6.18 The Police had background knowledge of some of the other adults in the extended family and in fact needed to deal with them in some of the incidents that took place, although there was little reference to the sharing of information in respect of them with other agencies. 6.19 The school experienced similar confusion in that when on one occasion the Half Brother mentioned his “Dad” at home, this was the only time he had made such a reference and the school had always understood that the Mother was a single parent. Overall the school did not have an accurate understanding of any of the extended family and were incorrect in considering that a family friend was the Mother’s step-father. 6.20 Overall there was a consistent lack of knowledge as well as a degree of confusion about members of the extended family and of friends who provided support or generated conflict within the family. In this way, no single agency had a clear understanding of the status or role of other adults, as none were specifically engaged by any professional to gain a greater understanding of their role and of any potential risks that they may have generated. It is not recorded, apart from the Police contact with the male in the hone at times of domestic abuse incidents, that any professional had direct contact with the fathers of the Half Brother or the Subject Child, although it was not apparent that they were resident in the home at any time. However they were occasionally visitors and there was contact between the Half Brother and his father and of the Subject Child’s father, so it was prudent for practitioners to have strived to gain information in respect of them. 7. The Implementation of Individual and Multi Agency Policies and Procedures 7.1 Whilst policies and procedures were generally followed by the respective agencies, for example with regard to domestic abuse notifications, it is apparent that no agencies made use of any definitive guidance or procedure for working with parental alcohol misuse. In this way there was no agreed understanding about what actually constituted alcohol misuse and consequently on the actual impact on the children involved. Whilst the concerns about parenting abilities were no doubt fairly obvious to practitioners in this case who directly witnessed the mother intoxicated, it was much less clear how risks could be assessed when there was no direct experience of alcohol misuse. Whilst it could be identified that “Misuse is taken to mean that the level of dependency or consumption is significant enough to 25 impact on family life and potentially the care of children”7, there was no policy or guidance used to support how practitioners could work to such a definition. The “Framework for Assessment” set of materials does however provide a questionnaire that could have been used to help understand the part that alcohol played in the Mother’s life and of the impact on parenting. 7.2 Some research undertaken with social workers working with parental alcohol abuse, identified how difficult it was to assess the impact on parenting capacity, especially when the carers are binge drinkers; “They recognised that carers could provide good enough parenting in between periods of binge drinking and found it all too easy to minimise the impact of this binge drinking on the children in the family”8. It could be argued that this was the sort of challenge which the practitioners who worked with this Mother faced, in that when not drinking she appeared to present as a capable and caring mother. 7.3 The policy context is addressed within a very recent report by the Children’s Commissioner9 which expresses the view that “The current family-focussed agenda does not address parental alcohol misuse at a strategic level. There is a lack of an alcohol specific focus. Similarly there is less recognition, and response, to alcohol abuse compared to drug misuse”. Unlike drug use, alcohol use is not illegal and this might go some way to explain why some studies have highlighted that “children living with parental alcohol misuse tend to come to the attention of care services much later than do those living with parental drug misuse”10. Similarly there is research evidence that children who experience parental drug use are much more likely to be subject to care proceedings or made subject to child protection plans than those children who live with parental alcohol misuse11. 8. Communication and Information sharing Re Domestic Abuse 8.1 Generally the Police appropriately shared information with family services and the health visitor about domestic abuse incidents, although as mentioned previously, there were some inconsistencies in this respect. It was also apparent that the GP surgery was given information about some incidents although not all, as they only seemed to hold information in respect of two incidents in early 2007. Their knowledge may well have come via the health visitor, but generally it was not clear that community health practitioners received all information about the domestic abuse incidents where the Half Brother was present. 7 “Parental Substance Misuse and Implications for Children” in “Child Neglect – Practice issues for Health and Social Care” – Taylor, J and Daniel, B – 2005 – Jessica Kingsley 8 “Child Neglect – Identification and Assessment” – Jan Howarth – 2007 – Palgrave Macmillan 9 “Silent Voices – Supporting children and young people affected by parental alcohol abuse” – The Children’s Commissioner – Adamson, J and Templeton, L – September 2012. 10 “Silent Voices – Supporting children and young people affected by parental alcohol abuse” – The Children’s Commissioner – Adamson, J and Templeton, L – September 2012. 11 “Parental substance misuse and child care work – findings from the first stage of a study of 100 families” – Child and Family Social Work 11:325-335 2006. 26 8.2 On the occasion in early 2007 when the Mother’s partner at that time was arrested of an assault committed against the Mother, it appeared as though there was no onward referral to the domestic violence advocate although the Police IMR identifies that such a referral would be much more likely under the current arrangements (MARU) in view of the co-location of advocacy workers. Other potential referrals to advocacy for the Mother were presumably not made because she would not engage with the Police in trying to resolve the problems she was encountering in an abusive relationship. 8.3 Generally therefore, there was key communication on most occasions between the Police and family services re domestic abuse concerns although the extent to which professionals from other agencies were informed, is unclear. Also the assessments which family services undertook at the time when there were domestic abuse concerns ,(Summer 2007 and Summer 2009) were primarily focussed on maternal alcohol misuse rather than domestic abuse, although it was agreed between the health visitor and social worker on the latter occasion that the Nursery would be a protective factor for the Half Brother. It was not apparent however that they were informed of the earlier domestic abuse incident prior to the Half Brother commencing at Nursery. Although it was also usual practice for the Children’s Centre to be notified of domestic abuse incidents, those which occurred in mid-2009 and early 2010 were not in relation to incidents involving the Mother’s partner at the time, which appeared to mean that they were not treated in the same way as intra-familial domestic abuse incidents. As there were no child protection conferences or CIN meetings within the time that domestic abuse was occurring, there were no obvious or formal means by which information could be shared. Re Alcohol Misuse 8.4 Whilst it was apparent that suspicions of alcohol misuse by the Mother was an on-going concern, unlike domestic abuse there was no process by which information would be formally shared between agencies. Because of the generally positive way that the Mother and the Half Brother presented at the Children’s Centre and the Primary School, then parental alcohol misuse was not an identified problem. However, if information had been shared more routinely at times of Initial or Core Assessments, then this could have been redressed. 8.5 The Police response to specific incidents when the Mother was found drunk in charge of the Half Brother were dealt with speedily and family services quickly informed. Generally however the way in which the Mother’s explanations for her behaviour were accepted without robust challenge, meant that her behaviours were not further addressed. In some ways the fact that she had a chronic condition affected by alcohol meant that there was greater likelihood that social workers would accept the Mother’s assertions that she had stopped drinking. For example she talked of how the GP had told her that she would die if she continued drinking, and so this was given as strong reasoning for her not drinking. Also one of the later family services assessments identified that the GP had said that if the Mother did consume any alcohol, that she would be in considerable pain. In this way there was a somewhat naïve belief that the Mother would not therefore drink. 27 8.6 It was apparent from the Practitioner’s Workshop held, that a number of practitioners who worked with the family did not know of the clear links between the Mother’s chronic abdominal condition and past and current alcohol misuse. This was not surprising as the links had never been formally made for those who worked in the Nursery, Primary School or Children’s Centre. To some extent there was an assumption by health practitioners that other non-medical professionals would nevertheless understand the links. 8.7 Whilst the GP knew of the Mother’s numerous hospital attendances, and made the link with continued alcohol use, the Hospital did not necessary make these links and make any external referrals as a result. In truth it would have been difficult to always make a definitive link between each Hospital admission and excessive alcohol use. The Mother in fact often talked of how eating spicy food led her to have flare ups of her condition. As part of the SCR process, clarification was sought from a consultant surgeon who had operated on the Mother, who explained that even if the Mother had completely ceased drinking alcohol, there could still be episodes or flare ups and that in this way “It would not be possible to say that the repeated A&E attendances were evidence of a resumption of alcoholic intake”. 8.8 The Hospital did not apparently always enquire with the Mother whether she had been drinking to cause the flare up of her condition, and so making links to any irresponsibility on her part in terms of her parenting was not made. There was of course other evidence of the Mother’s alcohol use and sometimes she admitted to drinking alcohol to the Hospital and the GP, although this did not lead the Hospital to make any referrals in respect of this. There was however a lack of clarity about the exact level of drinking which was reported on those occasions. For example the Mother’s descriptions of her drinking habits to professionals on three separate occasions, were unclear in terms of detail or of their frequency. If greater attention had been given to collecting the detail of the Mother’s drinking behaviours at that time, it would have improved chances of monitoring this or giving better detail as part of any referral onwards of concern. In fact at an A&E admission in early 2008 when the Mother described a high level of drinking, this was a clear opportunity to refer her to substance misuse services. 8.9 The GP was alert to the concern about alcohol misuse even though the Mother never actually presented as intoxicated at the surgery. However the GP Surgery appropriately made contact with family services and referred concerns at various times. In fact the respective IMR for the Surgery claimed that family services were “contacted repeatedly regarding the Mother’s alcohol problem” and on one occasion in the summer of 2009 the GP expressed the view to the social worker undertaking an assessment at that time that “the Mother needed to know that professionals were concerned about her drinking”. This was at the same time that the health visitor also made her concerns known that the alcohol misuse was not being addressed. The GP’s IMR also states how the GP had become frustrated by the lack of a robust response to alcohol misuse when a significant problem linked to care of the Half Brother had been identified. This situation met the criteria for an escalation of the concerns to a manager within family services, although there was no reason given why the GP surgery did not take this initiative. Alternatively there was the 28 option for the GP to discuss the case with the community consultant paediatrician and raise the concerns further in this way and potentially gain this level of specialist support for their concerns. The respective IMR has identified this as a learning point for the Surgery. 8.10 Although counselling had been offered and provided via the GP surgery, in reality the Mother failed to engage with this service, but when family services were informed of this, it was not considered overall to have been an indicator of the Mother failing to acknowledge or address her problems. Family services on several occasions recommended that the Mother attend a specialist service for substance misuse but left this to her to make contact. It was very unrealistic in the circumstances to expect that the Mother would have the necessary motivation to attend, particularly as her response was often to deny that any problem existed. For this strategy to have been successful, it would have needed much greater support and encouragement from the social worker and/or any other professional. It was apparent that the Mother was very plausible in her explanations of her circumstances to professionals and for example one of the reasons given for the substance misuse consultant not to request any follow up, was because the Mother said she was attending classes in building self-confidence. However, there was no other information in any IMR that such classes were provided or known about. Similarly in January 2012, the Mother reassured the Primary School that she was working with the health visitor on parenting issues. Again there was no evidence that this was in fact taking place. 8.11 Although the alcohol misuse concerns had the potential at an earlier stage to have raised the concerns to the child protection threshold, at least when a CIN process was established, this was an opportunity for the first time to share information and to try to tackle the problems from a multi-agency basis. However, there was no evidence that the CIN process progressed the work in any new way, not helped by the GP being unaware that this process had begun. The CIN meetings did identify that there had been concerns about maternal alcohol misuse and so the School were at least made aware of this as a potential concern 8.12 When the Primary School became directly concerned in early 2012 about the Mother’s alcohol use, they quickly informed family services, but to then leave it to the School to monitor was an insufficient response by family services at this time when a more proactive response was needed. What was particularly concerning was that at this time the Mother was eight months pregnant and the Half Brother’s behaviour was said to be deteriorating. 8.13 In fact there was only a limited link between the alcohol use and the pregnancy with the Subject Child in latter 2011 and early 2012, when in effect, with the benefit of hindsight this should have been a critical time to intervene with the Mother and address any concerns before the birth of the new baby. 8.14 Significantly, there was a change of community midwife at this time which meant that the Mother was not seen until she was seventeen weeks pregnant. Because the midwives do not have access to the hospital records when away from the Hospital, then it was clear that the new midwife, who did not seek out information, did not know of the concerns about alcohol misuse. Therefore the community midwife was reliant on the Mother who 29 outwardly presented with no concerns. It is difficult to understand in the circumstances that with so much information already known to a range of health professionals about the Mother’s background, that none of this became known to the new midwife. Even when the midwife was told of the Mother possibly drinking at the hospital a day after the Subject Child’s birth, this did not elicit a greater enquiry of background information. Instead the Mother’s assertions that there were no difficulties were accepted. 8.15 Although there were attempts made, there was no communication between the midwife and the health visitor about the pregnancy. It was most unfortunate that not only was the midwife new to the family, but the health visitor similarly had not had contact with the family previously and in fact when she did her “new birth” visit, did not even know the Mother’s name as she had been unable to speak to her colleagues before the visit. 8.16 Concerns however should have been raised during the pregnancy and before the direct involvement of the new midwife and health visitor, and the first opportunity to do so was at the CIN meetings in July and September 2011. Although it was reported that the CIN meeting was made aware of the new pregnancy, neither the original health visitor nor the nursery nurse was there to give their background concerns, as the Half Brother was now attending school. Also, his paper record was not handed over to the school nurse until a week after the first CIN meeting. 8.17 The GP was however concerned about the pregnancy and in particular about the Mother’s health and of her potential alcohol use, and so in the referral letter to the hospital, the GP asked for the antenatal clinic to “keep a close eye” on the Mother and referred for hospital based care, adding that the pregnancy was “high risk”. There was reference in the letter made to the Mother’s chronic medical condition and alcohol problems. The letter was not copied to the community midwife but she had access to the GP notes – however the GP did not know that this midwife would not be looking after this new pregnancy and would be replaced by a new midwife. 8.18 Therefore with the failure of the CIN process to identify the need for agencies to work closely during the pregnancy and in the post natal stages, alongside family services’ decision to close the case in October 2011, meant that there was no monitoring of the family circumstances during this period. Also, the unfortunate coincidences that left the Mother with a new midwife and a new health visitor who knew nothing of the family background, meant that the pregnancy went by without the necessary level of assessment, intervention and support that was required at this crucial time. Even when incidents of concern arose such as the school referral about the Mother smelling of alcohol just before the birth, and then the similar concerns of ward staff a day after the Subject Child’s birth, these still did not raise sufficient concerns to warrant purposeful interventions being undertaken by either family services or community health staff. The previous midwife and health visitor, who knew the family, should have provided the family background information to the new midwife and health visitor to enable them to have given an accurate response to the hospital and clarified that there had been previous maternal alcohol misuse problems. It was concerning that the new community midwife and health visitor embarked on providing 30 services to the family in complete naivety about the background. In fact, within the Hospital at this time, there were substantial medical records which could have been accessed prior to discharge, which would have clearly given evidence of past alcohol misuse by the Mother. 8.19 Communication would clearly have been more effective if the shared health recording software (known as Database) was more effective, but there were examples where not all information was held on this and there were historical anomalies. For example during the pregnancy with the Subject Child, the GP practice was using a computer system that did not communicate with Database, although full access to their records was given to the health visiting team. However the fact that there was a new health visitor at this time who did not access the records, and did not have any information that would alert her of the need to do so, meant that although the practice was under the impression that they had alerted the health visitor to this as a high risk pregnancy, in fact this had not happened. The same situation appeared to apply to the new community midwife. Also there were no other means by which routine communication would take place between the GP and the health visitor and community midwife. Furthermore for each unit of service which uses the database, they have to decide who can access their component of the record. Therefore all records were not accessible to all professionals who could access the database, such as the Children’s Centre. Community health services staff were trained in the use of the database as it was rolled out during the spring of 2011, with school nurses embarking on this more than a year later. Inevitably the introduction of new recording systems need time to bed in and for staff to understand how to use them, but there also needs to be recognition that this will always create the potential for poor or limited communication to take place during the interim. Mental Health 8.20 There was no assessment of the Mother’s alcohol use which informed the practitioners who were working with her. There was the one occasion when the Mother had an appointment with a specialist in this field, but because the finding on this occasion was that she drank “intermittently”, and that it was no longer a significant problem, then no link was made to any mental health concerns or whether there were any mental health issues associated with alcohol misuse. This was a missed opportunity to have linked occasions of the Mother misusing alcohol at times of stress or as a source of emotional support with potential mental health problems. There was one occasion when the Mother referred to being depressed following a family tragedy in early 2011, and she claimed that she would follow this up with the GP. In fact she did so and sought bereavement counselling via the GP, although she did not maintain any meaningful contact with the service. 9. The extent to which the views, wishes and feelings of the Children were sought and taken into account 9.1 It was apparent that during some of the assessments carried out by family services, that the Half Brother was separately spoken to, and the Mother recalled in her contribution to this 31 SCR that on two occasions the social worker requested to speak with him and seek his views. This was done in the company of the Mother. On the occasion when he was subject to Police Protection, it was appropriate the he was spoken to alone by the social worker. At least in these instances the Half Brother’s individual needs were considered and this was an important principle, but because of the generally short and focussed nature of the assessments, no rapport could realistically be built up that would enable him to feel free to talk openly about his wishes, feelings and experiences. 9.2 Within Nursery school, Children’s Centre and his Primary School, where he was well known, the Half Brother did not ever mention concerns about his home life, and with these professionals not being aware of much of the on-going concerns about maternal alcohol misuse, there was no apparent reason to engage him over and above that which would happen with any child. When he did however mention his “dad”, the School did ensure that they followed up what this meant. In respect of children’s experiences of parental alcohol misuse it is suggested that “Children draw upon a range of personal and other resources to cope and this changes over time. However coping does not equal resilience…”12 9.3 It may have been such coping strategies which meant that, possibly apart from the behaviour difficulties that the Half Brother presented, he was able to present a positive image in school. For example, “From a child’s point of view, a “don’t talk” rule is imposed and children are encouraged from an early age, not to tell”13. This therefore suggests that there would have to be some recognition of the problem of alcohol abuse by a professional and then for that professional to reach out to a child and gain their confidence to enable them to share their feelings about their home life. At no time in this case however was any practitioner at such a stage, and so there was no consistent or purposeful attempts to engage the Half Brother in this way. In fact on one occasion the social worker noted a good attachment between the Mother and the Half Brother, and no doubt this was the case as there was evidence at various times of them having a positive relationship. However in terms of parental alcohol misuse, an understanding of attachment would have to take other factors into consideration in that there may be an element of role reversal in that a child may take a protective or caring role with their parent. 9.4 Overall there was minimal attention paid to the potential of risk of significant harm to which the Half Brother may have been exposed to or more significantly to the Subject Child. When there were behavioural concerns however in respect of the Half Brother, the school did attend to these and worked with the Mother to address these by putting an Individual Educational Plan together and regularly reviewing this with the Mother. This was good practice. The Half Brother was however placed on an Action Plan at his Nursery School, which was a quite rare and reflected his additional needs. However when he moved from the Nursery School to Primary School, the Half Brother was in fact assessed at the being just above the band for Action Plans. 12 “Silent Voices – Supporting children and young people affected by parental alcohol abuse” – The Children’s Commissioner – Adamson, J and Templeton, L – September 2012. 13 Parental Substance Misuse and Child Welfare - Kroll, B and Taylor, A – Jessica Kingsley 2003 32 9.5 “Parental domestic abuse and alcohol misuse are strongly correlated. Research suggests that with either family problem, it is often the disruptive behaviour and associated worrying for the child that causes the most upset”14. This could have accounted for some of the Half Brother’s presenting difficulties although it needs to be acknowledged that incidents of domestic abuse were not common occurrences from 2009. However, it was apparent that some went unreported during the Mother’s pregnancy with the Subject Child and following her birth. 9.6 During the Mother’s attendances at the Hospital for her chronic medical condition, questions were sometimes asked by staff about the care of the half Brother, although arrangements were not questioned or challenged. Overall however there was no consistency about whether the Half Brother’s situation or needs were asked about, although in these circumstances of a background of a somewhat chaotic family lifestyle, then these enquiries should have been routinely made. 9.7 In terms of Police involvement, generally this took place when the Half Brother was too young to express his wishes and feelings, although at such times referrals were made to family services so as his needs could be addressed. However it could be argued that during later interventions in early 2011, greater opportunity should have been given to the Half Brother to express his views and form the Police to gain a greater understanding of the mother/child relationship. 9.8 Following the death of the Subject Child, the Half Brother was interviewed and his views were sought regarding his placement with carers. This was good practice at a very traumatic time. 9.9 The developmental needs of the Subject Child as an unborn child needed greater attention than she was afforded by professionals, in that with no assessment or understanding of any level of maternal alcohol misuse, then the potential impact upon the unborn child was not addressed. There is considerable research to suggest that alcohol use, depending on its frequency and severity, can have an adverse impact on the health and development of a growing baby. Although it is generally agreed that the more alcohol is consumed, the greater is the impact on the unborn child, “regular moderate use of substances is often less harmful than “bingeing”, as the sudden arrival of the substance in the baby’s system, followed by the subsequent withdrawal, can place him or her at more risk”15. During the pregnancy there were no occasions when the Mother attended hospital with her chronic medical problems, although there were two referrals made to family services, one from a member of the general public and one from the School passing on concerns about the Mother’s possible drinking. The Mother’s medical issues which were consistently addressed during the pregnancy by the Hospital and the GP missed the need to give as much attention to the needs of the unborn baby. 14 “Domestic Abuse experienced by Young People living with Alcohol Problems” – Vellerman, R et al, Child Abuse Review Nov- Dec 2008 15 “Caring for the pregnant drug user” Ford, C and Hepburn, M - 1997 33 10. Racial, Cultural, Linguistic and Religious diversity needs 10.1 The family’s background or culture did not have any bearing on how the family were dealt with, as no enquiry was made in respect of this. None of the assessment activity addressed this issue in any detail or considered it in a way of understanding the Mother’s lifestyle and her approach to parenting. 10.2 The involvement and role of the extended family was not assessed that would have helped to understand the Mother and her children’s experiences and lifestyle. The Half Brother appeared to be cared for by extended family members or friends fairly regularly although whether this was a cultural factor was not at all clear. In respect of alcohol use, it was not clarified to what extent this may have been a feature within the extended family. There could be a stereotypical view from a professional perspective about family alcohol use and the role of the extended family that “ can lead to either the realities of children’s lives being ignored or to assumptions being made about the way in which the extended family will swoop in and save them if need be”16. Overall, in this way the role of alcohol in the family’s culture needed greater understanding by professionals involved with the family, even if it was to identify how this context would make it additionally difficult for the Mother to manage her alcohol use or cease drinking all together. 11. Organisational Factors 11.1 The two services which have identified that workload or organisational issues had a direct impact on the services provided to this family, were those in relation to health visiting and also for the family services social work teams where issues of pressure of workload, training and management support have been highlighted. 11.2 In respect of health visiting, the small team which were linked with the Mother’s surgery saw their caseloads grow with the establishment of new local social housing, which generated a level of social isolation for local families. Additionally, from 2009 there were periods of long term sick and three periods of maternity leave. Overall, this reduction in capacity led to progressive work or targeted work not able to be prioritised or simply being unallocated. Whilst the reorganisation of some health visitor posts gave this Surgery an increase in establishment, the new health visitor had a phased return to work and did not reach full capacity until December 2011. This was a critical time at the closing period of the Mother’s pregnancy with the Subject Child, and as referred to earlier, the newness and lack of background knowledge possessed by this health visitor, meant that the service to the Mother and her new baby was to some extent compromised. 11.3 There were significant organisation issues which impacted on the work of family services alongside mangers identifying the constant stress of managing high numbers of referrals and some criticism locally of thresholds being too high for family services intervention. Alongside a high number of new or inexperienced social workers, there was pressure to 16 Parental Substance Misuse and Child Welfare - Kroll, B and Taylor, A – Jessica Kingsley 2003 34 achieve Initial and Core Assessments within time scales, which meant that Core Assessments were being undertaken within one visit. Whilst it was apparent how the organisational and workload pressures created this scenario, it would not have been possible to have completed a good quality assessment within these circumstances. As with other services, the introduction of the new recording system (from May 2008) generated teething problems with the system felt by practitioners and managers to be unstable, unpredictable and time consuming. An additional difficulty was the need to be simultaneously checking and collating both paper and computer files. 11.4 No doubt these factors had considerable impact on social workers and their managers to undertake effective child care practice, and in these circumstances it could be seen how the failure to link assessment activities and build up a more coherent and clearer picture of the pattern of family functioning, was significantly compromised. Of significance was that workers were not encouraged to undertake chronologies and the pressure was such that once checks were undertaken and a visit made, the pressure was to close the case. There were also tensions on what could be transferred to the long term team, as these cases had to have very clear social work tasks before a transfer could be made. Because each apparent crisis or incident of concern in this family was time limited and the Mother was quick to reassure any social worker that all was now well, then it can be seen how so many assessments were undertaken without any of them leading to more long term purposeful social work intervention. 11.5 By 2008, unqualified social workers were undertaking duty work, and Initial Assessments in respect of Children in Need were being undertaken by them. Alongside a high number of newly qualified staff, it can be seen that no matter how committed and well intentioned the workers, that there was a greater likelihood of risk issues being missed or misinterpreted. 11.6 Pressures were clearly experienced by family services managers and supervisors and so this would inevitably have compromised their ability to provide quality supervision, although they appropriately signed off completed work or assessments. In a less pressurised atmosphere, they may well have been more questioning of some of the quality of assessments, particularly where analysis did not always reflect the facts, and less agreement to move so quickly to deciding “no further action”. 12. Immediate or Long Term Changes 12.1 As stated previously, the MARU arrangements have been implemented recently which will help to improve communication by more day to day face to face discussions between practitioners from Police, family services and Health as well as Probation who are about to join the new initiative. In this way some of the reliance on formal systems such as CIN meetings or CP Conferences for communication to take place, will reduce and should assist with the ability to identify concerns at an early stage. 12.2 Family services has reorganised and implemented a different model of working through the development of a more systemic way of working which is intended to create better quality practice via increased professional autonomy, presumably in a move to emulate the 35 principles proposed by Munro17. Alongside the considerable development of Integrated Assessment Teams, which has included the need to undertake “threshold assessments”, it is anticipated that this can support families with interventions at an early stage. Such a service could have helped to address more effectively the needs of this family, as it was the failure to provide any consistent or purposeful input in the early stages of concerns about the Mother’s alcohol misuse, which meant that safeguarding issues were never fully addressed. Furthermore, changes within family services now ensure that all Initial and Core Assessments are undertaken by qualified social workers. 12.3 There is now a requirement for a CIN meeting to be called within the second week of a Core Assessment being undertaken, and that all relevant agencies to be involved. Certainly if such a process had been previously in place, it would have added significantly to information sharing. Whilst there is also now good practice guidance in respect of composing chronologies, this may need greater emphasis by operational managers to ensure that it is a consistent feature of child care cases where there are accumulated incidents and concerns. 12.4 The IMRs in respect of the Education services, including the involvement of the Children’s Centre and Nursery, and in respect of Community Services re health, have both identified the need for improvements in communication processes. However, whilst Education identify that improvements are needed in communication with outside agencies, Community Health Services identify that changes are needed in improvements between health visiting and community midwives. This has been further explored in the Health Overview Report. 13. The appropriateness of actions following the death of the Subject Child 13.1 Overall, the actions undertaken following the death of the Subject Child were efficient, effective and well-coordinated between the Hospital, Police and family services. The circumstances of the death led to the Half Brother being appropriately safeguarded, with him being placed immediately with family friends, who were provided with financial support to do so. Although this was not a local authority foster placement, this was a family whom the Half Brother knew well, and it was carefully considered as being appropriate to his needs in the circumstances, with contact arrangements being put in place for the Mother. 13.2 The Rapid Response process was undertaken appropriately with a visit made to the maternal grandmother’s home by health and Police personnel, which provided useful contextual information in respect of the circumstances of the death. The Mother had not wanted to return directly to her home after the death. The Police had attended the home address prior to the Rapid Response visit and information regarding the earlier visit had been shared. 13.3 The Strategy Meeting and Sec.47 investigations were undertaken in a timely manner, leading to a CP conference being convened in respect of the Half Brother within the required 15 days. Overall therefore the response to the Subject Child’s death and to the protection of 17 The Munro Review of Child Protection – A Child-Centred System – Eileen Munro – Dept of Education May 2011 36 the Half Brother represented a timely and well-coordinated piece of inter-agency intervention. 14. Summary 14.1 Whilst the background of domestic abuse during the early period of this SCR and the apparent continuation of the Mother’s alcohol misuse throughout much of the period, could be viewed as representing a chaotic lifestyle, in contrast the Mother generally presented well to professionals who had regular contact with her and demonstrated that her attitude to the Half Brother was appropriately caring. In this respect therefore the family did not present as being chaotic to those who were working with her on a day to day basis. The majority of those professionals who attended the practitioner workshop certainly echoed this view. The experience of the Police and family services however tended to reflect a contrasting picture where concerning incidents reflected a propensity for violence in relationships as well as the continuing feature of maternal alcohol misuse. The only occasions when these apparent different experiences of the family would come together would be when the range of assessments by family services would seek and provide information to the professionals working within health and education who had daily contact with the family. Such opportunities however were more focussed on seeking information rather than providing it, and so in this way the day to day services were to some extent compromised by retaining an overly positive view of the family. The only agency that had regular contact with the family and raised formal concerns was the GP practice although they appeared to experience some frustration at what they considered were ineffective responses to their concerns about parenting. 14.2 Whether the tragic death of the Subject Child could have been predicted or prevented by a different form of agency intervention is difficult to assess. If it is argued that the Mother’s alcohol use was a factor in the death, then potentially a more consistent service to addressing any alcohol problems or to challenging her more robustly on relevant occasions, could have had an impact on reducing her later alcohol use. However at no time was any plan put into place to address any potential alcohol problem as its extent and the impact on parenting had never been clarified or fully assessed. There was no step-down process following the CIN meetings or case closure by family services during the period of the pregnancy, and in this way the services tended to disperse at this point. The recent national report by the Children’s Commissioner identifies that in order to be effective in addressing parental alcohol misuse that “the links between universal /specialist services, adult/children and family services and alcohol/drug treatment services are crucial”. However, at no time in this case was there ever a coordinated response to the family’s presenting problems in respect of maternal alcohol misuse. 14.3 Parental alcohol misuse during pregnancy is a well-recognised risk factor, and if there had been a greater focus on this as part of interventions or assessments during the ante natal stages, then this potentially could have made a difference to the eventual outcome. The Mother was able to deny alcohol misuse and was often unchallenged about this. There was an incident when the Mother was intoxicated and the Half Brother had fallen asleep with her 37 on a settee, and whilst he was over 4 years old at the time and did not present the same level of risks as that for a baby, nevertheless this was not robustly challenged at the time in an attempt to get the Mother to learn the lesson that this was an inappropriate and potentially dangerous way to care for a child. 14.4 However, it could not realistically be said that the circumstances of the Subject Child’s death a predictable event. As said previously, without any real understanding by professionals of the extent of any maternal alcohol misuse problems, then such a tragic outcome was not predictable. Better ante-natal assessment prior to the Subject Child’s birth should however have identified it as a risk factor. The fact that the health visitor and midwife were new to the family for the period of time at the end of the pregnancy was undoubtedly a factor in this and it was very concerning that they had no background information to support their initial work with the Mother and her new baby. 14.5 The missed opportunities in this case for more purposeful interventions also reflected how valuable resources were underused and to some extent wasteful. The paediatric assessment of the Half Brother, the consultation with the substance misuse specialist and the limited involvement of the counsellor attached to the GP surgery, all reflected appropriate interventions at the time but which ultimately failed to add to any understanding of the maternal alcohol abuse or of the impact on the Half Brother or Subject Child at that time. 14.6 It was apparent that there were some committed and useful interventions however and that the Mother accessed some of these appropriately – these included the Children’s Centre, GP, Nursery and the support and advice offered by the Primary School. Those providing direct input to the Half Brother no doubt provided some much needed compensatory and positive experiences for him. 15. Lessons Learned 15.1 There is evidence that parental alcohol misuse is often minimized by professionals as representing less of a concern about parenting capacity than parental drug use. Research however identifies that the experiences of children living in such households have many similarities and can experience the same levels of significant harm18. 15.2 Assessment of the extent of chronic parental alcohol misuse usually takes place when the parent is no longer intoxicated. If any such assessment does not capture the reality of what actually occurred at the time that the parent was intoxicated, there will be the unintended potential for concerns to be downgraded and therefore any understanding of potential risks to the child, to be compromised. 18 “Silent Voices – Supporting children and young people affected by parental alcohol abuse” – The Children’s Commissioner – Adamson, J and Templeton, L – September 2012. 38 15.3 For any assessment of risk to primarily rely on accounts given by the parent, without any objective evidence being sought to confirm or challenge such accounts, is likely to miss identifying the potential safeguarding risks to the children. Overall professionals need to have “respectful uncertainty” in dealing with parents, particularly where there is known to be parental alcohol misuse 15.4 Practitioners need to be alert to parents displaying disguised compliance, and be mindful that an over optimistic view of parenting will be formed if this is not challenged. 15.5 Lack of understanding or knowledge by professionals, about a parent’s persistent or long term medical condition, will compromise their ability to work effectively with the family and in particular about understanding the meaning of that condition in terms of any impact on parenting ability. 15.6 For incidents of concern to be separately and individually addressed without any consideration of previous incidents or concerns, will mean that any patterns of parenting will be missed and the professionals could continue to respond in ways which had previously proved ineffective. The routine use of significant event chronologies which are easily accessible to the practitioner would greatly help in this respect. 15.7 The combination of maternal alcohol misuse and pregnancy must be viewed as a high risk scenario, not only to the unborn child but also to the parenting in the first six months of the child’s life. 15.8 If a professional experiences a belief or frustration that actions in response to concerns raised are not being appropriately responded to by another agency, then if these concerns are not escalated upwards to senior managers or sideways to specialist practitioners, it is possible that continued risks to children will remain unaddressed. 15.9 It is often the child’s development, behaviours and relationships with others which give indicators of difficulties within the home. If the sources of any such developmental delays or behaviour problems are not fully understood or assessed, it may mean that problems within family functioning are not identified and consequently that risks to the children are missed by practitioners. 15.10 It is important for practitioners to understand the lived experience of the child and to gear their interventions accordingly – without this it is not possible to form a true understanding of potential safeguarding risks. 16. Recommendations Note has been taken of the recommendations contained within the IMRs and within the Health Overview Report so as these recommendations reflect other findings from the overall analysis which are not otherwise identified. The recommendations below relate to multi-agency practice. 39 16.1 That existing multi-agency guidance for professionals working with parental alcohol misuse should be reviewed and re-launched. 16.2 That the LSCB ensures that all LSCB partner agencies conduct a single agency audit to identify the extent to which historical information is accessed and utilised to inform current assessment and practice 16.3 The LSCB provides training that meets the needs of professionals in all agencies to be able to identify and intervene effectively where parental alcohol misuse presents a risk to children and young people. 16.4 That the LSCB uses the learning from this case to remind practitioners at all levels and their managers of the following concepts required for effective safeguarding in order to address the identified shortfalls in practice in this case: • ‘respectful uncertainty’ • Professional curiosity • Disguised compliance from service users • The ‘lived’ experience of the child • Behaviour as understood in the light of child development knowledge • The need to escalate cases to address difficulties when inter agency practice is ineffective. 16.5 The LSCB should conduct a themed multi-agency review of cases in to the effectiveness of practice where parental alcohol misuse is a risk to the children in the family 16.6 That the LSCB and CDOP panel ensure that the information gathered and learning arising from the Rapid Response process is shared with operational staff as a matter of due course and urgency after a child dies 16.7 That the LSCB will monitor the progress of all agencies against the recommendations in their individual action plans. Ron Lock 31.12.12 40 |
NC049090 | Death of 17-year-old boy after his arrest for illegal entry into the UK and subsequent placement in foster care a day earlier. YT was found in the back of a cargo lorry in Enfield on 8th July and was taken into police custody. Once it was established YT was a child a foster placement was sought and he was taken to a foster family the same day. The foster family struggled to communicate with YT but were planning to introduce him to another Eritrean the next day. Late the next evening YT was found dead in his room hanging from the curtain rail. None of YTs family are in the UK and it is unclear how he was travelling to the UK. As YT had only been in the country for one day, and there was a language barrier there is very little known about him and his situation. Recommendations include reviewing out of hours emergency child protection to record all aspects of vulnerability, ensure the voice of the child is heard and facilitate effective communication.
| Title: Serious case review: ‘YT’. LSCB: Enfield Safeguarding Children Board Author: Richard Henson Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Enfield Safeguarding Children Board SERIOUS CASE REVIEW: ‘YT’ INDEPENDENT AUTHOR: RICHARD HENSON BA (HONS) Enfield Safeguarding Children Board ESCB SCR YT Final version Page 2 of 28 Table of Contents: Chapter Page No’s 1 Introduction 3 2 Scope of the SCR 3 3 Family composition 4 4 Arrangements for the SCR 4 - 5 5 Methodology for this SCR 6 6 Key events 7 - 10 7 An examination of any issues, in communication, information sharing or points of contact between: • YT and any agency • YT and the foster carers • Within or between services, to include those with responsibility for working out of hours, as well as those working in normal office hours and with particular reference to their knowledge of the processes (both national and local) for supporting an unaccompanied asylum seeking child? 10 - 14 8 Was the work in this case consistent with each organisation’s policy and procedures for safeguarding and promoting the welfare of an unaccompanied asylum seeking child and with wider professional standards? 15 - 18 9 What were the key relevant points / opportunities for; assessment, decision-making and effective intervention in this case in relation to YT? What was the quality and timeliness of interventions and decision-making? Was there more that could have been done? 18 - 20 10 Were professionals aware of ‘what it was like to actually be that child’, sensitive to the needs of an unaccompanied asylum seeking child, knowledgeable both about potential indicators of abuse and mental health and about what to do if they had concerns about a child’s welfare? 20 - 22 11 Was practice sensitive to an / or influenced by the racial, cultural, gender, sexuality, linguistic and religious identity and any issues of disability of YT and were these explored, taken on board and recorded? 23 - 24 12 Conclusions 24 - 26 13 Recommendations 27 Appendix 1 Section 46 Children Act 1989 (Police Protection) 28 - 29 Enfield Safeguarding Children Board ESCB SCR YT Final version Page 3 of 28 1. Introduction 1.1 YT, an Unaccompanied Asylum Seeking Child (UASC) presenting as a 17-year-old male from Eritrea first came to the notice following his arrest in Enfield, London on the 8th July 2016. After initial assessment and investigation of his situation he was placed under ‘Police Protection’ and looked after in emergency foster care commissioned by Enfield Children’s Social Care Emergency Duty Team (EDT). The following evening (9th July 2016), at approximately 9pm YT was found by his foster carers hanging in his bedroom. He was dead. The circumstances indicated that the death was a suicide. 1.2 This death of a ‘child in care’ therefore met statutory requirements for a Serious Case Review (SCR). An extraordinary meeting of the Enfield Safeguarding Children Board (ESCB), Serious Case Review Sub-Committee consisting of senior representatives from relevant agencies was held on 5th August. After discussion and consideration, the ESCB Independent Chair; Geraldine Gavin formally confirmed the decision to commission this review. 1.3 The SCR purpose is; • To establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; • To identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on and what is expected to change as a result; and • To improve intra and inter-agency working and better safeguard and promote the welfare of children. 2. Scope of the SCR 2.1 This SCR is focused on events between the dates of 8th July 2016 – 9th July 2016. This timeframe was agreed to reflect the period from YT being known to services in the United Kingdom (UK) up until the date of his death. 2.2 This SCR does not have within its own terms of reference latitude to comment on national or global drivers that are behind the international migration / asylum seeking of young people from Eritrea to European and other developed countries. However, a recent UK Home Office report is available. 1 Global human migration patterns and causes fall outside the published guidance on reasons for conducting SCRs2. 1Report of a Home Office Fact Finding Mission Eritrea: illegal exit and national service Conducted 7–20 February 2016 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/543863/Report_of_UK_FFM_to_Eritrea__7-20_February_2016.pdf 2 Working Together to Safeguard Children (2015), referred to in this report as “Working Together”.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/419595/Working_Together_to_Safeguard_Children.pdf Enfield Safeguarding Children Board ESCB SCR YT Final version Page 4 of 28 3. Family Composition 3.1 Name of Child: YT, assumed to be aged 17 (Working DoB: 01/01/1999) 3.2 Family members: Little information of substance has been established in respect of family members. It is believed that his parents are Eritreans and remain resident in Mende Fera, Southern Region, Eritrea. No family members are believed to be present in the UK however following YT’s death the Metropolitan Police have contacted a brother who is residing in Oklahoma in the United States of America (USA) and a cousin who lives in Milan, Italy. These individuals are also understood to be asylum seekers. Father: MT Mother: EA A family friend, Mr. FM and his daughter LM who are resident in the UK have been spoken to by the police. At this stage a formal identification of YT’s body remains to be made. 4. Arrangements for the SCR 4.1 The ESCB convened an SCR Panel (the Panel), consisting of senior representatives from relevant agencies, to inform the Review. Panel meetings were chaired by Geraldine Gavin the Independent ESCB Chair. This is the Overview report of this SCR and has been completed by an Independent author – Richard Henson BA (Hons). 4.2 A background note: Information obtained by HM Inspector, Nexus Custody Immigration Enforcement suggests that YT had been amongst a larger group of Eritreans who had concealed themselves in a Hungarian registered lorry that was transporting a cargo of wheelie bins. Prior to being stopped and searched at Calais the vehicle had stopped in St Hiliare des Cottes, Northern France. No personal identity details of persons in that group are known by UK authorities. It is possible that YT was overlooked in the search by the French officials and remained concealed in his hiding place until arrival in Enfield. The lorry did not stop in Dover. In any event, it is highly unlikely that any asylum seeker would have joined a lorry once in the UK as they could make an asylum claim immediately on arrival. 4.3 All relevant agencies were required to submit an Individual Management Review (IMR), on a template containing the following headings; 1. A summary of their agency involvement (what was the agencies’ involvement with his child and family? Include dates). 2. Response to specific questions as identified in the Terms of Reference (including reference to the general questions at 4.1 of the terms of reference and the agency specific questions at 4.2 of the TOR. 3. Summary and Analysis (what do we learn from this case?). 4. Recommendations. Enfield Safeguarding Children Board ESCB SCR YT Final version Page 5 of 28 Table of agencies contributing to the SCR: AGENCY NATURE OF INVOLVEMENT London Borough of Enfield Children’s Social Care Services (CSC) Emergency Duty Team attended police station and arranged for young person to be accommodated in foster care Metropolitan Police Service (MPS) Territorial Police covering London Boroughs of Enfield, Haringey and Barking & Dagenham deal with custody, child protection, transport and rapid response to unexpected death of the young person Future Fostering: - an Independent Fostering Agency Provision of care and accommodation services for the young person and support training to foster carer family United Kingdom Border and Immigration Agency (UKBA) Nexus Custody Policy and approach for unaccompanied child asylum seekers / migrants London Ambulance Service Trust Response to 999 call and attendance at death scene of sudden unexpected death of a child (SUDC) The East London Coroner, Waltham Forest Coroners Court* Post death arrangements and information ongoing family liaison / communication * There was no individual report submitted by the Coroner but relevant information was supplied through the MPS representative to the SCR panel 4.4 The Terms of reference for this SCR are outlined as; • What was the agencies’ involvement with this child and family? • Analysis of agency involvement • What do we learn from this case? • Recommendations for action 4.5 Five specific questions are to be covered in the scope of the SCR: Q1. An examination of any issues, in communication, information sharing or points of contact between: • YT and any agency • YT and the Foster Carers • Within or between services, to include those with responsibility for working out of hours, as well as those working in normal office hours and with particular reference to their knowledge of the processes (both national and local) for supporting an unaccompanied asylum seeking child? Enfield Safeguarding Children Board ESCB SCR YT Final version Page 6 of 28 Q2. Was the work in this case consistent with each organisation’s policy and procedures for safeguarding and promoting the welfare of an unaccompanied asylum seeking child and with wider professional standards? Q3. What were the key relevant points / opportunities for; assessment, decision-making and effective intervention in this case in relation to YT? What was the quality and timeliness of interventions and decision-making? Was there more that could have been done? Q4. Were professionals aware of ‘what it was like to actually be that child’, sensitive to the needs of an unaccompanied asylum seeking child, knowledgeable both about potential indicators of abuse and mental health and about what to do if they had concerns about a child’s welfare? Q5. Was practice sensitive to and / or influenced by the racial, cultural, gender, sexuality, linguistic and religious identity and any issues of disability of YT and were these explored, taken on board and recorded? 5. Methodology for this SCR 5.1 This report is based principally on the response to the questionnaire from participating agencies, background information gathered to assist the Rapid Response to SUDC and Child Death Overview Panel (CDOP) and subsequent Panel discussions with the concerned agencies representatives. 5.2 This overview consists of; • A factual context of key events within a brief chronological narrative; • Commentary on the family situation and their input to the SCR; • Analysis of the part played by each agency and of their submissions to the SCR; • Closer analysis of key issues arising from the review; and • Conclusions and recommendations. 5.3 The conduct of the SCR has not been determined by any single theoretical model but it has been carried out in accordance with the underlying principles of the statutory guidance, set out in Working Together and in accordance with the ‘Wood’ recommendations providing LSCBs with greater flexibility in how to approach SCRs on a case by case basis. 5.4 The review, recognises the complex circumstances in which professionals work together to safeguard children. It seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did. It seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than relying upon hindsight, except where hindsight promotes a fuller understanding of the events and causation. It is transparent about the way data is collected and analysed; and will reference relevant research and case evidence to inform the findings 5.5 The government has introduced arrangements for the publication of Overview Reports from SCRs, unless there are reasons why this would not be appropriate. This report has been written in the anticipation that it will be published. 6. Key events Enfield Safeguarding Children Board ESCB SCR YT Final version Page 7 of 28 6.1 On Friday 8th July 2016 a Hungarian lorry driver who had driven a heavy goods vehicle (HGV) via Calais, France – Dover UK, discovered YT amongst the cargo in the back of the trailer. The HGV had arrived at its destination, a freight company depot located at Duck lees Lane, Enfield. This location is a short distance from the M25 motorway and inside the local authority area of the London Borough of Enfield. The Metropolitan Police (MPS) were called and uniformed response officers arrived around about 4pm. 6.2 The police officers from Edmonton Police Station believing YT to have entered the UK illegally, arrested him, placed him in handcuffs and escorted him in a police vehicle to the custody suite at Wood Green Police Station where his detention was authorised by the custody officer at 5.10pm 6.3 Custody procedure is a statutory process and the police must comply with procedures outlined within the Codes of Practice for The Police and Criminal Evidence Act 19843. During the custody procedure, a written electronic custody record is completed containing all relevant information. As YT did not communicate in spoken English the police used a translation service provided on the telephone by ‘LanguageLine. Using this interpretation service YT could communicate with the police. By using this service the police established that YT was Eritrean and spoke the Tigrinya language4. The custody record includes information provided by YT that he was a 17-year-old Eritrean national and that he was seeking asylum in the UK. There was no other opportunity for police to verify this information as YT had no identification papers or other records with him. Police officers are trained to be professionally skeptical and to collaborate information from all available sources including professional judgement. YT’s’ demeanor and his physical appearance meant that the police retained some doubts as to his actual age. 6.4 Other personal information was also gathered and recorded by the police including several questions relating to his vulnerability, health and wellbeing. Police are required to establish contact details for parents or responsible adults when children (persons under the age of 18) are in custody situations. YT claimed that he was alone with no relatives in the UK. There are some countries where it is compulsory for police to notify respective Embassy’s or Consulates of the detention of their nationals. There is no such requirement in place for Eritrean citizens and YT had answered that he did not wish to communicate with his Embassy. During the detention process the police contacted staff from the Home Office Immigration Enforcement Service – Nexus Custody. 6.5 An Immigration Officer was not present at Wood Green Police Station (which is often the case as they may be deployed to deal with immigration cases at other police stations in the area). However, advice was given to the police that YT should be referred to the local authority Children’s Social Care (CSC) team. This was for promoting welfare / safeguarding and for an age assessment to be considered if there was continuing doubt 3 The Police and Criminal Evidence Act 1984 (PACE) is an Act of Parliament which instituted a legislative framework for the powers of police officers in England and Wales to combat crime, and provided codes of practice for the exercise of those powers Part V1 of PACE required the Home Secretary to issue Codes of Practice governing police powers. The aim of PACE is to establish a balance between the powers of the police in and the rights and freedoms of the public 4 Tigrinya, the correct spelling of which is Tigrigna is spoken by the Tigrayans and Tigrinyas of the Horn of Africa. Most Tigrigna speakers, close to 6 million, inhabit the northern region of Ethiopia known as Tigray. The remaining 3 million of the total 9 million Tigrigna speakers primarily inhabit Eritrea. This group is specifically known as the Tigrinyas in Eritrea. Tigrigna is also spoken by groups of emigrants from these regions. Enfield Safeguarding Children Board ESCB SCR YT Final version Page 8 of 28 about YT’s actual age. This is known as a ‘Merton compliant age assessment’5 No papers relating to immigration enforcement were served on YT. These would have been served if an Immigration officer was present prior to YT’s departure from Wood Green Police Station. 6.6 Consequently, YT was released from arrest by the police and the custody record closed as ‘No further action’. He was instead regarded as a vulnerable child likely to suffer significant harm if not assisted by the authorities and placed under ‘Police Protection S. 46 Children Act 1989 (Appendix 1). The Designated Officer was a police Inspector who instructed that Enfield CSC be informed of the situation including the uncertainty that remained for the police over YT’s actual age. It was noted that if CSC also felt there was doubt then a police Forensic Medical Examiner (FME) should be called to assist with an age assessment. The police officers then returned to the Borough of Enfield (Edmonton Police Station) with YT to liaise with Enfield CSC. 6.7 YT was accommodated in an interview room where he remained under escort of the police officers. He was not in detention but remained in a situation where police were being vigilant and mindful of the need to transfer responsibility to CSC. His physical presence was needed so that a social worker could complete an assessment and decision from CSC. During this period YT was seen to act in an agitated way and at one stage he stood up and punched a wall in the interview room causing a small dent. The police officers attempted to calm YT but communication due to the language barrier was difficult. The officers decided it was necessary to place handcuffs on to YT’s wrists and they did so in the ‘front stack position’. This meant that YT could sit down but that his arms were in front of him, slightly crossed at the wrists with one above the other. This can be considered as the officers applying force but using a restraint position that offers the least discomfort to the individual. The police officer’s stated intention was to prevent YT injuring himself (There was no visible injury to either of his hands from the punch to the wall) and to calm him down whilst awaiting the social worker. The police officers recorded their actions and rationale in their notes. There were no further aggressive outbursts with the potential to cause physical injury to YT while at the police station. 6.8 A social worker from the Enfield CSC Emergency Duty Team (EDT) attended at Edmonton Police Station at 7.50pm CSC having been contacted at 6.49pm and provided with some outline information on the circumstances. The police had also used Language Line to gain additional background information from YT and heard that he had no one to look after him or provide any form of shelter in the UK. They were told that he may have a brother in Milan, Italy. The social worker sought advice from the Enfield CSC Head of Service (for Assessment) on the matter of conducting an age assessment. They were advised that if at all in doubt then to err on the side of caution towards childhood and to accept responsibility for treating YT as an Unaccompanied Asylum Seeking Child (UASC). 6.9 The police officers dealing with YT had changed over (shift rotation) by the time of arrival of the EDT social worker. The social worker noted that YT did not look to be angry but appeared to be somewhat frustrated. At the arrival of the social worker YT was released from the handcuffs. In the opinion of the social worker, YT’s age was around 17 / 18 years and not significantly older than this. Communication in Italian was attempted by the social worker (as the information from the LanguageLine translator was that he had spent some time in Italy with his brother) but this was unsuccessful as YT did not understand Italian. The priority at this stage for CSC was to identify an appropriate care placement for YT so 5 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/257462/assessing-age.pdf Enfield Safeguarding Children Board ESCB SCR YT Final version Page 9 of 28 that they could place him safely before undertaking assessment work and processes associated with registration as an UASC. 6.10 The social worker left YT with the police officers while colleagues contacted various foster care agencies for a placement. This was achieved at approximately 10.30pm with an Independent Agency - Future Fostering. A social worker using the brief details available to them spoke to the Foster Parents and it was agreed that they would be able to look after YT initially to Monday 11th July 2016. The location of the Foster Carers home was in the London Borough of Barking and Dagenham. The details of the address were telephoned to the police officers who were still looking after YT and they agreed responsibility for driving him to the foster carers home. 6.11 Shortly before midnight on Friday 8th July 2016 police arrived at the house with YT. He had very few personal belongings but did possess a mobile phone. Before they left the premises the police officers again utilised LanguageLine so that the Foster Carers could communicate with YT to let him know that he was going to be staying with them and to also gather some additional information on his needs. This included information that he had no special dietary requirements apart from not eating pork, that he was not ill or on any medication. He indicated that he was of Christian faith and he was not allergic to anything. After this the police officers departed leaving YT with the foster carers. The foster carers told YT that they knew of another Eritrean boy who was also being looked after in foster care and that they would attempt to introduce them to each other the following day. 6.12 The carers contacted their agency at 12.45 am informing them that they had YT with them. YT was shown to a single bedroom on the 1st floor of the four-bedroomed dwelling house This room was for his sole use. Before going to bed he took a shower and was provided with some clean clothes by the carers. 6.13 Also living with the foster carers were their own birth son (aged 14) and another young person (aged 18) who was in a placement as part of ‘The Staying Put Scheme’6. Neither of these young people ever met YT. 6.14 On Saturday 9th July YT awoke and ate breakfast in the kitchen / dining room. He managed to communicate to his carers that he needed a charger with a UK electric plug for his mobile phone. The carer agreed to provide a compatible one later that day. Although communication was limited YT indicated that he would like to speak to the Eritrean boy they knew. However, they had yet to get in touch with this person and were still trying to arrange this. YT returned to his room and went back to bed. He re-emerged about 3.30pm for a short while before once again returning to his room. The foster carer sensed some frustration in YT and believed that this was caused by communication issues. They had attempted to use the internet to download a translation service for English / Eritrean but this was unsuccessful. 6.15 Around 6.30pm the foster carer tried to call YT downstairs for supper. He responded verbally but didn’t leave his room. At 8.30pm the foster carers husband returned home and she asked him to go to YT’s bedroom to bring him down stairs for something to eat. 6.16 On entering the bedroom the carers found YT hanging from a curtain rail by his own shoe laces tied around his neck. He was lifeless but the foster carers cut down his body and lay it on the bed while called the emergency services via 999 at 9.05pm 6 https://www.gov.uk/government/publications/staying-put-arrangements-for-care-leavers-aged-18-years-and-above Enfield Safeguarding Children Board ESCB SCR YT Final version Page 10 of 28 6.17 The carers attempted to revive YT and on arrival of the London Ambulance Service (LAS) the carer was performing cardio pulmonary resuscitation (CPR) on the body. 6.18 The assessment by the LAS paramedics of YT found his jaw was rigid, his tongue swollen and a deep ligature mark to his neck, there was evidence of rigor mortis and a low body temperature. Verification of the Fact of Death was recorded as 9.16pm on Saturday 9th July 2016. 6.19 The police had also been called to the foster carers address and a rapid response to the sudden and unexpected death of a child commenced. The Coroner’s office was contacted and other concerned parties including Social Care and the Fostering Agency notified. At about 01.30am on Sunday 10th July YT’s body was removed to the mortuary. 6.20 A post mortem examination was undertaken on the instructions of the Coroner for East London. No signs of abuse or issues arousing suspicion of unlawful activity were noted by the examination. The cause of death was recorded as ‘Suspension’. 7. An examination of any issues, in communication, information sharing or points of contact between: • YT and any agency • YT and the foster carers • Within or between services, to include those with responsibility for working out of hours, as well as those working in normal office hours and with particular reference to their knowledge of the processes (both national and local) for supporting an unaccompanied asylum seeking child? 7.1 YT came into direct contact with officers from two agencies, the Metropolitan Police Service and London Borough of Enfield Emergency Duty Team. He was also subject to decisions made by managers from the Home Office Immigration Enforcement (Nexus Custody) and London Borough of Enfield Children’s Social Care Department. 7.2 YT could not communicate effectively by using the English language. The circumstances of his discovery in the back of a HGV that had just arrived at its destination after travelling through France were sufficient grounds for police officers to suspect that he was committing immigration offences. These circumstances also provide justification for his arrest and for initial detention in the custody suite at Wood Green Police Station pending investigation by immigration officers from the Nexus Custody team. 7.3 The police appear to have fully followed the custody procedure and used the telephone translation service ‘LanguageLine’ to facilitate communication with him. LanguageLine is an independent company and provides the MPS commissions its service on a 24hrs basis to facilitate communication for all kinds of policing purposes. Extract taken from LanguageLine website: LanguageLine Solutions (LLS) has over twenty years’ experience of providing high quality language services to the Criminal Justice sector. LLS carries a proud history of association with the police sector and currently provides legal translation for all police forces across England, Scotland, Wales and the Republic of Ireland. LLS aims to provide a solution for all situations where a language barrier may exist. From assisting emergency services in life threatening situations to Enfield Safeguarding Children Board ESCB SCR YT Final version Page 11 of 28 supporting the local policing teams as they engage with an increasingly diverse community. To achieve this, the organisation offers a wide range of legal translation services that are continually developed according to the needs of its client base. Over the last two decades, many of LanguageLine Solutions services and systems have been developed to meet the specific requirements of the Criminal Justice sector. 7.4 The custody process requires a police sergeant to record substantial details of the detained person including place and date of birth. There is also a series of questions that must be answered in relation to the arrested persons’ health and wellbeing including fitness to be detained. 7.5 YT had no identification documents to confirm his age and the police remained sceptical that the age of 17 years and date of birth (12/01/1999) were true. Age is an important factor in investigating immigration offences as there are significant differences in how the authorities must respond to asylum claiming children and adults. 7.6 Additionally, children in custody situations must be treated differently to adults as they are vulnerable by virtue of age. Parents or other ‘Appropriate Adults’ are called into the custody situation when children are detained to facilitate communication and ensure the welfare of the child is safeguarded. 7.7 The role of any appropriate adult is distinct and a separate function to that of a lawyer or legal advisor. A lawyer cannot assume the role of appropriate adult for a young person in police detention. 7.8 YT’s age was communicated to the Immigration officer and the police were advised that as he appeared to be making a claim for asylum as a minor (a child) a referral to social services should be made. 7.9 In this situation, the advice from the immigration officer to police was followed and by releasing YT from arrest and placing him into ‘police protection’ the requirement for an appropriate adult and the potential introduction of a lawyer were negated. The police officers in line with their responsibilities under S46 Children Act 1989 contacted Enfield Social Services. The immigration officer was advised that YT had been taken into police protection and would be placed into the care of Enfield CSC. 7.10 The EDT Social workers sought advice from senior managers as to approach and making an age assessment and they followed this. A social worker personally visited YT and made an initial assessment relying on his own professional judgement. As there was some information indicating that YT had Italian connections there were attempts to speak with him in Italian. 7.11 The police officers had decided it was necessary to restrain YT with handcuffs following an outburst in which he had punched the wall in the interview room where he was being kept while awaiting the social worker. The officers interpreted YT’s actions as a sign of his frustration with the situation he was in. The handcuffs were removed following the arrival of the social worker. 7.12 Enfield EDT found an emergency foster placement for YT. Identifying suitable placements for children placed into police protection is a challenging matter for Local Authorities (It is outside this SCRs’ terms of reference to examine that issue in a greater depth). 7.13 The information used by Enfield EDT in seeking a suitable placement appears to have been very limited. The information made available was recorded by a manager at ‘Future Enfield Safeguarding Children Board ESCB SCR YT Final version Page 12 of 28 Fostering’ agency at 10.42 pm on a Friday evening. Essentially this was; ‘Enfield CSC were seeking a short-term placement (a weekend) for a 17-year-old Unaccompanied Eritrean Asylum seeking child of whom there was some doubt as to his actual age’. Little other information was provided, including to the fostering agency’s question of whether clothing provision was required. 7.14 The Future Fostering manager contacted the foster carers by telephone and they agreed to accept the placement based on the scarce details made available to them. Future Fostering asked the foster carers to gather additional information, including his name and date of birth once YT had arrival at their home and to telephone it through to them. This communication did not take place until 00.45 on Saturday morning. 7.15 The police had initially contacted Enfield EDT at 6.49 pm on Friday evening from Edmonton Police Station providing brief details of the circumstances leading to Police Protection being taken and including YT’s date of birth. This information was also that he had no family or friends present in the UK and would need accommodation but that police retained some doubts as to his actual age. On arrival at Edmonton Police Station at 7.50pm the social worker commenced an assessment. 7.16 Once the placement had been identified a telephone call between the Enfield EDT and the foster carers was held. This was an opportunity for additional information to have been requested or to be passed between agency professionals. It could also have been used to identify any important information gaps, including the current risk assessment. 7.17 The police officers were provided with the foster carers address and drove YT to the house arriving before midnight. Once again, the police utilised the LanguageLine service to facilitate communication between all parties and allow the foster carers to ask YT questions and to explain their role. There is evidence that the foster carers attempted to reassure YT and to make him feel less isolated e.g. They knew another Eritrean boy and explained to YT that they would take steps to bring them together the following day. 7.18 However, there does seem to have been some miscommunication as the foster carers attempted to facilitate communication in Italian language on an internet translation service when the police and social workers had previously established from YT that he did not speak Italian. 7.19 CSC was aware of its responsibility to support YT in respect of his UASC status and the need to initially prioritise his safety and promote his welfare through a suitable placement in foster care. 7.20 There are established procedures for dealing with UASC. The physical absence of an officer from Home Office Immigration Enforcement (Nexus Custody) at Wood Green Custody suite to serve papers on YT does not appear to have altered the timeline in which he was quickly released from police custody and care arrangements being implemented. 7.21 Accepting that it will not always be possible (due to other demands and out of hours times) to have an Immigration Officer present when a UASC is bought into a police station it would nevertheless be of great assistance to those with responsibility for safeguarding children could be provided with a reference and a priority pathway to assist in reducing the uncertainty for the child in these initial stages of contact. Analysis. The early interactions between the police and immigration officers were largely about primacy of responsibility and this depended upon the legal status of YT. Age was a Enfield Safeguarding Children Board ESCB SCR YT Final version Page 13 of 28 determining factor in which pathway should have been followed. UK law reflects the reality that children are vulnerable by age and should be dealt with differently to adults so that child welfare is promoted as the priority. This clearly did not mean that professionals should for a child ignore immigration requirements but that these were secondary to any safeguarding concerns. In establishing information from YT, the police relied upon the LanguageLine service to acquire some vital personal information from him. Even though, the police officers retained some doubt as to his actual age, their actions were consistent with giving him the benefit of doubt until assessments could be completed and with treating him with the legal status of being a child. This meant that he was released from arrest without delay and removed from the custody area at Wood Green Police Station. YT was escorted to Edmonton in the Borough of Enfield to be closer to the local Children’s Social Care team who were now responsible for finding suitable safe accommodation, promoting his welfare and assisting him in the asylum-seeking process. A question arises as to how much additional questioning or information gathering should have been progressed. Was it necessary or beneficial for the agencies to seek additional information from or about YT? The information that was available to agencies at this stage was very limited and almost entirely from a single source as it originated from YT’s’ answers to questions from the police while he was in detention and later in police protection. Due to the time of day there was very little other opportunity to gather additional information; e.g. from a trusted member of the Eritrean community or a Tigrigna speaker. For the police to have done so, may also be considered as a potentially abusive or threating experience for a child in YT’s situation, as police officers in many countries fled by asylum seekers are linked with Government oppression. The reliability of any additional information gathered in such circumstances is likely to have been questionable. In the event, and until the time of the arrival of the social worker further questioning was avoided. Instead, YT was treated as being vulnerable and measures were put in place to protect him. The use of restraint by the police and the reassessment of the need for continued handcuffing following the arrival of the social worker and the additional information exchange indicates that the situation was being dynamically assessed. This provides some evidence of information being shared between agencies and proportionality being applied in the officer’s approach to safeguarding. Record keeping is an essential activity for professionals involved in multi-agency safeguarding. Records should as far as possible be made in a timely way and contain sufficient information to support the rationale behind any decisions and allocation of resources. Not every decision made during dynamic operational settings will prove in the long term to be the best choice. So, where a child is found in a situation where they have suffered or are considered likely to suffer from significant harm a record should be made of what that harm is thought to be. The description should be detailed so that those who are required to take actions have sufficient information to progress actions that reduce the impact of the harm and remove the child from continued exposure to sources of harm. This can be described as ‘risk assessment’. Professionals must use the information they have at hand for risk assessments and to support decisions based upon ‘what is actually known at the time’. It is also reasonable Enfield Safeguarding Children Board ESCB SCR YT Final version Page 14 of 28 to expect that these professionals will identify information gaps and take steps to gather additional material to fill such gaps. This should be about being proactive and on the front foot in assisting other service providers who are also currently involved, or will be involved in any future safeguarding activity for the child. Therefore, strategy decisions should be recorded with a supporting rationale and passed on in a timely way so that risk can be effectively managed. Where children are older young people as in this case, it is vital to gather as much information as possible in relation to their perception of risk, their wishes and their needs. We know from many years of experience with child protection processes that effective communication with young people is necessary for improving chances of successful safeguarding outcomes. In other words; professionals need to hear the voice of the child. There is a deficiency in record keeping in this case of useable information (including identifying information gaps) for continuing risk assessment. This is particularly evident in the provision of information between CSC, the fostering agency and the foster carers. This situation may have arisen partly because of changes to the officers dealing with the case (shift changes). The police officers handed over when shifts changed, several members of the EDT were involved and the Foster carers received information from their agency, a telephone call from EDT and then from the escorting police officers. If we project professional contact forward over the next few days, it is highly likely that several other professionals and those involved as carers will be involved and required to make decisions and provide safeguarding services. The absence of any form of log / decision sheet that also contains accurate personal information and a current assessment of risk and the safeguarding strategy means that important information may be missed or overlooked. Indeed, if we look towards the taking of history in medical settings and then the notes kept on patient’s progress following operations we can understand the benefits from updating and maintaining chronological records. Improvements to rectify this deficiency are clearly possible and need not be onerous or bureaucratic. 8. Was the work in this case consistent with each organisation’s policy and procedures for safeguarding and promoting the welfare of an unaccompanied asylum seeking child and with wider professional standards? 8.1 The HOIE (Nexus Custody) policy and procedures were applied by its staff. Albeit that the immigration Officer was elsewhere the advice was consistent with safeguarding and promoting the welfare of a UASC. In effect the police were advised that a person under the age of 18 was to be treated as a child and referred to the relevant CSC department. 8.2 The concern raised by police that YT may be 18 years or older was met with advice that CSC should follow a Merton compliant age assessment while at the same time ensuring welfare and safety. 8.3 The initial police officers who called to the lorry depot decided to arrest YT on suspicion of committing Immigration offences. The circumstances of his presence in that place and his inability to provide any explanation justified their actions. They complied with legislation and took him directly to an authorised custody centre at Wood Green Police Station. Enfield Safeguarding Children Board ESCB SCR YT Final version Page 15 of 28 8.4 During the custody procedure the police complied with procedure and utilised a translation service to communicate with YT. Questions gathering personal information and others concerned with his wellbeing and suitability for detention were asked and answered. This information led to contact with HOIE (Nexus Custody) who have jurisdiction in immigration offence investigation. The HOIE advised, based on the information and date of birth given, that police should release YT from arrest and contact CSC. 8.5 The police followed this advice and reviewed the status of YT. The promotion of his welfare was now the priority and he was placed under police protection. This is a statutory power and should only be used where its use is considered necessary to protect a child from significant harm. 8.6 When a child is placed under police protection an officer of the rank of Inspector is required to perform the role of ‘Designated Officer’ and ensure that communication of the child’s situation is expedited with various concerned parties (including the child itself). This ensures that the child is safeguarded and steps are in place to maintain this situation for up to 72 hrs. The contacting of the relevant CSC department is an essential part of this process. The designated Officer must create a record of actions when a child is taken into police protection and this record is subsequently brought to the attention of specially trained child protection officers for oversight. These actions and activities were completed. The Inspector gave instructions to ensure the referral was passed to CSC and that if doubt continued in relation to age then a police forensic medical examiner should be consulted. The actions of the Inspector and officers were in accordance with the Operation Nexus Toolkit that is available to operational officers on the MPS Intranet system. However, the report dealing with the use of Police Protection was not closed in accordance with MPS standard operating procedures (This does not appear to have any bearing on the case outcome but meant that YT was still under Police Protection at the time of his death). 8.7 While in police protection at Edmonton Police Station YT exhibited some anger and agitation in which he punched the wall of the interview room in which he was placed. The wall was slightly indented but YT received no physical injury from this incident. The officers decided to handcuff YT to prevent any similar outbursts of frustration that may cause injury to him or any other person. The handcuffing of an individual is an application of force and police officers are lawfully permitted to apply force and restraint if this is only such as is necessary and proportional to prevent injury or damage. The officers recorded their actions and rationale in notes at the time. Following the death, the MPS referred the actions of the officers in restraining YT for scrutiny by investigators from the MPS Department for Professional Standards. No untoward behaviour has been identified. 8.8 The police utilised LanguageLine on at least three occasions to facilitate communication between themselves and YT and for the benefit of the social workers and foster carers. This was consistent and good practice. 8.9 There was a good initial repose to the referral from police and particularly in seeking advice from the ‘Head of Service’ in relation to how best to approach the issue of age assessment. This was followed up by a timely visit to Edmonton Police Station and attempts to garner additional information from YT himself. 8.10 Social workers and staff on Emergency Duty Teams have a complex task and finding the most appropriate service provision for high risk child protection cases takes considerable amounts of resources and skills. Finding a suitable placement for YT as a UASC and getting him there from the police station within 5 hours was an achievement particularly as other high risk safeguarding situations were being responded to simultaneously. Enfield Safeguarding Children Board ESCB SCR YT Final version Page 16 of 28 8.11 Although the social worker had visited YT at the police station there does not appear to have been any emphasis placed upon ensuring YT understood what was happening to him. Social care records are absent of information on his emotional, physical health and his well-being. This information could have been obtained from the police records and supplemented by material from additional questions using LanguageLine. The social worker was qualified to comment on either the presence or absence of mental health concerns but does not appear to have recorded this. Neither was anything recorded in regards to YT’s motivation and aspiration or whether he was hiding from any specific threat(s). 8.12 Future Fostering were contacted by CSC and indicated that they were likely to have a suitable temporary placement available based upon the information provided. The actual information was very scant but it was shared with the prospective foster carers who agreed to offer their services for YT. 8.13 In the agency report template for this SCR, Future Fostering state; “Future fostering expects that Local authority undertakes a careful assessment of the young person’s needs and wishes irrespective of the young person’s immigration status and shares the same with the Independent Fostering Agency at the time of seeking a placement, even if it falls under the Out of Hours service of the Local Authority.” They go on to state; “It is a requirement that foster carers will need to be carefully and accurately briefed about the young person’s cultural, religious and ethnic needs and any particular dietary needs.” Both statements appear to be reasonable requirements for initial assessment as to the suitability of the placement being considered. 8.14 In the event a decision to accommodate was made before a careful assessment was made and then there was no careful or accurate local authority briefing available for the Foster Carers. Instead, the escorting police officers were relied upon to facilitate communication and gain some additional details (using LanguageLine) on arrival at the placement. Analysis. Agencies have followed the letter of organisational policy and procedures for safeguarding and promoting the welfare of UASC. The use of statutory power was proportionate and records show largely good recording of process and timely communication between agencies. Application of process and procedures by all the professionals in this case was good and there is no evidence to suggest that any changes are required. The use of handcuffs to retrain YT when he became agitated and was violent was not excessive and was only maintained for as long as was needed for him to calm down. His later demeanor and cooperation with the professionals he met and the foster carers did not raise any additional concerns in relation to a repeat of any similar aggression. All the agencies involved have substantial experience of dealing with asylum seekers and for the most part these families or individuals will be adults. There are different pathways in place for processing asylum claims by adults or family groups containing children. A solitary child / young person in this situation is clearly very vulnerable. There is in place an agreed procedure for dealing with UASC and despite the police retaining some doubts as to whether or not they were dealing with an under 18-year-old (child) the correct process was followed and he was treated as a child. This meant he was placed under police protection and CSC were informed of the circumstances without delay. There being no family or friends who it would have been Enfield Safeguarding Children Board ESCB SCR YT Final version Page 17 of 28 safe to place the child with CSC immediately began to search their contacts for a suitable short-term placement. This is a routine task for social workers attached to Emergency Duty Teams and may be necessary for all forms of child protection. There was a weakness in the process of gathering information from YT. S 46 Children Act expresses that when a child is in police protection officers should ‘take such steps as are reasonably practicable to discover the wishes and feelings of the child’. This equally applies to CSC staff dealing with the situation. There are no records outside those at the time of the custody procedure that show that questions were systematically asked which would form the basis of either a risk assessment or an assessment of needs. Where there is a concern of a child suffering significant harm a strategy discussion between professionals who will make decisions and take actions to protect that child should always occur. Even if the outcome is not to initiate S47 enquiries it is good practice to record the issues and decision with rationale. This approach not only supports the professionals at the time by ensuring the decisions are based on comprehensive considerations but will be highly useful for those who take on responsibility for further service provision. Refugees may have significant health issues, that either motivate their migration or appear during the journey because of the physical environment or interaction with others. Neither the police or social workers adopted a systematic approach to gathering comprehensive information to support either safety or welfare decisions and in a suitable format for handover to other colleagues. The absence of such information was compounded by the Fostering Agency approach when they did not demand sufficient information from the EDT contact. Instead, the professionals and foster carers relied on LanguageLine to assist in providing information on a demand basis. This is poor practice as without any records of information already gathered it is difficult to identify any changes in response, conflicting information or areas where vital information has not yet been gathered. When viewed with hindsight, the information gaps appear to be largely; YT’s mental health situation (were there unrecognised issues?), Was the wall punching incident a signal of instability that may cause risk to him or others and what were the implications to him from being alone and isolated from any of the support he may previously relied upon? The question; ‘How do we know it is safe and appropriate to place this child in this home?’ should have been considered and addressed by those responsible for the emergency placement. Wider professional standards include ‘evidence supported decision making.’ This is required operationally and should also include a proactive approach to review decisions periodically and when additional information is received. There is insufficient evidence that this approach was at the forefront of practice when arranging the placement for YT. 9. What were the key relevant points / opportunities for; assessment, decision-making and effective intervention in this case in relation to YT? What was the quality and timeliness of interventions and decision-making? Was there more that could have been done? Enfield Safeguarding Children Board ESCB SCR YT Final version Page 18 of 28 9.1 Decision making and assessment commenced in this case when the police officers were called to the freight depot in Enfield. There initial investigations provided reasonable grounds to believe that YT had committed immigration offences and they made an arrest to secure his presence at a police station so that the matter could be properly investigated. 9.2 During custody procedure at Wood Green Police Station, the police used a translation service LanguageLine to gather personal information including questions relating to his vulnerability and wellbeing. This was an assessment process and used to support decisions as to whether any specialist assistance was required such as an interpreter, a doctor, a lawyer or an appropriate adult. It also included consideration as to whether as a foreign national there was a requirement to inform the relevant embassy or consulate. 9.3 The police contacted the Immigration Service by telephone as the on-duty immigration officer was working at another police station. The circumstances were outlined including the fact that YT was claiming to be aged 17 and seeking asylum. The Immigration officer advised the police on the protocol for UASC and instructed them to contact the relevant Local Authority Children Social Care department. 9.4 This advice was followed by the police who released YT from detention but assessing him and his circumstances as a child requiring safeguarding they placed him into ‘Police Protection’ S46 Children Act 1989. As Enfield was the relevant local authority the officers escorted YT to a police station in that Borough and telephoned a referral to the CSC Emergency Duty Team. 9.5 A social worker who spoke Italian and was also an approved mental health practitioners attended the police station and was introduced to YT. This was an appropriate and timely response. This was the first opportunity for a trained social worker to commence any assessment of needs and as an initial priority to ensure a suitable placement for the child’s safety. 9.6 During this meeting between the social worker and YT some information was gained and an assessment was made using personal judgement that he was likely to be a child. This clarified that CSC would assume responsibility for finding a suitable short-term placement and for assisting him with UASC matters. This decision and the information obtained were passed by the social worker to a colleague who began to seek a short-term foster placement. The meeting appears to have focused upon issues around age assessment and UASC protocol which were immediate and pressing matters due to the time of day on a Friday evening. 9.7 A child centered approach that focused on understanding YT’s wishes and feelings was possible and this would have benefitted assessment and provided additional information for better safeguarding provision. 9.8 The information provided verbally by EDT to the Future Fostering Agency was scant. Nevertheless, it was sufficient for the agency to offer a potential placement from what little was known. The chances of finding an identical match at short notice between foster families and unaccompanied young people are remote. But, the Foster agency judged that the proposed Foster carers could provide • a safe and supportive living space; Enfield Safeguarding Children Board ESCB SCR YT Final version Page 19 of 28 • a place where experiences are recognised but the young person would not be placed under pressure to talk about them; • somewhere that is appropriate in terms of language, culture and religion. The first two criteria above were certainly provided by the foster care setting and based upon what information was available the placement had a good potential to achieve the remaining requirements. 9.9 The Foster Carers also needed to make decisions following the arrival of the police and YT at their home. Once again, the police made available the LanguageLine translation service to facilitate communication between the parties. At this point, there were attempts to made to support YT and make him feel less isolated with the possibility of introducing a young person from Eritrea to him the following day. Other information regarding his dietary needs was also established. Analysis. Throughout the period of contact between YT and officers from the safeguarding agencies there was ongoing assessment. This was not a single agency assessment but forms of assessment took place at several decision points e.g. To treat YT as a child rather than an adult. These assessments relied almost entirely on two sources of information. The first being the agencies’ policy and procedures (including statutory legislation), the second being information gathered from YT himself by questioning with the aid of translation services. Apart from Future Fostering offering a placement on information that was insufficient to fully meet its own requirements for suitable placements the decisions made were based upon sufficient assessment of the available information to support the case progression. In terms of timeliness of the decisions these were made expeditiously. EDT officers must often juggle several emergency matters that arise at the same time and a major feature of their role is to respond to the presenting emergency and make situations safe until the normal social care office resumes services including undertaking in-depth and holistic assessments. In this situation, there was a weakness in the quality of assessing the actual needs and wishes of the child. There was a strong indication that he had been agitated and the fact that police officers judged it necessary at one point to restrain him using handcuffs should have prompted questions as to his intentions, wishes and feelings. Ideally, the information gathered from such questions should have been recorded and assessed and any issues communicated to the Foster Carers. This would have provided significant benefits in assisting their decision as to the suitability of their offer of a placement and in meeting the presenting needs of the placed child. In any event, EDT knew that this was to be a short-term emergency placement and any information as to the child’s risk or vulnerabilities would be needed in the near future as the case progressed. 10. Were professionals aware of ‘what it was like to actually be that child’, sensitive to the needs of an unaccompanied asylum seeking child, Enfield Safeguarding Children Board ESCB SCR YT Final version Page 20 of 28 knowledgeable both about potential indicators of abuse and mental health and about what to do if they had concerns about a child’s welfare? 10.1 There is some evidence of professionals taking a sensitive approach to YT as an UASC. This occurred immediately following the Immigration Officers advice to the police and the decision to place him into ‘Police Protection’, release him from detention and remove him to a suitable place to wait for social workers to progress his case. 10.2 Police officers are required for both law enforcement and to protect vulnerable people. Police stations are not ‘places of safety’ for accommodating children subject to child protection concerns but as a temporary measure to provide time for other agencies to deploy resources they may be used to retain a vulnerable child. An interview room was used for this purpose. 10.3 YT did become agitated and punched a wall. The police officers thought that this was a sign of frustration associated with being in his situation, not being able to communicate very well with the officers due to the language barrier and waiting around for unknown persons (a social worker). The use of handcuffs has been addressed previously (above) in this SCR. There is a duty on police when using police protection to ‘take such steps as are reasonably practicable to discover the wishes and feelings of the child.’ Unfortunately, this does not appear to have been a priority area for the police. Instead the major focus was in provision of a temporary place of safety and retaining his physical presence until CSC could take responsibility for assessment and case progression. This approach to YT stems directly from the age uncertainty issue but a consequence was that the police made no or little effort to gather information about his feelings that would assist a wider assessment of need such as, motivation, intentions and whether he was a victim of neglect or abuse. 10.4 The arrival of the EDT social worker was an opportunity for these issues to be raised and for a child centred assessment to commence. Instead, the priority once the social worker had decided that YT should be treated as a child was to find a suitable placement for him. This is understandable in terms of the pressing workload of EDT but from the perspective of establishing if a sufficiently child focused approach was in place it is deficient. 10.5 Professionals had opportunity during the ‘assessment meeting’ in the interview room at Edmonton Police Station to ask wider questions via the LanguageLine translator service. This opportunity was missed and therefore EDT had very little to pass on to Future Fostering when seeking the emergency placement. A more significant issue was that YT himself remained in an information vacuum as opportunities for him to express his needs and feelings were bypassed. 10.6 On arrival at the foster home the prospective foster carers needed to establish communication with YT to satisfy themselves they could provide a suitable environment for him. EDT were not present at this introductory meeting and the Foster Carers could not speak to YT in any common language. Again, the police facilitated communication using LanguageLine interpretation services on the telephone. This was helpful and allowed the carers to gather information on language, diet and clothing. They recognised YT’s need to speak to someone in his own tongue and let him know that they were in touch Enfield Safeguarding Children Board ESCB SCR YT Final version Page 21 of 28 with another Eritrean boy and that they would attempt to bring them together the following day. 10.7 The foster carers were sensitive to YT’s needs and they provided him with food after asking of his dietary requirements, facilities to wash, sleep and fresh clothes. The time of day was also relevant to the questioning and the depth of detail that were appropriate. The Future Fostering Agency does offer specific training to its carers in relation to looking after UASC but these particular carers had not completed that training and were expected to rely on previous general training and experience. Indeed, the Agency has noted that one of the Carers has a Master’s Degree in Counselling. Analysis. YT came to the attention of the agencies on a Friday evening. This tends to be a period of high demand and when mainstream (9am to 5pm Monday-Friday) capability is not usually available to provide services. Instead, agencies rely upon emergency response and short term service provision to deal with acute and arising operational demands. There is nothing untoward or new in this situation and these arrangements are monitored and resourced commensurate with the levels of demand and/or projected demand experienced by the services responsible for providing emergency support. The provision of short notice foster care for children taken into police protection or from other incidents arising is a regular demand for EDT. The actual causational incident type is a significant factor when arranging suitable placements but this is only one of several highly relevant issues that should be considered in deciding suitability of placements. Information about the needs and vulnerability of each child should be gathered so that the best possible placement for that child is commissioned. Decisions on safety and promotion of welfare should be supported with evidence to quantify aligned behind any decisions. This evidence may be; information received from others or existing records, it may be gathered from observation and dynamic assessment and it may be obtained by speaking to the child themselves. Indeed, for older children it should be vital for professionals to gather their point of view and in so doing assess their levels of perception to vulnerability and risk of harm. This includes identifying specific welfare issues or any underlying illness in the child. In this situation, the professionals and carers involved have acted in line with existing expectations to the presenting demand at hand. It would have been possible at several points; on taking YT into police protection, while waiting for the arrival of a social worker, during the assessment on arrival of the EDT social worker and on arrival at the foster home to ask additional questions aimed at and enriching the professional understanding of YT’s situation. But there was no guarantee for the professionals that additional probing of what was an already tired and unsettled young person would add much to their understanding of his needs. Indeed, his willingness to respond to communication via LanguageLine would have provided some reassurance to professionals that there were not acute emotional or mental health issues requiring an immediate response. There were no obvious indications to any of those who met and assisted YT that he was a suicide risk. Indeed, when considering what was known (information given by YT) about the purpose of his presence in the UK (Asylum seeker), his being released from Enfield Safeguarding Children Board ESCB SCR YT Final version Page 22 of 28 detention by the police and provided with care and accommodation it could be thought that he was in a positive situation. What is not known is the detail of his journey from Eritrea to arrival in the UK. Was he travelling in a family or friendship group that had become separated? Had he previously been following the leadership of another and was now isolated or feeling abandoned? He possessed a mobile phone that was connected to the French network and analysis of calls made on that device show a few contacts in France and Italy. When police contacted people, including a person who claimed to be YT’s cousin, on these telephone numbers the information provided was limited but in essence it was that a larger family group had left Eritrea with the intention of migrating to the West. There was no fixed plan but individuals intended to meet up in the future. YT phone was not used in the UK and he requested the foster carers to provide him with a charger as the one he had was not suitable for the UK and his phone battery was depleted. There was therefore an indication for professionals and carers that YT was feeling isolated and wanted to speak with others who he could contact on his telephone. As he was being treated as an UASC a first step in assessing his situation would have been to ask questions as to how to contact his family or any adult family friends by using stored numbers from within the phone. It is speculative to assume whether such actions would have provided any useful information or assistance in assessing vulnerability or need as they were not pursued. But agencies and carers alike should be aware of the importance of mobile devices in everyday life especially to the young. Mobile Phones and other devices hold a wealth of information and matters such as patterns of use, contact details and messages can be highly useful for analysis and assessment. 11. Was practice sensitive to and / or influenced by the racial, cultural, gender, sexuality, linguistic and religious identity and any issues of disability of YT and were these explored, taken on board and recorded? 11.1 The use of the translation service LanguageLine by the police at three separate stages assisted interaction with YT. Each time either the police were attempting to gain information about his status, welfare and any significant needs or requirements that needed to be taken into consideration in service delivery. 11.2 Apart from a questionnaire which is a standard part of the police custody process there was no standard format or process for gathering and recording personal information to assist in supporting service delivery that is appropriate to; race, culture, gender, sexuality, linguistic, religious identity and to any form of disability. 11.3 The foster carers asked questions about; diet, illness, medication, allergies and religious persuasion to help them assess their ability to provide a suitable accommodation for this child. The answers given using LanguageLine together with verbal information from the police and their observation of YT’s initial presentation allowed them to agree to the placement. Enfield Safeguarding Children Board ESCB SCR YT Final version Page 23 of 28 11.4 In fact, the foster carers had only limited information available to them. They knew nothing substantial of YT’s background or personal experience beyond the period he was found by police. They were not informed that he had become agitated and police had found the need to handcuff him for a period. They also had no provision for translation services beyond the internet once the police departed. This was an emergency short-term placement at a weekend and the Carers were given no definite timeline for either an assessment process or for the UASC process with the immigration authorities. 11.5 Despite this and based largely upon the availability of a suitable bedroom, their training with support from the Future Fostering Agency and the polite presentation of YT himself the foster carers felt that they would be able to meet his immediate needs. Analysis. The timescale relating to this incident is short. The statutory agencies used the available time to focus on the main presenting issues and these were firstly the immigration status and secondly the requirement to find suitable short-notice accommodation for a child who had been placed under police protection. During this activity, there is evidence to confirm that the police, CSC and the foster carers were sensitive to significant intrinsic factors such as gender, cultural identity, diet and language. There was no obvious or presenting disability and sexuality does not appear to have arisen as an issue in this short period for assessment or response. Aside from the custody questionnaire, that was not in any event shared with other agencies, there was not any systematic record keeping or process for risk assessment that incorporated consideration of sympathetic practice to best support the child’s needs. Time was a factor in this case, but a child was taken into care and it is reasonable to expect that at the very least a rudimentary care plan that documented known or likely risks including consideration of cultural and personal factors would be drawn up and its information available to all those with responsibility for safeguarding and promoting the welfare of the child. Such a plan would also benefit from the inclusion of a communication strategy. As an individual YT was isolated from friends and his community. His ability to communicate even simple needs was limited due to the language barrier and being in a new country for a very short time. He was therefore vulnerable. The availability of interpretation services on demand for foster carers in cases such as this where there is no common language between the child and the carers would greatly assist communication, reassurance and understanding any pressing needs the child may have. 12. Conclusions 12.1 In most SCRs the views of family members are sought and encouraged whatever their personal involvement with the situation leading to the incident prompting the LSCB to hold a review. In this case, there is no suggestion that any family members are present or have been present in the UK. Police officers have spoken to family friends in the UK and have also spoken on the telephone to other relatives who are overseas. The little information Enfield Safeguarding Children Board ESCB SCR YT Final version Page 24 of 28 from these sources that has been forthcoming to this review is that YT was amongst others from his family who had decided to migrate from Eritrea to the West. There is no corroboration for this information and it is very sparse. Indeed, it is not certain if the UK was intended as the final destination for YT or other members of his family. There is no solid information on his actual motivations and the circumstances of his life prior to leaving Eritrea or while travelling from Africa, into Europe. 12.2 There are several reasons why family members of asylum seekers would not wish to provide information to ‘the authorities’. One may be their negative experiences with authority in home countries. While other reasons may be due to the current circumstances they find themselves in such as attempting passage themselves. So, there is no blame to be laid at the door of the family or any agency for this situation but rather it is pertinent to acknowledge the situation and that it may weaken the analysis and conclusions. 12.3 Consequently, this review has virtually no information on YT’s state of mind, his pre-existing vulnerabilities and any needs beyond that which was gathered by police officers, social workers and the foster carers who interacted with him during the very short time he was with them. This period was insufficient for anyone to complete an in-depth assessment of need or a comprehensive risk assessment. The assessment that was undertaken was largely focused upon ascertaining his status and particularly his age. This was critical to the police, the immigration officers and to social workers as age determined which agency should have primacy and responsibility for his safety and welfare. 12.4 In the reception of asylum seekers, age is relevant to the approach and pathways in place for processing applicants. The Children Act is applicable to the Immigration Service and officers in this case have given and advice which is consistent with that legislation and Home Office policy. The police followed the advice from the immigration officer releasing YT from arrest and criminal investigation, and taking him into ‘police protection’ with the status of a child likely to be at risk of significant harm. This meant a referral to CSC was made. A social worker travelled to see YT and decided to treat YT as a child in need of service provision. In effect this was an assessment decision. 12.5 Although YT had become quite agitated while waiting with a police escort in the interview room for the arrival of a social worker all the agencies had acted diligently and were progressing the assessment expeditiously. A discussion between the social worker and police that saw the removal of the restraining handcuffs provides evidence that consideration was given to his welfare and demeanour. If it was considered that he would continue to use aggression, harm himself or others the police would have been unlikely to remove the restraints. In fact, YT was compliant and cooperative as he answered questions and provided information to the social worker via an interpreter service. This information was used by EDT to find a short-notice foster care placement to accommodate YT for at least the weekend. 12.6 The role of EDT is to respond to immediate matters in a ‘task centred approach’. In this case a priority was to find suitable accommodation and they did this without undue delay. Where the EDT response was less effective was in commencing and recording an assessment that considered wider aspects of vulnerability and risk in the context of the wishes and feelings of the child. There is nothing to suggest that time was not available for these purposes. Enfield Safeguarding Children Board ESCB SCR YT Final version Page 25 of 28 12.7 A fully comprehensive and holistic assessment would not be possible or even appropriate but there was opportunity to initiate and record a dynamic initial assessment that would assist others in managing risk and meeting the individual needs of that child. This type of activity too, can be considered as a vital and a ‘task centred approach’. The absence of such a record to pass on and build upon means that the future carers and the professionals who deal with the case are deficient of some important information. Consequently, they must either ‘start again’ with assessment and / or they may need to operate in a generic way that is not centred on the known needs of the child. Both situations are inefficient and can add to the stresses for the child and safeguarders alike. 12.8 There is an understandable reluctance to add to the bureaucracy of the EDT workers but the absence of records containing; rationale for decisions, risk management strategies and how the wishes / needs of the child are being supported creates uncertainty in the short term and additional work in handovers and case progression for all stakeholders. 12.9 There is almost nothing to suggest to any professional or carer that YT was a suicide risk. He was undoubtedly in a situation where he was isolated from his family and friends and in a place where verbal communication with professionals and the carers was difficult. A full assessment of his mental health situation was not possible or appropriate to the initial meeting with the EDT social worker. However, the social worker was an approved mental health practitioner and he made no assessment of pressing mental health concern. 12.10 There was no formal risk assessment for the handover to the carers. This meant that the foster carers were not in possession of all known relevant information. The fact that YT had become agitated and punched a wall inside the police station and had been handcuffed was relevant and should have been recorded and passed to others who had responsibility for his welfare. This may have prompted increased levels of vigilance including observation of his demeanour for new signs of agitation and allowed the foster carers to respond to needs more effectively or seek assistance from other professionals. 12.11 Although a weakness in the professional approach to this UASC the absence of such a risk assessment does not provide any direct causational factors that contributed to YT’s own actions and death. 12.12 In considering the policy, processes and actions of professionals and the foster agency carers there is no evidence of any changes that could be made that would have specifically acted to deter YT from taking his own life. His death was not reasonably predictable to those who dealt with him. It would not have been appropriate to intrusively monitor him in his bedroom based upon what was known at the time. Enfield Safeguarding Children Board ESCB SCR YT Final version Page 26 of 28 13. Recommendation 13.1 The analysis of agency submissions to this SCR permits evaluation on the quality of practice and analysis of the circumstances and allows recommendations for improvements to be made. This recommendation has arisen out of a case where the presenting vulnerability of the child was as an unaccompanied asylum seeker who needed to be accommodated out of hours. The recommendation will also apply to other situations where children at risk of significant harm require emergency care provision. 13.2 The single recommendation is intended to support safer and more efficient operational practice by introducing changes to support communication in respect of risk management and ensuring the focus of emergency activity is centred on the child’s needs. 13.3 Timescales for delivering the changes needed for this recommendation are short / as soon as possible. Recommendation 1. Enfield Safeguarding Children Board (ESCB) should review and improve the ways in which professionals who are responsible for out-of-hours emergency child protection complete and record assessments and decisions; • to record all aspects of vulnerability, • to ensure the voice of the child is heard, • to detail necessary actions to reduce the risk of harm and promote welfare, • to facilitate effective communication, • to assist other / subsequent service providers. Enfield Safeguarding Children Board ESCB SCR YT Final version Page 27 of 28 Appendix 1 Section 46 Children Act 1989: Removal and accommodation of children by police in cases of emergency. (1) Where a constable has reasonable cause to believe that a child would otherwise be likely to suffer significant harm, he may— (a)remove the child to suitable accommodation and keep him there; or (b)take such steps as are reasonable to ensure that the child’s removal from any hospital, or other place, in which he is then being accommodated is prevented. (2) For the purposes of this Act, a child with respect to whom a constable has exercised his powers under this section is referred to as having been taken into police protection. (3) As soon as is reasonably practicable after taking a child into police protection, the constable concerned shall— (a)inform the local authority within whose area the child was found of the steps that have been, and are proposed to be, taken with respect to the child under this section and the reasons for taking them; (b)give details to the authority within whose area the child is ordinarily resident (“the appropriate authority”) of the place at which the child is being accommodated; (c)inform the child (if he appears capable of understanding)— (i)of the steps that have been taken with respect to him under this section and of the reasons for taking them; and (ii)of the further steps that may be taken with respect to him under this section; (d)take such steps as are reasonably practicable to discover the wishes and feelings of the child; (e)secure that the case is inquired into by an officer designated for the purposes of this section by the chief officer of the police area concerned; and (f)where the child was taken into police protection by being removed to accommodation which is not provided— (i)by or on behalf of a local authority; or (ii)as a refuge, in compliance with the requirements of section 51, secure that he is moved to accommodation which is so provided. (4) As soon as is reasonably practicable after taking a child into police protection, the constable concerned shall take such steps as are reasonably practicable to inform— (a)the child’s parents; (b)every person who is not a parent of his but who has parental responsibility for him; and (c)any other person with whom the child was living immediately before being taken into police protection, of the steps that he has taken under this section with respect to the child, the reasons for taking them and the further steps that may be taken with respect to him under this section. Enfield Safeguarding Children Board ESCB SCR YT Final version Page 28 of 28 (5) On completing any inquiry under subsection (3)(e), the officer conducting it shall release the child from police protection unless he considers that there is still reasonable cause for believing that the child would be likely to suffer significant harm if released. (6) No child may be kept in police protection for more than 72 hours. (7) While a child is being kept in police protection, the designated officer may apply on behalf of the appropriate authority for an emergency protection order to be made under section 44 with respect to the child. (8) An application may be made under subsection (7) whether or not the authority know of it or agree to its being made. (9) While a child is being kept in police protection— (a)neither the constable concerned nor the designated officer shall have parental responsibility for him; but (b)the designated officer shall do what is reasonable in all the circumstances of the case for the purpose of safeguarding or promoting the child’s welfare (having regard in particular to the length of the period during which the child will be so protected). (10) Where a child has been taken into police protection, the designated officer shall allow— (a)the child’s parents; (b)any person who is not a parent of the child but who has parental responsibility for him; (c)any person with whom the child was living immediately before he was taken into police protection; (d)any person named in a child arrangements order as a person with whom the child is to spend time or otherwise have contact; (e)any person who is allowed to have contact with the child by virtue of an order under section 34; and (f)any person acting on behalf of any of those persons, to have such contact (if any) with the child as, in the opinion of the designated officer, is both reasonable and in the child’s best interests. (11) Where a child who has been taken into police protection is in accommodation provided by, or on behalf of, the appropriate authority, subsection (10) shall have effect as if it referred to the authority rather than to the designated officer. |
NC51223 | Death of a 16-year-old boy by suicide in June 2017. Peter was known to multiple agencies including children's social care (CSC) and child and adolescent mental health services (CAMHS) in relation to self-harm, obsessive compulsive disorder, body image, eating disorder, his sexuality and possible child sexual exploitation (CSE). Peter struggled with his own identity. Attempts at agency intervention declined by Peter and mother. Peers suggested that Peter was meeting men for money in exchange for sex arranged over social media. Peters father was concerned that Peter had a lot of unaccounted for money. Ethnicity or nationality is not stated. Learning includes: professionals should make notes of disclosures made by children as soon as possible after the conversation, which must not include leading questions; notes must be suitable for disclosure to any future enquiry or investigation. Recommendations include: ensure that staff understand, in line with the schools updated policy, that it is not the role of staff to investigate disclosures by interviewing the child or others involved, unless asked to do so by police, CSC or NSPCC; review the interagency CSE procedures to ensure that when there are sufficient concerns to support a section 47 enquiry that the appropriate multi-agency response is triggered; undertake an audit of CSE meetings; promote the increased use of the Early Help Assessment Framework by agencies and explore the barriers which prevent professionals from completing them. Please note this report was originally published in 2018 but was amended in July 2019.
| Title: Overview report: serious case review of the circumstances concerning ‘Peter’. LSCB: Nottinghamshire Safeguarding Children Board Author: Malcolm Ross Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Overview Report Serious Case Review of the Circumstances Concerning ‘Peter’ Independent Author Malcolm Ross M.Sc. Date 19th October 2018 2 Contents Page List of Abbreviations 3 Introduction 4 - 8 Serious Case Review Process 4 - 5 LSCB responsibilities 5 Independent Reviewer 5 - 6 SCR Panel 6 Individual Management Reviews 7 Timescales 7 Learning Model 7 - 8 Family Involvement 8 Subjects of the Review 8 Genogram 9 Sequence of events leading to the death of Peter 10 - 23 Events within time period of review 11 - 23 Views of the family 23 - 24 Analysis and recommendations 24 - 48 Referrals 24 - 33 Peter’s response to referrals and agency involvement 33 - 34 Record Keeping in school 34 MASH referral of 21st April 2017 35 - 36 Child Sexual Exploitation Multi-agency Strategy Meeting 36 - 41 7th June 2017 and Nottinghamshire Police response. British Transport Police response 42 - 43 School Nurse 1 43 - 44 Summary of agency conclusions and recommendations 44 - 48 Conclusions 48 - 50 Recommendations 51 Bibliography 52 Appendix 1 - Terms of Reference 53 - 58 Appendix 2 - IMR Recommendations 59 - 60 3 List of Abbreviations ADVIS Adult Deaf and Visual Impairment Service ASD Autistic Spectrum Disorder BTP British Transport Police CAIU Child Abuse Investigation Unit (Police) CATS Police Child Abuse Tracking System CAMHS Child and Adolescent Mental Health Service CCG Clinical Commissioning Group CDOP Child Death Overview Panel CEOP Child Exploitation and On Line Protection Command of National Crime Agency CSC Children’s Social Care CSE Child Sexual Exploitation DfE Department for Education DNA Deoxyribonucleic Acid EHAF Early Help Assessment Framework EHCP Education, Health and Care Plan EMAS East Midlands Ambulance Service GP General Practitioner IMR Individual Management Review LSCB Local Safeguarding Children Board MASH Multi Agency Safeguarding Hub MISPER Missing Person (Police form) SCB Safeguarding Children Board SCR Serious Case Review SCRP Serious Case Review Panel SEIU Sexual Exploitation Investigation Unit (Police) SLSA Senior Learning Support Assistant WTSC Working Together to Safeguard Children 4 Overview Report of the Serious Case Review of the Circumstances Concerning ‘Peter’ The Serious Case Review Panel offer their sincere condolences to the family of Peter (not his real name) in their sad loss and thanks them for their kind assistance in this review process which must have been difficult for them. 1. Introduction 1.1 Peter was a 16 year old boy who took his own life on 8th June 2017 by jumping in front of a moving train in Nottinghamshire. According to evidence gathered by British Transport Police who investigated the death, it appears to have been a deliberate act. The train driver had no chance of avoiding him as the train was travelling at approximately 80 m.p.h. 1.2 The review process has determined that there were issues identified with the emotional stability of Peter emanating from his family background, his chaotic family circumstances and he was known to mental health services as well as Children Social’s Care, GP, School Nurse and CAMHS in relation to a range of concerns including self-harm, OCD, body image, eating disorder, his sexuality and possible CSE. These issues will be explored later in this report. 1.3 HM Coroner was notified of the death of Peter. H.M. Assistant Coroner for Nottingham, Dr. Elizabeth Didcock, held an Inquest into Peter’s death on 13th, 14th and 21st September 2018. After hearing evidence from numerous witnesses, H.M. Assistant Coroner returned a determination of suicide adding: ‘I do not think that even those who knew him very well, particularly his parents, could have predicted what he would do – what is not predictable is not preventable’. Serious Case Review process 1.4 This Serious Case Review has been commissioned under Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 which sets out the functions of Local Safeguarding Children’s Boards (SCBs). This includes the requirement for SCBs to undertake reviews of serious cases in specified circumstances. 1.5 Regulation 5(1) (e) and (2) set out an SCB’s function in relation to serious case reviews, namely: 5 (1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1) (e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 5 “Seriously harmed” in the context of regulation 5(2)(b)(ii) above includes, but is not limited to, cases where the child has sustained, as a result of abuse or neglect, any or all of the following: • a potentially life-threatening injury; • serious and/or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development 1.6 Cases which meet one of these criteria (i.e. regulation 5(2) (a) and (b) (i) or 5 (2) (a) and (b) (ii) above) must always trigger a Serious Case Review. Regulation 5(2)(b)(i) includes cases where a child died by suspected suicide. 1.7 The Terms of Reference and Scope of this review are detailed in Appendix No 1 to this report. Local Safeguarding Children Board responsibilities 1.8 Chapter 4 of Working Together 20151, states: ‘The LSCB for the area in which the child is normally resident should decide whether an incident notified to them meets the criteria for an SCR. This decision should normally be made within one month of notification of the incident. The final decision rests with the Chair of the LSCB. The Chair may seek peer challenge from another LSCB Chair when considering this decision and also at other stages in the SCR process. The LSCB should let Ofsted, DfE and the national panel of independent experts know their decision within five working days of the Chair’s decision.’ 1.9 The Chair of Nottinghamshire SCB was informed of this incident on 18th September 2017 and a decision to commission a Serious Case review (SCR) was made on that day. Independent Reviewer 1.10 Chapter 4 of Working Together to Safeguard Children (WTSC)2 gives guidance on the appointment of an independent reviewer and states: ‘The LSCB must appoint one or more suitable individuals to lead the SCR who have demonstrated that they are qualified to conduct reviews using the approach set out in this guidance. The lead reviewer should be independent of the LSCB and the organisations involved in the case. The LSCB should provide the national panel of independent experts with the name(s) of the individual(s) they appoint to conduct the SCR. The LSCB should consider carefully any advice from the independent expert panel about appointment of reviewers’. 1.11 Nottinghamshire SCB has commissioned Mr. Malcolm Ross to undertake this review as author and chair of the Serious Case Review Panel (SCRP). Mr Malcolm Ross was appointed at an early stage, to carry out this function. He is a former Detective Superintendent with West Midlands Police and has many years’ experience in writing over 80 Serious Case Reviews and chairing those reviews. He has also performed 1 Working Together to Safeguard Children - A guide to inter-agency working to safeguard and promote the welfare of children H.M. Government 2015 page 78 2 Working Together to Safeguard Children - A guide to inter-agency working to safeguard and promote the welfare of children H.M. Government 2015 page 78 6 both functions in relation to over 30 Domestic Homicide Reviews. Prior to this review process he had no involvement either directly or indirectly with the members of the family concerned or the delivery or management of services by any of the agencies involved. He has attended the meetings of the panel, the members of which have contributed to the process of the preparation of the Report and have helpfully commented upon it. Serious Case Review Panel 1.12 WTSC guidance goes on to say: ‘The LSCB should ensure that there is appropriate representation in the review process of professionals and organisations who were involved with the child and family. The priority should be to engage organisations in a way which will ensure that important factors in the case can be identified and appropriate action taken to make improvements. The LSCB may decide as part of the SCR to ask each relevant organisation to provide information in writing about its involvement with the child who is the subject of the review.’ 1.13 In order to satisfy this part of the guidance, Nottinghamshire SCB created a Serious Case Review Panel consisting of senior members of organisations concerned with the family together with the important element of independent members to give a neutral oversight to the proceedings and findings of the review. None of the panel members had any operational dealings with the family. 1.14 The panel members were: Malcolm Ross Lead Reviewer/Overview Report Author Julie Gardner Associate Director for Safeguarding and Social Care, Nottinghamshire Healthcare NHS Foundation Trust Nicola Bramhall Director of Nursing and Quality, Nottingham West Clinical Commissioning Group Mel Bowden D.C.I. in Public Protection, Nottinghamshire Police Steve Edwards Service Director, Youth, Families & Social Work, Nottinghamshire County Council Marion Clay Service Director, Education, Learning & Skills, Nottinghamshire County Council Deputy Head Teacher Deputy Head Teacher, Nottingham School Bob Ross NSCB Development Manager Steve Baumber Safeguarding, Assurance and Improvement, Nottinghamshire County Council Carol Fowler Child Death Administrator Nottinghamshire County Council 7 Individual Management Reviews 1.15 WTSC suggests: ‘The SCB may decide as part of the SCR to ask each relevant organisation to provide information in writing about its involvement with the child who is the subject of the review.’ 1.16 In order to gather information for the review process, the following agencies were requested to provide an Individual Management Review (IMR): • Nottinghamshire Police • Nottinghamshire Healthcare NHS Foundation Trust • Nottingham West Clinical Commissioning Group • Education • Children’s Social Care The below named agencies were asked to provide an Information Report; • British Transport Police • Nottingham University Hospital • Nottinghamshire County Council Adult Social Care (Adult Deaf and Visual Impairment Service) • Nottinghamshire County Council Adult Social Care (Community Mental Health Team) • East Midlands Ambulance Service • Cafcass Timescales 1.17 Guidance mentions Timescale for SCR completion: ‘The LSCB should aim for completion of an SCR within six months of initiating it. If this is not possible (for example, because of potential prejudice to related court proceedings), every effort should be made while the SCR is in progress to: (i) capture points from the case about improvements needed; and (ii) take corrective action to implement improvements and disseminate learning.’ 1.18 The National Panel was informed of the commencement of this review on 25th September 2017 and all efforts have been made to complete the review within the 6 months guidance. 1.19 The scope of this review and the parameters for IMRs was determined as being from 1st May 2014, the month when the first indication of suicidal ideations was brought to the attention of professionals, until the date of the ‘Child Death Initial Case Discussion Meeting’ on 12th June 2017. Learning Model 1.20 WTSC guidance states: 8 ‘SCBs may use any learning model which is consistent with the principles in this guidance, including the systems methodology recommended by Professor Munro’.3 In this review Nottinghamshire SCB decided to use the traditional model of reviews. Family Involvement 1.21 Page 74 of the guidance deals with family involvement in the review process: ‘Families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process.’ 1.22 To this end family members were written to indicating that a review is being undertaken and inviting them to engage. The Author and the NSCB Safeguarding Development Manager saw Peter’s mother at County Hall on 19th December 2017 and also visited his father at his home on 30th January 2018. There has also been considerable telephone contact between the Development Manager and the father during the remainder of this review period. Both parents have been consulted extensively and have engaged throughout with the review panel and process. Subjects of this review 1.23 The below matrix indicates the principle people involved in this review and how the report refers each to them to protect their identity. Mother Mother of Peter and of S1, S2, S3, and S4 Father Father of Peter and of S3 and S4 S1 Female Oldest sibling S2 Male Second oldest sibling S3 Female Third oldest sibling Peter Male Deceased Fourth oldest sibling S4 Male Fifth oldest sibling 3 Department for Education The Munro Review of Child Protection: Final Report: A Child Centred System, Cm 8062, May 2011. 9 Genogram Previous Partner Step brother Step sister PETER Sister Brother Female Male Divorced/separated Mother Father 10 2. Sequence of Events leading to the death of Peter 2.1 Family structure and history. 2.2 Mother and Father separated years before the scope of this review. Mother had two children, S1 and S2 from a previous relationship. Mother and Father went on to have three other children, S3, Peter and S4. 2.3 Mother is registered with Nottinghamshire County Council as being Deaf with Speech. She has been known to Adult Social Care since December 1999 and remains known to the Adult Deaf and Visual Impairment Services (ADVIS). Mother’s general health problem concerned her hearing that affected her communication, albeit she was able to adequately lip read. She had a full time job. She acknowledged that communication with Peter was sometimes difficult. 2.4 The father has a long history with mental health services dating from when he was a child. He developed a personality disorder and obsessive compulsive disorder. The impact of his mental health and the risk to his children was considered but there was no referral made to Children’s Social Care (CSC). The children appeared well cared for and the father expressed ‘the upmost concern for his children’. The father disclosed to various medical and mental health practitioners that he had suicidal ideation of killing himself at a local train station. He also stated to a professional that his grandmother had taken her own life 2 – 3 years before.4 Peter had to live through the suicide of his uncle. 2.5 Health Visiting records indicate that the older children remember an incident of domestic abuse while the mother was pregnant with Peter. There is evidence of social care intervention and some multi-agency information sharing. S3, Peter’s older sister had been diagnosed with Autistic Spectrum Disorder (ASD) at the age of 14½ years and the mother was concerned that Peter was displaying similar behaviours. 2.6 Education records indicate that all of the children in the family attended local schools and Peter in particular, was described as being happy at school and making good progress. His attitude to learning was noted as being universally good or outstanding. One incident worthy of mention prior to the scoping dates of this review, occurred in 2013, when Child Exploitation and On Line Protection (CEOP), a National Police Unit, came across a video that Peter had posted of himself on line engaging in a sexual act. He was identified by the school blazer in the background of the video. 2.7 Peter was traced and interviewed stating that it was his own stupidity and no-one else was involved. He denied that he had been coerced or bullied into acting in this way. No further police action was taken and the matter closed, however details of the incident were not shared with CSC. CEOP’s involvement was not shared with Nottinghamshire CSC. 2.8 Peter was described by his mother and family members as being the joker of the family. He liked to drink alcohol and attend parties and enjoyed sport and music festivals. He did not eat with the family but would binge eat and then make himself vomit. He was described as being overweight, something that Peter himself was concerned about but not long before his death, Peter had lost a considerable amount of weight, according to his mother, estimated to be around 9 stones. He was a goal keeper for a local football team for some years. 2.9 It is of interest that Peter’s school indicate that by the end of year 8, (13 years of age) his attitude to learning was described as good or outstanding in all but 3 subjects where 4 Contrary information has been received subsequently that his grandmother’s death was an accident. 11 improvement was needed. At the end of year 9, (14 years of age) records indicate his attitude to learning was good or outstanding in all subjects apart from 5 subjects that required improvement. By the end of year 10, (15 years of age) his attitude to learning was good or outstanding in all subjects. It is considered by his school that he would have achieved passes in his GCSE subjects with good grades. 2.10 At Secondary school, the Year Head became Peter’s pastoral lead and would follow him through years 7 to 11. That Head of Year was interviewed by the Education IMR author during the process of this review and stated that he knew Peter well and Peter and other pupils would often join him at lunch time in general conversation. It is clear from what Peter’s mother stated that Peter got on well with the Head of Year and confided in him about all sorts of issues. It is interesting to note that not long before his death, Peter wrote the Head of Year a letter, described by the IMR author as ‘remarkable’, making the case for Peter to be appointed a school prefect. Extracts of the letter state; ‘I feel that I have reclaimed a favourable relationship with certain subjects; along with a constructive relationship with teachers. However there is no hiding the fact that my attitude coming in to year seven was quite poor, reflected in my ‘attitude to learning’ scores. Nonetheless, after maturing throughout my time at [school], I have developed a whole new persona – having been supported thoroughly by the school in helping me achieve my full potential’ ‘My willingness for the school to succeed is distinctive as I am a frequent volunteer in after school clubs, parents’ evenings and even in the classroom. These traits all give worthy reasoning that I am an enthusiastic individual … with positivity amongst my fellow students and teachers and also my longing for success within the school. I am full committed (to) becoming a prefect with only the full intention of helping others. Despite my looming face I deem myself well-mannered, well-spoken and most (definitely) – collected.’ 2.11 This letter seems to indicate that at the time of writing, Peter had the intention to continue at school and indeed offered himself for a position of responsibility, perhaps even being content with his school life. Events within the time period of the scope of this review 2.12 On 27th May 2014, Peter’s school sent an email to their local School Nursing Team saying that the mother had had a conversation where she suspected Peter was demonstrating similar behaviour to that of his older sister who had been diagnosed with ASD. The email referred to a suicide notes that Peter had written about a month prior. The mother was advised by the School Nurse to take Peter to see his GP as soon as possible and it was intended that the school would make a referral to CAMHS. The mother was offered support over the forthcoming school holiday. 2.13 The School Nurse met with the mother during the school holiday on 30th May 2014, where the mother expressed her concerns that Peter had low self-esteem around his weight and appearance, spending hours in the bathroom over his appearance, showering up to three times a day. She said that Peter became angry and inflexible. She had found an empty box of paracetamol tablets in his room and he had been in trouble at school for stealing a memory stick from a teacher. Mother reported that Peter had posted a photograph of himself on You Tube, although the content of the photograph was not recorded in Peter’s health record. The School Nurse was told that the police were involved indicating that the nature of the photograph was probably inappropriate. Mother stated that she felt that Peter had become withdrawn since going to secondary school and that she had not noticed the changes in him due to her being 12 preoccupied with the diagnosis of her daughter with ASD. She said that Peter wanted to be tall and skinny like his peers. 2.14 On 30th May 2014, the School Nurse suggested that the Early Help Assessment Framework (EHAF) would help to identify the family’s needs and a plan could be devised to address them. It was acknowledged that the mother was a busy working single mother with her own disabilities that may well make communication at home with the children difficult. She also mentioned that her daughter had been diagnosed with Asperger’s and a lot of time was being taken dealing with that. The School Nurse again discussed a CAMHS referral with the school. (However CAMHS were unable to attend the first meeting and did not engage any further in the early intervention stage.) 2.15 On 25th June 2014, a meeting took place with the School Nurse, the school and the mother to initiate the EHAF process. The School Nurse had documented that the CAMHS referral was, at that time, ‘in process’. The mother stated that Peter’s emotional health appeared calmer at this stage and not at risk of immediate harm to himself. The School Nurse suggested that Peter should be seen by his GP for a referral to a Community Paediatrician. The school would support this referral. However, when the report from the school was received by the School Nurse on 23rd September 2014, there was no evidence to suggest that the GP was made aware of the proposed referral to a Paediatrician as per the Concerning Behaviour Pathway.5 2.16 On 17th September 2014, the School Nurse met with mother. She had not yet taken Peter to see his GP and therefore the referral to the Community Paediatrician had not been made. The mother explained how Peter could talk to his father much better than he could communicate with her. The School Nurse planned to see Peter in school. 2.17 After that meeting the School Nurse had a meeting with the school where she was informed of the previous episodes of Peter posting a video of himself and the intervention of CEOP6. The school have no record of the CEOP incident but school do acknowledge that CEOP contacted the school. There does not appear to have been due regard to any safeguarding concerns or risk to Peter as a result of this information exchange. 2.18 On 1st October 2014, the School Nurse had a one-to-one conversation with Peter at school. He is reported to be open and honest in his views but the School Nurse could not decide if he was crying or sweating profusely. He denied crying. The suicide note was discussed and Peter stated that he did not feel like that anymore. He did however say that he thought his home circumstances lacked routine and he also lacked personal space. He was at variance with his mother over the statement she made to the effect that he could talk to his father better than his mother. He said that it would be his mother he would turn to if he ever felt suicidal again. The School Nurse’s plan was to continue with the referral pathways to CAMHS or the Paediatrician. There is nothing recorded as to why she had not done that thus far. 2.19 On 30th October 2014, the School Nurse again saw Peter with his mother at the Health Centre. He was very weepy and stated that he felt more relaxed at his father’s house where there was less pressure. He completed a ‘mood diary’ and the School Nurse 5 The role school nursing service is well documented due to the quality and consistency of the record keeping in line with the Trusts record keeping policy. It therefore has been noted that the day to day contact within the school is not recorded in this way. The role of the school nurse must be seen within the context of the school nursing services role, responsibilities and the proportion of the overall interaction between Peter and all agencies. In particular the school nursing service had not had active involvement with Peter for the year prior to his death which is in line with the service provided. The Concerning Behaviour Pathway was introduced in 2013 6 CEOP – Child Exploitation and Online Protection Command of National Crime Agency 13 suggested a referral to CAMHS. Peter declined the referral but did consent to half termly appointments with the School Nurse. 2.20 Peter met the School Nurse again on 30th December 2014, when he told her that some of the issues at home had been resolved and he was in a ‘much better place’. He was spending more time with his mother and looking forward to going on holiday with the rest of the family. 2.21 On 13th March 2015, the School Nurse attended a meeting at school and was informed that Peter had self-harmed in school. He was very anxious about this and stated that he did not want his mother informed of what had happened. Consideration was again given to the school making a referral to CAMHS, a Paediatrician and also to Young Carers. In fact the School Nurse or the school could have made that referral. Mother thought that ASD may have contributed to this behaviour and decision making. 2.22 Later that day the School Nurse saw Peter at school. He said that he had used the blade from a pencil sharpener to cut himself because he was annoyed that he had been late for school and he had self-harmed to calm himself down. He said it was a ‘one-off’ incident and he would not do it again. He stressed that he didn’t want his mother to know as this would worry her. The School Nurse also tried to discuss other concerns that had been raised at school about his sexuality but Peter would not engage with that conversation. 2.23 An appointment was made for the School Nurse to see Peter’s mother on 18th March 2015. The School Nurse told the mother that she was leaving the School Nursing Service. The School Nurse told the mother that she had been seeing Peter at school and she had no concerns about him. Mother said that she knew Peter was self-harming albeit Peter had said that he had scratched his hands in football practice. Mother also stated that her daughter had overheard a telephone conversation between Peter and another male who was asking Peter out. Peter had been seeing less of his father and it was clear that mother required on-going support for herself. She was advised to seek help and guidance from her GP. The School Nurse in fact communicated her concerns to the mother’s GP. 2.24 On 20th March 2015, the School Nurse met with school management and expressed concern that no-one seems to be taking the lead in supporting Peter at which the Head of Year agreed to take ownership of this and support Peter in school. 2.25 On 24th March 2015, the School Nurse had a conversation with the GP and informed the GP of Peter’s low mood, low self-esteem and possible autistic traits. It was noted that there was still no referral to CAMHS despite the ongoing concerns raised by the school nurse. In addition Peter had been involved in an incident at school where he had threatened another student with a bottle opener. The school nurse saw Peter together with a teaching assistant and discussed this latest incident, he said he had been drinking alcohol and had acted out a scene from a computer game. He indicated that he regretted the incident and had self-harmed as a result. 2.26 The following day the teaching assistant met Peter’s mother and had a conversation about Peter wearing a sports bra and that he is very sensitive regarding his weight and his ‘man boobs’. The teaching assistant had been in a meeting with Mother regarding the sister who had ASD and during that conversation, Mother brought the subject of what Peter had been wearing. The sister had heard Peter on the phone to someone talking about a boy who had asked him out but during the telephone conversation Peter self-harmed. Mother confirmed that Peter had an appointment with the GP for 31st March 2015 but he refused to attend that appointment. 14 2.27 In May 2015 a new school nurse took over Peter’s case, the previous nurse having left the service. The new school nurse (SN2) was informed by Peter’s GP that he had not attended an appointment to discuss his breast size. SN2 attempted to meet with Peter on 3 occasions but it was clear that Peter was starting to disengage from offers of support. SN2 gave Peter an open appointment should he wish to see SN2. 2.28 On 15th June 2015 Peter’s mother saw the GP and was concerned that Peter was isolating himself and she was worried that he had similar traits to her daughter who had autism. She described Peter as being ‘desperately unhappy’. The GP spoke to SN2 and it was agreed that a referral would be made to CAMHS and a comprehensive referral was made by the SN2. The GP’s records were also highlighted with ‘emotional problems’ which would alert clinicians to ongoing problems. 2.29 On 24th June 2015 SN2 tackled Peter as to why he didn’t attend to see his GP about his breast size problem. Peter denied ever having a GP appointment, he stated he was well and he didn’t require any further input in school. He was eager to leave and get back to class. 2.30 On 5th August 2015 mother attended the local Police Station to report that Peter had bought alcohol at a local shop. She stated that he was asked for ID but he said that he had forgotten to bring it with him and the shop owner ‘let him off on that occasion’. A Police Officer made enquiries at the shop and checked the CCTV but was unable to identify Peter with alcohol. The ‘refusal book’ which is a log of occasions of when the shop refuses to sell alcohol was in order and no further action was taken. 2.31 During the school holiday in August 2015 SN2 met with mother at a local health centre. Mother raised several issues about Peter, his self-harming had escalated during the school holidays, he had attempted to strangle himself on two occasion during a family holiday and he had threatened his sibling with a knife. There appeared to be an escalation in his obsessional behaviour and mother reported she had removed knives, blades and medication from the home. Peter was obsessed with showers and cleanliness and he had attempted to set fire to curtains in his bedroom with matches. Mother also disclosed that Peter’s father misuses drugs and alcohol and she worries when her children stay there with him. SN2 advised mother to take Peter to the Accident and Emergency department if she felt he was at immediate risk and there is nothing to suggest that the safety of the others in the same household was considered. 2.32 The following day SN2 visited the family home to discuss the CAMHS referrals with Peter who agreed that he needed support and consented to the referral being made. The referral was made to CAMHS on 20th August 2015. Peter had been referred to CAMHS in October 2014 but had declined to attend. 2.33 On 27th August 2015 CAMHS accepted the referral and escalated Peter’s case to Specialist CAMHS. Peter was offered an appointment on 15th September 2015. 2.34 On 9th September 2015 the Special Educational Needs Co-ordinator (SENCO) at Peter’s school emailed the Head of Year to the effect that Peter had been accepted by CAMHS and that CAMHS were very concerned about his mental health particularly around his self-harming. The Head of Year recalls that he understood that Peter only attended one CAMHS meeting and then stopped going. The Head of Year thinks that it was Peter that wanted to stop, not his mother who had tried to get Peter to attend self-help groups for eating disorders which again he failed to attend. It is the opinion of the Head of Year when interviewed by the IMR author for education that; 15 ‘[Peter] saw the weight loss as about a healthy body and a good look. Mother saw the weight loss as a link to [Peter’s] interest in the gay community with associated concern with body image.’ 2.35 On 15th September 2015 Peter and his mother attended a CAMHS initial assessment appointment. A discussion took place about Peter’s difficulties within family relationships especially with his sister, the frustration with communicating with his mother and the fact that he had not had contact with his father for six weeks due to lack of transport. He described how he enjoyed staying with his father. He also disclosed self-harming recently and admitted he attempted to strangle himself in July 2015. He denied trying the set fire to his bedroom curtains. Notes indicate that Mother was seen first at this meeting which took a long time and the assessment with Peter was only half competed. Another appointment to complete the assessment was arranged. 2.36 At 22.19 hours the same day Peter was reported missing by family members. He had been seen last at 18.30 hours by family members and had left with his mobile which he was now not answering. His was wearing his school uniform. 2.37 At 22.27 hours the same day Peter’s father phoned the Police as Peter was still missing. A note had been found at the family home indicating that he wanted to commit suicide as he was depressed. An officer was sent to the home but on arrival Peter returned having been found walking the streets by his mother. On being interviewed by the Police officer Peter stated he had been arguing with his mother and siblings, which had caused him to feel down. He had had the first session with CAMHS that morning and found it a positive experience. 2.38 On 17th September 2015, Peter’s sister (S3) disclosed to the Senior Learning Support Assistant at school that her brother had been missing and the Police involved. She disclosed that; ‘he has been suffering from depression and had been cutting himself on his arms.’ She had seen him at home holding a knife to his neck and on holiday they had found him with a belt around his neck 3 times and he had marks on his neck from trying to strangle himself. Mother and Father were said to be both aware of this but didn’t want [S3] to tell anyone’. 2.39 The Head Teacher (Senior Designated Safeguarding Person) contacted the Early Help Team who advised a referral to the Multi-Agency Safeguarding Hub (MASH). The referral stated that Peter was not in a good place at that time and needed significant support. It is noted that Peter went missing on the same day as his initial assessment with CAMHS. 2.40 On 25th September 2015 a social worker from CSC visited the mother at the home address, but the mother refused to allow her into the house saying that Peter was now engaging with CAMHS. Mother refused to sign the consent form to allow the SW to speak to other agencies and refused to allow the SW to speak to the other children. Children’s Social Care closed the case and informed the school. Mother refused to cooperate. The Head Teacher emailed the mother confirming that the CSC referral had been closed and asking the mother’s permission for CSC to undertake checks with CAMHS. 2.41 As a result of the mother’s refusal to engage with CSC, Peter’s case was closed as it was thought that he was engaging with CAMHS and had a good relationship with the Head of Year at school. 16 2.42 On 7th October 2015 Peter’s GP spoke to CAMHS confirming Peter’s attendance, an indication of the GP following up Peter’s best interest. 2.43 On 19th October 2015 in an email communication between CAMHS and the mother, mother stated that Peter was refusing to attend any further CAMHS appointment. Mother had disclosed difficulties in managing Peter’s behaviour in that he was displaying controlling behaviour towards her and he was struggling to show any empathy and was again concerned about his obsessive cleanliness. With the CAMHS assessment only half complete, Peter was discharged from the service, unsupported. There was no further communication between CAMHS and the school nursing team. The GP’s records indicate that whilst Peter had declined any further contact from CAMHS he and the family had been offered support from Young Carers or the Deaf Society. The Healthcare Trust IMR indicates that ‘All Health Services failed to engage with [Peter] as he refused additional support offered by [SN2]. [Peter] was offered an open appointment with the school nursing service and advised to attend his GP if he required further support,’ and; ‘The CAMHS discharge left Peter without CAMHS support as there was no further communication between CAMHS and the School Nursing Team’ 2.44 Peter was at this stage two weeks away from his 15th birthday. There is nothing to suggest what Peter’s thoughts were, what his strengths were, what he liked and the details of the difficulties at home. He had been seen with a belt around his neck. He communicated at a distance at school and did not get involved with things going on at school. The barriers preventing him communicating did not appear to have been explored. 2.45 On 9th December 2015 Peter was seen by SN2 at school. He stated that he thought CAMHS to be a waste of time and would not engage further in any discussion other than to say he did not have any other concerns or worries at that time. He declined to engage with SN2 any further but was left with an open appointment. 2.46 According to the CCG IMR Peter was discussed between the GP and SN2 on 16th December 2015 at the practice safeguarding meeting. SN2 reported details of her last contact with Peter on 9th December 2015 and the CCG IMR concludes; ‘At this meeting it was agreed that [Peter] would be monitored by [SN2] in partnership with the school.’ 2.47 On 28th January 2016 Peter was discussed at a GP’s Practice Safeguarding Meeting. It was reported by the School Nurse that Peter still did not wish to engage for support and he was removed from the list with a proviso that SN2 continued to monitor and liaise with the school on a ‘watch and wait’ basis. Over the next few months Peter engaged well at school. By the end of year 10 all of his subject teachers described his attitude to learning as either good or outstanding. In two subjects he had gone from a judgement of ‘requires improvement’ to ‘outstanding’. 2.48 On 26th September 2016 Peter and his mother saw his GP. He had been sporadically vomiting for a month. He was examined but no clinical abnormalities could be found. 17 The GP signposted Peter to Harmless7, Kooth8 and Base9. Peter was encouraged to eat regular meals and stop taking laxatives to reduce his weight. 2.49 Just after 23.00 hours on 2nd November 2016, mother’s partner called the Police to say that Peter had not returned home after having an argument about his weight loss with his mother and brother. Within 30 minutes Peter had returned home safe and well. The matter was reported to CSC by the Police and the CSC note indicates that Peter stated he felt like an outsider within the family. Mother reported that Peter walked around the house saying ‘it’s nearly over’. 2.50 On 8th November 2016 a worker from Family Services made contact with the mother about Peter going missing and the school to request permission to meet Peter in order to complete the return interview following him being missing on 3rd November 2016. Mother initially agreed but then withdrew her consent after reading about how information would be shared between agencies stating that the family did not need any support. There is no compulsion to engage under these circumstances. This was done in line with the missing children protocol. Peter was not always keen to accept support, but it appeared that it was his mother who refused support. 2.51 On 20th January 2017 Peter saw his GP with pain in his chest and being concerned about the excess breast tissue he had as a result of extreme weight loss. His GP reassured him that a good diet and putting weight on would correct this. This was the last recorded contact between Peter and the GP. 2.52 On 6th February 2017 Peter’s father contacted Peter’s GP explaining Peter’s anxiety and that fact that Peter said he might be gay and was possibly having sex with an older man. The GP advised the father to discuss this with Peter and his mother and if this older man is much older there would be safeguarding concerns that need referring to social care and the Police. The CCG IMR Author considered the dilemma the GP was placed in here as to making a referral based on speculative information is discussed in the analysis section of this report, but on the facts presented to the GP, the CCG Author considers her decision is seen as being appropriate in all of the circumstances. 2.53 On 8th February 2017 Peter had a meeting at school with the head of sixth form who had had no prior contact with Peter. Peter was concerned about his home circumstances and lacking in privacy. He wanted to know if he could attend the sixth form at this school if he moved to live with his father. It was pointed out to him that would be two bus rides to get to school making it difficult. Peter told the head of sixth form that; • His father is an alcoholic and his current accommodation was unsuitable – mattress on the floor, beer cans all around. Dad was moving to where he thought the accommodation would be fine • his mother has started a new relationship 3 months ago, with a woman, they are due to be married in the next few weeks • they are 8 people living in a three bedroom house at the moment, this is why he needs to move out, he has no space 7 Harmless is a user led organisation that provides a range of services about self-harm including support, information, training and consultancy to people who self-harm, their friends and families and professionals. 8 Kooth.com is an online service for young people aged 11-25 living in Nottinghamshire which provides free counselling, advice and support on-line. Staffed by fully trained and qualified counsellors and available Monday to Friday from 12 noon until 10pm each night, and weekends from 6pm to 10pm, 365 days per year, it provides confidential and instant access service. 9 The Base 51 Counselling service offers short and longer term counselling and psychotherapy to young people aged 12-25. Counsellors are trained in a number of approaches and have experience of working with young people to work towards their aims. 18 • he can’t talk to mum • he has slept rough in the past 2.54 The teacher reported this to the Head Teacher of the school and to the Head of Year, who knew Peter well and thought that the home situation was resolved. 2.55 On 21st April 2017 the mother went to the school to see the Head of Year concerned about Peter. She explained she was at the end of her tether and that Peter’s behaviour was affecting home life. She said that Peter was in possession of money and she feared he may be a ‘rent boy’. To support this she explained that on Boxing Day an older man visited the house with a gift for Peter and often when his phone rang he would go outside to answer it. 2.56 On the same day Peter went to see the Head of Year at school and made a series of disclosures which the Head of Year made a note of and on being interviewed by the Education IMR author the notes can be summarised as Peter telling the Head of Year that; • Things started a long time ago, him alleging sexual abuse within the family • Another pupil had been asking Peter ‘to meet older guys…for money’ • At the last such meeting he had to pretend to be the other pupil and meet a man in a supermarket car park. The other pupil had been meeting older men through a phone app. A second pupil was also meeting up with guys for money as well. • The first pupil was worried about this becoming known and keeps asking Peter if everything is OK …squeezing his shoulder firmly and whispering ‘I hope you keep your mouth shut.’ A third pupil saw this happen • other pupils were becoming aware of this and a fourth pupil had approached him because Peter ‘knew ways to make some money’ • he had arranged to meet a man in the city…picked up in a black Mercedes and driven to the other side of the city…went in to the man’s house…felt that the guy was a dealer…had protected intimate sex …drove him back and Peter went straight to a fifth pupil’s house and broke down in tears, told the fifth pupil what happened…couldn’t stop shaking, eventually went home. 2.57 The Head of Year reassured Peter that he’d done the right thing in disclosing and explained that he’d have to share that information to which Peter said in that case he would deny it. 2.58 On interview with the IMR author, the Head of Year stated; ‘I left the meeting with [Peter] feeling that he had made a genuine disclosure. At the very end when I told him I’d need to share these concerns he said, very simply ‘…and I’ll just deny them.’ And that is what he did. I recall other ‘clues’ in things [he] had said previously that now fitted with the disclosure. After being found sleeping rough and sleeping on a tram [Peter] had said ‘it’s about what those bad men did to me.’ This was not a sudden disclosure, [he] would come and chat several times a week and I felt he was leading up to something important. [Pupil 5] had also expressed concerns about [Peter] and some other pupils reported having sight of phone messages between [Peter] and older men that caused them concern. So when the disclosure came I was not totally surprised.’ 19 2.59 The Head of Year took the matter to the Head Teacher who met with Peter and went through the statement he had received from the Head of Year to which Peter said ‘it’s all a load of rubbish. I needed the attention’. The Head Teacher was of the opinion that what Peter said didn’t make sense. Peter had mentioned a boy at school dealing in drugs, a statement the Head Teacher didn’t believe. Despite any reservations the Head Teacher had about the disclosure the Head Teacher decided to make a referral. The allegation Peter made about intra-familial abuse was the area the Head Teacher doubted most. 2.60 The Head Teacher went to see the head of sixth form and told her of Peter’s disclosures but also that he had retracted them. As the Head Teacher left the head of sixth form’s office, Peter entered and said to the head of sixth form ‘[the Head Teacher] will tell you that things I said aren’t true, but that is not true’, meaning that the disclosure he had made to the Head of Year were true and it was his retraction that was not true. He said; ‘The reason I said it was a lie is that it’s too much bother, causing too much trouble but it’s all true’ 2.61 The Deputy Head Teacher correctly made his referral to the MASH Officer. The Head Teacher delegated the role of completing the safeguarding referral form to the Deputy Head. The form gave a brief summary of Peter’s disclosure; ‘On Friday 21st April 2017, Peter disclosed that he had met two men on separate occasions. The first meeting was with a man who drove a large black Mercedes. This man took Peter back to his house and he claimed that they had had penetrative and oral sex. This meeting was arranged through an unnamed app. The second meeting with a different man was in Tesco Beeston car park. Furthermore, he disclosed that he had been sexually abused [within the family]. ‘Following lengthy conversations with [Peter] by the Senior Child Protection officer (Head Teacher) it is believed much of his statement is fabrication, especially the [intra-familial abuse] meeting with older men and the use of an app to meet up with older men. However we are concerned that through the level of fabrication [Peter] is displaying features of low self-esteem, has lost a significant amount of weight, vomits regularly and is demonstrating hazardous substance abuse through alcohol. [Peter] freely admitted that much of the information he provided was a fabrication. However there is still much to be investigated.’ 2.62 The Head of Year recalls how after the disclosure Peter ‘froze him out’ and didn’t communicate with him anymore. The Head of Year described how, a couple of days before Peter died he was very angry and stormed out of school. 2.63 On 10th May 2017, a Social Worker contacted the Head of Year and there was an exchange of information about Peter. The Education IMR quotes the conversation: ‘[The Head of Year] said that as a school they had spoken to other young people who confirmed that possibly those inappropriate contacts with older males had taken place. [The Head of Year] said that following the referral to Social Care (Peter) had said that he had made up the stories for attention seeking. [The Head of Year] said that [Peter] is a compulsive liar and dangerous in the process as things he could say could place someone’s profession at risk. [The Head of Year] advised that when I [Social Worker] came to see [Peter] I sit with someone.’ 20 2.64 CSC files record a Family Assessment being carried out at school on 12th May 2017. Peter was seen and told the Social Worker that he had lied to the teacher about meeting up with older men. He was also seen at home with his mother but would not talk to the Social Worker. The main areas of concern were his weight, Mother described how she had taken Peter to the GP to discuss how Peter had lost 9 stone within one year due to starving himself, taking laxatives and forcing himself to vomit. From the school’s view, Peter losing weight was seen as a positive step in his improvement of his health and appearance. He was taking care of his hair and clothes and looking smarter. Peter had lost weight in a very short time, nearly nine stone in one year. He was using his mother’s make up, going out without telling her where he was going and being seen with unaccounted for money. 2.65 On 2nd June 2017, CSC saw the father at his home in preparation for the forthcoming CSE meeting. The father explained that he was concerned that Peter had a lot of unaccounted for money. He stated that Peter’s maternal grandfather had taken his own life 8 years previously and Peter’s maternal uncle, had done the same in 2016 and this had had a significant impact of Peter’s emotional well-being. He said that he did not want to attend the CSE meeting as he thought it would embarrass him. The father was uncertain if the meeting would achieve anything apart from causing Peter to feel embarrassed. 2.66 A Child Sexual Exploitation Multi-agency Strategy Meeting was convened five days later, on 7th June 2017. The meeting was attended by: • A Child protection Co-ordinator acting as Independent Chair • Two Social Workers • Head Teacher from Peter’s school • Peter’s mother and father and mother’s then partner. 2.67 Apologies were received from Nottinghamshire Police, who were unable to attend due to resourcing problems. A report was submitted confirming that no incidents were recorded connecting Peter to their system. The police acknowledged that at that stage No Further Action was going to be taken regarding Peter’s disclosures however, it was appreciated that he was 16 years of age and not considered a high risk by the police. Due to an administrative error the School Nurse did not receive an invitation to attend the meeting although the Social Worker had requested for her to be invited. There is no record of an invitation being sent to CAMHS. Peter was invited but chose not to attend. 2.68 The Chair of the meeting commented about Peter being labelled as; ‘a compulsive liar by a school representative in some of the contact with CSC and her concern was that his disclosures had been discounted.’ 2.69 The Head Teacher explained that; ‘that was not the case and the school has concerns about [Peter]. There are elements of the disclosure known to be wrong however where there is explicit detail, this cannot be discounted as fantasy.’ 2.70 During the course of the review process, the Head of Year has been seen by the Education IMR author and concedes to the fact that the choice of words describing Peter as a compulsive liar was unfortunate and in hindsight an incorrect use of the words. He regrets using this phrase and explains that he was trying to demonstrate that Peter told him a story which the Head of Year believed and then Peter retracted on the events, which in itself was the lie. There is no suggestion that the Head of Year 21 did not believe Peter’s account of being sexually exploited. He apologises for any misunderstanding or distress his comments have caused. To clarify, Peter was saying that the disclosures he had made to the Head of Year were true and his retraction was not true. He told the Head of Year; “The reason I said it was a lie is that it’s too much bother, causing too much trouble but it’s all true”. 2.71 Actions that emanated from the meeting: For CSC • CSC to share the contents of school statement with the police and agree actions regarding [the four boys] Action for SW by 11.07.17 • CSC to explore the alleged historical incident [between the Perpetrator and two brothers] and discuss with the police and agree actions. Action for SW by 11.07.17 • CSC to check whether the 4 other boys are known to CSC. Action for SW by 11.07.17 • CSC to refer [Peter] to The Children’s Society to increase his understanding of CSE. Action for SW by 11.07.17 For the school: • School to sensitively explore the concerns relating to [the four boys] and liaise with CSC. Action for Head Teacher by 11.07.17 • School to continue to offer support to [Peter] and make a named person available to him. Action for Head Teacher immediately. For health: • School Nurse to arrange an appointment to see [Peter] regarding a possible eating disorder. Action for School Nurse by 11.7.17 For parents: • Parents to work together to monitor [Peter’s] movement and finances. Action for parents. Action for both parents – ongoing • Disruption Plan. Parents to agree a curfew time with [Peter] and to report him missing to the police if he is not home within 30 minutes. Action for both parents – on going. For [Peter]: • [Peter] to tell parents where he is going • [Peter] is to remain in mobile contact when out. 22 2.72 In line with the actions outlined, the Head Teacher spoke to four boys mentioned by Peter. The first said that he knew nothing about Peter meeting men for money but did recall an occasion when Peter tried to kiss him when Peter was drunk. The second stated he witnessed No 4 in this list, whispering to Peter that he hoped Peter could keep his mouth shut. He also said that Peter had told him that he had got into a car with someone he knew. 2.73 The third boy spoken to recalls the time when Peter disclosed to him that he had been taken to a house and engaged in sexual acts. He said ‘He [Peter] burst into tears and was shaking’ and that Peter had said, ‘something bad had happened’. 2.74 The fourth boy, who was alleged to have made arrangements for Peter to meet a man, denied all knowledge of this and was described as being shocked at the suggestion that he did know. 2.75 The Head Teacher interviewed the four boys as described above as Head of Safeguarding for the school. However, he failed to keep any notes from the interview and had to rely on his memory of the events when interviewed by the Education IMR Author. The Head Teacher also interviewed Peter and Peter’s younger brother. 2.76 The Head Teacher came to the view that much of the disclosures were not credible, which is reflected in the MASH referral: ‘Following lengthy conversations with Peter by the Senior Child Protection Officer (Head Teacher) it is believed much of his statement is fabrication, especially the step-brother, meeting with older men and the use of an app to meet up with older men.’ 2.77 The Head Teacher referred two of the boys to CSC on 12th June 2017, to the relevant Local Authorities. Additional reference to the Head Teacher interviewing all of these boys is made in the analysis section of this report. 2.78 On the morning of 8th June 2017, Peter went to see the Head Teacher and enquired how the CSE meeting had gone the previous day. On the basis that Peter had been invited and chose not to attend the meeting, the Head Teacher thought it proper to tell Peter what had occurred and the decisions that had been made. Peter asked the Head Teacher about the curfew that had been imposed by his mother the previous evening (following advice from the CSE meeting). 2.79 The Head Teacher told Peter to speak to his mother about that. He also explained that the meeting had agreed for him and the police to make further enquiries. Peter was agitated about this and the curfew and when the Head Teacher explained to Peter the options open to him for support regarding his sexuality, Peter stated that he was not gay. 2.80 Later that day CSC and the police held a strategy discussion about the allegations of intra-familial abuse and it was agreed that a Section 47 investigation should be commenced. The Social Worker planned to speak to Peter and his siblings and the parents. The mother stated that she was worried about the information being shared and explained that Peter had ‘lost it’ the previous night when he had been told about the meeting. Mother said that she did not believe the disclosure was true. 2.81 It would appear that there was no agreement or consistent message made at the CSE meeting as to how the decisions made were going to be communicated to Peter. In the event, it appears that this was left to the mother, who was going to be the first person to see him after the meeting, to inform Peter in a supportive and informative way as 23 opposed to the curfew being seen as a punishment. She told Peter that a curfew had been imposed to which he reacted by becoming angry and moody, perhaps seeing that decision as a punishment of some kind, rather than a way of protecting him. The following day he saw the Head Teacher who told him about the decisions which would have included the Head Teacher speaking to the four boys. The Head Teacher referred Peter to speak to his mother about the curfew, which had been a decision made at the meeting. 2.82 On the morning of 8th June 2017, Peter had taken an examination at school. He returned home at lunch time and saw his older half-brother who had asked him how the examination had gone to which Peter replied it had gone well. Peter called his father and after a short conversation he left the house. He was still wearing his school uniform. 2.83 At 15.22 hours that day, a call was received by British Transport Police to the effect that a person has been struck by a moving train near to a railway station in Nottingham. Peter was later identified by DNA. 2.84 Once Peter had been found on the railway line and agencies were informed, including the Rapid Response Team. On 12th June 2017 an Initial Child Death Strategy Meeting was held. CSC IMR records that the British Transport Police (BTP) visited the family without representatives from Health or CSC, which is not in line with the Nottinghamshire Child Death protocol. This is examined later in this report. 2.85 Later on 12th June 2017, the father of Peter sent text messages to the Social Worker involved with Peter blaming him and the CSE meeting for his son’s death. 3. Views of the family 3.1 On 19th December 2017, the report Author and the NSCB Development Manager met with mother at her request at County Hall. She described Peter as being a funny lad, always joking and carefree but once he started at the Secondary School from the age of 11 to 12 years, his personality changed. He became overweight and wanted to fit in and be ‘one of the lads’. He had been a goal keeper for a local football team and always wanted to be everyone’s friend. At home he engaged with social networks, his computer and mobile phone and played his music. He was fond of attending live ‘gigs’ and often travelled some distance to see various bands, sometimes without telling his mother where he was going. He would travel to Manchester and Birmingham on his own to see bands. 3.2 By the age of 13/14 years old, Peter became self-conscious about his weight. His mother described him as a ‘big lad’ overweight and well groomed. She illustrated how he would spend hours grooming himself in the bathroom and constantly showering. He was concerned about his ‘man boobs’ and considered asking his GP for surgery at one time. He turned to ‘Weightwatchers’ meals, then he went vegetarian, then vegan and then he started to self-harm. He slashed his wrists with a mirror, tied a rope around his neck marking himself and during a family holiday he was found with a belt around his neck which again marked his neck. The mother stated that she sought help from the School Nurse. The mother said that she wondered about his sexuality. 3.3 The mother stated that Peter did not attend an appointment with the GP and she found CAMHS of little use. He had been referred to CAMHS by the School Nurse. Peter got into the habit of eating, sometimes binge eating and then vomiting. Peter denied that he had a problem and he eventually saw his GP who gave him a web site to explore, but the mother said, ‘He was so screwed up he was not interested’. She explained that 24 Peter would tell the GP what he thought the GP wanted to hear but overall she did not think that GP was very helpful. The mother said that she arranged to go to First Steps with Peter, an eating disorder advice centre in Derby but they could not help him as he denied having a problem. 3.4 About CAMHS, the mother said that the first assessment for Peter was made a long time in the future and Peter couldn’t keep other appointments. She found CAMHS to be inflexible and rigid in appointment making and eventually they closed the case, with Peter only having attended one appointment and his assessment incomplete. Mother also said that CAMHS would try to ring her but with her hearing disability she was not aware of that. She said CAMHS should have easily tried to email her. 3.5 The mother described Peter as buying boxes of laxatives in order to assist his weight loss. She said the GP did not speak to Peter much during consultations. She became concerned about his sexuality when Peter constantly showered and was using her make up. She was aware that he had been asked out by both boys and girls and this, she said, confused Peter. She knew about a suicide note that Peter had written in which he named the boy who had asked him out and that the notes also mentioned the Year Teacher with whom Peter confided about losing weight. She was aware that Peter had been speaking to that particular teacher for some time. 3.6 The mother expressed her frustration to the Author and the Development Manager that she perceived that she could not know everything from school, she perceived, because of confidentiality. With regard to the CSE meeting, she said that it was discussed that Peter was probably meeting men for money in exchange for sex and was suspected of being involved in sexual exploitation. She was aware that Peter would be in possession of quite a lot of money on occasions about which, Peter stated his father had given it to him. The mother was well aware that his father would not be able to give him the amounts of money he had, which aroused her suspicions. 3.7 The mother was upset that the police did not attend the CSE meeting and she thought the Social Worker’s report was inadequate and missing pages. The only result she got from the meeting was the fact that a curfew was suggested. She imposed the curfew the night before Peter‘s death which upset Peter and made him angry. She told the British Transport Police in a statement that she felt that police had not attended the CSE meeting because Peter ‘was not underage and had not known that other boys were involved’. She said that CAMHS was not present and neither was the School Nurse. She described the whole meeting as an appalling mess. She said the only thing that came out of the meeting was the curfew and she had told Peter that the meeting was ‘a complete waste of time’. 3.8 On 30th January 2018, the report Author and the NSCB Development Manager saw Peter’s father at his home. The father was mindful that the CSE meeting should not have taken place as he thought that Peter would be badly affected by it and that Peter was very nervous of the rumours that may be spreading at school if the meeting took place. 3.9 The father said that he was badly affected by the death of his son and has been referred for counselling and medical treatment as a result. The father told them that he would often tell Peter that he loved him and accepted him for what and who he was. He told his son he was his best friend and the father wanted Peter to move in with him. He refuted that he knew about the alleged intra-familial abuse Peter stated he was subjected to. 25 4. Analysis and recommendations 4.1 There are several areas worthy of mention and more detailed examination in the circumstances of this case. Referrals 4.2 Peter and his siblings were known to NCC Education Authority for many years. His sister, S3, was known to the Educational Psychologist Service since 2005 regarding her diagnosis of ASD. There was contact between CSC and the Primary school in 2009 regarding concerns about the way the parents were caring for the children, but at that time there were no concerns whatsoever about the children whilst in school. 4.3 It is clear from the IMRs that home life for Peter was not particularly easy. His father and mother had separated years before and Peter still had contact with his father. The relationship between his mother and father was acrimonious. Mother is deaf and has to lip read, which caused her frustration when communicating with the children. Peter had to share a bedroom with a younger brother due to limited space in the household thereby restricting his privacy. 4.4 Peter was having problems with his body image, being concerned about the size of his breasts even to the point of considering surgery. He was partaking in risky behaviour situations and via the internet was visiting websites concerning meeting men for sex. He reported that he had met a man in a car park of a supermarket and had been taken to the man’s house where sex had taken place; and another occasion when he had sat in a man’s car on a car park for whatever reason. He had previously posted an indecent video of himself on YouTube. 4.5 Peter formed a bond with the Head of Year and confided in him about his weight loss and eventually disclosed to the Head of Year the sexual behaviour he was indulging in. It was the duty of the Head of Year to do something about that information which later resulted in the CSE meeting being held. Peter ‘froze the Head of Year out’ and Peter felt let down and feared that details of his behaviour would become common knowledge in school. 4.6 Research10 shows barriers to disclosing are well known and include individuals who feel that they will not be believed, they will have no control over the information and events after disclosure leading to a feeling that they wish they had not disclosed in the first instance. Children try to identify a trusted adult who can help and who has the time and motivation to help. Peter found these qualities within the Head of Year. By disengaging with the Head of Year, Peter became more isolated. 2014 CAMHS Referral 4.7 In May 2014, Peter wrote a suicide note. This came to the attention of the School Nurse a couple of weeks later. She discussed this with the school who stated that they intended to make a referral to CAMHS. On 30th May 2014, the School Nurse saw Peter’s mother and spoke with her about completing an Early Help Assessment Form (EHAF) and a possible referral to a paediatrician. The School Nurse discussed the pending CAMHS referral with the school and set about initiating some actions such as liaison with CAMHS and arranging meeting dates with the school. CAMHS were unable to attend and did not engage any further in the early intervention stages. 10 Nottinghamshire Serious Case Review DN11 December 2011 pages 53-55. This section of the SCR explains in detail the barriers to reporting sexual abuse especially by male children and within the Overview Report quotes from a variety of authors and literature. 26 4.8 On 25th June 2014, another meeting was held with the School Nurse, the mother and the school. The School Nurse noted that the CAMHS referral was ‘in process’ and the school undertook to check the progress. The Healthcare Trust IMR indicates that the School Nurse took no action to follow up or complete the CAMHS referral which is considered as a missed opportunity by the School Nurse. The CAMHS referral had not been submitted after nearly a month.11 4.9 By 17th September 2014, the referral to CAMHS had still not been made because the school was waiting for the mother to take Peter to see his GP, which she had not yet done. Likewise the planned referral to the paediatrician had not been made. 4.10 On 1st October 2014, the School Nurse saw Peter at school. Peter was upset and had serious negative thoughts. Following this meeting, the School Nurse was to continue to consider the appropriate referral pathway, which was either CAMHS or a paediatrician. The IMR indicates that the reasons for the School Nurse not making the referral to CAMHS or the paediatrician may have been pursued at interview between the IMR author and the School Nurse. However, the School Nurse, who has since left the service, declined to be interviewed.12 4.11 On 30th October 2014, the School Nurse again spoke to Peter. He declined a CAMHS referral. It had now been 5 months since the involvement of CAMHS was first identified. 4.12 More recent Education Psychology Service guidance13 indicates that the CAMHS Primary Mental Health Team are available for consultation with school staff regarding issues of self-harming, and goes on to say; ‘The CAMHS Single Point of Access (tel. no. provided) can be contacted to discuss the perceived level of risk and identify any potential role for the CAMHS Crisis Team’. 4.13 There were therefore plenty of opportunities for the School Nurse and the School to make contact with CAMHS and to follow up any referral that was made. The initial CAMHS appointment with Peter did not occur until 15th September 2015. The Healthcare Trust IMR Author comments: ‘This CAMHS referral was very comprehensive and clearly documented the chronology of events and risk factors leading up to the referral. However, it did not identify the safeguarding concerns and this referral came over a year after professionals first became aware of Peter’s suicide note’. 2014 Referrals to Paediatrician 4.14 During a meeting between the School Nurse and the Mother in May 2014, the School Nurse, whilst talking about making a referral to CAMHS, also mentioned the option of making a referral for Peter to see a Paediatrician. No referral was made at that stage and in June 2014, the School Nurse again stated that a referral to a Paediatrician via the GP would be completed and; ‘the school would do a report to support this referral’. 11 In 2014 informal conversations documented in School Nurse records about a possible referral to CAMHS would not be expected to go on a child’s safeguarding file at school. School now have ‘my concerns’ software, which enables staff to log any issues about any student. 12 There have since been changes in school referral process to CAMHS. Any child of concern is now discussed at a monthly consultation meeting with the Primary Mental Health Care Team and if necessary a referral is made. 13 Young People and Self-harm: Guidance for Schools -Nottinghamshire County Council Educational Psychology Service September 2017 page 9 27 4.15 On 23rd June 2014 there is still no evidence of the referral to the Paediatrician being made. The Healthcare Trust IMR Author notes: ‘It appeared the [School Nurse] worked hard but with little effect. The lack of a clear plan with SMARTER actions means that the case showed significant drift. There is no evidence to suggest that any minutes to meetings were produced and circulated leaving discussions had within them open to interpretation’ 4.16 On 1st October 2014, the School Nurse had another meeting with Peter, where her plan was; ‘to continue to consider the most appropriate referral pathway; CAMHS or Paediatrician’ 4.17 On 30th October 2014, the School Nurse again saw Peter. He refused a CAMHS referral but wanted half termly appointment with the School Nurse in order to discuss his low mood and how to cope with a busy household. There is no mention of the outstanding Paediatricians referral, which may have resulted in an appointment being offered. 4.18 On 13th March 2015, the School Nurse attended the school’s year leadership meeting where she advised the school to consider a CAMHS referral and a referral to a Paediatrician. It was at this meeting that the School Nurse informed Peter and his mother that she was leaving the service. It is also at this time that Peter’s anxiety and risky behaviour were escalating. The School Nurse’s analysis of the then current situation was that she would consider whether mother was able to respond appropriately to her son’s needs. No referrals were made or child protection risk assessment conducted, nor is there evidence that the School Nurse sought advice from her supervisors or senior management team. 4.19 The referral process for Peter to attend CAMHS and the Paediatrician was disjointed and without continuity. The School Nurse expressed the correct intentions but this was not followed through with timely referrals. There is nothing to indicate that her supervision addressed the problem. The Healthcare Trust IMR author states; ‘The school nurse took no action to follow up or complete the CAMHS referral, which amounts to a missed opportunity. Unfortunately it has not been possible to explore this further as the School Nurse declined the invitation to attend the interview [with the IMR Author].14 4.20 The School Nurse made decisions about the probability of mother being able to respond appropriately to Peter’s needs, despite the history of the contrary. This may have been seen as confirmation bias. Confirmation bias suggests that professionals (in this case) seek out information that confirms their existing opinions and ignore contrary information that refutes them. This psychological phenomenon occurs when decision makers filter out potentially useful facts and opinions that don't coincide with their preconceived notions. 4.21 Research illustrated in the paper by the Behavioural Insights Team15 into decision making by Social Workers, indicates that analysis suggested that there are a range of 14 The School Nurse referred to here was the first school nurse, who had significant dealings with Peter. She left the service and initially declined to be interviewed by the Healthcare Trust IMR Author. She has now been interviewed - see page 46. 15 Clinical Judgement and Decision-Making in Children’s Social Work: An analysis of the ‘front door’ system Research Report by Elspeth Kirkman and Karen Melrose - The Behavioural Insights Team Department for Education April 2014 28 overarching behavioural factors that complicate or reduce the efficiency of social workers’ decision-making. The four which were identified as being of most significance are: a) Time and workload pressures increase the reliance upon social workers’ intuition to make decisions. b) A range of behavioural biases affect social workers’ ability to make objective judgements. c) The complexity of social workers’ decision-making is increased further by the fact that many sequential decisions have to be made through the course of a single day, which engenders depletion or ‘decision fatigue’. d) The information provided to social workers is often of relatively low quality. This means that significant energy is expended piecing together a full picture of the relevant information, leaving less time for analysis of each case. 4.22 This research can equally be applied to other professionals. 2015 Referrals 4.23 On 13th March 2015, the School Nurse was informed that Peter had self-harmed in school and he was insistent that he did not want his mother told. He had used a blade from a pencil sharpener to cut his arm. Consideration was given to informing CAMHS but Peter insisted he didn’t want that done. The School Nurse spoke to Peter about his self-harming and his sexuality but again Peter declined to discuss either issue, other than to say that he regretted doing what he had done and would not do it again. 4.24 At this time, the self-harming was not the first time that Peter had engaged in this behaviour. He had written a suicide note prior to this incident and had displayed many of the identified risks research informs about suicide. 4.25 More recent NCC’s Educational Psychology Service ‘Young People and Self-harm Guidance for Schools’16 states; ‘Young people aged 16 or over are presumed to have capacity to consent to withhold information from others including parents, unless it is assessed that they do not have capacity. They may consent to having treatment and be happy for parents/carers to be involved – this would be best practice. If young people do not want their parents to be involved then this right to confidentiality has to be weighed up against risk. For example, the confidentiality of a young person may be honoured in the case of self-harm e.g., superficial cutting (where there may be no immediate/significant risk). However, if the young person is deemed to be a high risk of suicide then, despite treatment compliance, risk management may over-rule rights to confidentiality and parents/carers would be informed.’ 4.26 Nottinghamshire SCR NN1517 report quotes recognised overlapping risk factors of both self-harm and suicide as being; 16 Young People and Self-harm: Guidance for Schools -Nottinghamshire County Council Educational Psychology Service September 2017 page 8 17 Nottinghamshire Safeguarding Children Board Serious Case Review NN15 2016 29 • mental health problems including depression • family issues • disruptive upbringing • physical or sexual abuse • having worries about sexual orientation • family relationship problems • self-harm in a family member • low self-image and low self esteem 4.27 The above risks are confirmed in the Child Sexual Exploitation (CSE) Multi-Agency Pathway.18 All of the above traits were demonstrated by Peter. The School Nurse advised the school to consider a CAMHS and a paediatric referral and also a referral to young carers was considered but none of the referrals were made. The School Nurse could have made a referral to CAMHS herself despite Peter expressing the wish that he wanted no-one informed of his self-harming episode. With hindsight, there were indicators of suggestive suicide at that time and Peter was a high risk of suicide at that time based on the evidence on suicide in young people. There was a further missed opportunity to contact CAMHS or any other support organisation for Peter. 4.28 The risks associated with young people threatening to take their own lives is well documented in a significant amount if literature including ‘Suicide by children and young people in England’19 This study of 145 children and young people found that 13% had suffered physical emotional or sexual abuse, 36% had suffered bereavement, 22% had been victims of bullying, 13% felt they had been socially isolated, 23% had used the internet in connection with suicide, 3% were struggling with their sexuality and 53% had suffered with academic pressures. Peter had experienced most, if not all of those issues and was clearly a very vulnerable person. 4.29 Further research20 indicates that in cases where there may have been a lot of risk factors present as with Peter, on a national level available statistics show that very few young people go on to take their own life. Suicide in young people is a very rare event. Of those aged 15 to 19 years, figures show that male teenagers in this age group are more likely to commit suicide than females but only 7.5 young men out of 100,000 across the UK are likely to commit suicide, which in proportion of all suicides is very low. 4.30 On 18th March 2015, the School Nurse met with the mother and told the mother that she was leaving her post. She said that she had been working with Peter and had no concerns about him, yet it was only 5 days prior that Peter had self-harmed. This together with the known history of suicidal ideations and self-harm that the School Nurse was aware of, made her comment to the mother that she had no concerns about Peter appear contrary to the concerns she had showed about Peter for some time. The School Nurse highlighted the fact that no-one in school appeared to be taking the lead with regard to supporting Peter at which point, the Head of Year took the lead. 4.31 In March 2015, there was an opportunity for either the School Nurse or the School to complete an Early Help Assessment Form (EHAF) as per Nottinghamshire’s Children’s Services Pathway to Provision.21 This guidance indicates that when a child fulfils the criteria for a level 2 Threshold, the practitioner should complete an EHAF. This can be 18 Nottinghamshire County Council Child Sexual Abuse Multi-agency Pathway 2017 19 Suicide by children and young people in England National Confidential Inquiry into Suicide and Homicide by people with Mental illness. University of Manchester May 2016 20 Office of National Statistics Statistical bulletin: Suicides in the UK: 2016 registrations 21 Pathway to Provision Multi-Agency Thresholds Guidance for Nottinghamshire Children’s Services Version7 February 2018 30 used by all agencies working with a child and their families and is used to identify a child’s needs, strengths and goals and where there are worries, concerns or conflicts over an extended period. 4.32 The Level 2 Threshold illustrates the child’s needs as including having sexual relationships, alcohol abuse, being involved in anti-social behaviour, insecurities around identity and sexuality, having difficulty in maintaining relationships and being exposed to dangerous situation in the home or in the community. Most of these issues were present in Peter’s life at that time. Whilst it is appreciated that before an EHAF is completed consent should be obtained from the child or the parent. The EHAF form was not completed for whatever reason although professionals did discuss the submission of such a form22. Recommendation 1 NSCB to promote the increased use of the EHAF by agencies and explore the barriers which prevent professionals from completing them. 4.33 The original School Nurse had left the service and a new School Nurse took over Peter’s case in May 2015. Despite attempting to meet with Peter, the new School Nurse was unable to engage with him. The new School Nurse did however make a referral to CAMHS with Peter’s agreement after another incident of setting fire to the bedroom curtains. The referral was made on 20th August 2015. A comment in the Healthcare Trust report from the IMR author about that referral reads; ‘It is my opinion that this CAMHS referral was very comprehensive and clearly documented the chronology of events and risk factors leading up to the referral. However, it did not identify the safeguarding concerns and this referral came over a year after the professionals first became aware of [Peter’s] suicide note’ 4.34 In September 2015, school were made aware, through Peter’s sister, that Peter was self-harming and going missing from home which involved the police. His sister told the Senior Learning Support Assistant (SLSA) at school that Peter; ‘had been suffering from depression and had been cutting himself on his arms’. 4.35 S3 also stated that Peter had been found with a belt round his neck. She added that the mother and father were aware of this but didn’t want her, S3, to tell anyone. This could be seen as casting doubt on mother and father’s ability to act as positive factors acting in the best interests of Peter. 4.36 The Head Teacher, as the designated safeguarding person at the school made a referral to MASH on the same day and wrote to Peter’s mother telling her what he had done and to expect CSC to arrange an assessment of Peter. The Head Teacher’s view was that Peter was not in a good place at that time. On 22nd September 2015, the Head Teacher received confirmation that the assessment would be undertaken but on 30th September 2015, the Head Teacher learned that Peter’s mother had refused to engage with the assessment and the CSC case had been closed. CSC made a request for the school to follow this up with the mother and seek permission from her to provide support to Peter should he feel the need. On 6th October 2015, the Head Teacher wrote to the mother asking permission for CSC to undertake agency checks with CAMHS. There is no record of any reply to this letter. 22 At the end of 2017, an audit of the EHAF form was conducted and the form revised. The revised form has now been adopted. 31 4.37 The Head Teacher spoke to Peter who stated he did not want to engage with CAMHS and it was left that the school would KIV (Keep in View) the situation with Peter. The Head Teacher was aware that Peter had a good relationship with the Head of Year and saw that as positive signs. It was thought that the reluctance not to engage with the assessment was Peter’s choice as opposed to any obstruction from the mother. 4.38 It was clear that for some time no-one had taken the lead to make referrals to CAMHS and the Paediatrician. 4.39 The Healthcare Trust IMR comments regarding the half completed CAMHS assessment in November 2015 and Peter being discharged from the CAMHS service due to a failure to engage. The Author makes the following observation; ‘Given the amount of previous involvement from the School Nursing service and the level of concerns raised it would be reasonable to assume that [School Nurse] would have enquired about Peter’s wellbeing in school, or that school or mother would have re-referred him back to the team given the on-going concerns highlighted by the social worker following the MASH referral in May 2017. However, there is no evidence in the health records that Peter was ever discussed, re-referred or seen by health services after he was discharged in November 2015. [School Nurse] confirmed at interview that she did not have contact with Peter or his mother after this point and that she left the School Nursing service in September 2016. 4.40 The CAMHS visit to Peter in September 2015, resulted in the mother being spoken to first and not enough time was left for the assessment to be fully completed. During the course of this review questions were raised with the Healthcare Trust asking if this was the usual practice to see the parent/carer before the child. The response received indicated that this was not usual practice and clinicians will usually see the family together initially and explain about the assessment process. They would then offer the young person the opportunity to be seen on their own initially and then the parents and family together at the end. It will depend on the wishes of the child/young person. Clinicians offer young people and families the opportunity to contact them after the assessment should they think of something they want to talk about or if there was something they did not feel comfortable speaking about during the assessment. 4.41 Asked why this did not happen in this case the IMR author stated the worker had since left the service but was asked about this in interview and was unable to provide a rationale for seeing the mother first. 4.42 The IMR Author is content that this this appears to be a one off incident and there are no recommendations for the Healthcare Trust linked to this issue. The importance of seeing the young person first to validate their voice is to be re-iterated when the learning from this review is shared, which is usual practice for staff currently. There are ‘minimum clinical standards for assessment’ which state that: ’The clinician should ensure that they spend time with the young person and where possible with the carers too. The young person should be offered time alone with the assessing clinician to discuss anything privately’. 2017 Referrals 4.43 In February 2017, Peter’s father telephoned the family GP concerned that Peter had intimated that he was gay and the father wondered if his son was having sex with older men. The details the father could give were only scant and the GP advised that he should speak to Peter and his mother. If there were partners much older than Peter, 32 and the father had safeguarding concerns then a referral to social care or the police may be needed. 4.44 It could be considered whether at this point the GP could have made a referral to children’s social care in light of Peter’s comment. The CCG IMR Author’s view concerns the difficulty that the GP faced was lack of any specific information to include in a referral and whether this would have met the threshold for further response. With the benefit of hindsight it would appear significant, but at the time the GP was faced with the dilemma of the possibility of making a referral to the Local Authority based on tenuous non-specific information without the knowledge or consent of the young person concerned. 4.45 The CCG IMR Author’s view is GPs have to weigh up the public interest of maintaining the public confidence in a confidential medical service, with the responsibility to act in the best interests to safeguard children. Disclosure of tenuous and apparently speculative information without the knowledge of the young man concerned could have resulted in both Peter and his father losing confidence in the GP patient relationship and subsequently not accessing help when needed in future. It would also have very likely affected Peter’s relationship with his father and put Peter at risk. 4.46 The IMR Author is content that the advice to the father to find out more from Peter and his mother was appropriate. The GP was aware that the father in particular, with his disclosures of historical child sexual abuse, was acutely aware of this issue and appeared keen to safeguard his children from similar abuse. 4.47 With hindsight the GP could have taken this information to the Practice Safeguarding multi-disciplinary meeting or daily team meeting to identify whether there was any additional information known by other GPs or the School nurse which would have checked out any additional concerns known in relation to risks of sexual abuse. Peter was taken off the Red Flag meeting after the relationship between him and the School Nurse collapsed. 4.48 It is noteworthy that the GP had no information in relation to Peter or his siblings being at risk of sexual exploitation until June 2017. 4.49 It could be argued that a more proactive decision could have been taken by the GP. Peter had a history with the GP and the School Nurse about his weight loss, his dissatisfaction about his appearance. 4.50 In November 2016, after Peter went missing, mother told the police that she had taken Peter to the GP as he seemed detached from the family and walked around the house saying, ‘Its nearly all over’. However there is nothing recorded in the GP’s records of an appointment for Peter in November 2016. The GP was unaware of the missing episode and the extent of mothers concerns for her son at this time. 4.51 In January 2017, the GP was aware that Peter had disengaged from CAMHS and this was discussed at the GP’s Practice Safeguarding Meeting. However, the recent concerns around the suicide note and the missing episodes were not known by the GP. 4.52 There is variance among the panel members about this point. Whilst there is an appreciation of the dilemma the GP faced (as outlined in the IMR) with the degree of information supplied by the father about his worries that his son may be engaging in sexual activity with older men, the Overview Author considers that all of the circumstances of Peter’s history should have warranted a more positive response than to advise the father to speak to his son and the mother. 4.53 The Overview Author considers an enquiry should have been made to Children’s Social Care via the MASH. If the enquiry reached the threshold for a referral, police 33 and Children’s Social Care would have had an opportunity to establish if the allegations made by the father had any truth to them. It was not the role of the GP to determine this. The facts as presented by the father constituted a possible safeguarding concern irrespective if the circumstances were vague. The Pathway to Provision is clear on this. 4.54 On 21st April 2017, the Deputy Head Teacher from school telephoned the MASH to report that Peter had been meeting older men via an app. on his mobile telephone. A conversation took place between the MASH operative and the Deputy Head Teacher that stated that Peter had disclosed that he had been seeing older men, he had been sitting in a car with one man and had been paid money for that. On another occasion had been taken to a house where consensual protective sex had taken place. The MASH operative asked if Peter’s parents had been informed and the Deputy Head Teacher said at that stage they had not. The operative suggested that the Deputy Head Teacher inform Peter’s parents. The panel consider that this was not wise advice and should have been left to CSC or the police to inform parents of the disclosure. 4.55 A written referral was sent to the MASH by the same member of staff. This contained information about incidents of intra-familial abuse that Peter had allegedly been subjected to sometime before and had only just disclosed to the school. This information was not passed to the MASH during the telephone referral. The alleged intra-familial abuse was disclosed at the same time as the ‘prostitution’ concerns. 4.56 It appears that once the written referral had arrived at the MASH the information about the alleged intra-familial abuse was missed by a social worker and supervisor. An examination of the written MASH referral form indicates that there was one line about the alleged abuse on the front page of the form but a more detailed entry, including mention of the four boys, on pages near to the back of the form. The referral resulted in a Child Sexual Exploitation meeting being held on 7th June 2017. Following the initial disclosure by Peter, to the Head of Year, the Head Teacher chose to re-interview Peter. Peter’s response to referrals and agency involvement 4.57 Agency involvement with Peter and his family was significant over a number of years. As can be seen by the sequence of events, Peter’s behaviour and reaction to intervention by agencies escalated as time went by. Much of his reaction resulted in ‘risky behaviour’. He went missing on two occasions and again on the day of his death. Both the Police and the Social Worker followed their respective procedures regarding missing people especially with the ‘return interviews’. 4.58 Peter often self-harmed, became anxious and was seen with a belt around his neck. In March 2015, he self-harmed with a sharp instrument. His mother raised concerns that he may have ASD as his sister does. On another occasion she suggested he might have a personality disorder. He had already written a suicide note and had been investigated by Nottinghamshire Police for posting an indecent image of himself on social media as a result of a referral from CEOP. 4.59 The first reported incident of him going missing was in September 2015 It transpired that he had been depressed in the previous weeks and had attempted suicide before and self-harmed 3 weeks previously. A note had been found at his address indicating his wish to take his own life. In addition he had recently been referred to CAMHS as outlined above. Police informed CSC of the circumstances. 4.60 The next missing episode was in November 2016, when police were informed but Peter arrived at his father’s house before the police could find him. His mother had taken him to see his GP due to him walking around the house saying “it’s nearly over”. A worker 34 from the Family Services made arrangement to see Peter for a return interview but Mother changed her mind after seeing the information sharing agreement. Albeit Peter had returned before the police had found him, the officers still completed the necessary MISPER forms to properly record the incident. On each occasion of his being reported missing and then returning CSC conducted a ‘return interview’ to ascertain from Peter the reason for him going missing and to enquire into his general safety. 4.61 The third missing report was on the day of Peter’s death, when his family reported him missing at 22.15 hours on 8th June 2017. The day before there had been the CSE meeting to discuss Peter and it is thought that he was concerned that information about his sexuality and his behaviour would become common knowledge among his peers. He had been told that he was under a curfew and the Head Teacher had explained to him the outcome of the CSE meeting. He was found on the railway line after colliding with the train. 4.62 Peter reacted to stressful occurrences in his life. He was a very vulnerable person. The pattern of his likely reactions and the possibility of him harming himself were not identified and therefore it was difficult to manage his reaction to events that occurred in his life. It was clear that there was lots done for Peter by various professionals but he had no control over what was happening to him. Once he had disclosed he was aware that he had exposed some of his family members, friends and men he had possibly been associating with, to questioning and investigation. He had lost his trust in the Head of Year and there was no consideration as to how anyone was going to keep Peter safe or what his wishes and feelings were now that his issues had been exposed. Record keeping within school 4.63 During the course of this review there are several instances that have come to notice regarding the lack of record keeping of significant events at school. The first was the visit to the school by the CEOP after Peter had posted images of himself on social media. He had been identified by his blazer shown in the background of the video and the matter dealt with accordingly as set out above. Later enquiries with the school indicate that there were no written records of this occurrence although some members of staff could remember the incident. 4.64 The submission of the referral to the MASH when Peter disclosed involved three members of staff at the school. The first was the Head of Year who had received the disclosure. The second was the Head Teacher who instructed that a referral be completed and the third was the Deputy Head Teacher who actually completed and submitted the written referral form. In doing so information about alleged intra-familial abuse was not communicated during the initial telephone referral and missed at the MASH when the written referral arrived. Consequently the alleged intra-familial abuse was not recognised or investigated. 4.65 There were no records made immediately after the conversation that the Head Teacher had with Peter following Peter’s disclosure to the Head of Year. The Review Author considers this interview was unnecessary and improper when dealing with reported allegations of child abuse especially when the Head of Year had made copious notes of the disclosure from Peter himself. Similarly, the Head Teacher was left with the responsibility of speaking to the four boys named at the CSE meeting by the Chair. This he did in relation an immediate assessment of any possible risk, but again there are no notes made immediately after the interviews Learning Point: Professionals are reminded for the need to make notes of disclosures made by children as soon as possible after the conversation and the conversation must 35 not include leading questions. The notes must be suitable for disclosure to any future enquiry or investigation. MASH referral, 21st April 2017 4.66 The referral into the MASH on 21st April 2017, emanated from disclosures Peter made to the Head of Year Teacher. Those disclosures involved: • Meeting men in car parks (possibly for money) • Meeting one man in particular, a man, who took him to a house and had penetrative and oral sex with him • Meeting men on a mobile phone app. • His actions being known to other boys at school • There had been intra-familial sexual abuse. • Peter had previously disclosed he had been sleeping rough • It was known that he had anxiety about his weight, low self- esteem and other emotional problems 4.67 There was no indication that consideration was given to recording this as a Section 47 investigation; that Peter was in danger of significant harm and therefore would have warranted the multi-agency response that a Section 47 investigation deserves. 4.68 When asked to clarify this CSC stated: ‘A decision about sec 47 was given consideration, it was decided that a CSE risk assessment together with a child and family assessment, would be undertaken to gather further information about Peter and his family. This work started and Peter was seen in school on the 12th May 2017 by his social worker. Had a sec 47 investigation been completed it is unlikely that there would have been a different outcome, the Police have indicated that because of Peter’s age they would not be involved and the Police did not attend the strategy meeting when it was held. CSC would have undertaken a child and family assessment and completed a CSE risk assessment to gather information about Peter and his family. It is important to say that risk to Peter was recognised. On the day of the telephone referral the MASH SW phoned Peter’s mother as follows; mother is deaf so I spoke to (sibling aged 19 in the same house) to ring the police if he leaves and family is not sure where he goes. [Sibling] confirmed he will ring police himself. 4.69 The Police had not in fact said they would not be involved because of Peter’s age, comment from the police was; ‘[Peter] is 16 and whilst this does not stop him being subject of CSE it does allow him to legally engage in sex with older males’. 4.70 The referral form to MASH contained information about Peter being abused within the family which had not been communicated by telephone at the time of the original referral. 4.71 When asked to clarify the fact that this information was missed by MASH workers, CSC stated: 36 The written referral has the additional information at the very end of the report, i.e. after “page 7 of 7” and follows a Blank page. It is completely understandable that this information was missed. The Social Worker contacted the school on the 10th May 2017 to discuss Peter and arrange a visit to the school. A new “online” referral form is about to be introduced. Recommendation 2 NSCB needs assurance from MASH that written referrals are being used and that they add value to the process. 4.72 The fact is that the information about alleged intra-familial abuse was also contained on the first page in line 5 of a narrative description of the disclosures Peter was making. A more detailed account of that part of the disclosure is contained on pages after page 7. Whoever read the report did not read the whole document and information about alleged intra-familial abuse was missed and did not come to light until the CSE meeting. That would have added weight to the decision to hold a Section 47 investigation as the alleged perpetrator of that abuse was still in the family setting. H.M. Coroner commented: ‘I find that the failure to understand the disclosure in full, was made not just by the individual social worker, but also by the Team Managers in the MASH’ 4.73 Regarding the seven week delay in calling the CSE meeting, when asked to expand CSC stated: Peter and his family were seen during the seven week period between the referral and the CSE meeting, a CSE risk assessment and a child and family assessment were both completed by the 30th May, this is within statutory timescales. The NSCB policy re child sexual exploitation states that; Comprehensive Interagency assessments that are conducted at an early stage are essential in the support and protection of children and young people who are, or are at risk of becoming, sexually exploited. The immediate presenting problems need to be considered in the context of the care that the young person is receiving at that time taking into account the family history, the child’s background and any previous harm or neglect experienced. 4.74 Following assessment a strategy meeting was then convened. Had the strategy meeting been held before the child and family assessment and the CSE risk assessment it would not have been able to consider this information. 4.75 The information about the alleged intra-familial abuse came to light during the CSE meeting, seven weeks after the MASH referral. During that time, according to CSC, two significant assessments took place, the Child and Family Assessment and completion of the CSE risk assessment tool. Both processes involved discussion with partner agencies but in neither assessment was the issue of alleged intra-familial abuse (as detailed in the written MASH referral) apparently discussed. Had it been it is likely serious consideration would have been given to initiating S47 enquiries. In the event this opportunity was missed. Child Sexual Exploitation Multi-agency Strategy Meeting, 7th June 2017, and Nottinghamshire Police response 4.76 This meeting was convened as a result of the referral made by the school on 21st April 2017, following the disclosure by Peter that he had been associating with older men 37 for sexual purposes. The information was passed to CSC but when Peter was told that CSC would have to be made aware, he stated that he would deny the disclosure was true. CSC conducted a CSE Risk Assessment and concluded that he was at high risk of sexual exploitation. 4.77 The referral resulted in the CSE meeting being held on 7th June. It was chaired by an Independent Child Protection Coordinator and attended by two Social Workers, the Head Teacher from Peter’s school, Peter’s mother and her partner and also Peter’s father. There was no representative from the police, CAMHS or the school nursing service. Peter was invited but declined to attend. 4.78 The Chair heard an overview from the agencies present and also about the allegation of intra-familial abuse, which had not been included in the verbal referral from the school, but had been included in the written version submitted the next working day. CSC had not yet investigated this disclosure by Peter because the alleged intra-familial abuse had not been picked up by CSC until the Head Teacher raised it verbally at the CSE meeting. The meeting also heard from a Social Worker that there were fears over Peter having suicidal thoughts and that there had been previous suicides within the family. 4.79 The Chair read from an email received from the police giving their apologies and stating that they had no information on Peter on their systems. The report stated that the police were to take no further action regarding the disclosures, and whilst they acknowledged that Peter was vulnerable, he was 16 years of age and the police did not consider him to be a high risk. The Chair commented that the police could be contacted if more information was required 4.80 Further examination of the police records indicated that the check that was made resulting in the CSE meeting being told there was no information on police records was not thorough enough. The Police CATS23 system and safeguarding systems were not checked and a more detailed examination of the Compact system would have revealed details of the two missing episodes involving Peter. 4.81 The Police did not attend the CSE meeting due to resourcing problems and other pre-arranged commitments. The decision not to attend was a subjective decision to make and the police report that based on the facts that they had been given, which of course did not include the allegation of intra-familial abuse, did not appear to indicate a high risk referral. An Officer from the Sexual Exploitation Investigation Unit (SEIU) stated that not attending the meeting was simply a resourcing issue and even if the alleged intra-familial abuse was known about, it was unlikely to have led to police attendance at the CSE meeting on 7th June 2017. The Officer noted; ‘[Peter] is 16 and whilst this does not stop him being subject of CSE it does allow him to legally engage in sex with older males’. 4.82 When asked to clarify the reasons for not attending the CSE meeting, Nottinghamshire Police stated: The reason for non-attendance was purely resourcing given the number of CSE meetings the same department were being asked to attend at the same time on the same day. The research issue only affected attendance in that, having found (incorrectly) no record of Peter on Police systems, the meeting was considered to be a lower 23 CATS Police Child Abuse Tracking System 38 priority than the others. It is doubtful that had the officer identified the previous MFH episode, it would have changed the position (i.e. made the meeting a higher priority than those elsewhere). The researching error is attributable to the officer not checking the MFH system. This was an error and communications have gone out to rectify that. Recommendation 3 NSCB to review the interagency CSE procedures to ensure that when there are sufficient concerns to support a section 47 enquiry that the appropriate multi-agency response is triggered. Recommendation 4 NSCB to disseminate the learning from this review. 4.83 Previous contact with Peter by the Police had been missing from home reports, the earlier investigation into him posting indecent images of himself on social media and a minor incident where Peter had purchased alcohol whilst being under age. The Police had not been made aware of his disclosures at school. The allegations of intra-familial abuse were only realised at the CSE meeting from the written referral. 4.84 The Chair also commented about the note made in the referral to the effect that Peter was a compulsive liar. The Chair said; ‘[Peter] had been labelled a compulsive liar by a school representative in some of the contact with CSC and my concern is that his disclosure has been discounted.’ 4.85 Father stated that Peter told him about that 2 years previously but father didn’t believe Peter. Father now disputes that he had known about this before. CSC made the point that they had not been told about that allegation and therefore nothing had been done about it at the time of disclosure. 4.86 The conclusion of the meeting was that Peter was at high risk of being sexually exploited and the actions outlined earlier in this report decided upon. 4.87 Because Peter did not attend the CSE meeting, it was left to his Mother to inform him of the conclusions, part of which was the details of the curfew that was to be imposed. She told Peter about the curfew later that evening and she described him as ‘losing it’. He was annoyed and had nothing more to do with her that evening. Whether he saw that decision as some form of punishment will never be known, save to say he was upset about the CSE meeting. 4.88 The following day Peter went to see the Head Teacher and asked what had happened at the CSE meeting. The Head Teacher felt obliged to tell Peter of the result and what action had been decided upon including the fact that the four boys would be spoken to. 4.89 It appears that there was no thought given as to how the result of the meeting was to be conveyed to Peter in a manged and structured way. It would have been wiser for a strategy to be agreed for someone to sit down with Peter and talk through the results of the meeting immediately after the meeting and probably someone who was not close to Peter, perhaps even the Chair of the meeting. The way the outcome of the meeting was disseminated to Peter could have been managed better. His reactions to sensitive issues in his life were well known, self-harming, going missing and suicidal ideations. 39 The minutes of the CSE meeting do not indicate that there was an understanding or consideration of the impact the meeting may have had on Peter. HM Assistant Coroner concurred with this finding at the inquest and expressed her concern that the NSCB inter-agency CSE guidance had not been followed in this regard. 4.90 Calling the CSE meeting should have been earlier when concerns were identified and the result of the CSE meeting should have been a joint Section 47 investigation led by the police. That would have been even more relevant as there were the four other boys to interview. The CSC IMR author states; ‘Upon hindsight it would have been more appropriate for this to have been a joint agency investigation due to the information about [Peter] meeting with older men for money alongside the allegation of intra-familial abuse.’ 4.91 The minutes of the CSE meeting indicate that references were made to Peter’s self-harm and suicidal ideations. • [Head Teacher] said he had concerns about Peter’s emotional wellbeing and the previous incidents of self-harming’ • ‘[Mother] said that his diet is a type of self-harm and he is still losing weight’ • ‘In [Father’s] opinion, Peter is suffering from depression and he is worried about his son’s mental health • [Social Worker] said there was some concern regarding Peter’s suicidal thoughts.’ • [Mother’s partner] mentioned that Mother’s brother had committed suicide. 4.92 However it does not appear from the minutes as if self-harm, suicide or Peter’s general well-being were explicitly identified as current risks and none of the actions in the action plan appear to be designed to directly address those risks. 4.93 The actions regarding the other four boys who may have been either witnesses or potential victims, to corroborate Peter’s disclosures of sexual exploitation were left to the Head Teacher to ‘investigate’. The fifth point within the action plan states that the school should sensitively explore the concerns with the named boys and liaise with social care. This action was not appropriate as any further communication with these boys should have been agreed with the police. 4.94 The Chair of the meeting had not intended the school to have any further conversations with the boys but had instead wanted school to share the information gathered to date with the social worker. The wording of the action was unhelpful and led to confusion about further discussions with the named boys. The Education IMR Author comments about this and the fact that the Head Teacher also interviewed Peter after he had disclosed to the Head of Year, possibly unintentionally conveying the impression that Peter was not to be believed. The IMR Author quotes from the school’s Child Protection Policy of 2017; (which was not in place at the time and therefore the Head teacher was not in breach of this guidance. The following quote was not contained in the 2016 guidance). • ‘Staff should never attempt to carry out an investigation of suspected child abuse by interviewing the child or any others involved. The only people who should investigate child abuse and harm are Social Care, Police or the NSPCC.’ 40 4.95 The Education IMR Author also points out that the Head Teacher (also the Designated Safeguarding Officer at the school) attended the CSE meeting, yet the person with whom Peter had had most dealing with at school and had supported him throughout his troubles, was the Head of Year. The Head of Year started off the referral process by informing the Head Teacher of Peter’s disclosures. The Head Teacher then interviewed Peter as stated above and then the Deputy Head Teacher, firstly telephoned through the referral which did not include the alleged intra-familial abuse, and then submitted a written referral that did include the alleged intra-familial abuse. 4.96 During the course of panel meetings dealing with this review, clarification was sought as to the Head Teacher’s purpose in interviewing the four boys and in addition what did the Head himself understood his role to be. 4.97 The Head Teacher explained that his view of the purpose of the meetings with the boys was to further clarify any risk factors and clarify the views of the four students and ensure they themselves were not at risk. This was based on the Head Teacher’s five years of knowing the boys and none of them having ever demonstrated behaviour that had raised safeguarding concerns. He had seen three of the boys both before and after the CSE meeting, but before the minutes of the meeting were received. 4.98 The Head Teacher was of the view that the purpose of the meetings was to ascertain the veracity of some of Peter’s claims relative to the individual and to also assess risk. During a conversation with the Education IMR Author the Head Teacher stated: ‘It would be fair to note that advice to the school prior to the CSE meeting would have been more than welcome. In the period between our submission and the CSE meeting all students presented no further issues within school of a safeguarding nature. We maintained a high level of monitoring.’ 4.99 It appears from the Head Teachers answers to the questions posed by the panel that his understanding of his role was to ensure that no other child at his school was at risk in a similar way as Peter had been placed at risk. None the less, as stated before in this report, the Head Teacher did obtain information from the four boys that related to what may have been considered evidence. The directions from the CSE meeting as to what was expected of the Head Teacher were unclear and the Head Teacher had rightly, acted before the minutes were produced and circulated. The specific expectations of the outcome of the CSE meeting should have been made clear by the Chair before the meeting ended. 4.100 The Chair of the CSE meeting picked up on the reference to Peter being described as a ‘compulsive liar’ and raised it with the Head Teacher. It would have been better for the Head of Year to attend and present to the meeting the benefit of his experience and extensive knowledge of Peter. The Head of Year when interviewed stated that he expected to go to the CSE meeting but was told that he wouldn’t be going as the Head Teacher, being the Designated Safeguarding Lead for the school, would be attending. 4.101 Because police were not able to attend the CSE meeting, it is considered that the relevance of the other four boys named by Peter in the overall possible exploitation of Peter was not realised. The four boys named during the CSE meeting were spoken to by the Head Teacher and the police had dealings with only one of these boys 4.102 The police did however trace one of the adults that Peter had been contacting, who stated he could not recall Peter personally or their interaction in June 2017. He used ‘Grindr’ to meet gay men and this was most probably where he had met Peter and exchanged messages. Peter’s number was in his phone as 'XnX' and he said that he 41 would have got this from one of his online profiles. It was not established whether he actually had sex with Peter. 4.103 The Police IMR Author is content that given the information known at the time of the police involvement there was nothing more that could have been done to improve their dealings with Peter. Their absence from the CSE meeting was unfortunate. 4.104 With regard to the actions from the CSE meeting concerning the four boys, CSC opened a Section 47 joint agency investigation on all four boys. One lived in a neighbouring county and was seen with by agencies in that county. With regard to the remaining three boys that resided in Nottinghamshire, they were all seen by social workers and by the Head Teacher. Information gathered by the social workers and the Head Teacher was passed onto the police. The Head Teacher expressed the view that only one of the boys he had spoken to was worthy of further police attention with regard to his knowledge of events. Officers saw this boy and obtained a witness statement from him and a forensic examination of Peter’s telephone was conducted as a result. The police were content with the Head Teacher speaking to the boys as he was acting under the provisions of a section 47 joint investigation. 4.105 When asked for specific clarification on this matter, Nottinghamshire Police responded: By the time the Police became involved the Head Teacher had already spoken to a number of boys. A more accurate observation is that the Police considered the view of the Head Teacher in determining who needed to be spoken to by Police to identify whether any of the boys were victims of crime. It is considered this position to be appropriate in the same way that the Police consider the views of social workers in establishing next steps. Had the boys been spoken to by somebody with no grounding in child protection or safeguarding then I would perhaps have a different view but a head teacher (who is also Child Protection lead for the school) does not fall into this category. 4.106 In Nottinghamshire the practice of a joint investigation will often involve one agency conducting enquiries and sharing information with other agencies to decide the next steps. However this is a subjective decision and consideration has to be given as to whether the people concerned could be witnesses to criminal activity and if the purpose of the contact by agencies is safeguarding, a trawl for witnesses or both. In an ideal situation police officers should have considered speaking to all four boys. 4.107 Immediately after the CSE meeting a Section 47 multi-agency investigation was opened in respect of the other siblings in Peter’s family but not Peter. 4.108 The man who sent Peter explicit texts in the days before his death was traced by the police and he was interviewed. He admitted using a gay app. on his phone to meet others and that is how he contacted Peter. There was no reason to suspect that he knew Peter’s age or identity before the contact. Police were satisfied that their investigation found no evidence that this man posed a risk to children and there was nothing to indicate that he used the app. to specifically seek out children. 4.109 There was no sharing of information in 2013 when the CEOP investigation took place. That concentrated on determining if any criminal offences had been committed or whether Peter was being exploited. It did not necessarily consider the wider issues of safeguarding of Peter, his family circumstances and any safeguarding needs of his siblings. That may have uncovered the issues of sexual abuse reported much later by Peter. 42 Recommendation 5 NSCB to undertake an audit of Child Sexual Exploitation (CSE) meetings. British Transport Police response 4.110 British Transport Police (BTP) are responsible for policing incidents that occur on Network Rail Property and therefore have primacy when dealing with deaths on railways, be they suicide or other causes of deaths such as criminal actions and accidents. 4.111 During the year 2017, nationally, BTP dealt with 23 child fatal incidents. Five were classed as accidents, 11 were recorded as suspected suicides and there were 7 child homicides as a result of the terrorist attack in Manchester. 4.112 BTP had no prior contact with Peter before his death on 8th June 2017. BTP officers were called to the scene and dealt with the initial investigations as per their policy and procedures. Part of their investigation was to inform Peter’s father of his son’s death. During that contact the father disclosed allegations of intra-familial abuse that Peter had made to him sometime previous. This information was passed to Nottinghamshire Police. 4.113 BTP Suicide Prevention and Mental Health Team supported the father. Due to his understandable reaction to the news of the death of his son, BPT officers from this unit arranged for an ambulance to take him to hospital for a mental health assessment. 4.114 Working Together to Safeguard Children 201524 chapter 5 deals with the responsibility of each Local Safeguarding Children Board to ensure a review of the death of each child via the Child Death Overview Panel (CDOP) process. The CDOP has a fixed core membership drawn from organisations represented on the LSCB with flexibility to co-opt other relevant professionals to discuss certain types of death as and when appropriate. 4.115 Page 91 Working Together to Safeguard Children illustrates by way of a flow chart the ‘Rapid Response’ process in the event of a child death. Beside the initial police response to the scene, the guidance requires a police officer to attend at the hospital and liaise with the duty Paediatrician. BTP Officers were in attendance and liaised with the designated nurse for child death that was an acceptable alternative to the Paediatrician. 4.116 The flow chart goes on to indicate that there should follow a joint home visit by the police and a designated paediatrician. This emanates from guidance issued in 2016 by Section 5 of the guidance, Sudden Unexpected Death in Infancy and Childhood25 (SUDIC), which states: ‘As soon as possible after the infant’s death, the lead health professional (designated paediatrician, specialist nurse or on-call paediatrician) and police investigator, accompanied by the family’s GP or health visitor if possible, should 24 Working Together to Safeguard Children A guide to inter-agency working to safeguard and promote the welfare of children March 2015 HM Government 25 Sudden unexpected death in infancy and childhood - Multi-agency guidelines for care and investigation. The report of a working group convened by The Royal College of Pathologists and endorsed by The Royal College of Paediatrics and Child Health Chair: The Baroness Helena Kennedy QC. Royal College of Paediatrics and Chid Health 2016 43 visit the family at home or at the site of the infant’s collapse or death. The purpose of this visit is to obtain further, more detailed information about the circumstances and environment in which the infant died, and to provide the family with information and support.’ 4.117 The officer from BTP that attended the family home was a family liaison/ support officer who stated himself that he was not aware of the rapid response process and he was the wrong officer to attend the home for that purpose as he was there to support the family and not satisfy the requirements of the Helena Kennedy guidance. However the action taken did satisfy the requirement of the BTP guidance ‘Fatality Management Policy’26 regarding interaction with SUDIC and CDOP processes. 4.118 The Nottingham University Hospital IMR comments about the Rapid Response process following the death of a child or young person. It states that the Rapid Response was appropriately initiated at the hospital following the death of Peter. In cases where the family do not attend the hospital, the IMR points out that there is no opportunity for a history to be taken by the paediatrician. At this point it is expected that a joint agency discussion will take place to agree the next steps. This would include whether a joint home visit was to be made and who should attend. The IMR states that a joint home visit is useful in order to obtain background information and to explain about the child death review process and identify who is best to support the family. A report of this visit is usually sent to the Coroner and information shared at the initial joint agency meeting. 4.119 The Author identifies that a home visit was undertaken by a BTP officer followed by a separate visit by CSC and health, and that the BTP visit had a separate purpose. The IMR concludes that it appeared that the BTP officer had little knowledge of the Child Death Review process. Equally it is identified that neither CSC nor Heath had an understanding of BTP responsibilities in these circumstances. The joint decision making would have been based not only on the circumstances of Peter’s death but also taken into account his full social history as it was then known, including his safeguarding and complex social background. 4.120 BTP IMR Author states that all officers have training on the requirements of the rapid response guidance and the guidance should have been followed regarding the home visit. This matter has been addressed in the BTP recommendations which require a review of the training to ensure that all officers are reminded of the need to conform to the guidance. ‘BTP will refresh and reinforce the guidance set out in the Fatality Management Policy regarding interaction with SUDIC and CDOP processes to relevant staff to ensure that they are fully aware of their responsibilities’ and; ‘BTP will also review what training is given to officers regarding the specific requirements in child fatalities to ensure that that remains relevant and up to date.’ School Nurse 1 4.121 SN1 has subsequently been interviewed by the commissioner of the Healthcare Trust IMR. 4.122 The death of Peter had a significant impact on SN1. She openly shared her work with Peter in the period August 2013 – April 2015 and her commitment to supporting him 26 British Transport Police Fatality Management Guidance 2013. 44 and his family. It was clear from the interview that SN1 worked hard with Peter and his family and was a consistent source of support for them. 4.123 SN1 recalled that at the time she faced a number of challenges – including covering a vacant caseload and the competing demands of her role and her own caseload. Despite this, she was able to reflect that she was committed to providing a good service to Peter, his family and the school. 4.124 SN1 shared her reflections on the issue of the EHAF not being completed. She was open and honest that she could not, from memory, provide a rationale for this. She confirmed that she has confidence in the EHAF as a process and that if she had felt the completion of the EHAF would have made a significant difference in supporting Peter, she would have prioritised this, irrespective of competing demands. However she does not recall this as being the case at any time in her work with Peter. Summary of agency conclusions and recommendations Children’s Social Care 4.125 The conclusions in the Children’s Social Care IMR concentrate on the efforts professionals took to encourage Peter to engage and how often his mother declined to allow that until the time of the last referral but by that time Peter was finding it difficult to openly engage with his social worker. He was also angry with school making a referral and was distressed about the amount of information being shared about him. 4.126 As stated above, CSC is of the opinion that a Section 47 joint investigation would have been a better way of managing his disclosures. 4.127 The CSC IMR makes two recommendations; • When CSE issues have been identified when working with a young person, discussions should always be held with the chair and the team manager to carefully consider the timing, format and participation in all proposed CSE meetings. When it has been agreed that a CSE meeting should be held then this meeting should take place as early as possible. • Written referrals should always be read alongside the information contained within the MASH referral. Nottingham West Clinical Commissioning Group 4.128 The CCG IMR makes one recommendation • Outcomes of the Practice Untoward Event Analysis will be shared with the CCG Designated Doctor for Safeguarding Children to identify whether further learning can be cascaded to other GP practices across the CCG and illustrates contact with the GP practice has highlighted some areas of good practice; • Holding safeguarding reviews regularly enabling peer review of children of concern. • Learning from previous SCRs: young members of this family were offered appropriate confidential consultation and signposted to local services to suit their needs. • The identification of a safeguarding lead who can attend learning events. 45 • The GP recognising that Peter may have underlying emotional needs, signposted him to self-help and on-line resources. • Offering flexible consultations to vulnerable adults in the family, i.e. Peter’s mother and father. Nottinghamshire Healthcare NHS Foundation Trust 4.129 The IMR from the Healthcare Trust makes an interesting comment about the reasons why Peter declined to engage with services especially around his sexuality and the suggestion that he was being exploited. In March 2015 Peter was in conversation with the School Nurse, with whom he had had significant dealings, but once the conversation erred on the subject of his sexuality he disengaged. Other women that he had dealings with, for example CAMHS etc., were identified as being significantly older than he was, meaning that he may not have been comfortable talking to them about his sexuality and the potential abuse he was suffering. This is somewhat supported by the fact that he spoke openly to the Head of Year about his abusive relationships with men, the alleged intra-familial abuse, his sexuality and concerns over his weight and then his ‘man boobs’ after losing a great deal of weight. 4.130 Conversely, it is suggested that female members of staff may not have felt comfortable talking to Peter about sexual issues and he may have picked up on that and decided not to engage with them. The truth about that area of Peter’s life will never be known. 4.131 Another useful insight mentioned in the Healthcare Trust IMR is the area which has been identified in previous SCRs, that of confirmatory bias. The IMR considers that it is apparent in this case that professionals were seen to be looking for more comfortable explanations for Peter’s presenting behaviours rather than considering child protection concerns. Peter could have spoken for himself in the meetings that were held and the IMR begs the question of, ‘Whose needs were being met at the meetings as the voice of the child was not heard?’ 4.132 The subject of supervision was examined in the Healthcare Trust IMR with a CAMHS professional who was of the view that cases would only be taken to supervision if there were concerns. As Peter’s case was not taken to supervision, it has to be assumed that there were no concerns. However, the Author was told that this case would have been discussed at the multi-disciplinary team meeting both before and after seeing Peter and any risks or concerns would have been discussed then. The point is made that has supervision been accessed, and the appropriate supervision was available to be accessed, the case may have been formulated and a plan made around how to minimise the risks involved. 4.133 During an interview with School Nurse 2, the IMR author was told that at the time of dealing with Peter, her caseload was very high and a number of staff were off sick. There was a feeling of exhaustion among staff, with management making changes that made the situation worse, and caseload numbers rising. However the IMR indicates that the supervision framework is being embedded in practice across the Trust and staff with supervisory responsibilities are being trained in safeguarding supervision skills, to respond immediately if safeguarding issues are raised within teams. 4.134 In addition and in conclusion the Healthcare Trust IMR considers whilst both school nurses worked hard to engage with Peter and to understand the family’s individual needs, it is unfortunate that the assessment tools available at the time such as EHAF were not used effectively resulting in plans not being robust enough to prevent significant drift of the case. The new Healthy Family Teams introduced since this case will enable children, young people and families to have their mental health needs addressed more effectively. This, together with the Primary Mental Health Teams, 46 ensures that specialist mental health advice for universal service is now available for the Healthy Family Teams and school and is being offered in consultations on a regular basis. 4.135 The ‘did not attend’ policy has been re-visited and a ‘was not brought’ policy introduced in its stead. This will include following up those who do not attend for appointments rather than closing the case after so many times of failure. 4.136 Since March 2015 and the publication of Future in Mind27, CAMHS has attempted to move away from a culture where the responsibility was on families to go to the service and engage with them, to one which is a more community based approach with improved accessibility. 4.137 The IMR does however identify good interagency working between the school nursing service and the GP. This ensured that concerns were kept active and agencies were kept up to date. 4.138 Following the Coroner’s inquest the Healthcare Trust have provided an addendum to their IMR giving additional information and assurances in the following areas:- • School Nursing Service • CSE training • Safeguarding supervision • ‘Think Family’ • CAMHS, including o Assessment of suicide risk and, o Discharge arrangements 4.139 In particular, in terms of discharge from community CAMHS due to non-engagement, the process in place at the time and which was followed in this case, is that the referrer is notified of the failure to engage and informed that a re-referral can be made. There would be an expectation that, if efforts to engage the young person in CAMHS services have failed, then the referrer should take primary responsibility for trying to facilitate engagement via a re-referral or referring to alternative services. Education 4.140 Peter’s school became aware of concerns of Peter’s self-harm and suicidal thoughts in September 2015 and the IMR state that the school’s response was timely and in accordance with school and NCC guidance and policy. However the Head Teacher’s decision to determine Peter as a ‘Keep in View’ pupil and to remain vigilant for other signs causing concern, would have had more significance if there had been formal opportunities for a review process among teachers which there was not. In view of that the school make two recommendations; • School should consider ways in which their good pastoral support could be further strengthened by the addition of more formal and recorded ‘plan and review’ processes for pupils causing high levels of concern. • NCC have recently developed and launched a suite of guidance and advice on self-harm and suicide. This school have resolved to make use of this new material in their future training and guidance for staff. 27 Future in Mind: Promoting, Protecting and Improving our Children and Young People’s Mental Health and Wellbeing HM Government March 2015 47 4.141 The Education IMR points out that the CSE strategy meeting minutes do not appear to include self-harm and suicide explicitly as current risks and none of the actions in the action plan appear to be designed to directly address those risks. Accordingly the following IMR recommendation is made; • All staff involved in multi-agency planning meetings where self-harm and suicidal ideation are a factor should ensure that the action plan from the meeting takes account of those risks and puts in place actions to mitigate them. 4.142 The Education IMR discusses the schools ‘Whole School Policy for Child Protection 2016’ which states that recognising signs of sexual abuse can be difficult for any child unless the child disclosed and is believed. This is in reference to Peter being described as labelled as a compulsive liar by a school representative. The IMR author points out that such guidance is not contained in the current 2017 version of the policy; • School should review its School Policy for Child Protection to ensure through its training and guidance to staff that when a pupil discloses abuse the young person feels that their voice is being heard and take seriously. • Nottinghamshire County Council should ensure that their ‘School Child Protection Policy’ template provides similar advice. 4.143 The IMR comments about the wisdom of the Head Teacher interviewing the four boys named in the CSE Strategy meeting against the school’s 2017 Child Protection Policy; • School should ensure through its training and guidance to staff, that staff understand, in line with the school’s updated policy that it is not the role of staff to investigate disclosures by interviewing the child or others involved, unless asked to do so by Police, CSC or the NSPCC. 4.144 In line with this recommendation from Education, the Overview Author considers that there is a role for NSCB: Recommendation 6 NSCB should ensure through its training and guidance to staff, that staff understand, in line with the school’s updated policy that it is not the role of staff to investigate disclosures by interviewing the child or others involved, unless asked to do so by police, CSC or NSPCC. 4.145 Regarding the attendance of the relevant member of staff to the CSE Strategy meeting, the IMR makes this recommendation; • In complex cases (such as this) senior designated person for safeguarding and the teacher who knows the child best, or who hear the original disclosures, should attend multi-agency meetings. 4.146 Finally, the IMR discusses how Peter ‘froze out’ the Head of Year after it was determined that details of the disclosure would be shared. This left Peter isolated and without his trusted point of support. The IMR makes the following recommendation; • Nottinghamshire County Council should review guidance to all staff regarding support for children and young people following a disclosure. If the disclosure leads to a breaking of important sources of support 48 (either because the young person chooses to do so, or because of a subsequent move) there should be careful planning to ensure that a new supportive framework is created for the young person. 5. Conclusions 5.1 The reason why Peter came to the decision to end his life in the way he did and at the particular time he did is not known. As a result, whilst this review has identified learning for agencies, it is not possible to say that had agencies done things differently Peter would not have taken his own life. 5.2 There is substantial evidence to show that Peter and his mother received significant agency support from May 2014 onwards when agencies were first made aware of the suicide note that he had written approximately one month earlier. 5.3 There were two School Nurses involved with Peter. With the first, SN1, Peter built a long and trusted relationship. SN1 also had a good relationship with Peter’s mother meeting her on a number of occasions to discuss her concerns about Peter and considerable personal support was offered. H.M. Assistant Coroner for Nottinghamshire comments during her determination: ‘It is clear that [School Nurse 1] tried hard to support [mother] with both children’. 5.4 There is also evidence to suggest that there was a good working relationship between both School Nurses and the school as well as the family GP. Information was shared by the School Nurses and Peter was flagged at the GP surgery for their monthly ‘Red Card’ meetings. However, when SN1 left and SN2 took over, the relationship between SN2 and Peter broke down despite best efforts of SN2 to maintain the relationship at the level SN1 had been able to do. When Peter did not engage with SN2, she made an appropriate referral to CAMHS and advised the school to put measures in place to provide pastoral support for Peter. School followed this advice in the form of the Head of Year teacher with whom Peter established a good relationship for a considerable amount of time. 5.5 The option of referring Peter to CAMHS was first mentioned in May 2014, but there was a delay in making the referral and he was finally seen by CAMHS in September 2015. After only one appointment, with the assessment being only half completed, both mother and Peter disengaged and CAMHS discharged him from the service. CAMHS procedures have since been changed where monthly liaison meeting are held between school and CAMHS, where concerns about children are discussed and reviewed regularly and Healthy Family Teams now provide specialist mental health advice. 5.6 In 2015 when Peter was reported as missing from home, school, social care and the police had numerous contacts with him and offered support in doing so. Agencies worked hard to engage with Peter and his mother, sometimes that support was accepted but on other occasions neither Peter nor his mother engaged with agencies. 5.7 There were two reports made when Peter went missing. The police dealt with those incidents appropriately and speedily. They shared information with CSC and the follow up by CSC was timely and in line with inter-agency procedures. During the first ‘missing from home’ return interview a Family Service worker was able to spend time with Peter and he established a good rapport. Attempts by the same worker to conduct the second return interview did not succeed as the mother declined to consent to the interview taking place. The Review considered whether there was sufficient 49 information for the Family Service worker to lawfully override the wishes of Peter’s mother and concluded there were not at that time. 5.8 Examining the early support Peter was offered, the Review concluded that the use of an EHAF may have helped professionals working with Peter obtain a fuller understanding of the issues impacting on him and his family. It is disappointing that no professional working with Peter took responsibility for completing the Early Help Assessment which may have led to improved identification and coordination of services required to address his needs. 5.9 Peter found a great deal of stability at school, he made satisfactory educational progress and was expected to pass his GCSEs with good grades. His attitude to learning improved as he grew older and this is reflected in the letter he wrote applying to be a school prefect which is referred to earlier in this report.. He lost weight, improved his appearance, and took pride in the way he looked and presented himself. He had good support at school and school was a positive influence in his life. He took an examination at school on the morning of his death. He had good relationships with staff at school, mainly with the Head of Year teacher with whom he formed a bond. Peter trusted the Head of Year however when he told the Head Teacher the details of Peter’s disclosures Peter felt that trust had been breached. 5.10 The Head of Year made the correct decision by reporting Peter’s disclosure in April 2017. Peter had disclosed information in relation to child sexual exploitation and alleged intra-familial abuse which suggested he was likely to suffer significant harm. School were well aware of his history of other concerns in relation to self-harm, suicidal ideation, extreme weight loss, OCD tendencies and poor self-image. The Head of Year would have been in contravention of guidance and procedures if he had not done so. It is unfortunate that this caused a breakdown in the relationship between Peter and the Head of Year. What Peter saw as a breach of confidentiality was the Head of Year acting with his best interests at heart and complying fully with the Nottinghamshire Safeguarding Children Board inter-agency procedures. 5.11 Following Peter’s disclosure the Head of Year made a detailed written record of what had been said. This is good practice and in line with procedures. He correctly reported the disclosure to the Head Teacher. The Head Teacher re-interviewed Peter which was unnecessary and not good practice, as the full disclosure had been obtained by the Head of Year; a referral to statutory agencies via MASH was the next step to take. 5.12 The Head Teacher delegated the Deputy Head Teacher to make the MASH referral, which initially was by telephone. It mentioned that Peter had disclosed behaviour described as ‘prostitution with older men’ and it was clear from the call made that the school recognised this as a serious safeguarding issue. The details were recorded by the MASH Officer and a written referral was requested which was submitted the next working day by the Deputy Head Teacher. 5.13 The written referral contained additional information not passed to the MASH Officer as part of the telephone referral. It contained detailed information taken from the Head of Years notes of the disclosure made by Peter. It included further information in relation to ‘male prostitution’ and the names of four other boys who may have been able to provide additional information and/ or who may themselves have been at risk from CSE. The written referral also contained information about alleged intra-familial abuse not provided in the telephone referral. It is regrettable that MASH did not consider the information in the written referral as part of its decision making and the Social Worker allocated to the enquiry based his investigations on the information contained in the verbal referral and missed the additional information provided in the written one. This 50 error was not picked up until the CSE meeting seven weeks after the initial referral. It is accepted that this was an individual error rather than a systems failure. 5.14 The MASH referral eventually led to a CSE meeting, held on 7th June 2017. Several agencies could not attend for a variety of reasons meaning that the meeting was less effective. Given the serious disclosures made by Peter the MASH referral should have led to a more timely multi-agency response Due to the lack of attendees, roles, responsibilities and actions that followed were less clear. Plans for communicating with Peter could have been more explicit. Communication was via mother and head teacher but was not part of a considered and agreed plan devised in the child’s best interests. H.M. Assistant Coroner commented in her determination: ‘I find that the guidance was not followed in respect of Peter. The outcomes from the CSE meeting should have been carefully and sensitively shared with him, with thought given as to how the impact on Peter, of these, such difficult issues, could be minimised. There was no consideration given as to who might share the outcomes with him, and how this might be done. I find, and the safeguarding Board accept, that this should have been the social worker, likely with a parent present and this should have been done immediately after the meeting on 7th June 17’. 5.15 The information about alleged familial abuse was missed by the Social Worker and also the Team manager in the MASH. The delay in holding the CSE meeting was because a decision was made to complete a Child and Family Assessment before completing the CSE risk assessment tool which triggered the CSE meeting. It may have been better practice to have completed the CSE risk assessment tool based on the information known at the time of referral. This would have indicated a CSE meeting was necessary and so avoided some of the delay. 5.16 With the benefit of hindsight it may be viewed that Peter’s disclosure to the Head of Year of child sexual exploitation was a sign that he wanted to talk to somebody about what was happening to him but had not thought through what should happen next. Once he was informed by the Head of Year that the information had to be shared his immediate retraction was an indication that he was not happy with others being involved. His disclosure led to a number of consequences, which appeared to be both unforeseen and unwanted by him. This included questions being asked of him and his peers and a course of action culminating in the CSE meeting. It illustrates a potential conflict between our statutory duty to protect children and the need to take into account the child/young person’s wishes and feelings. It may be that Peter felt he had lost control of events and this was troubling him. 5.17 The information known through the disclosure by Peter and other indicators of sexual exploitation was such that a multi-agency response was required and the CSE meeting was an appropriate means of coordinating those efforts. It was also good practice to invite the family and young person to be part of the work to reduce the risks to Peter. It is important to acknowledge the difficulties and sensitivities involved and how best to engage with young people at risk of sexual exploitation. An individual response focused on the specific needs and circumstances of the child/young person is needed. 5.18 Peter displayed a number of risk factors for self-harm and suicide and considerable efforts were made to provide support to him in a number of ways. Unfortunately the level of engagement with Peter that practitioners were able to achieve did not allow for these risks to be fully assessed. HM Assistant Coroner concluded that even those who knew him very well, particularly his parents, could not have predicted what he would do and observed that - ‘what is not predictable is not preventable’. 51 Recommendations Recommendation 1 Page 30 NSCB to promote the increased use of the EHAF by agencies and explore the barriers which prevent professionals from completing them. Recommendation 2 Page 36 NSCB needs assurance from MASH that written referrals are being used and that they add value to the process Recommendation 3 Page 38 NSCB to review the interagency CSE procedures to ensure that when there are sufficient concerns to support a section 47 enquiry that the appropriate multi-agency response is triggered. Recommendation 4 Page 38 NSCB to disseminate the learning from this review. Recommendation 5 Page 41 NSCB to undertake an audit of Child Sexual Exploitation (CSE) meetings. Recommendation 6 Page 47 NSCB should ensure through its training and guidance to staff, that staff understand, in line with the school’s updated policy that it is not the role of staff to investigate disclosures by interviewing the child or others involved, unless asked to do so by police, CSC or NSPCC. Learning Point Page 34 Professionals are reminded for the need to make notes of disclosures made by children as soon as possible after the conversation and the conversation must not include leading questions. The notes must be suitable for disclosure to any future enquiry or investigation. 52 Bibliography Working Together to Safeguard Children - A guide to inter-agency working to safeguard and promote the welfare of children. HM Government 2015 The Munro Review of Child Protection: Final Report: A Child Centred System Department for Education May 2011. Young People and Self-harm: Guidance for Schools Nottinghamshire County Council Educational Psychology Service September 2017 Serious Case Review NN15 Nottinghamshire Safeguarding Children Board 2016 Child Sexual Abuse Multi-agency Pathway Nottinghamshire County Council 2017 Suicide by children and young people in England - National Confidential Inquiry into Suicide and Homicide by people with Mental illness. University of Manchester May 2016 Serious Case Review DN11 Nottinghamshire Safeguarding Children Board 2011. Young People and Self-harm: Guidance for Schools Nottinghamshire County Council Educational Psychology Service September 2017 Clinical Judgement and Decision-Making in Children’s Social Work: An analysis of the ‘front door’ system Research Report by Elspeth Kirkman and Karen Melrose - The Behavioural Insights Team Department for Education April 2014 Suicides in the UK: 2016 registrations Office of National Statistics Statistical bulletin: Pathway to Provision Multi-Agency Thresholds Guidance for Nottinghamshire Children’s Services Version7 February 2018 Sudden unexpected death in infancy and childhood - Multi-agency guidelines for care and investigation. The Royal College of Pathologists and endorsed by The Royal College of Paediatrics and Child Health Chair: The Baroness Helena Kennedy QC. Royal College of Paediatrics and Chid Health 2016 Fatality Management Guidance British Transport Police 2013. Future in Mind: Promoting, Protecting and Improving our Children and Young People’s Mental Health and Wellbeing HM Government March 2015 53 Appendix 1 Scope and Terms of Reference Decision to hold a SCR Background Towards the end of April 17 Nottinghamshire Children’s Social Care (CSC) received a referral from school which raised concerns in relation to Peter being a victim of child sexual exploitation (CSE) and historical sexual abuse by a family member. Given the nature of the concerns a CSE Risk Assessment was undertaken and completed at the end of May 17 which concluded that Peter was a "high risk". This led to a CSE Meeting being convened during the first week in June 17 and an action plan being devised. Both parents attended the CSE Meeting but Peter declined the invitation. During the CSE meeting it became apparent that the disclosure in relation to sexual abuse by the family member had not been picked up from the initial referral. In addition to providing further information in relation to the CSE the meeting also established that there were a number of other concerns in relation to Peter including incidents of self-harm, suicidal ideation, excessive alcohol consumption, issues regarding his sexual identity, a potential eating disorder OCD traits and general concerns around his emotional well-being. Following the CSE Meeting Peter’s mother informed him that he was on a curfew and that if he was not home by 10.00pm then she would be reporting him to the police (this was an action for mother from the CSE meeting). That evening Peter did not go out as he was reported to be revising for an exam the following day. The following morning mother briefly saw Peter as he left for school. Between 11.30am - 12.00pm he returned home after his exam and briefly spoke to his older half-sibling to say that he thought his exam went well. He then left the property and called his father at approximately 12.30pm. It is known Peter exchanged sexually explicit text messages with a person not yet identified. At 3.18pm that day there was a report to the transport police that a person had been hit on the local train line. Peter was reported missing at 10.00pm that evening. British Transport Police investigated the death and linked Peter’s missing report to the person who had walked in front of the train earlier in the day. Peter was subsequently positively identified through DNA. 54 Decision making process This case was considered by the SIR sub group on 13th September 2017 when a decision was made to recommend a SCR be carried out. A summary of the recommendation was passed to the independent chair of Nottinghamshire Safeguarding Children Board and on 18th September the Chair confirmed his decision to carry out a SCR. On 25h September 2017 Ofsted and the National Panel of Independent Experts were notified of this decision. The review will be conducted in line with the principles set out in Working Together 2015 and NSCB/NCSCB Interagency Procedures to safeguard Children. Period to be covered by the review Chronology Agencies will be required to provide a chronology of their involvement with the subjects of the review from 1st May 2014, the month when the first indication of suicidal ideation was brought to the attention of professionals, until the date of the child death Initial Case Discussion meeting on 12th June 2017. Chronologies must use the Chronolatry template. The chronology should cover only the period identified within the scope of the review. Only relevant and significant information which was known to the agency at the time should be included. Individual Management Reviews In addition to providing a detailed narrative and analysis of events during the scope period detailed above, Individual Management Reviews should provide a summary of any relevant information prior to this period which may help assist in understanding subsequent events and be relevant to the key issues for the review. Details of immediate actions following the incident to safeguard Peter’s siblings and other children considered at risk of Child Sexual Exploitation should also be included within the agency report in summary form. Include in this section a summary of how the death of Peter impacted on the response to CSE. Individual Management Reviews may be subject of requests for disclosure by other parallel processes e.g. Coroner, Criminal etc. 55 Focus / key issues for the review All agencies IMR authors are required to produce an IMR on the template provided which will address the key issues listed below. Examine and analyse the response of your organisation to the following issues in accordance with individual agency and multi-agency safeguarding procedures. 1. Consider the response to any known reports and concerns in relation to sexual abuse and child sexual exploitation. 2. Examine how your organisation identified and responded to any known concerns around suicidal ideation and self-harm. 3. Explore your organisations engagement with Peter and his family and consider its response to any known reluctance to work with services. 4. Did your organisation identify issues around parental mental health, alcohol and substance misuse and if so how did it assess the impact on the children within the family and respond to any risks identified. 5. Did agencies hear the voice of the child and was it acted upon by agencies working with the family? If not, what were the barriers to them doing so? 6. Were there any racial, cultural, linguistic, faith, disability, or sexual identity issues that needed to be taken into account in the assessment and provision of services? How were these issues managed by each agency? 7. Did professionals working with the family receive appropriate supervision and support? Was there appropriate management oversight in this case? 8. Were there issues in relation to capacity or resources in any agency that impacted on the provision of services? (It is particularly important to identify any actions that could have led to a different outcome for the children). Police only (in addition to the above) 1. Examine the response to the referral from CEOP in November 2013 56 Methodology for the Review Working Together to Safeguard Children 2015 (WT2015) allows local safeguarding children Boards flexibility around the methodology to be adopted for serious case reviews. This review will adhere to the principles laid out in WT2015 and the NSCB local procedures. In view of the period of time covered by this review it is proposed that the methodology to be adopted for this review is as follows: - • Briefing event for authors. Commissioners will also be invited to attend the briefing event should they be available to do so. • Chronologies will be prepared by agencies on the approved template and integrated. • Individual Management Reviews/Information Reports as appropriate. • Involvement of practitioners in the review will be via IMR authors. Should the Lead Reviewer consider further contact with practitioners is desirable this will be considered by the SCR Panel at that point • SCR Panel meetings, as required, to consider the IMRs and the SCR report. • SCR Panel meeting to agree the learning from the review and the appropriate response. • Extraordinary meeting of the NSCB to sign off the SCR report. Interviewing of staff Agencies should seek to immediately identify staff they would wish to interview as part of completion of their Individual Management Review. The Police have indicated that there is no barrier to staff being interviewed. Involvement of Family Peter’s mother and father are separated and each was notified of the review by letter on 10th October 2017. The Lead Reviewer and the NSCB Development Manager will consider how Mother and Father can best be supported to contribute to the review in order to gain an understanding of any learning they can provide. Consideration will be given by the SCR panel as to how engagement with the siblings in the review process will be managed. A further meeting/communication will be undertaken prior to publication to share the learning with the family. 57 Expert opinion The Panel will explore whether additional expert involvement in the area of self-harm and suicide in young people would aid the review. Other parallel reviews A Coroner will hold an inquest into Peter’s death. NSCB are not aware of any other reviews in connection with this death. Organisations to be involved in the SCR The following organisations are required to provide chronologies and individual management reviews. • Nottinghamshire Healthcare NHS Foundation Trust (school nurse, adult mental health, CAMHS) • Nottingham West Clinical Commissioning Group (GP contracted services) • Nottinghamshire Police • NCC Children’s Social Care • NCC Education The following organisation is required to provide an information report only • CAFCASS • Nottingham University Hospitals NHS Trust • NCC Adult Social Care • British Transport Police (BTP) • East Midlands Ambulance Service (EMAS) Peter’s School will be invited to nominate a suitable senior member of staff to sit on the SCR Panel. Involvement of agencies in other LSCB areas There are no agencies from other LSCB areas required to take part in this review. The NSCB Development Manager will link in with Nottingham City Safeguarding Children Board to ensure any cross authority issues are identified. Coroner’s inquiries / criminal investigations The death is scheduled for inquest in Nottingham Coroner’s Court. The Assistant Coroner has indicated that the inquest will take place after the serious case review is completed. The NSCB Development Manager will be responsible for liaison with the Coroner. The Coroner has been notified that a serious case review is being undertaken. 58 Media coverage There has been some local media coverage of this incident. The media have not been notified of the decision by NSCB to carry out a serious case review in this case. Should agencies become aware of any media interest they are to notify the NSCB Development Manager. All media enquiries should be directed to the Nottinghamshire County Council (NCC) Communications Department. Legal advice There is no requirement for independent legal advice at this stage however should this become necessary it will be provided by the NCC Legal Department. SCR timescales The target date for completion is 6 months from the decision of the independent Chair to carry out this Serious Case Review which is 18th March 2018. Commissioning of an Independent Author and Independent chair for the SCRP In accordance with Working Together 2015 an independent person will be appointed to lead the review and author the overview report. A suitable chair will be appointed to manage the SCR panel meetings. Implementation of IMR recommendations and feedback to staff Agencies which are required to produce IMRs will be responsible for producing internal recommendations to improve practice and for the implementation of associated action plans. Agencies should not wait until the end of the review process to implement any learning identified. Agencies are required to provide feedback to their own staff who were involved in the review. Agencies are required to disseminate any learning that is specific to their organisation and the NSCB will facilitate the dissemination of any broader multi-agency learning through the NSCB Learning and Improvement Framework. Liaison with Ofsted and DfE Liaison with Ofsted and the DfE will be the responsibility of the NSCB Development Manager 59 Appendix 2 Individual Management Reviews Recommendations Nottingham West Clinical Commissioning Group 1. Outcomes of the Practice Untoward Event Analysis will be shared with the CCG Designated Doctor for Safeguarding Children to identify whether further learning can be cascaded to other GP practices across the CCG Children’s Social Care 1. Child Sexual Exploitation meetings to be held as early as possible. 2. Written referrals should always be read alongside the information contained within the MASH referral. British Transport Police 1. British Transport Police will refresh and reinforce guidance set out in the Fatality Management Policy regarding interaction with SUDUIC and CDOP processes to relevant staff to ensure that they are fully aware of their responsibilities. 2. British Transport Police will review what training is given to officers regarding the specific requirements in child fatalities to ensure that it remains relevant and up to date. Education 1. [The School] will consider ways in which their good pastoral support could be further strengthened by the addition of more formal and recorded ‘plan and review’ processes for pupils causing high levels of concern. 2. NCC have recently developed and launched a suite of guidance and advice on self-harm and suicide. [The School] will make use of this new material in their future training and guidance for staff. 3. All staff involved in multi-agency planning meetings where self-harm and suicidal ideation are a factor should ensure that the action plan from the meeting takes account of those risks and puts in place actions to mitigate them. 4. a) [The School] should review its School Policy for Child Protection to ensure through its training and guidance to staff that when a pupil discloses abuse the young person feels that their voice has been heard and taken seriously. b) Nottinghamshire County Council should ensure that their ‘school child protection policy template’ provides similar advice. 5. [The School] should ensure through its training and guidance to staff that staff understand, in line with the school’s updated policy, that it is not the role of staff to investigate disclosures by interviewing the child or others involved, unless asked to do so my Police, CSC or NSPCC. 60 6. In complex cases such as this the school should consider sending both the senior designated person for safeguarding and the teacher who knows the child best, or who heard the original disclosures, to initial multi-agency meetings. 7. Nottinghamshire County Council should review guidance to all staff regarding support for children and young people following a disclosure. If the disclosure leads to the breaking of important sources of support (either because the young person chooses to do so, or because of a subsequent move) there should be careful planning to ensure that a new supportive framework is created for the young person. |
NC52751 | Serious, life changing injuries, sustained by 18-month-old girl in June 2019 while in the care of her mother's partner. Recommendations include: ensure that there is a joint understanding and agreement in the application of thresholds of all levels of need and that referral pathways are clear and understood; ensure that both Child in Need and Child Protection Plans and processes are robust, outcome focused and clearly understood and owned by all agencies; to develop a one multi-agency safeguarding access point, that there is robust and consistent management oversight; to ensure that information is effectively shared to make effective and safe decisions including in domestic abuse cases; ensure multi-agency responsibility to identify and respond to all aspects of neglect, including educational and emotional neglect and the effects of non-dependent alcohol use by parents and the impact of these on children; to ensure the impact of domestic abuse on children is understood and prioritised. Learning includes: training on the cycle of change and motivational interviewing; escalation and professional disagreement; and recognition and prevention of abusive head injury in infants.
| Title: Serious case review Louise: executive summary. LSCB: Herefordshire Safeguarding Children Board Author: Jon Chapman Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Published November 2022 1 Serious Case Review Louise Executive Summary Serious Case Review in respect of Louise Author Jon Chapman Date of submission 3rd April 2020 Version Version 7 Published November 2022 2 EXECUTIVE SUMMARY 1. Introduction 1.1 This case review focuses on the serious injuries which were sustained by Louise in June 2019, who was 18 months old at the time. The injuries caused had a life changing impact on Louise. When the injuries occurred, Louise was being cared for by her mother’s partner at the mother’s address. Prior to the incident, there were concerns about domestic abuse and child neglect. 1.2 This review was commissioned to examine the circumstances of this case and, by involving those most closely involved in it, to understand if there are areas from which learning can be elicited to improve services and reduce the potential of harm to children in the future. 1.3 This report was published more than two years after the review was completed due to waiting for parallel processes to conclude. Due to the timeframe involved in publishing the report and to reduce the risk of re-traumatising the family, the Herefordshire Safeguarding Partners are publishing an Executive Summary of the report only. 2. About the Author 2.1 The author in this review is Jonathan Chapman, he has no prior involvement with the case and is not connected to any of the agencies involved. He is a retired senior police officer, who had responsibility for strategic and operational safeguarding and was a senior investigating officer. 3. Terms of reference and methodology 3.1 This review was commissioned under the statutory guidance provided by Working Together 2015. This guidance allows Local Safeguarding Children Boards to determine their own processes for review. The Case Review Sub-Group of the Herefordshire Safeguarding Board decided that the review would be undertaken by agencies involved providing Individual Management Reports (IMR) and a chronology of their involvement. This information would be enhanced by facilitated practitioner discussions. 3.2 A scoping exercise was conducted to understand which agencies should be consulted and included. The time period agreed for the review was June 2018 to June 2019 with any relevant background information outside of this period being made available to the review process to support learning and improvement. 3.3 Each identified agency was asked to research their information, and where necessary interview key staff, and to prepare a chronology and Individual Management Report (IMR). Published November 2022 3 3.4 There then followed a practitioner discussion at which professionals, managers and IMR authors gathered to discuss the case. 3.5 Based on the reports and discussions the overview author compiled this report, which was then subject to another practitioner discussion to enable the development of the learning and recommendations which flowed from the analysis. 3.6 The below agencies and staff were involved in the information sharing and discussion event. Herefordshire Children Social Care Early Help Herefordshire County Council Herefordshire and Worcestershire Clinical Commissioning Group Warwickshire and West Mercia Community Rehabilitation Company 2gether NHS Foundation Trust Education Children Centre West Midlands Ambulance Service University NHS Trust West Mercia Police Worcestershire Health Care NHS Trust Worcestershire Children Services Wye Valley NHS Trust Local third sector provider 4. Learning points identified from this case 4.1 One of the factors which impacted most significantly on action taken, or not taken in this case, relates from the ability for the wider context of a case to be considered. Referrals and information received were often considered in isolation, instead of looking at the wider context of the safeguarding concerns and the factors that were impacting on the children. The connection between two families was overlooked and the common denominator, the mother’s partner, was not taken into account. 4.2 When assessing the impact of domestic abuse, and there are children involved, there should be a focus on the children and the impact the abuse has on them. Consideration should be given to all preventative and protective tools such as DVPN and MARAC. Consideration should be given to the cumulative effect of domestic abuse. 4.3 Information was submitted to an agency professional in the MASH and there were instances when the information did not move past the agency representative when what was needed was a referral to CSC. There appears to be more than one pathway for information to be received and recorded, which should be addressed. Published November 2022 4 4.4 Safeguarding children is very important for all adult focussed services, they need to be reminded of adherence to their policies and where necessary to refer to their named safeguarding professional. 4.5 The cumulative effects of neglect, and in particular emotional neglect linked to domestic abuse, needs to be a focus for professionals. The work to recognise and effectively assess neglect, embedding the Graded Care Profile should continue to be a focus. 4.6 Where there are new partners in families there should be appropriate assessment of the risks that they may present. 4.7 There continues to be a need to impress on practitioners the need to be more professionally curious. To not accept information on face value and to try to check and triangulate information where possible. 4.8 All information should be assessed against what is known, anonymous information should be given credibility until the necessary checks have been put in place to verify or negate it. 4.9 Schools are integral to the safeguarding of children; they know the children and families better than most organisations and are able to provide a real insight into the lived experience of the child. 4.10 There is still a reluctance to challenge decisions which are not considered to be correct. Where practitioners do not agree with decisions, they should work to resolve them with reference to Herefordshire Resolution of Professional Disagreements Policy. 4.11 There should be more awareness of the potential signs and symptoms of abusive head trauma in infants and interventions focussed on preventing them. 5. Recommendations 5.1 In February 2020, The Safeguarding Children and Young People Partnership in Herefordshire (SCYPiH) Safeguarding Partners Board and Quality and Effectiveness Group hosted a workshop chaired by the Partnership Independent Scrutineer. This group comprises of senior leaders from agencies involved in safeguarding. The author presented this and another case, which has similar themes. The Scrutineer and author worked with the group to identify themes and resulting actions to address the learning identified in this review. This process has assisted in achieving joint agreement, understanding and collective responsibility of the identified areas of learning and development. 5.2 The areas of recommendations were classified as following: The partnership improvement priorities for SCYPiH Partnership. Key areas of partnership activity that SCYPiH should seek assurance on. Published November 2022 5 Any matters that need to be brought to the attention of and/or addressed by other strategic partnerships. Identified learning opportunities 5.3 The agreed priorities will form part of the new partnership strategic plan and the partnership will be held to account by the Independent Scrutineer, Quality and Effectiveness Group and annual reporting to ensure that the areas are addressed. The partnership improvement priorities for SCYPiH Partnership. 1. Framework of need and pathways – To ensure that there is a joint understanding and agreement in the application of thresholds of all levels of need and that referral pathways are clear and understood. That both Child in Need and Child Protection Plans and processes are robust, outcome focused and clearly understood and owned by all agencies. 2. Multi Agency Safeguarding Hub – to develop one access point, that there is robust and consistent management oversight. That the functions are collaborative and there is a clear and understood collective responsibility. To ensure that information is effectively shared to make effective and safe decisions including in domestic abuse cases. 3. Neglect – The multi-agency responsibility to identify and respond to all aspects of neglect. To include educational and emotional neglect and the effects of non-dependent alcohol use by parents and the impact of these on children. Key areas of partnership activity that SCYPiH should seek assurance on: 1. Application of thresholds, to be undertaken by multi-agency audit. 2. Escalation and professional disagreement policy. 3. Neglect. 4. Safeguarding of children in mental health services. Any matters that need to be brought to the attention of and/or addressed by other strategic partnerships. 1. Domestic Abuse Strategic Board/ Community Safety Partnership Board – to ensure that MARAC and other interventions such a Domestic Violence Prevention Orders are understood and embedded. That the impact of domestic abuse on children is understood and prioritised. That there is a greater emphasis Published November 2022 6 on working with and managing offenders. That there is a greater understanding and recognition of same sex domestic abuse. Identified learning opportunities 1. Training on the cycle of change and motivational interviewing. 2. Escalation and professional disagreement. 3. Recognition and prevention of abusive head injury in infants. Additional There were also a number of single agency actions that were identified in this review and the completion and progress on these will be overseen by the SCYPiH. 6. Changes implemented during this review 6.1 The engagement of agencies in this review has been very positive, there has been a real demonstration of agency reflection to enable learning. 6.2 The GP practice have held two internal learning events as a result of this case and their engagement in the discussion events for this process was excellent. As a result of internal discussion, they have introduced a template of safeguarding prompt questions which are asked when any adult presents with low mood, depression or is prescribed anti-depressant medication. This was recognised as good practice and should be communicated to other GP practices. |
NC52528 | Death of an 11-month-old girl in April 2020, due to asphyxiation. Child T was found by her birth mother, between the bed guard and the mattress. Learning includes: need for effective and appropriate transfer of children's cases between safeguarding agencies; children's cultural and ethnic backgrounds should be considered in assessments and care planning; the voluntary sector, including specialist domestic abuse services should be part of safeguarding partnership arrangements; impact of trauma experienced by parents can affect their ability to care for their own children; need for professionals to fully understand the role of absent or non-resident birth fathers; the temporary safety of a refuge should not influence decision making in relation to the significant harm experienced by the children; professionals should have an understanding about safer sleeping and be able to question arrangements. Recommendations include: families moving to refuge accommodation and making homelessness applications to a local authorities should be referred to the local children's social care arrangements in the authority to which they are moving; survivors of domestic abuse moving from refuge, to new accommodation should be afforded a risk assessment as to its suitability; the Child Death Overview Panel, Public Health and Trading Standards should consider additional warnings regarding the safety of bed guards and their appropriate use in safer sleeping messages.
| Title: A local child safeguarding practice review: Child T. LSCB: Royal Borough of Windsor and Maidenhead Safeguarding Partnership Author: Ian Vinall Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Final April 2021 Page 1 of 21 Royal Borough of Windsor and Maidenhead Multi-agency adults and children’s safeguarding arrangements A Local Child Safeguarding Practice Review Child T April 2021 Independent Author – Ian Vinall Final April 2021 Page 2 of 21 Contents Introduction Methodology and Process Key Practice Episodes Emerging Practice Themes Examples of Good Practice Conclusions Summary of learning Recommendations Final April 2021 Page 3 of 21 1. Introduction to Child T 1.1 Child T was born in May 2019 and was the second child of the birth parents. She has a dual heritage background and at the time of her death, aged 11 months, she was living solely with birth mother and her older sister. Her birth parents have both Christian and Muslim faiths and the children have been brought up in both faiths at different stages of their lives. Child T was described by her birth mother as a happy and healthy child who had a strong relationship with her older sister. She loved dancing, music and loved her food. Child T was described by her mother as being a ‘big child’ for her age. Child T had moved to new accommodation with her birth mother and sister a month before her death. Child T and her sister have had several disruptions to their care arrangements in a very short period. 1.2 Child T and her sister had been known to safeguarding agencies in 4 previous local authorities. 1.3 Child T died in late April 2020 from asphyxiation. She was found by her birth mother lying face down with her head wedged between the bed guard and the mattress. 2. Introduction to the Review 2.1 Following the death of Child T, a Rapid Review was undertaken, and the local review panel concluded that the criteria for a local child safeguarding practice review was met and that the case offered the opportunity to provide learning which could prevent similar deaths occurring in the future. There is learning for several agencies across the 4 local authorities involved with the family. This review is being carried out to identify learning and is not about blame or culpability. 3. Methodology and Process 3.1 Child T’s birth parents were separately interviewed in the presence of their social worker for this review. These discussions were understandably difficult for both parents and their contribution to this review was welcomed. 3.2 A review panel was established and chaired by a senior representative from the police. The review panel requested the timing of the review should be from November 2019 up to the death of Child T in April 2020. There has been significant involvement of agencies in 2 previous local authorities which is relevant to the children’s lived experience and are included in the timeline of the review. The information provided by the parents and agencies involved with the family, formed the basis of the review and some agencies provided chronologies and analysis of their involvement and what improvements they have made as a result of this situation. Interviews took place with representatives from the safeguarding and voluntary sector partners. Final April 2021 Page 4 of 21 3.3 There was some anxiety in the voluntary and community sector being involved in the process of a child safeguarding practice review owing to their lack of experience of the process yet there has been a good level of engagement and subsequent learning. 3.4 For the purposes of the review, the local authorities involved with the family are in chronological order and recorded as ‘local authorities 1, 2, 3, 4 and 5’. The agencies that provided chronologies and an analysis of practice included: - Children’s social care in three local authorities - Services from the voluntary and community sector - Health Visiting Services in two NHS Trust areas - Police - An NHS Hospital Trust - Community Safety Partnership 4. Key Practice Episodes May 2017 – April 2020 4.1 Child T’s sister had been the subject of child protection and child in need planning in local authority’s 1 and 2. This was primarily owing to birth mother’s lack of engagement with services and professionals, the conditions of the home environment, birth mother’s ongoing use of drugs and her association with adults that placed the child at risk of harm. Ongoing concerns remained about domestic abuse perpetrated by birth father. Evidence from the police indicated that birth mother was a high-risk victim of domestic abuse and homicide with allegations of domestic and sexual violence over a 4-year period. Birth father has never been convicted of any domestically abusive behaviour and strongly denied acting in a domestically abusive way. 4.2 The level of risk prompted local authority 1 to seek legal advice with a recommendation to support birth father with a private law application so he could resume full care of the eldest child. 4.3 A pre-birth assessment was undertaken on Child T in local authority 2 with the recommendation of an initial child in need plan leading to an initial child protection conference at 30 weeks gestation. Birth mother did not engage with the child in need plan and the threshold was considered not met for an initial child protection case conference despite the recommendation from the assessment. 4.4 Child T was born in May 2019 and was cared for by birth mother and children’s social care in local authority 2 closed Child T’s case in July 2019. 4.5 A further domestic abuse incident occurred in October 2019 which prompted birth mother to apply for a Non-molestation Order1 and 1 Family Law Act 1996 Final April 2021 Page 5 of 21 Prohibited Steps Order2 and she resumed the full sole care of both children and moved to a refuge in local authority 3. This was reported by birth father as the last time that he saw Child T alive. 4.6 Children’s social care in local authority 3 were of the understanding that the family still had an allocated social worker in local authority 2 and an assessment was being undertaken so they did not progress any work with the family. Information provided by local authority 2 confirmed the case was in fact closed to them the day before the family moved to the refuge. 4.7 The refuge made several referrals for support for birth mother including to the MASH (Multi-agency Safeguarding Hub)3 and a homeless application to local authority 4. Birth mother described struggling with her own mental health and parenting Child T’s older sister. She was displaying worrying behaviour including pulling her mother’s hair, constantly eating, and seeking out food, had stopped potty training, and was having nightmares. Child T had not been weighed since her 3-week check and not had her 16-week inoculations and at 8 months, was not sitting up unsupported and not crawling. 4.8 There were several issues raised in the practice of the health visiting service in local authority 3 and these have been addressed through a separate Significant Incident Review4. 4.9 Birth mother and the children moved to local authority 5 in March 2020. This was accommodation found by the domestic abuse housing officer in local authority 4 and birth mother was assisted in making the application for Housing Benefit and Council Tax. The case was then closed to the Housing Team in local authority 4. The flat was part furnished, with 2 bedrooms, including bunk beds and mattresses for the children. The Housing Team in local authority 5 were not made aware that a vulnerable family had moved into their area. 4.10 Local authority 5 was emailed by the refuge yet this email went to an obsolete email box in the MASH but was picked up by staff by chance. The address given was incorrect and no consent was given for the referral. This referral was consequently ’sent back’ to the refuge. The refuge have no record of this. At this point no statutory safeguarding agency in local authority 5 knew that the family were moving to accommodation in their area. 4.11 The refuge did make a referral to a voluntary agency in local authority 5. This voluntary agency provided short term support to families and provided practical and emotional support via volunteers. They offered support to the family in settling into the area and with practical help. The refuge agreed 2 A Prohibited Steps Order is an order which prohibits a party (usually a parent) from a certain activity relating to a child(ren), and which also prohibits a party from exercising their parental responsibility. 3 Often the first point of contact, MASH acts as a triage service within the social care front door. The team delivers an information gathering and co-ordination service to identify the most appropriate outcome for children and families. 4 A Significant Child Protection Incident Review aims to help health staff prevent or minimise recurrence and future harm of children they suspect of being at risk. Final April 2021 Page 6 of 21 to continue to offer the family support via the telephone after they moved out. 4.12 The UK went into ‘lockdown’ owing to the Covid-19 pandemic on the 23rd of March with the UK government ordering people to ‘stay at home’. This resulted in agencies restricting home visiting to a minimum. 4.13 The voluntary agency was tasked with sourcing and delivering household and child related items. Birth mother requested a bed guard for the bottom bunk. She reported to the volunteer that it was her intention to place Child T in the bottom bunk bed with the bed guard. Child T’s sister aged 3 would occupy the top bunk. 4.14 The voluntary agency referred the family to a local specialist domestic abuse charity and the case was allocated to an outreach worker. The outreach worker was told by birth mother that she had registered with a local GP and was awaiting contact with the health visitor. This was in fact, not the case. There was no liaison between the health visiting team and the voluntary sector agencies as birth mother had not registered and the health visiting service in local authority 3 had not communicated that the family had moved. 4.15 The outreach worker had several calls with birth mother, and she repeated her concerns about the behaviour and presentation of her eldest daughter. 4.16 The volunteer reported that birth mother was not adhering to social distancing5 and birth mother reported that a friend was staying at the flat during this period of lockdown. 4.17 There were a further 5 calls between the outreach worker and birth mother, 2 of which went unanswered and two short phone calls from the volunteer. 4.18 The night before Child T died, mother reported seeing her at approximately 10pm in bed in the bottom bunk with the bed guard attached. Birth mother confirmed that evening that she and a number of friends drank alcohol and smoked cannabis together in the flat until the early hours. 5. Emerging Practice Themes o The children’s experience. o Birth mother and birth father relationship and domestic abuse. o The number of moves for the children and the transfer of children’s cases between local authorities and safeguarding partner agencies. o Safer sleeping advice and guidance. o Voluntary sector engagement with safeguarding partnerships. o COVID-19 and its influence on practice. 5 To stop the spread of coronavirus (COVID-19), the public were advised to avoid close contact with anyone they do not live with. This was called social distancing. Final April 2021 Page 7 of 21 6. The children’s experience. 6.1 The children had been the subject of child in need, child protection and early help plans, 4 child and family assessments, referrals, risk assessments and private law court processes by the ages of 3 and 11 months, respectively. Child T’s sister was probably more ‘visible’ to agencies given there was significantly more information available about her. 6.2 There is limited evidence available on how these processes impacted on the children. The children did seem lost in the issues of their parents and decisions regarding their care were based on who was deemed the most appropriate parent to care for them at the time. There were references to the children being ‘safe’ in the care of either birth parent. The perception that the children were considered safe at the refuge and in the care of birth mother took no account of the children’s history. 6.3 There is little evidence, from the point of Child T’s birth, that consideration was given to the impact on the children of experiencing domestic abuse and neglect6. When the family moved to the refuge, Child T was assessed as developmentally delayed and Child T’s elder sister was clearly ‘communicating’ to her mother and professionals how she was feeling. Birth mother reported this behaviour was in response to her witnessing domestic abuse. These two very small children’s lives had been one of parental discord, disruptive family moves, domestic abuse, adult mental health, drug and alcohol misuse and parental neglect. An integrated chronology was not undertaken to inform assessments and interventions and therefore no purposeful and child centred assessments of the risks and needs were undertaken after Child T’s birth and at each transition stage. 6.4 There was a significant lack of communication and information sharing between local authority’s children’s services, health, and two of the voluntary sector agencies. There can be no clear reason for this, other than individuals not considering the importance of information sharing about the children and a focus on the needs and issues of the parents. The refuge staff did contact partner agencies and sought support for the mother and the children whilst at the refuge, yet this still did not prompt agencies to discuss the children with each other. 6.5 Birth mother asked for help and the community nursery nurse did provide practical guidance for Child T’s development. Given birth mother already had significant needs of her own, it is questionable whether providing her with behaviour management techniques for her child was likely to be effective. 6.6 Safeguarding agencies focused attention on the behaviour of the adults to address safety from risk and harm. Safety for the children was birth mother taking appropriate action to flee a domestically abusive relationship yet 6 Hazardous home conditions for the child including broken glass on the floor, soiled nappies and health and developmental appointments missed. Use of cannabis and heroin and refusal to engage with any services appointed to support the family. Final April 2021 Page 8 of 21 safeguarding agencies did not investigate and were not professionally curious as to the children’s presentation. The history of poor parenting and neglect, as well as the children’s experience of domestic abuse had not been fully considered. 6.7 The refuge highlighted the lack of support and services for children under 5 who have experienced domestic abuse and have raised this as a gap in service provision. 6.8 The impact and children’s experiences of domestic abuse on children should prompt children’s social care to assess need under Section 17 of the Children Act 1989 regardless of who is considered the ‘so called’ protective parent. 7. Birth mother and birth father relationship and domestic abuse 7.1 There is a consistent pattern of reconciliation and separation of the birth parents and the eldest child has lived between both parents in her short life. There have been protracted custody disputes, contact arrangements and a history of one or either parent removing the children at contact sessions or not returning them to the other parents’ care. The referrals that brought the family to the attention of children’s social care were reports of a domestic abuse incident perpetrated by birth father. Birth father himself accepts that he needed support at that time and had agreed to work alongside a family support domestic abuse worker, but this work never materialised. 7.2 The birth parents originate from different religious and cultural backgrounds. Birth father is black African and birth mother is of Pakistani origin and their relationship was a source of tension in birth mother’s family, particularly birth mother’s stepfather. This caused additional stress to the birth mother and made it more challenging for her to seek family support in her situation. The children had a different religious upbringing until they were in the sole care of birth mother when she reverted to her Muslim faith. The issues of race, culture and religion and their impact on risk and harm were not fully considered in the assessments completed. 7.3 Birth father continued to raise concerns about birth mother’s care of the eldest child and children’s social care chronology back up his assertion that birth mother was involved in drug and alcohol misuse, that the family home was in a very poor condition and birth mother’s associations placed the eldest child at risk. Birth mother reported threats had been made by birth father about the future care of the children. Those issues were not the subject of much analysis in assessments and whether the concerns were considered a true reflection of birth mother’s care or part of birth father’s Final April 2021 Page 9 of 21 ongoing domestically abusive behaviour through coercive control7 of birth mother. 7.4 Birth mother has a significant history of childhood trauma and abusive, controlling, exploitative adult relationships. She struggled to engage with services and actively disengaged with support. Her experiences have impacted upon her ability to make decisions based on the needs of her children. 7.5 Birth father was assessed as providing child focused care. Despite allegations of domestic abuse and rape made against him by his ex-partner, the courts and children’s social care assessed birth father to be the most appropriate parent to care for the eldest child. There is little or no challenge in those assessments on how birth father’s alleged domestically abusive behaviour impacted upon the children. 7.6 Birth father denies the allegations made against him of domestic abuse. The large number of police reports and the judgements of the risk assessment checklists of birth mother are contrary to this view. 7.7 The period leading up to birth mother’s move to the refuge, the couple had again reconciled and were living together against the advice and hidden from children’s social care. It was after this period that birth mother reported a further domestic abuse incident to which the eldest child was present and witnessed. Birth mother reports that her child attempted to intervene. It is not clear why children’s social care did not assess the risks under Section 47 of the Children Act 19898. This prompted birth mother to apply herself for refuge accommodation and father being arrested. The Child Arrangements Order (CAO) and Prohibited Steps Order (PSO) made in favour of birth mother was the catalyst for the family to move to the refuge. This was the last time that birth father saw Child T alive. There was no engagement or contact from any agency with birth father post the children’s move to the refuge until he was informed of Child T’s death. Significantly, no agency or service appear to have picked up that this would have been the first time that birth mother was caring for both of her children on her own. 7.8 CAFCASS were involved in the private law proceedings that saw birth father resume care of the eldest child, yet the report author has been unable to obtain information from CAFCASS as to their assessment and judgement. Information available indicates that local authority 2 were not asked to comment or give advice to the court when birth mother made her application for the CAO and PSO other than provide a copy of the pre-birth assessment. There were ongoing private law hearings about contact and 7 Coercive control is an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim. 8 Where a local authority have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm. the authority shall make, or cause to be made, such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare. Final April 2021 Page 10 of 21 residency to which no local authority was asked to contribute as far as we know. 7.9 Birth mother and the children who were fleeing a domestically abusive relationship and moving to refuge accommodation were considered to be at significant risk of personal harm. However, it is difficult to reconcile that birth father was completely excluded from further assessment or involvement with the children when they moved to the refuge. He was not afforded the opportunity to contribute and be considered as an important part of the children’s lives. The lack of contact and consideration of birth father’s role appears to be a judgement made by agencies about the risk he posed to his ex-partner. This decision is based on the history of domestic abuse and the risks he has posed to birth mother and the children by his behaviour. However, this conflicts with the previous judgements made about his care of the eldest child in court reports and assessments. The family court has been heavily involved in making care related decisions for the children and the history of domestic abuse has been considered by the courts in making those decisions. The balanced decisions needed in this case is based on the principle of the child’s welfare being paramount. It raises the challenge as to whether adults who are domestically abusive in their relationships can safely parent their children and what support and services need to be provided to make that arrangement safe. 8. The number of moves for the children and the transfer of the children’s cases between local authorities and safeguarding partner agencies. 8.1 Child T and her sister were known to 5 local authorities and associated safeguarding partners. They were known to at least 4 voluntary sector agencies. The children experienced inconsistent and disruptive care and the eldest child had moved homes on at least 6 different occasions. They did not experience stability and security and keeping track of the children’s movements between local authorities had been problematic. This has led to a lack of information being shared across agency boundaries and a lack of curiosity by safeguarding agencies as to the children’s history. 8.2 This review has led to one voluntary sector agency changing their procedures to reflect the learning from this situation, now asking for information from other agencies with consent. One agency is implementing a ‘health gateway’ which will automatically notify health and others that they are working with a family. Children’s social care 8.3 There were prompt and effective arrangements in place for case transfer between local authority children’s social care when the children were subject to statutory child protection planning. However, when the children were not subject to statutory processes and the case closed, there was no effective transfer of the case information. The birth mother self-reported Final April 2021 Page 11 of 21 that she was involved with children’s social care, which prompted the refuge to seek further information. 8.4 There is limited evidence that birth mother participated in offers of support for herself and the children. There was outstanding work in the child protection and child in need plans. The closure of the children’s cases was based on alternative care arrangements of the children rather than addressing the underlying parenting issues. The decision to close the children’s case in local authority 2 was just two months after Child T was born. Local authority 2 accept their practice was ‘below expected standards.’ 8.5 The outline plan highlighted the need for birth mother to address her cannabis use, direct work with the social worker to explore her experience of being parented and birth mother attending health appointments. The closure record indicated birth mother engaged with health services only. It is questionable that a lack of cooperation should be a benchmark or threshold for case closure without a clear understanding of the impact of that lack of cooperation on the child and whether this decision is based on current assessment or the chronology of non-engagement. Whether there was a changed perception of the risk to the children is unclear and whilst positive co-operation is observed in assessments, this should be seen in the context of the history of non-engagement. Resources and caseloads may be a significant factor in decision making and this is a wider practice theme that needs further consideration. 8.6 The children’s case appears to have been opened again on the back of the referral from police in October 2019. The judgement made by local authority 2 to visit birth mother following the referral and then to fund transport for the move to the refuge without assessing the children and informing local authority 3 is poor practice. The reasoning for this is unclear but the information available points to the swift exit of the family to another local authority without taking case responsibility or accountability for effective transfer of information. 8.7 It highlights a dilemma as to who has case responsibility in children’s social care when families move to refuge accommodation on a temporary basis and whether they are habitually resident in the originating authority. This is not resolved in the records with confusion about who was assessing the family. Transient families in the safeguarding system need one local authority to ‘own’ the children and not revert to quickly closing cases when they move authority. However, it is accepted that this is decision based on capacity and threshold. 8.8 With the belief that children’s social care in local authority 2 were undertaking an assessment, local authority 3 did not undertake any statutory assessment of the children. Despite requests from local authority 3, no information was provided by local authority 2. Escalation routes for professional disagreement only appear to refer to those agencies within a local authority boundary and not between local authorities. It may be Final April 2021 Page 12 of 21 sensible for local authorities to expand this protocol to other local authorities to ensure disagreements or issues can be resolved more formally. In this case, the failure of local authority 2 to provide detailed information about the children’s known history led to risks for the children remaining unassessed. 8.9 Consent based practice, where adults agree for information to be shared as part of a referral, does have the best outcomes for children. However, it does place a barrier to effective information sharing, particularly when an agency must then seek that consent. It is not unreasonable for children’s social care to hold open those children to ensure that they receive an effective response. There have been practice changes in local authority 5 because of this case which means children are ‘held’ open for 48 hours whilst that consent is sought. It would be sensible to consider this more widely to ensure children do not fall out of sight of children’s social care. Health 8.10 The health visiting service in local authority 3 have undertaken a Serious Incident Review9 on the children. There are significant gaps in the practice of the agency health visitor which have been addressed through the Significant Incident Review and subsequent referral to the Nursing and Midwifery Council. 8.11 The health visitor in local authority 3 was an agency health visitor employed in the service from August 2019. The agency health visitor was dismissed from the role in May 2020. 8.12 The importance of ensuring that children are transferred safely and effectively between local authority areas needs to be reinforced with health visiting staff, both employed and contracted. Health visitors hold children’s cases under the nationwide Healthy Child Programme, that being ‘universal, universal plus and universal partnership plus10’. As the children had previously been subject to a child protection plan, they should have been referred through the existing process under Universal Partnership Plus. It is a reminder to health visiting services across all the boroughs to reinforce this issue through effective supervision and management oversight. 8.13 Referral pathways in health visiting services should be well understood by practitioners in health and beyond to ensure children are receiving the correct level of support and intervention from the health visiting service. 8.14 There needs to be awareness raising of partner agencies, including health and the voluntary sector, as to the complexity and impact of domestic 9 The Serious Incident framework describes the process and procedures to help ensure serious incidents are identified correctly, investigated thoroughly and, most importantly, learned from to prevent the likelihood of similar incidents happening again. 10 Health visitors lead and deliver the Healthy Child Programme. The HCP is the evidence based public health programme for children and young people, which provides a range of health interventions and support beginning in pregnancy and continuing through early childhood. Final April 2021 Page 13 of 21 abuse on children. The children’s presentation and experiences did not prompt further enquiry and investigation. Housing 8.15 Birth mother had made a homeless application to local authority 4 and the domestic abuse housing officer in local authority 4 undertook a CAADA Risk Identification assessment (now known as ‘Safelives’ Dash risk checklist/ assessments), which deemed mother to be at high risk. The domestic abuse housing officer did not believe that birth mother could afford a property in the borough and this may have been the reasoning for not referring the family to other services in the borough. The assumption, which has been reinforced in other commentary, is that birth mother was ‘safe’ in the refuge and that she was receiving appropriate support. The needs and risks of the children do not appear to have been considered separately. 8.16 Birth mother reported that she wished to move from refuge accommodation as she was finding the environment difficult to live in with the children. The domestic abuse housing officer did support birth mother with an application for housing benefit and council tax. 8.17 Local authority 5 housing department had no contact with local authority 4. Local authority 4’s placement policy for temporary accommodation and private rented accommodation states that ‘We will aim to ensure that information concerning details of placements in temporary accommodation and private rented accommodation outside of the borough is shared as far as possible in a fair and timely manner with the relevant councils in areas where families are moving to’ and ‘Vulnerable families – so far as is practicable if placing vulnerable families outside of the borough we will ensure that such families will continue to receive appropriate support’. Neither of these actions were followed in the case of Child T and her family as the case was closed at the point of the family moving. This is despite the CAADA risk assessment indicating birth mother was at high risk of domestic abuse and the high likelihood that if the family had rehoused in local authority 4, they would have been referred to children’s social care and the MARAC. 8.18 The housing department in local authority 4 have reflected that all families moving from refuge accommodation and making homelessness applications to the borough should be referred to the MASH or similar children’s social care front door arrangements. 9. Safer sleeping advice and guidance 9.1 Birth mother recalls receiving safer sleeping advice from her previous health visitor when her first daughter was born. She stated she understood the risks regarding safe sleeping, but she recalled this was particular to co-sleeping advice. Final April 2021 Page 14 of 21 9.2 In the refuge accommodation, birth mother was provided with a cot, a bunk bed and a single bed in her room. This is standard furniture for rooms in the refuge. The refuge have confirmed that their health and safety policy states that no children under 7 should use the top bunk bed and staff advise new residents that children who cannot sleep on their own in a bed must be in a cot. Birth mother reports that Child T slept in the cot in the refuge. 9.3 Birth father recalls that he purchased a cot for Child T. This was not present in the 2-bedroom flat that mother and the children moved to in local authority 5. 9.4 The property found in local authority 5 was a furnished flat and in the children’s bedroom there was a bunk bed with mattresses. Birth mother had requested a bed guard from the voluntary sector agency for Child T to sleep on the bottom bunk and told the report author that ‘everyone was aware that I needed the bed guard for Child T to sleep on the bunk bed’. This was a safety measure birth mother put in place to prevent Child T falling out of bed thus considering her wider safety. Birth mother also described Child T as being a ‘big child’ for her age and had been eating solid food from the age of 6 months. This was birth mother’s reasoning for allowing Child T to sleep in the bunk bed with a bed guard. Without appropriate guidance and advice from safeguarding professionals, birth mother made a judgement based on what would keep Child T safe in a bunk bed and what was available to her in terms of bedroom furniture. 9.5 Given there were indications of Child T having some developmental delay, which remained unassessed until February 2020, this sleeping arrangement may have been less safe for Child T. 9.6 No professional or agency entered the accommodation in local authority 5 owing to COVID-19 restrictions and therefore no advice was given to birth mother as the suitability of the sleeping arrangements for 2 very young children. Birth mother was managing on what was provided. 9.7 The housing officer and the estate agent resolved issues regarding the condition of the flat and some physical repairs were made. Whilst landlords have responsibilities to ensure that furniture provided meets the legal standards of flame resistance, it is not the role of housing officers, landlords or estate agents to consider the suitability of the accommodation or furniture provided for families with young children. This is a wider safeguarding issue that housing authorities may need to consider as part of their assessment of suitability. Tenants do have to take personal responsibility, but it is not unreasonable for a risk assessment to be undertaken given these circumstances. 9.8 Whilst there is information provided to professionals on local authority child safeguarding partnership websites regarding safer sleeping, this does not appear to ‘land’ with the wider network and appears to remain the responsibility of health practitioners. 9.9 Whilst local authority 5 have published a ‘Safe Baby Toolkit’ it makes no reference to the safe use of bed guards. There is a need to ensure there is Final April 2021 Page 15 of 21 a public health message that touches a wider audience. This view is reflected in the recently published review of sudden unexpected death in infancy report published by the Child Safeguarding Practice Review Panel11. “We believe that practitioners in all agencies who are working with families with children at risk need to develop a clearer evidence-informed understanding of parental decision-making in relation to the sleep environment and how this might be changed”. 9.10 The report goes on to state that “It’s important that we give all families information about safe sleeping, but for some families who are struggling with multiple issues the existing information is simply not enough. This is not about blaming parents who have suffered such tragedies. This is a societal issue, and we need to listen to and talk with families realistically and honestly so we can make sure that their babies sleep safely all the time.” 9.11 The report also suggests that children’s changing circumstances became a risk factor, in that routine infant sleeping arrangements were disrupted. It is argued that the extent to which sudden infant death syndrome in out-of-routine circumstances, is not predictable, it can nevertheless be made more preventable. 9.12 Rightly, co-sleeping has been the focus of safer sleeping messages, but this should now be extended to the safe use of bed guards. 9.13 There is no indication that the second-hand bedroom furniture was a causal factor in Child T’s death. There are studies that suggest that second-hand mattresses are indicative of an increased likelihood of sudden infant death12 yet more significantly, is the use of the bed guard. Whilst modern cots conform to British Safety Standards negating the need for cot bumpers, this is not the case for children’s bed guards. There are no British Safety Standards specifically for bed guards for children but there is reference in the Health and Safety Executive (HSE) about the safe use of bed rails13. Poorly fitting mattresses and bed guards have led to mobile babies and young children trapping themselves between the mattress and the bed guard. In normal circumstances, the manufacturer’s instructions contain information on the dimensions and other characteristics, to reduce the risk of possible entrapment. They also contain information on the compatibility with other equipment and whether they are suitable for babies and children. 9.14 The evidence points to agencies avoiding the use of second-hand bed guards without the necessary instructions for use. Whilst this is parental choice, agencies providing such equipment through a volunteer or statutory sector agency, should consider the risks and the child’s sleeping 11 Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm. Final report July 2020 12 Used infant mattresses and sudden infant death syndrome in Scotland: Case-control study, December 2002. BMJ Online 13 Health Services - Safe use of bed rails Final April 2021 Page 16 of 21 arrangements prior to providing such equipment, particularly if second hand. 9.15 Whilst birth mother disputes the impact and significance of her own drug and alcohol use on the evening prior to Child T’s death and whether this impaired her ability to care for the children, this is sadly reported in almost all sudden infant deaths reviewed in the report. The post-mortem report and hair strand testing on Child T indicated she had been exposed to cannabis and cocaine but there was no causal link between this and her death. Birth mother denies this was a factor in Child T’s death but, the fact that drugs were found in toxicology reports on Child T suggests she was regularly exposed to birth mother’s drug use at some level. Birth mother reported that she was able to care for the children safely despite her drug and alcohol use the night before Child T’s death. 10. Voluntary sector engagement with safeguarding partnerships 10.1 What became evident through this review, was the lack of engagement and relationship with the voluntary sector agencies involved with Child T and her family and the statutory safeguarding partners. It was concerning that there was no contact between these agencies despite the history of the children. Increasingly, the voluntary sector is taking responsibility for families and providing support where previously this would have been the role of statutory services. In this case, the children had suffered significant harm in the care of their birth mother previously and birth mother was fleeing domestic abuse. The children’s presentation did raise worry and concern to the agencies working with the family. However, these children were managed via a universal health offer and several referrals to voluntary sector agencies. Whilst it is vital to have a mixed economy of available support to families, this must be in the context of risk, harm and need. Referrals for support are not an intervention in themselves and leaves open missed opportunities to assess the direct needs of the children. 10.2 With the changes in safeguarding partnership arrangements with the introduction of Working Together 2018, there remains a crucial need to ensure engagement with voluntary sector partners on safeguarding matters. Whilst not diminishing their role and expertise in this case, these agencies were working in isolation with a highly complex set of circumstances with volunteers who do not have the requisite safeguarding skills, experience and knowledge despite training and development opportunities being in place. This is a wider safeguarding issue and if there remains an expectation that voluntary sector agencies fill those gaps in services, they must be supported strategically and operationally by those agencies with safeguarding knowledge, skills, and accountabilities. Final April 2021 Page 17 of 21 11. COVID-19 and its influence on practice 11.1 The family moved to the new accommodation in early March and the first ‘lockdown’ as a result of the COVID-19 pandemic occurred on the 23rd of March. This banned all non-essential travel and contact with people outside of their home. This shut almost all schools, venues, facilities, and amenities. Nationally, children’s social care services put in place several measures to ensure services were provided to vulnerable children and families. During the initial lockdown they were visiting children that were already categorised as child protection (subject to child protection plans) or were deemed at risk under Section 47 of the Children Act 1989 following a strategy discussion. Some children had an individual risk assessment to consider the most appropriate and proportionate response. Children who were subject to child in need plans or assessments were predominantly visited virtually using Facetime or WhatsApp. Some local authorities instigated a RAG system (red, amber, green dependent on their risk and need) to determine the level of support that would be offered during lockdown. 11.2 Sadly, as Child T and her sister were not known to statutory agencies in local authority 5, they were not afforded any of that support. In the case of Child T and her family, the timing of their move could not have been at a more challenging time. The subsequent lockdown had resulted in the only agency contact being via telephone. Birth mother had not registered with a GP, was in new accommodation, in a new area, with no family support and was faced with remaining in the flat for significant periods with 2 very young children, one of whom had challenging behaviour. Birth mother had not had full time permanent sole care of her older daughter for some months prior to the move to the refuge. 11.3 Birth mother’s own experiences have influenced and impacted on her ability to effectively care for her children. She had very limited family support and relied on friends and relationships to support and meet her needs. She has a history of abusive and controlling relationships where she has struggled to place the needs of the children first. She has a history of not engaging with the support that has been offered. The move to the refuge was intended to be a fresh start. Her move to new accommodation in a new area was to ‘start again’. Without doubt, the restrictions associated with COVID-19 limited significantly, the contact with supportive agencies. It is within this context that birth mother sought support and to avoid loneliness through friends who stayed with her during lockdown. This sadly triggered a regular use of drugs and alcohol again. 11.4 COVID-19 had no influence on the poor practice of not transferring, referring, communicating, assessing or appropriately planning for the children. Final April 2021 Page 18 of 21 11.5 Between April and October 2020, almost 40% of serious incident notifications to Ofsted were for babies14. There was also an increase of unexpected baby deaths in this period, deemed to be preventable tragedies with babies for example not being put down to sleep safely. It was argued that all professionals who work with families must be curious and whilst ‘continuing restrictions may be hampering face-to-face visits…these children are out of sight; they should never be out of mind’. 12. Examples of good practice - The refuge worker remaining involved with the family despite the move to new accommodation in local authority 5. - The positive engagement and impact of the work of the community nursery nurse in local authority 3 - The referrals to support services by the early help practitioner in local authority 3 were appropriate and considered the needs of the children. - As a result of this case, health visitors are now assigned to refuge accommodation in local authority 3. - 2 voluntary sector agencies have changed their referral processes in response to this case and now ask for more detailed information regarding the history of the family and previous and current agency involvement. 13. Conclusions 13.1 The sad death of Child T could not have been predicted by safeguarding agencies, yet there is learning for agencies and services arising from the review of the children’s circumstances. 13.2 Vulnerable families who move regularly between local authorities challenge local agencies to remain focused on the needs and risks of children. Accountability and responsibility for children transferring between local authorities requires proactive action from safeguarding professionals and their responsibilities need to be reinforced. 13.3 A lack of knowledge of children’s histories and the role of birth fathers leads to no agency fully understanding the context of children’s risks and needs. 13.4 The behaviour of young, particularly pre-school children, needs to prompt further enquiry as to the reasons behind those behaviours rather than addressing this through behaviour management. To do so supports a better understanding of a child’s trauma. 13.5 The ability of parents to make use of interventions must be considered in the context of their own childhood experience and current trauma. 13.6 Children’s experience of domestic abuse needs to be better understood by all practitioners who meet them. 14 Amanda Spielman, Ofsted Chief Inspector 2020 Final April 2021 Page 19 of 21 13.7 Professionals need to be aware of their own bias and judgements of risk when working with adults in domestically abusive relationships. Perpetrators of abuse can invoke strong feelings in professionals and this needs to be regularly considered in robust case work supervision and how it influences thinking and judgment. Supervision should be the safe vehicle to explore such issues and provide challenge and support to thinking and planning. Equally, parenting capacity and the impact of domestic abuse on survivors parenting needs to be considered alongside the support those survivors need. 13.8 Children’s need to be separately assessed from the needs of their birth parent when they move to refuge accommodation. Children’s social care need to be proactive in informing their colleagues of family’s moves and reassure themselves that accountability for the children’s case is clear. 13.9 Safeguarding agencies need to reinforce information sharing and communication both within agencies and between agencies. The voluntary and community sector and statutory safeguarding agencies need to take a proactive role in ensuring they join up. 13.10 Children’s social care need to review their arrangements for closure of children’s cases owing to non-engagement with the plan. These judgements, whilst appearing appropriate management of workload, should consider the risks associated with such a decision based on the history of the children’s circumstances. 13.11 Integrated chronologies hold considerable value in fully understanding a child’s risks and needs. Local Child Safeguarding Practice Reviews should not be the only opportunity to pull together integrated chronologies. Equally, this information should be shared when children move home. 13.12 Survivors of domestic abuse who leave their family homes and flee to refuge accommodation do so with very little or nothing. When it comes to them being rehoused from the refuge, survivors are faced with having to move to a new property at very short notice. Grants and donations of second-hand furniture are the norm to furnish their new properties. It is therefore not unreasonable to consider whether a housing risk assessment should be undertaken for survivors moving from refuge accommodation, to ensure that the property and furnishings meet expected standards and are considered safe for children. 13.13 The safe use of bed guards needs to be added to the safe sleeping messages from safeguarding partnerships. Suitable sleeping arrangements for children should be part of all professional’s assessment when working with vulnerable families. Safeguarding partnerships need to ensure the learning from the National Child Safeguarding Practice Review Panel’s recent report into sudden unexpected death in infancy are shared widely. 13.14 COVID-19 prevented agencies from visiting family homes. The use of video and social media applications that enable video calling should be encouraged when it may be challenging to visit family homes and as a way of seeing children’s living environments. Final April 2021 Page 20 of 21 14. Summary of learning - There should be effective and appropriate transfer of children’s cases between safeguarding agencies and implementation of escalation routes between local authorities if this is not achieved. - Children’s cultural and ethnic backgrounds should always be considered in assessments and care planning. - The voluntary sector, including specialist domestic abuse services, have a key role to play in supporting vulnerable families and should be part of safeguarding partnership arrangements. - All professionals need to recognise the impact of trauma experienced by parents can have on their ability and availability to then focus on the needs of their own children. - Professionals need to fully understand the role and importance of absent or non-resident birth fathers in children’s lives. - Assessments of children should be undertaken alongside the provision of services and interventions to ensure those services are also appropriately targeted to children’s needs. - Information sharing and communication within and between agencies needs to be reinforced. - Children moving to refuge accommodation should be assessed under Section 17 of the Children Act 1989. The temporary safety of refuge accommodation for the mother and the children should not influence the decision making in relation to the significant harm experienced by the children. - Risk assessments of adults also need to address the impact of risk to children. - Professionals working with vulnerable families need to have support to reflect upon their own professional bias particularly when working with birth fathers who are perpetrators of domestic abuse, such as reflective supervision. - Closing of children’s case files needs to be based on judgements of risk rather than family moves or non-engagement with a plan. - All professionals working with families should have a level of understanding about safer sleeping and be able to question the suitability of those arrangements. 15. Recommendations - Safeguarding partners need to seek assurance that individual organisations have effective escalation procedures and policies that go beyond local boundaries. - The safeguarding partnership needs to consider the appropriateness of implementing integrated chronologies for families that are transient and move between local authorities. - All families moving to refuge accommodation and making homelessness applications to local authority housing should be referred to the MASH or similar Final April 2021 Page 21 of 21 children’s social care front door arrangements in the authority to which they are moving. - Survivors of domestic abuse moving from refuge accommodation to new properties should be afforded a risk assessment as to the suitability of the accommodation and its furnishings. - MASH or Single Point of Access arrangements in children’s social care should consider ‘holding’ children open for a short period of time (48 hours) when families are referred as moving into the local authority without consent. - Local authorities need to consider the use of ‘Transfer In’ meetings to ensure effective transfer of children and families between local authorities regardless of the case ‘status’. - The Child Death Overview Panel, Public Health and Trading Standards should consider additional warnings regarding the safety of bed guards and their appropriate use in safer sleeping messages. - The safeguarding partnership should encourage the engagement of the voluntary and community sector agencies in safeguarding partnership arrangements, particularly providers of domestic abuse services. - Safeguarding partnerships need to ensure there is a strategic link between safeguarding partnerships and Community Safety Partnership and MARAC arrangements. |
NC048649 | Serious non-accidental injuries to a one-year-11-month-old girl requiring hospital treatment and made subject to police protection. Parents supported to care for first child Sarah through a multi-agency Child in Need plan in 2011; parents split up that year with concerns voiced about the mother's lifestyle. Following the birth of Emma at the end of 2011 both children became subject to Child in Need plans, continuing to be cared for by mother and new partner. After Emma's injuries, she and her sister were placed in foster care. Police charged the mother with neglect and she was given a custodial sentence. Identifies learning: all legal and case work decisions and their rationales need to be recorded, including reasons for children's social care not following legal advice when care proceedings are proposed; all actions assigned to professionals, especially assessments, must be completed before Child Protection (CP) Plans are discontinued; need to engage with individual members of the family including significant others; case management needs to be authoritative and robust when working with difficult to engage and non-cooperative parents/carers. Recommendations include: the appointment of a named GP for Safeguarding Children with a priority on supporting GP practices put in place robust internal policies and practice; the quality of first line management supervision and case work oversight of both Child Protection and Child in Need cases is consistent with agency standards; the impact of the toxic trio (domestic abuse, adult mental health and adult substance misuse) on children and young people must be included in all family and risk assessments.
| Title: Independent overview report of the serious case review concerning ‘Emma’. LSCB: Redcar and Cleveland Safeguarding Children Board Author: Paul Sharkey Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Publication Date - 30 June 2016 Redcar and Cleveland Safeguarding Children Board Independent Overview Report of the Serious Case Review Concerning ‘EMMA’ This report has been commissioned and prepared on behalf of Redcar and Cleveland Local Safeguarding Children Board (RCSCB) and will be available for publication once it has been finalised. Until publication this report is confidential and must not be shared with non-relevant parties. References relating to the subject child have been anonymised. Lead Reviewer and Independent Overview Author - Mr Paul Sharkey Independent Chair, Serious Case Review Panel - Mr Bruce Dickie Independent Chair, RCSCB - Mr Jan Van Wagtendonk 2 3 CONTENTS Introduction page 5 Purpose of SCR page 5 Reasons for SCR and Brief Background page 5 Timescale of Review page 6 Terms of Reference page 6 Methodology and Panel page 7 Review Process page 8 Parallel Enquiries page 8 Family Involvement page 9 Completion of SCR page 9 Report Format page 9 Overview of Agencies’ Involvement page 9 Analysis page 24 Family Views page 40 Conclusions and Key Lessons page 44 Recommendations page 50 Appendix 1: Glossary page 53 Appendix 2: References page 55 4 5 INTRODUCTION PURPOSE OF THE SERIOUS CASE REVIEW 1. This Serious Case Review (henceforth referred to as a SCR) was commissioned by the Redcar and Cleveland Safeguarding Children Board (henceforth, the RCSCB) on the 04.04.14 in accordance with the HM Government statutory guidance ‘Working Together to Safeguard Children’ 2013. This states1 that where a child has died or suffered serious harm and abuse or neglect is either known or suspected; and in the latter case, there is cause for concern as to the way in which the (local) authority, their Board partners or other relevant partners have worked together to safeguard the child, the Local Safeguarding Children Board is required to undertake a SCR. 2. The overall purpose of a SCR is to: ‘ Look at what happened in the case, and why, and what action will be taken to learn from the review findings, so that, action results in lasting improvements to services which safeguard and promote the welfare of children and help protect them from harm; and there is transparency about the issues arising from individual cases and the actions which organisations are taking in response to them, including sharing the final report of the SCR with the Public’ ( Working Together, 2013, page 65) REASONS FOR THE SCR AND BRIEF CASE BACKGROUND 3. The subject of this SCR is Emma which is not her real name but anonymised to protect her identity. She was born at the end of 2011 and is the younger sister to Sarah; both are the children to Lisa (mother) and Lee (father). She and her family are of White British heritage whose only language is English. It is not known what, if any, their religious background is. The parents had been supported to care for Sarah through a multi-agency Child in Need (CiN) plan in 2011. Their relationship was conflictual and they split up in the spring of that year, albeit with the father having regular contact with Sarah. 4. Professional concerns mounted through 2011 around aspects of Lisa’s lifestyle, reports of anti-social behaviour, suggestions of substance misuse, Lee’s violence and missed health appointments for Sarah. Following Emma’s birth in late 2011 she and Sarah were made the subjects of multi-agency child protection plans in January 2012 under the category of Neglect. The plans were ended in May 2013 and the children became subject to Child in Need plans, continuing to be cared for by their mother and her new partner, Tom. 5. Emma, aged almost two, suffered serious non–accidental injuries in October 2013 whilst in the care of her mother and Tom. She was taken to a local hospital for treatment and made the subject of Police protection. She and her sister were placed in foster care by the local 1 As per Regulation 5 of the Local Safeguarding Children Board Regulations 2006 ( see page 68 of ‘ Working Together to Safeguard Children, 2013, page 68) 6 authority under section 20 of the Children Act 1989, with the consent of their mother. Care proceedings were started shortly after and were concluded in March 2014 when both children were placed in long term care of a member of the extended family. 6. Cleveland Police started a criminal investigation into the incident which resulted in Lisa being charged in October 2014 with neglect. She stood trial in late 2015 and was given a custodial sentence. 7. The care proceedings in March 2014 made several findings of fact relevant to this SCR. Firstly, that Emma sustained serious non-accidental bruising to her face and other parts of her body. Secondly, that both Lisa and Tom had been in the house in the days leading up to Emma’s hospital admission and therefore neither of them could be excluded from causing the injuries. Thirdly, that both adults failed to protect Emma and that there was some considerable delay in getting medical help for her. Finally, the court found that Emma had suffered significant harm whilst in the care of her mother which was attributable to that care. 8. The serious harm suffered by Emma and aspects of the multi-agency intervention with the child and her family therefore met the criteria for a SCR. TIMESCALE OF THE REVIEW 9. The Review is from the 08.07.10 to the 31.10.13. This covers the period from when Lisa informed the midwife that she was pregnant with her first child, Sarah, to the point where care proceedings were started by the local authority on the children in response to the injuries to Emma in October 2013. TERMS OF REFERENCE 10. In addition to the overall purpose of the SCR, four case specific terms of reference (ToRs) were identified. These were, 1. How effective was the child protection plan and reviewing process in safeguarding and promoting the welfare of Emma? 2. How well did agencies engage with individual members of the family including the extended family and significant others? 3. To what extent did agencies understand the risks presented to Emma in respect of the violent behaviour of the individual members of the family, including the extended family and significant others? 4. Was the work in this case consistent with each organisation’s and the RCSCB policy and procedures for safeguarding and promoting the welfare of children and within wider professional standards? 7 METHODOLOGY AND PANEL 11. The SCR Panel (henceforth known as the Panel) comprised senior agency representatives who considered the information obtained from agency chronologies, Individual Management Reviews, the Learning Event and Court documents. The Panel was independently chaired by Mr Bruce Dickie (MSc) who is an Independent Management Consultant ( est. 2011), having worked in the NHS for 25 years, the last 6 of which were as Director of Children & Young People’s service in a Trust in the north east. He has been a member of several children’s and adult safeguarding boards. He has had no previous connection to Redcar & Cleveland Council nor any of its partners prior to this SCR. 12. The Lead Reviewer was Mr Paul Sharkey (MPA)2 who has wide experience of both writing and chairing Serious Case Reviews since 2002. He is presently an independent safeguarding consultant with over thirty years background in both statutory and third sector child protection agencies. He completed the Department of Education/ NSPCC/ Action for Children/ ‘Improving Serious Case Reviews’ course in July 2013 and is on the Association of Independent Chairs of LSCBs register for independent SCR Chairs and Lead Reviewers. He has had no previous involvement with the RCSCB or any of its partner agencies prior to this SCR. 13. The Panel included senior representatives from the following agencies; Designated Nurse Safeguarding Children-South Tees Clinical Commissioning Group Lead Nurse Safeguarding- South Tees Hospitals NHS Foundation Trust Associate Director of Nursing and Governance- Tees, Esk and Wear Valleys NHS Foundation Trust Service Manager- Redcar and Cleveland People Services-Children’s Social Care Detective Superintendent-Cleveland Police Head of Independent Living Services, Coast and Country Housing, Redcar Business Manager, Redcar and Cleveland Safeguarding Children Board (RCSCB) 14. The Panel met on the following dates; 6 May 2014, included IMR author’s briefing with Lead Reviewer and Chair 9 July 2014, included meeting with IMR authors 20 August 2014, included meeting with IMR authors 4 September 2014, Learning Event that included all IMR authors and front line managers and practitioners 28 October 2014 25 November 2014 2 Master’s in Public Administration ( 2007) from Warwick University Business School 8 REVIEW PROCESS 15. Individual Management Review [IMR] authors spoke to their reports with the Panel on the 9 July and the 20 August 2014. Key Practice Episodes3 were identified by the Panel and the Lead Reviewer. These informed the basis of analysis of the four terms of reference conducted at the Learning Event of 4 September 2014, at which all Panel members, IMR authors and relevant front line practitioners attended. 16.The Learning Event was facilitated by the Lead Reviewer using the ‘5 Whys’ and the ‘Cause and Effect/ Fishbone’ ( Hill : 2000, page 517) analytical techniques in an attempt to understand from a systems view why and how decisions and actions were made within the context of prevailing organisational and agency practices and expectations. The Panel and Lead Reviewer were mindful of hindsight and outcome bias (Kahneman: 2011, page 201) in conducting the analysis. The Panel critiqued a draft Overview Report on the 28 October 2014 and the 25 November 2014. 17. Sources of Information were taken from the following; 1. Independent Management Reviews from; Tees, Esk and Wear Valleys NHS Foundation Trust NHS England Durham, Darlington and Tees Area Team South Tees Hospitals NHS Foundation Trust Cleveland Police Coast and Country Housing, Redcar Redcar and Cleveland People Services- Children’s Social Care 2. Composite Review chronology 3. Court documents from the Care proceedings ( March 2014) 4. Minutes of Initial Child Protection and Review Conferences from 12.01.12 to 22.05.13 PARALLEL ENQUIRIES 18. Care proceedings on Emma and her sister were concluded in March 2014. There were ongoing Police enquiries which resulted in the children’s mother being charged with neglect in October 2014. She stood trial in late 2015 and was given a custodial sentence. 3 These are episodes from the case that require further analysis and are thought to be significant to understanding the way the case developed and was handled. They are not restricted to specific actions or inactions but can extend over longer periods. See SCIE ‘Learning together to safeguard children, developing a multi-agency systems approach for case reviews (2008). 9 FAMILY INVOLVEMENT 19. The Children’s parents, paternal and maternal grandmothers and Tom were informed that a SCR was being conducted shortly after the beginning of the Review. At the request of the Cleveland Police due to the impending trial of Lisa, none of the above family members were interviewed by the lead reviewer until after the criminal proceedings and sentencing were concluded in late 2015. Subsequently, the parents and grandmothers were able to give their views on the case to the lead reviewer and RCSCB Business Manager in January and February 2016. These are included in pages 40 to 44 below. COMPLETION OF SCR 20. Apart from the family interviews undertaken in early 2016, the rest of this report was completed in December 2014 and considered by the full Board of the RCSCB on the 13.02.15. The learning and recommendations of the Review were translated into an Action Plan and implementation has been ongoing since February 2015. FORMAT OF REPORT 21. This report has been written in a way that is mindful of recent (July 2014) publications4 about the need for SCR Reports to be succinct, shorter and focussed on learning points and lessons. It has also sought to comply with current statutory guidance (Working Together, 2013) regarding Reports being written in a way that publication will not be likely to harm the welfare of any children or vulnerable adults and is compliant with the Data Protection Act.1998. Therefore, identifying information and personal details have been omitted whilst attempting to achieve a balance with the need for public accountability and transparency. OVERVIEW OF AGENCIES’ INVOLVEMENT WITH EMMA AND HER FAMILY 2010 22. Emma’s mother, Lisa, was given a three month referral order in January 2010 to the Youth Offending Service (YOS). She failed to engage on three occasions which delayed the start of the work with YOS. In July 2010 she informed the midwife that she was sixteen weeks pregnant and was referred at her request by YOS and CREST (a substance misuse service) in August to the Teenage Pregnancy service. 23. General Practitioner (GP) records of October noted that Emma’s father, Lee, had been previously involved with the Tees, Esk and Wear Valley mental health service. A letter from the agency contained information about an assessment by a forensic consultant psychiatrist undertaken in the previous January. This opined that whilst he did not appear to be a direct risk to his younger half siblings there were potential risks from a situational context were he 4 See ‘First Annual Report’ of the National panel of independent experts on serious case reviews ( July 2014) and the DfE Research Report into Barriers to Learning from Serious Case Reviews (July 2014, Anne Rawlings et al) 10 to reside in the family home again. His risk to others needed to be acknowledged if alcohol was a factor. 24. By October it was recorded in the GP records that Lisa was living with her mother. She was reminded by the midwife in October of the importance of attending ante-natal appointments, having missed several. She had also not complied with the conditions of her referral order and received a court summons in late November. She continued not to attend her midwife appointments in November and was advised by the community midwife (MW2) in mid- December that a referral would be made to Children’s Social Care if she failed to attend further appointments. MW2 visited her on the 29.12.10 at her mother’s house. Lisa said she was prepared for the baby’s birth. 2011 25. Sarah was born in hospital (H1) in early January 2011 and transferred to another hospital (H2) soon after for specialist medical care. A referral was made by the hospital social worker to Redcar and Cleveland Children’s Social Care (CSC) on the 12.01.11. Concerns had emerged about Lisa and baby Sarah returning to the maternal grandmother’s address, following reports of an unsuitable home environment and lifestyle. Pending an assessment by CSC arrangements were made for Sarah and her mother to stay with the paternal grandmother and both were discharged from H2 on the 13.01.11. 26. Lisa was given a six month conditional discharge for breach of her referral order in mid-January with the involvement of the Youth Offending Service ending. The CSC initial assessment finished on the 19.01.11. This identified concerns around previous convictions of violence for Lisa and Lee (mother and father), lack of compliance by Lisa with her recent referral order and suggestions from earlier local authority information of neglect and domestic violence in the maternal grandmother’s history. A decision was made to proceed to a core assessment to explore parenting history, parenting capacity and the suitability of the maternal grandmother’s home. 27. The health visitor undertook a primary visit on the 26.01.11. There were no concerns noted. The parents were taking Sarah for her specialist medical care every three weeks. The student social worker (SW9) visited on the 28.01.11 and was informed by Lee that he had been previously involved with the adult mental health early intervention team for anger issues and substance (drug and alcohol) misuse. SW9 emphasised that Sarah should not be left unsupervised with Margaret, the maternal grandmother. The parents mentioned that they were planning to move to privately rented accommodation. 28. At the end of January Lee ‘trashed’ his mother’s house in front of his younger siblings and Sarah. He had reportedly hit Lisa and pushed his mother. He was arrested by the Police and an assessment was undertaken following a referral from his GP. He was described in the Crisis Team notes (that were faxed to his GP), as ‘can be a very dangerous young man’. The information received by the GP did not indicate there were children in the household or safeguarding concerns. Tees, Esk and Wear Valley Trust (TEWV) records indicated that there had been a long history of involvement with Lee. The Police made a referral to CSC about the incident. 11 29. CSC (SW8) telephoned on the 02.02.11 to establish Sarah’s welfare following the earlier incident with Lee; she was reported to be ‘fine’. A core assessment planning meeting was held the next day (03.02.11) at a children’s centre attended by the parents and SW9 but which did not include the YOS, Probation and the Police. Maternal grandmother was not engaging in the core assessment but Lisa agreed to speak to her. Home visits were planned with dates given to the parents but there would also be unannounced visits. SW9 agreed to write a letter of support to housing and a further planning meeting was arranged. 30. Sarah attended the paediatric day unit on the 07.02.11 from Accident and Emergency because of concerns about aspects of her medical condition. After being X-rayed she was discharged home. SW8 and SW9 were told by the mental health Crisis Team on the 09.02.11 that Lee was deemed to be a high risk to professionals and that all future contact would be through joint visiting. The lone worker policy was to be followed with CSC personnel. There was no record of any discussion amongst CSC about possible risks to Sarah, her mother, other family members, or risks to other professionals. Information was sent from the early intervention team to SW9 regarding Lee’s discharge report and his last contact with the community forensic team. Additional information on Lee’s involvement with an Early Intervention Team was provided to SW9 on the 16.02.11 as part of the core assessment. 31. Sarah received her first immunisation on the 28.02.11. She and her parents moved to a flat on the same date. SW9 received supervision on the 01.03.11 where it was agreed that there would be monthly visiting, that the core assessment needed to be finished and that the case would be transferred to a social worker (SW10) as SW9, a student, would be completing her placement. 32. Sarah had started attending a local children centre and was seen for her 6-8 week check by the GP on the 02.03.11. SW9 noted on the 04.03.11 that the mental health risk assessment of Lee indicated concerns about his mental health when he had consumed alcohol. He needed some education around relapse prevention for his alcohol and drug abuse and psychological work to address his anger, self -esteem and inter personal communication. 33. The CSC core assessment was completed on the 08.03.11 by SW9. It questioned how the parents would care for Sarah once they were living away from the support of the wider family (i.e. paternal grandmother), raised concerns about Lee’s mental health and violent behaviour, debts and the current insecure housing situation. The maternal grandmother’s home was not viewed as suitable for Sarah. There was no reference to domestic violence or its possible impact on Sarah and little reference to Lee’s mental assessment and its implications for risk to Lisa and the baby. 34. The family became involved with a health visitor on the 09.03.11 following their move to the area. On the same date CSC (SW9) decided that following a discussion with the Probation service about the maternal grandmother (Margaret) and information from her social worker, it would be possible for Sarah and her mother to stay overnight there. The working agreement was to be reviewed to include Margaret having unsupervised contact with Sarah consequent to her being assessed that she could care for the baby. A planning meeting was held with Lisa and the health visitor on the 10.03.11. The home was ‘warm and comfortably furnished’. Lee was reportedly at work. 12 35. Sarah and both parents attended the clinic on the 14.03.11 and were seen by the health visitor who noted satisfactory growth; the baby was smiling, clean and appropriately dressed. The parents were reminded about second immunisations and invited to the local children’s centre activities. The case was transferred on the 15.03.11 from SW9 to SW10 and their manager, SWTM2. 36. Sarah was seen on the 25.03.11 at Dr1’s outpatient clinic at H2 and was noted to be thriving. Dr1 was happy with her progress; the parents seemed to be coping well with managing her medical needs. SW10 visited on the 30.03.11 and discussed the working agreement with Lisa and Lee. Sarah was not seen on the visit and had not been seen by a social worker since the 09.03.11. Lisa was unhappy that her mother was only allowed two hours of unsupervised contact with Sarah. 37. By early April the health visitor was noting that Lisa was not attending baby clinic and that Sarah had missed her appointment at H2. Lisa notified the community midwife on the 07.04.11 that she was again pregnant. 38. A multi-agency meeting was held at the children centre on the 21.04.11 with the health visitor, SW10 and Lisa. Sarah was noted to be behind in her immunisations and had not attended H2 for her specialist medical care. 39. Lisa and Lee split up in late April. SW10 was informed on the 03.05.11 that Lisa had threatened Lee’s mother and had left Lee to care for Sarah who had been poorly. She received her second set of immunisations on the 03.05.11, some two months late. 40. Lisa reported to the Police on the 05.05.11 that Lee had assaulted her whilst Sarah had been present. He was arrested and a domestic violence and child protection referral was sent to CSC by the Police. Lisa refused to make a complaint statement, there were no visible injury signs and Lee denied the assault. The enquiry was finalised as ‘insufficient evidence to proceed’ and Lisa failed to engage with the offer from the Police domestic violence safety planning service. 41. Lisa and Sarah were by the 06.05.11 living with the maternal grandmother which prompted a visit by SW10 on the same day. There was no record of the outcome of the visit or any mention of the pregnancy. The health visitor visited Sarah on the 11.05.11 and found Lee caring for her; she was clean and appropriately dressed. It was noted that he handled the baby well, with good care seen in relation to her medical needs. There was an appropriate feeding regime reported and no concerns for Sarah’s growth with the baby smiling. He was going to have weekend contact with Lisa and Sarah. 42. Lisa failed to attend several midwifery appointments in May. She was advised to contact the local housing agency in mid-May regarding seeking her own accommodation. 43. In early June Sarah and both parents were seen at the children’s centre by the health visitor who noted no concerns. A ‘network’ meeting was held when it was noted that Lisa was pregnant with estimated date of delivery of the 26.11.11. She and Lee were separated and Lisa had moved back with her mother. She was looking for her own accommodation as was Lee. There was to be a change of GP for Sarah and Lisa. 13 44. SW10 and her manager held a supervision session on the 09.06.11. Sarah was reported to be thriving in her mother’s care. SW10 was directed to make a referral on the unborn child at the eighteen weeks pregnancy mark. A joint social work probation visit was made to see Lisa and her mother on the 22.06.11.This was the first time that Sarah had been seen by CSC in two months. Lee was arrested on the 25.06.11 for being drunk and disorderly. 45. Lisa missed several ante-natal appointments in June and early July which were noted in the community midwife’s supervision. It was also noted that CSC was thinking of closing the case as things appeared to be going well with no other concerns. The midwife’s assessment was that it was not appropriate for CSC to close the case given that Lisa was not attending her ante-natal appointments. The midwife questioned how Lisa would cope with two babies, one with additional health needs without on-going support. It was decided to speak to the social worker about her concerns, monitor Lisa’s ante-natal attendance, liaise with the health visitor and alert the central delivery suite. 46. Following discussion with the social worker it was decided that CSC should continue working with Sarah and Lisa (and the unborn child) under a Child in Need plan. Very significantly in this case, a child protection referral was made by the community midwife (CM1) to CSC on the 07.07.11 regarding Lisa’s non-attendance at ante-natal appointments and concerns around how she would manage with two babies. 47. On the 07.07.11, the Police were called to an incident involving Tom (later partner to Lisa from May 2012) and his father in an argument. No offence was reported but Tom was taken to a friend’s address and domestic violence forms were submitted by PC4. 48. A Child in Need meeting was held on the 12.07.11 at the children’s centre. The health visitor noted that both of Sarah’s parents were living with their respective mothers, Sarah’s immunisations were again overdue, the estimated delivery date for the unborn child was the 26.11.11, there had been missed ante-natal appointments by Lisa, Lee had Sarah every weekend at his mother’s home. He was also, allegedly, on bail for a GBH charge with the possibility of a custodial sentence. 49. Sarah was seen at the Child Health Clinic on the 14.07.11 and the health visitor noted no concerns for growth, development, presentation or Lisa’s handling of her child. The third set of immunisations were arranged for that afternoon which Lisa did not attend. It was agreed that the health visitor would review Sarah every 2-4 weeks; Lisa was waiting for an appointment at H2 for Sarah’s specialist medical care. The health visitor updated the social worker on developments and the latter decided to undertake an unannounced visit. On the same day, Lee was arrested for causing damage to a house window and seen by the Criminal Justice Liaison Service. No further action was taken. 50. On the 19.07.11 the Maternity delivery suite at H1 was alerted to the forthcoming birth of Lisa’s unborn child, the need to inform the social worker of the delivery and the requirement of a pre-discharge meeting. Clearly, arrangements were in place for the birth of Lisa’s second child. The social worker had tried unsuccessfully on several occasions to visit/contact Lisa around the end of July. The midwife had reported Lisa’s missing her ante-natal sessions and had not registered with a local GP. SW10 saw Lisa on the 26.07.11 on a home visit. There was no cot for Sarah. Lisa said that she wanted Sarah to sleep with her and she was advised that this was not safe for the child. 14 51. Lisa’s GP received a letter on the 27.07.11 from a consultant obstetrician saying that she had missed three growth scans. This was significant given Sarah’s particular health issues. The GP was asked to contact Lisa with a view to her attending hospital appointments. The letter was not copied or sent to the health visitor or midwife. 52. A joint social work/health visitor visit was made to Lisa on the 03.08.11. She said that Sarah was now sleeping in a cot and showed that she understood safe sleeping and the need for a bedtime routine. Some four months late, Sarah’s third immunisations were given on the 04.08.11. 53. Several key risk factors were identified by the community midwife at a supervision session of the 09.08.11 regarding Lisa’s care of Sarah and her unborn child. It was thought that the Child in Need plan was not facilitating the desired improvements and that the children were at risk of harm from neglect. It was decided that the midwife would suggest to CSC that child protection measures be started by the end of the week on Sarah and the unborn child. 54. On the 11.09.11 Lisa registered a priority band 1 (on the grounds of domestic abuse) housing application with the local authority homeless section. Tom, who at this point was not with Lisa, was stopped by the Police in the early hours of the 12.08.11 and found with a small amount of cannabis. He was given a cannabis warning. 55. Sarah was in specialist hospital having surgery in mid-August. SW10 visited Lisa and her mother on the 25.08.11 who said that they were unhappy at continued CSC involvement. However, they agreed to work with CSC and other agencies on a continuing Child in Need basis. There was no sign that the midwife’s thinking around escalating to a formal child protection level had been considered by CSC. No concerns were noted by SW10 regarding Sarah. 56. Sarah was admitted on the 15.09.11 to A and E with vomiting and not eating, with evidence of dehydration and possible post-surgery complications around bowel obstruction. She was discharged the next day but there was no recorded communication (beyond the usual discharge letter sent after an admission) with the health visitor or the social worker, or clarification by the hospital as to why the family was involved with CSC. It was noted that Lisa lived with her mother ‘who is going through court for access to own children’. 57. The health visitor made several unsuccessful attempts to contact Lisa in late September, including a cancelled (by maternal grandmother) joint home visit with the social worker in early October. A Child in Need meeting was arranged for the 11.10.11. There had been no social work contact to see Sarah since late August. 58. Some four weeks late, the core assessment on the unborn child was finished on the 05.10.11. Information was limited due to Lisa’s refusal to engage. The Child in Need meeting of the 11.10.11 decided to proceed to a strategy meeting because of Lisa’s refusal to engage with health service regarding the unborn child. She had done nothing about getting her own accommodation and had not co-operated with the CSC in the core assessment. There was no mention of the previous alleged domestic violence incidents and the Police had noted that the two grandmothers had had a verbal argument during contact with Sarah. 15 59. A child protection strategy meeting was held on the 13.10.11 which decided to start a section 47 enquiry and update the core assessment. On the 28.10.11 the section 47 enquiry concluded that although there were significant concerns, Lisa was to be given’ one last chance’ to work with CSC on the Child in Need plan. She was given the tenancy of a property at the end of October. Sarah was not taken for her 9 month development check on the 28.10.11 which was completed on the 03.11.11. The social worker and health visitor were present; no concerns were noted for Sarah. Lisa said that she did not want CSC service involvement, was prepared for the new baby and would work with CSC until February 2012. 60. Emma was born in late November and discharged to her mother’s care shortly after her birth with the approval of CSC who reported that there had not been any concerns for Sarah. There were two midwife visits on the 29 November and 5 December with no concerns noted. The social worker visited on the 28 November and noted no concerns. 61. The revised core assessment was completed on the 01.12.11 which concluded that multi-agency support services should continue under a Child in Need plan, at least over the short term to ensure that Sarah’s health needs were met and appointments kept. Reports of Lee’s violence required discussion with him. He was visited by SW10 on the 05.12.11 to share the core assessment and admitted involvement in fights. He did not want contact with Lisa and was in a new relationship where he was happy. He said that there were lots of ‘lads’ at Lisa’s property drinking and agreed to a referral to the alcohol treatment service. 62. Lisa disclosed to the health visitor on the 06.12.11 a history of domestic abuse with Lee who she said also had a history of alcohol abuse and criminal convictions. They had been separated for some months. She said that her mother had had her own children removed from her due to previous lifestyle issues. 63. An anti-social behaviour case file was opened (by Coast and Country Housing) on Lisa on the 12.12.11 following reports of loud music and a party in the early hours. SW10 visited the home unannounced and found an unidentified male in the property with no sign of Lisa. Piles of rubbish and lager cans were noted with a smell of cannabis. The same male and a female were there on the second visit. There were concerns for the children’s welfare and a Police ‘safe and well’ visit was made the next day when the children were seen. The anti- social behaviour officer (TA1) visited on the 15.12.11 and closed the case on the basis that Lisa, whilst admitting to having held an 18th birthday party, apologised and said it would not happen again. 64. Lisa was given a warning letter on the 20.12.11 by the anti-social behaviour team (Police Community Support Officer (PCSO 1) and TA1 following further complaints of loud parties, aggressive young males coming and going, alleged drug dealing and concerns for the two children. CSC was informed of the developments and SW10 visited on the 22.12.11. She found several young people in the house and told Lisa that her lifestyle was inappropriate given she was caring for two babies. Lisa refused to accept the concerns. 65. A strategy meeting was held on the 23.12.11 due to the concerns. A decision was made to proceed to a section 47 enquiry and an Initial Child Protection Conference (ICPC). Arrangements were made for outreach visits to be made and increased policing over the Christmas period. In the event, the children stayed with their paternal grandmother for part of 16 the holiday. SW10 undertook four unannounced visits to Lisa at the end of December and beginning of January with no response from the visits. 2012 66. At the beginning of January, Tom was arrested for assaulting his father and a domestic violence report was submitted. Further unannounced and unsuccessful visits were made by SW10 and the emergency duty team (EDT) in early January. EDT found the two babies in the care of several young males on the 4 January with no sign of Lisa. She was contacted and arrived home. Sarah was seen to have some nappy rash. 67. Both children were made the subjects of child protection plans on the 12.01.12 under the category of Neglect. Lisa did not agree with the decision and denied that she neglected her children. The Initial Child Protection Conference (ICPC) identified the risks to the children as being, The mother’s lifestyle; allowing the home to be used by large numbers of young people for a party-type lifestyle The misuse of drugs, particularly cannabis Concerns around the children’s health needs being neglected Parental conflict and previous domestic violence 68. A second warning letter was issued to Lisa by the Anti-Social Behaviour (ASB) team on the 16.01.12 following further complaints of a party and children crying. She agreed to a referral being made to the Coast and Country’s floating support service and was told that any further complaints would result in the involvement of tenancy enforcement and the serving of a notice seeking possession. She said that there would be no further incidents. This incident was only four days after the ICPC. 69. Lisa did not take Sarah for her immunisations on the 19.01.12 despite being reminded by the health visitor. Emma missed her hearing screening tests in December and mid-January. CSC was informed. The first core group met on the 24.01.12 in the family home. One of the tasks noted by the health visitor was for Lisa to provide a list of people coming to the house to be police checked. Sarah attended the immunisation clinic on the 26.01.12 with her mother, sister and an unknown male. The social worker (SW1) visited on the 30.01.12 and noted the children to be ‘fine’. They were in the kitchen with four young men. SW1 queried their names and was told by Lisa that SW10 had them. 70. The ASB team visited Lisa on the 03.02.12 about further complaints of noise nuisance and disruptive behaviour outside her house with people going in and shouting. Her house had been targeted by the Police as a ‘hotspot’. She was advised that if the problem continued consideration would be given to serving her with a Notice of Seeking Possession. On the same day, SW1 was informed by the sure start worker that a female known to be a crack user, whose children had been removed, was present in Lisa’s house during a home visit. 71. The second core group met on the 20.02.12. It noted that there had been no recent reports of anti-social behaviour about Lisa. She wanted a move closer to her family but was in rent arrears and still subject to ASB warnings. There were no concerns for the children’s 17 growth or development, despite the previous concerns from the health visitor of the 16.02.12, that Lisa was not meeting the children’s health needs regarding missed appointments and Sarah’s immunisations being outstanding. It was agreed that a ‘Working agreement’ with Lisa would be drawn up. The ASB team closed her case on the 27.02.12 as there had been no further complaints. Emma’s primary immunisations were a month late (23.02.12). The floating support referral was closed on the 07.03.12 as there had been no contact from Lisa. 72. The children were seen on the 16.03.12 at a planned clinic attendance with their mother (35 minutes late). It was noted that their growth was satisfactory, that Lisa’s handling of them was appropriate and that she interacted positively with them. The planned core group for later on that day was postponed to the 19.03.12. SW1 noted some improvements but ongoing concerns about Lisa’s commitment and consistency in accepting help. The health visitor noted Lisa’s continued failure to act on professionals’ requests and her minimal engagement. There were no specific concerns for the children’s health and development. The core assessment by CSC was still outstanding. 73. The first Child Protection Review Conference (CPRC) was held on the 27.03.12. Lisa, Lee and his mother attended with the social worker (SW1) and the health visitor present but no one from Coast and Country (on holiday). The Conference heard of some positives in the children’s care (i.e. no recent nuisance complaints) but concerns remained around the parents’ conflictual relationship and its impact on the children, and missed health appointments. The written agreement underpinning the Child Protection Plan was still outstanding. It was decided to continue with the Child Protection Plans. 74. There were three unsuccessful home visits made by SW1 in early April. On the 10.04.12 SW1 made a visit and saw Emma through the house window crying in a car seat. A working agreement was signed by Lisa. A failed planned home visit was made by the health visitor on the 12.04.12 and SW1 was informed. Emma had her second immunisations on the same day, some three weeks late. There was a further failed planned home visit by the health visitor on the 17.04.12. Lisa and the children were seen by the health visitor at maternal grandmothers’ on an opportunistic visit later that day. They had been staying there for two weeks as Lisa had no electric but had not told any of the professionals about the move. Sarah was seen but Emma was reportedly out with a female friend of Lisa’s. There was no record of the social worker being told of this or a follow up on who the ‘friend’ was or whether it was safe for the children to be with the maternal grandmother. 75. A core group meeting met on the 23.04.12 with apologies from TA1 (Coast and Country Housing). There was little evidence of progress with the child protection plan. Lisa was seen on the 27.04.12 moving her things into a friend’s house. This was notified by Coast and Country to SW1 who visited the same day. Lisa denied moving in with a friend and was with her mother. 76. Lee was arrested on the 01.05.12 following a serious incident of domestic violence against his current partner. However, no action followed due to no complaint being made from the partner and Lee was released. The partner’s child was placed with family members by CSC. SW1 told Lisa on the 04.05.12 that she should not allow Lee to have the children at the weekend. Emma was not taken for her immunisation on the 10.05.12. In supervision, the health visitor noted on the 15.05.12 Lisa’s continuing lack of co-operation with home visits and health appointments. An ASB file was opened on the same day following a complaint 18 made about Lisa and her mother. Reportedly, the maternal grandmother had acted in a threatening manner to a neighbour and had climbed onto the roof. This was witnessed by the two children. 77. On the 18.05.12 the Independent Reviewing Officer (SW5-Chair of the CPRC) responded in an e-mail to a query from SW1 about difficulties in implementing the Child Protection Plan. The suggestion was to discuss the case with her team manager and seek legal advice. This was the first reference of recourse to legal action in this case. 78. Despite being reminded, Lisa failed to attend the planned core group meeting of the 21.05.12. Serious concerns about housing and the prospect of eviction for the children were noted in addition to ongoing health appointments. There appeared to be no mention of the recent incident with the maternal grandmother’s aggressive behaviour. There were two unsuccessful social work visits made in late May and a further missed immunisation appointment for Emma. The health visitor did manage a planned visit on the 29.05.12 and saw both children. She noted no concerns for their development and presentation and observed Lisa showing emotional warmth and affection towards her children. She said that she had a boyfriend living nearby. 79. A legal meeting was held on the 31.05.12 when a recommendation was made to start the pre-proceedings, Public Law Outline. SW1 noted on the 01.06.12 that no evidence had been forthcoming regarding Lee’s alleged assault against his partner. On this basis it was decided that Lee could resume weekend contact (it having been stopped on the 04.05.12 at the request of CSC) with Sarah and Emma. The PLO option was not pursued by SW1 as the aggression was with the maternal grandmother and not Lisa. 80. The sixth core group met on the 18.06.12. It was noted that Lisa’s new partner’s details were to be obtained with a view to CSC requesting police checks on him. The core assessment was still outstanding. The partner, Tom, was present when the health visitor visited the home on the 28.06.12. He was also present on the same day at the GP surgery for the children’s immunisation appointment. Lee and his partner were involved in a late night drunken argument in late June. Lee was arrested and given a fixed penalty notice. The information was passed to SW1. 81 Lisa refused to let SW1 in during an unannounced visit to see the children on the 10.07.12. The Police were called to an incident on the 12.07.12 alleging that Lisa and Tom had been fighting in the street in front of the children. All was quiet on arrival and the children were seen ‘safe and well’. A domestic violence report was submitted to SW1. Lee told SW1 on the 13.07.12 that the girls were dirty and hungry, that Lisa was using cannabis and was always fighting with her boyfriend as she had put it out on Facebook. 82. The seventh core group met on the 17.07.12. It was noted that Lisa remained hostile to professionals, that she had a new partner and had agreed for police checks to be done. Lisa said that she was no longer in a relationship with Tom. She was seen to have numerous bruises to both arms which she said she got from a ride at a theme park. Sarah, who was on a child protection plan, was noted to have red discolouration to her upper lip. Lisa said that she had fallen over at her partner’s mother’s house and banged it. No further consideration was given to the injury. 19 83. It was noted in the GP records of the 25.07.12 that Sarah had attended the Walk in Centre for a bump to her head; this information was also shared with the Health Visitor. The eighth core group meeting was held on the 30.07.12 which was not attended by Lisa; Lee was present but there was no discussion of the previous incidents between him and his girlfriend. There was no mention of the minor injury to Sarah by the Health Visitor at the core group. 84. On the 02.08.12 Lee and partner were involved in a domestic violence incident. Lee became violent to the Police and was arrested. The information was passed to SW2. There was a violence incident involving Lee on the 07.08.12 with his partner. A police officer’s hand was bitten by Lee. 85. A legal meeting involving SW1, her manager (SWTM2) and a legal advisor (solicitor) was held on the 09.08.12 when it was agreed that the matter should go to care proceedings. A letter from the legal advisor on the 10.08.12 stated that in the light of the lack of co-operation and engagement by the parents a ‘letter before proceedings’ was not an appropriate option. The advice was that the section 31 (Children Act 1989) threshold for court intervention was available to the local authority and the recommendation was to issue care proceedings immediately. The solicitor was instructed by the team manager and social worker to start care proceedings urgently and to have the matter listed before the Court. There was no record of the decision being discussed with and agreed to by a more senior manager. 86. The second CPRC was held on the 15.08.12. Although a local authority legal representative was present there was no record in the conference minutes of any discussion of the recent legal advice. It was noted that there had been no Coast and Country Housing representation at core groups or child protection review conferences for some time. There was an expectation that they attend all meetings as a member of the core group and the social worker was tasked to contact them within one week. The children remained on their child protection plans given the continuing concerns about them, the lack of progress with the plans and Lisa’s intransigence. Lisa agreed that she would work with the plans. 87. A further legal meeting was convened on the 16.08.12 by a senior line manager who had been informed of the ineffective practice of SW1. She was not made aware of the legal letter of the 10.08.12, or (presumably) the advice and subsequent instruction for care proceedings to be issued. It was agreed that Lisa would have one week to show that she could co-operate with the multi-agency child protection plan prior to the local authority sending out a ‘letter before proceedings’ initiating the Public Law Outline (PLO) process. 88. A follow up PLO meeting of the 30.08.12 noted that Lisa had engaged with CSC and other agencies over the previous two weeks. In the light of this it was decided to take no further legal action at that stage. Children’s Social Care was to keep the matter under close review in ensuring the parents’ adherence to the plan with the group being told of any change in circumstances. The letter before proceedings was therefore not sent; Lisa and her mother said that they were agreeable to the proposed plan for the children. There was an expectation from CSC that both parents would now co-operate with the child protection plan and show at the next CPRC in January 2013 that positive change could be sustained in the longer term to meet their children’s safety needs. 20 89. Lisa and the children started to attend the crèche at the local children’s centre at the beginning of September as per the child protection plan. Both children settled in well and Lisa was to start a ‘Mellow parenting’ course. The ninth core group meeting was held on the 04.09.12 and attended by Lisa. The new social worker (SW3-an experienced social worker in child protection cases) was introduced. There was no mention of the outcome of the recent legal meetings, the result of any police checks on Tom; nor was the core assessment completed and distributed. SW3 visited the family on the 11.09.12 with no concerns noted. The children attended the children centre on the 10.09.12. and the 17.09.12. A bruise was noted by the health visitor on Lisa’s right lower arm on the 13.09.12, apparently done on the stairway. 90. Tom (Lisa’s partner) attended his GP (GP14) in mid-September for mental health matters. It was noted that he got angry easily, punched doors and self-harmed (cut). It is important to note that at no time was information relating to Tom requested from the GP. Lisa made a new application for a housing transfer on the 21.09.12. The children continued to attend the children’s centre in late September. 91. Lisa’s progress and positive engagement with agencies proved to be short lived and started to break down in early October. She was unable to attend the tenth core group scheduled for the 02.10.12 as she was ‘unwell’. It was re-arranged for the 29.10.12 which, in the event, she did not attend. Lee was arrested for an assault on his partner on the 07.10.12 and a referral was made to the Multi-agency risk assessment conference (MARAC)5 in the local authority area where he resided. An ASB case was re-opened on Lisa on the 09.10.12 because of alleged intimidation and threats made by her on Facebook. The social worker heard a verbal argument between her and Tom on a home visit on the 09.10.12. She was reported by the health visitor not to have attended the Mellow Parenting course on the 10.10.12 (but did attend the next day). Her attendance over the next four months was sporadic. 92. Lisa did not attend the core group of the 29.10.12. Her minimal engagement and sporadic attendance at the Mellow Parenting course was noted. However, there were no reported concerns about the children’s general care and safety. The ASB case was closed on the 07.11.12. Tom gave SW3 his details for a police check at a home visit in mid-November and said that he did not have a police record, which was not true. Sarah was noted to show aggressive behaviour towards other children at the children’s centre on the 22.11.12 and was deemed to need one to one staff support. 93. The eleventh core group met on the 27.11.12 and discussed Tom’s dishonesty about his police record and the verbal argument he and Lisa had during SW3’s visit in October. Lisa continued not to attend the Mellow Parenting sessions in early December. A MARAC (Multi-Agency Risk Assessment Conference for domestic abuse victims) meeting on the 05.12.12, held in the local authority area where he resided, noted that Lee stated that he was having unsupervised contact with Sarah and Emma every fortnight. This was not risked assessed. He was arrested on the 06.12.12 for an assault on his partner and reported to have cut himself with a knife and overdosed, leading to a mental health assessment. His partner was 5 This is a multi-agency risk assessment conference for domestic abuse victims which develops a multi-agency plan to minimise and manage risk in order to protect victims of domestic abuse. 21 issued with a ‘threat to life’ notice as directed by the MARAC. There was no evidence to suggest that the incident had been notified to CSC and risk assessed. 94. Further evidence of Lisa’s non-engagement was when the health visitor attempted a planned home visit on the 12.12.12 to see the children and was told by Lisa that it was not convenient as the children were having a nap. She was asked to attend the clinic on the 14.12.12 and reminded of the core group meeting of the 18.12.12. The children’s centre noted on the 13.12.12 that Lisa was moody and short tempered. She shared with the Mellow Parenting group that she was a good mother and did not meet the criteria for attendance. Concerns were shared with her about her present partner (Tom) staying at the house overnight, given that he had not yet been policed checked. There was no record that she brought the children to the clinic and she did not attend the core group (the twelfth) held on the 18.12.12.The children’s centre staff noted on the 20.12.12, following a home visit, that the children were ill, according to Lisa, with chickenpox. 2013 95. The Children’s Centre noted on the 10.01.13 that the children were not appropriately dressed and did not have coats. Sarah’s behaviour was difficult; she had physically attacked another child causing bleeding. The third Child Protection Review Conference was held on the 15.01.13 which was not attended by Lisa. It was noted that her attendance at the Mellow Parents course had been sporadic and that it was part of the child protection plan that she complete it which had not happened. Reference was also made to Tom and that the police check on him had been done. However, he was not part of the written agreement and had not been included in the core assessment which remained uncompleted. Concerns were expressed about the risk Lee presented to the children given his recent violence towards his partner and being subject to a MARAC in in the local authority area where he resided. The Review Chair stated that Lisa needed to attend all future core groups. The Chair commented on some progress having been made by Lisa with the child protection plan but suggested that the children remain on their plans and that a CPRC be set for three or four months hence, given the ‘stringent efforts’ made by their mother. 96. On the 12.02.13 the health visitor noticed that Emma had two scratches to her neck which, according to her mother, were self- inflicted. The children’s growth and development gave no cause for concern. The thirteenth core group met on the same day and was attended by Lisa. It noted that there had been no reported concerns regarding inappropriate people being in the family home and that Lisa had allowed the social worker and health visitor access to the house. Discussion took place about the recent domestic violence incidents between Lee and his partner and the risks presented to Emma and Sarah. It was agreed that the local authority would supervise contact between Lee and the children given the concerns about him. 97. CSC received information from the Probation service that the maternal grandmother had a new partner who had a record of concerning behaviour. There was no record of this having been followed up by CSC. 98. Lisa attended the urgent care centre on the 21.02.13 (according to her GP records) , she said that she had, ‘fell on a pint glass and cut her head’. The hospital noted that she had attended for a head laceration and head injury that required an X- ray. 22 99. Neither child attended the crèche on the 05.03.13 and there was a failed unplanned home visit by the health visitor the next day. There were two further occasions in March when Emma did not attend crèche with no apparent explanation. The Children’s Centre informed SW3 of the non-attendance. Sarah did not attend an appointment with Dr1 at the specialist hospital on the 22.03.13. The fourteenth core group meeting was held on the 26.03.13 which was attended by Lisa who said that the children had not been to crèche due to a tummy upset. No concerns were reported about the children’s care. Outstanding dental appointments for the children had not been made by Lisa. 100. Regarding contact with their father, it was agreed that Lee could see the children once a fortnight under local authority supervision and that they could have an overnight stay with their paternal grandmother on condition that she did not allow contact with Lee in the home. 101. Crèche sessions and important health appointments for the children were missed in early-mid April and the social worker was notified. A joint health visitor/social worker home visit was made mid-morning on the 18.04.13 with Lisa and the children still in bed. A development review was completed with no concerns for Sarah. Emma’s growth and development were deemed satisfactory. However, she was noted to have a scratch to her right shoulder and neck and bruising under her left arm, sustained by falling off a trampoline, according to her mother. The explanation was accepted despite Emma being on a child protection plan. 102. Lee and his partner were involved in a further serious incident of violence on the 21.04.13 when the former was arrested for grievous bodily harm. A core group (fifteenth) met on the 23.04.13 which was not attended by Lisa despite being asked to do so by the Chair of the recent CPRC. There was no Coast and Country housing professional present. The meeting noted the missed health appointments, no dental appointment despite this being a requirement of the child protection plan and non-attendance at the nursery. The injury to Emma was not discussed and supervised contact with Lee had not been arranged. There were no reported concerns on either child. 103. The children continued not to attend nursery in late April and early May. The children did attend on the 14.05.13 when there was a core group meeting which was attended by Lisa (twenty minutes late), Lee and his mother. A small cut to Emma’s inside upper lip and a small bruise to her left check were noted by the GP on the 20.05.13. Lisa said she had received it by falling on a safety gate. There was no reference made by the GP to the children being on child protection plans. However the GP had recorded the injury was consistent with the explanation. Lisa told the social worker the next day about the GP visit and the injury to Emma. This was the second injury to Emma within a month. 104. The final Child Protection Review Conference (CPRC) was held on the 22.05.13. A report was requested from the GP but there was no information sent about the recent injury to Emma although the issue was referred to by the health visitor. The children were taken off their child protection plans and several recommendations were made regarding their attendance for health appointments and at Sure Start. Six weekly multi-agency meetings were to continue, the next being on the 09.07.13. 105. Emma was not taken to the nursery in June, Sarah did not attend a specialist hospital appointment and no dental appointments were made. SW3 was made aware of this by the 23 children centre. They were seen by the health visitor at home on the 20.06.13 and reported to be happy and sociable. The children’s centre recorded on the 02.07.13 that Lisa had said that Emma was dragging one of her legs. The multi-agency meeting of the 09.07.13 was not attended by Lisa who seemed to have effectively dis-engaged from the professionals. 106. An Anti-Social Behaviour case referral was opened on Lisa on the 15.07.13 following reports that she had been arguing loudly with her boyfriend at various times of the day. Emma failed to attend the nursery on the 16.07.13 and SW3 was notified. There was a further ASB report made on the 26.07.13 regarding allegations that Lisa and Tom were being threatening to others in the neighbourhood. The Police were alerted. 107. SW3 asked the Children Centre to send their engagement officer to see Lisa with a view to getting her and the children back to the nursery. Lisa failed to attend a meeting with the housing office on the 05.08.13 to discuss the ASB complaint. The health visitor noted on the 15.08.13 that Sarah’s weight was static from the last recording and that Emma’s had dropped a centile. There was still no dental appointment. No-one attended the multi-agency meeting of the 21.08.13. The CSC supervision session of the 23.08.13 noted that the children were progressing well with mother parenting well. 108. Lisa was seen by the ASB team (Police Community Safety Officer/Coast and Country tenant adviser) on the 06.09.13 to discuss the complaints. The presence of the children was noted. Lisa stated that she and Tom were no longer seeing each other so there would be no further issues of domestic violence. There was no liaison with CSC regarding this visit. A warning letter was issued by the ASB team on the 09.09.13 and the case closed. 109. A multi-agency meeting was held on the 10.09.13 when the children were reported to be with Tom whilst Lisa attended. It was noted that Emma had recently fallen down some steps and sustained bruising to her forehead and cheek. Lisa did not seek medical attention believing Emma to be alright. This was the third reported injury to Emma since April but was not followed through by CSC as a possible non-accidental injury. SW3 had spoken to Tom the previous day on a home visit whilst the Police were there regarding the ASB issue so he was in contact with the children. Lisa was arrested for possession of cannabis on the 20.09.13 and given a caution. There was no liaison with CSC regarding the children. Another ASB case was opened on Lisa and Tom on the 23.09.13 following further complaints about their alleged threatening behaviour which involved the reported crying and screaming with fear of a local five year old child. The Police received further intelligence on the 30.09.13 about Lisa and Tom’s alleged drug taking and causing anti-social behaviour. There was no intelligence sharing with CSC. 110. At a home visit on the 03.10.13 the health visitor saw both children. Emma was reported by her mother to have had some swelling and discolouration to her right eye, apparently caused by a puppy knocking her off balance and falling onto a toy. Three small scabs/spots on her cheek bone were noted. This was the fourth injury to Emma since April. No medical attention was sought. Several attempts were made by the Children’s Centre to contact Lisa in early October to see if Emma wanted to start at crèche. Lisa agreed on the 10.10.13 to Emma starting crèche on the following Wednesday. SW3 saw the children on the same day on an unannounced visit and noted no concerns. 24 111. On the 19.10.13 Emma was taken by ambulance to hospital (H1) with burns to her left hand, thigh and unexplained bruising. Emma and Sarah were taken into Police protection. Lisa and Tom were arrested and interviewed by the Police about the injuries. A criminal investigation was started. Care proceedings were started on the 22.10.13 regarding the children who were placed in foster care. ANALYSIS 112. This section of the Report seeks to address the four terms of reference. It is informed by the SCR Panel’s examination of agencies’ Individual Management Reviews and the findings of the learning event which considered the five key practice episodes. Term of Reference 1 How effective were the child protection plan and reviewing process in safeguarding Emma and promoting her welfare? 113. Emma and her sister were appropriately identified at the Initial Child Protection Conference (ICPC) as being at risk of likely significant harm and properly made the subjects of child protection plans under the Neglect category. The reasons identified for doing so were around their mother’s lifestyle and the attendant dangers to and impact on the children. Specific risk factors included allowing the home to be used by large numbers of young people for a party type lifestyle; the misuse of drugs, particularly cannabis; concerns around the children’s health needs being neglected, parental conflict and previous domestic violence. Emma’s mother had not been willing to accept the professionals’ concerns and dangers posed to her children and had not previously engaged with agencies to mitigate them. Indeed, she did not agree with the decision for child protection plans and denied that she had neglected them. 114. The evidence of this Review suggests that Emma and her sister did not suffer any actual significant harm whilst subject to their child protection plans (CPP) from January 2012 to their ending in May 2013. Moreover, their physical growth and development were noted by the core group and subsequent Child Protection Review Conferences (CPRC) to be satisfactory and within the normal limits for young children. From this limited perspective the child protection plans thus seemed to have prevented any significant harm befalling Emma and her sister. 115. The detailed CPP of January 2012 was in principle of good quality in content. It accurately identified the children’s needs and risks and set out an appropriate range of child focused outcomes and services aimed at reducing the risks and meeting their needs. The outcomes could have been more specific by way of being SMART6. The core group’s membership was appropriate in the early stages of the CP Plan, although the later non-attendance of the Coast and Country representative was not helpful. There was a clear contingency measure, namely that, 6 Specific, Measurable, Achievable, Realistic and Timely (SMART). 25 ‘Should the protection plan not be followed or should Emma be placed at risk of further significant harm, then the local authority to take immediate legal advice’. 116. However, it was in the Plan’s implementation that problems very quickly arose with difficulties emerging from the beginning. These were due principally to Lisa’s denial of concerns about her parenting and its impact on her children; her resulting lack of commitment to the plan and reluctance to engage with the core group of professionals. Her behaviour was part of a pattern. She had a previous known record of not engaging with agencies as evidenced by her breach of the referral order with the Youth Offending Service and lack of involvement with the Child in Need plans of 2011. 117. Albeit, there was no evidence that she had been asked to agree to the CP Plan and sign it, her non-cooperation resulted at an early stage in many of its key objectives not being met. These included, stopping unknown males from being in her home, taking the children to important health appointments, completion of the Mellow Parenting course, ensuring her children’s consistent attendance at the nursery and avoidance of professionals at scheduled contacts. Such important omissions compromised the safety and welfare of Emma and her sister and limited the effectiveness of the child protection plan in optimally promoting their wellbeing. Lisa’s non-co-operation should have triggered an early discussion with her about the stated contingency measures of the CP Plan. 118. By the first CPRC in late March 2012, it had become evident that the CP plan was not being fully and effectively progressed, due in large part to Lisa’s unwillingness to co-operate with it. To be sure, the Review Conference noted some ‘positive progress in the care of (the girls)’. The health visitor’s report stated that the children had a positive relationship with their mother and that Emma was a ‘happy sociable baby who was growing appropriately and reaching her developmental milestones’. However, concerns remained about the continued conflict in the parental relationship and the impact of this on the attempts at sharing the care of their children, missed health appointments and support for Lisa. In short, minimal progress had been made with implementing the CP Plan. All of the numerous outcomes and children’s needs were noted as only partially achieved or unachieved; the exception being the Police and CSC knowing of the addresses where the children were staying. The contingency measures had not changed. The Housing agency representative had given her apologies for absence. 119. Lisa’s non-engagement continued through April and May 2012 with missed health appointments for the children and unsuccessful home visits by professionals. She and the girls had been staying with her mother since late April and there had been an incident of violence reported to the Police that involved the maternal grandmother and a neighbour which was witnessed by the children. Moreover, Lee had been involved in a serious domestic violence incident in May with his (then) current partner. This had implications for Emma and her sister’s safety and wellbeing given they were having regular contact with their father. 120. By mid-May it had become clear that the child protection plans for Emma and her sister were not achieving their purpose of safeguarding them from likely (future) significant harm and promoting their welfare. Lisa’s continuing non-compliance with the Plan and the deteriorating situation prompted a legal review at the end of May which recommended to CSC that the Public Law Outline (PLO)/pre-proceedings process be started. SW1 and her 26 manager (SWTM2) chose not to pursue this option on the grounds that the aggression was on the part of the maternal grandmother and not Lisa. It may be asked, why were Lisa and the children allowed to live with their maternal grandmother, given the concerns around her and the lack of any robust risk assessment? Lee was also allowed to resume contact with the girls on the somewhat questionable basis that his partner declined to make a complaint against him regarding the recent alleged violent incident. An additional new and unknown factor was the presence from late May 2012 of Tom (Lisa’s new boyfriend/partner) in the household where he was taking on a caring role for the children. 121. A key objective of the CP Plan stipulated the need for an adult who was to be considered as a potential carer for the children to be assessed as safe to do so. There was no evidence that either the maternal grandmother, Lee or Tom had been effectively risk assessed in relation to any possible dangers they may have presented to Emma and her sister. Self-evidently they should have been as per the CP Plan and reflected the poor standard of social work, management oversight and supervision in this case during this period. 122. CSC’s decision not to start the PLO process at the end of May 2012 was, in the lead reviewer’s opinion, a missed opportunity to take control of the Plan and encourage Lisa to focus on engaging with it in the interests of her children. The evidence of Lisa’s previous history (and her mother’s own hostility towards CSC due to her children being placed with their father in 2010) of non-engagement with agencies should have indicated to CSC that a more robust and authoritative approach was needed to get the CP Plan back on track and protect the children. 123. The CP Plan continued to drift during June and July with little or no progress being made and Lisa’s continuing intransigence. Further worrying reports of arguments in the street between Lisa and Tom, more incidents involving Lee’s violence towards his partner, unsuccessful attempts at home visits by SW1, reports of cannabis use by Lisa, bruises to her arm and a mark on Sarah’s lip, added to the increased sense of risk to the children. 124. The legal meeting of the 09.08.12, assessed that the Section 31 (Children Act 1989) threshold for significant harm was met and recommended in writing (letter dated 10.08.12) that CSC should issue care proceedings immediately, without recourse to the PLO process. The social worker and her team manager instructed the legal adviser to start care proceedings immediately. There was no consultation with or agreement by the Service Manager about starting care proceedings, which given the seriousness of such a step, would have been expected to have happened. It is not known why this did not occur and would seem to be have been a key gap in the CSC’s ‘gatekeeping’ and accountability processes around decision making regarding children entering the care system. An important, albeit obvious, piece of learning from this episode is the requirement for senior management to have an input into decision making around starting care proceedings and the PLO process. 125. The minutes of the second CPRC of the 15.08.12, (which was inquorate), do not record any mention or discussion of the legal recommendation or that the Section 31 ‘significant harm’ threshold had been met. However, the minutes of the meeting records that there was a local authority legal representative in attendance. According to evidence provided to the Panel by CSC (feedback from the first draft overview report meeting of the 28th October) the conference chair did ask about the legal position. The legal representative advised the 27 conference that a legal meeting had been held and that the legal view was that the threshold for court intervention was available. The conference was advised that a further legal meeting would be arranged to formulate a plan. 126. The CPRC did not consider the risk implications to the children of the argument between Tom and Lisa, Tom’s presence in the home or the bruising and marks to Lisa and Sarah respectively. The core assessment was still outstanding. None of the identified needs of the children or the safeguarding actions of the CP Plan had been met or achieved (or even partially achieved). The evidence was clear that the CP Plan had made minimal progress since its inception in January 2012 and was not effective in safeguarding the children from likely, future significant harm or promoting their welfare. The Conference Chair should have promoted a discussion and had it noted that that the local authority was considering legal proceedings as per the stated contingency measure. The logic of the situation indicated that the CP Plan’s continuation needed to be considered at that point in mid-August, in favour of care proceedings, or at least a robust PLO process. SW1 was tasked with contacting the Coast and Country core group member within one week as there had been no attendance from them since March. 127. The rationale for CSC’s decision (SW1, SWTM2 and ADSW), taken at the meeting of the 17.08.12 with a legal adviser, not to start care proceedings is not entirely apparent, given the very clear written legal advice of the 10.08.12 and CSC’s instruction to initiate them. The legal record (given to the lead reviewer) of the later meeting (17.08.12) does not reference the earlier legal advice of the 9/10.08.12. Indeed, the ADSW has stated (in a communication to the lead reviewer) that she was unaware of it. This begs the question as to why she was not told about it by TMSW2 and SW1. The legal note of the 17.08.12 meeting references some criticism of SW1 and her failure to ‘adequately visit or work with this family’. Again, there are no CSC case records of the meeting which, in itself is concerning. ADSW, in her communication to the lead reviewer, states that SW1 was challenged about what she had done to support the family in meeting the tasks within the plan. It was evident to ADSW that SW1 had done insufficient work with the family. 128. The meeting came to the view that SW1 had not given Lisa the opportunity, advice and encouragement to make improvements. On this basis a decision was made to provide a tight, time limited, seven day support package. It was intended for the local authority to be able to demonstrate the support provided to enable mum to engage with services, as at that point it was evident the plan was not progressing. It was not established as an alternative to initiating services. According to CSC, the meeting that initiated the 7 day support package was agreed at the moment in time when the Service Manager was alerted to the ineffective social work practice of SW1. The support provided was implemented immediately within the 7 days in order to establish the immediate risk; to ascertain whether there was enough evidence to remove the children; and ensure all support services had been made available to engage the family. 129. This was to be Lisa’s, ‘last chance’, (given the previous legal advice in May 2012 for the use of PLO proceedings), to show she could co-operate with CSC and the core group prior to the local authority invoking care proceedings. SW3 was allocated as the key social worker in early September. 28 130. The threat of potential legal proceedings resulted in Lisa’s short term co-operation with CSC and the CP Plan. The follow up legal meeting at the end of August decided not to issue the ‘letter before proceedings’. However, Lisa was not able to sustain the changes made in late August and September. By October, with the pressure of possible legal proceedings off her, she had reverted back to her ‘default’ position of non-cooperation and non-engagement. In the lead reviewer’s opinion there should have been a longer ‘pre-proceedings’ period of say three months, rather than one week to test out whether Lisa could keep to the CP Plan. 131. Given her record of previous non-cooperation with agencies it should have come as no surprise that she was unable to sustain the short lived changes made. In the lead reviewer’s opinion, and that of the CSC IMR author, a significant opportunity was missed by the local authority in August to secure the safety and wellbeing of Emma and her sister. Care proceedings should have been started following the legal advice of the 9/10 August; or, at least an insistence on a longer pre-proceedings period to test out Lisa’s insight and willingness to engage with the CP Plan in the interests of her children. It is of concern that there were no case recordings setting out the rationale for decision making regarding this key practice episode. Moreover, inter-agency communication on this important matter seems to have been poor as there was no evidence that other members of the core group or the CPRC Chair were apprised of the situation regarding the legal considerations after the meeting of the 17.08.12. 132. Key learning points from this episode are that, firstly, all legal and case work decisions and their rationales need to be recorded, in line with existing agency policy and practice. This includes setting out the reasons for CSC not following legal advice when care proceedings are proposed. Secondly, senior management, core groups and Conference Chairs need to be told of significant developments which need to be recorded. Thirdly, pre-proceedings planning needs to be over a reasonable period of more than one week in order for families to show that change is sustainable. Fourthly, PLO plans need to have clarity regarding outcomes, actions and milestones that families need to achieve as part of these proceedings. Finally, PLO planning needs to be consistent with existing Child Protection Planning. 133. Lisa continued not to co-operate with the CP Plan for the remainder of 2012 (October to end of December), failing to attend core groups, not presenting the children for important health appointments, sporadic attendance at the ‘Mellow Parenting’ programme and involvement with the ASB team. The implications of Tom’s presence in the home had still not been assessed, despite police checks of the previous August indicating that he had five recorded violent incidents to his name, and reports of conflict with Lisa. Lee’s known violence against his partner and involvement with the MARAC, in the local authority area where he resided, had not been assessed. The core assessment was still outstanding. These issues will be explored in the next Term of Reference. 134. Neither parent attended the Child Protection Review Conference of the 15.01.13 with no apologies given. SW3, the health visitor and a worker from the local Sure Start programme were present, with reports provided by the Police and the GP. There was no representative from Coast and Country. Emma and her sister were noted to be sociable children who were doing well with their growth and development. Despite not completing the ‘ Mellow Parenting’ course and sporadic attendance, Lisa was described by the Sure Start 29 worker as being the best parent in the group who always interacted with her daughters and responded, ‘lovely’ to them. SW3 agreed with the observation. Somewhat in contradiction it was also noted that Lisa had missed too much of the course to benefit from it. The Conference Chair said that she wanted Lisa to start another parenting course as part of the Plan and also attend all future core groups. 135. However, notwithstanding the positive observations it was still the case that Lisa had not co-operated with many of the outstanding actions of the Child Protection Plan and practically all of the outcomes of the Plan remained unachieved. Tom, who had been Police checked still remained unassessed regarding any potential risk to the children. He was known to be having a significant amount of contact with them. One of the actions was to include him in the written agreement. To be sure, the Conference was concerned about Lee and his involvement with the MARAC and resolved to follow this up. Contact between the children, their father and paternal grandmother was to halt pending an assessment. 136. The overall Conference view was that although some positives had been noted regarding the children’s growth and development concerns remained. It was too early to stop the CP Plan as professionals felt that Lisa would not be able to sustain the changes and would revert back to type without it. The Chair suggested that Lisa still needed to complete outstanding work and therefore the CP Plan needed to continue but with a shorter review period of 3-4 months. The proposal was agreed by the Conference. 137. Given Lisa’s continued lack of engagement to the CP Plan, evidenced by her non-attendance at the CPRC and the large number of unachieved outcomes noted by the Conference Chair, there seemed to be little logic in shortening the review period. Arguably, it should have been kept to the usual six months to see if she could have kept to the Plan and maintained the changes. The spate of minor injuries, neglect of medical needs and sporadic engagement with the nursery and parenting course were not given due consideration. Moreover, Tom’s presence was still not assessed. The focus was predominantly on the risk from Lee. It seemed as though Lisa’s consistent attrition tactic of non, or at best, selective co-operation had worn down the core group and wrested control away from it in relation to the implementation of the CP Plan. However, by this time CSC and the core group had effectively run out of options in trying to elicit Lisa’s engagement and keep control of the CP Plan. There was no evidence identified by conference members at this time that Emma and her sister had suffered significant harm, indeed, they were reportedly thriving in terms of their growth and development. The Conference seemed to have become subject to the ‘Rule of Optimism’ (a common phenomenon in cases involving intransigent families) where greater emphasis was given to weighing up the positives against the negatives. The ‘threat’ of using the PLO/ Care proceedings route was therefore not a realistic option, at this point in the case, for CSC and the core group. 138. Lisa’s head laceration (‘fell on a pint glass and cut her head’) in late February and the scratches to Emma’s head the week before were not followed up by CSC and the health visitor; albeit, there was no communication between the GP/hospital and the core group regarding the injury to Lisa. The children were not taken to the crèche in March and April as per the CP Plan. Lisa did not attend any new parenting group as stipulated by the Chair of the recent CPRC and health appointments were missed. The CP Plan continued to be ignored by Lisa although Lee did obtain supervised contact with his children once a fortnight 30 under local authority auspices. Emma’s growth and development were eventually noted in mid-April as being satisfactory but the marks and bruising to her shoulder, neck and right underarm (said to have been caused by falling off a trampoline-at the age of 17 months) were not followed up as a possible child protection concern. Tom’s risk potential remained unknown to CSC and the core group. None of these issues were discussed at the fifteenth core group of the 23.04.13 which was not attended by Lisa, despite being asked to. 139. The final Child Protection Review Conference met on the 22.05.13 and decided to discontinue the Child Protection Plans for Emma and her sister. The rationale for doing so was that the children no longer met the criteria for being at risk of significant harm in so far as the original concerns around Lisa’s lifestyle were far less. Arguably, the decision to discontinue the plans was, to an extent understandable, within the narrow rationale of the original risk factors having lessened, the positive reports of the children’s growth and development, and both of them doing well in their mother’s care with significant improvements having been made; albeit that Lisa had not attended all of the core groups or the parenting class as previously insisted upon by the Conference Chair. 140. However, in the view of the Overview Panel and the lead reviewer, the decision was flawed. This was because there were two key risks that remained to be assessed, namely, the impact of Tom’s presence in the household and its implications for the children. Secondly, the matter of Lee’s violence towards his partner and the conditions for safe contact. Both matters had been outstanding for some-time and were important elements of the Child Protection Plans. They should have been completed by SW3 and signed off by her manager prior to the Child Protection Review Conference. Moreover, the Conference Chair should have insisted on both items being completed before agreeing to the CP Plans being discontinued. 141. Had these been done and no new significant risks been identified then it would have been valid to have discontinued the CP Plans, albeit that Lisa had not effectively engaged with the core group and CSC. Lisa was not likely to co-operate with a further period of her children being on child protection plans so no future value would have come from prolonging them. Moreover, the option of starting the PLO/care proceedings process - on the assumption that neither Tom nor Lee presented any risks - would not have been a realistic proposition as there was little evidence to suggest that the children had suffered or were likely to suffer significant harm. The Child Protection Plan was ‘stepped down’ to a Child in Need plan to run for six months. 142. The key lesson from this practice episode is for Conference Chairs, core groups and managers to ensure that all actions assigned to professionals; especially assessments, have been completed before Child Protection Plans are considered for dis-continuation. 31 Term of Reference 2 How well did agencies engage with individual members of the family including the extended family and significant others? 143. A key issue in this Serious Case Review was Lisa’s lack of engagement and non-compliance with agencies which runs right through the time period under examination. From the start in 2010 she refused to comply with the Referral Order and did not co-operate with the Youth Offending Service in its implementation. The Service was eventually required to breach her in late 2010 resulting in a conditional discharge in early 2011, after the birth of Sarah. 144. The midwifery service only learnt of her first pregnancy at 16 weeks and quickly became concerned at the number of missed ante-natal visits; necessitating the prospect of informing CSC of their concerns, which, in the event was not needed. 145. Redcar CSC’s involvement with Lisa and the new baby, Sarah, in early January 2011 resulted in a core assessment being undertaken and both mother and baby going to stay with the paternal grandmother and the father. The evidence suggests that there was a relatively effective level of engagement between the social workers, Lisa, Lee and the paternal grandmother during the assessment phase. However, as was to become the dominant pattern later in the case, Lisa, on moving into her own accommodation with Lee in February, quickly became dis-engaged with CSC and other professionals such as the health visitor. The resultant Child in Need multi-agency plan was, by April 2011, not being adhered to by Lisa and concerns arose around Sarah’s welfare in respect of missed specialist hospital appointments and health visiting checks. 146. Like Lisa, her own mother proved to be difficult for professionals to engage, possibly due to her reported dislike of CSC whom she seemed to associate with the removal of her two other children and their placement with their father. To be sure, the maternal grandmother in her conversation with the lead reviewer did acknowledge that on occasions she might have been perceived by CSC staff as aggressive when responding to emotional situations. Whilst not wanting to minimise the potential challenges and complexities for professionals working in the safeguarding arena, the lead reviewer had some sympathies with the maternal grandmother’s view for grandparent involvement in the child protection process and for professionals to be mindful of setting up barriers to partnership working with significant adults in the lives of children, through their labelling as ‘aggressive’. 147. Following the knowledge of Lisa’s second pregnancy in mid-2011, a pre-birth assessment was started, partly in response to the child protection referral from the midwife in July 2011. This took place concurrently with the on-going work around the faltering Child in Need plan. The mounting concerns from professionals during the remainder of 2011 met with a denial of any problems with her childcare from Lisa and her mother. No supportive work around childcare and parenting was able to be undertaken by the multi-agency group of CSC, the health visitor, midwife and the Children’s Centre. The lack of Lisa’s engagement and the mounting risks to Sarah and the unborn child steered CSC and the other professionals down the track of starting the formal child protection process. This eventually resulted in Emma and Sarah becoming the subjects of Child Protection Plans in January 2012. 32 148. The evidence thus suggests that prior to the start of the Child Protection Plans in January 2012, CSC and the other involved professionals did try and engage with Lisa in the interests of herself and her children through a Child in Need approach, but with only limited success. Lee was able to be engaged by CSC and had already been involved with the Adult mental health services, his GP and the Police. Likewise, his mother was co-operative with the CSC and was an important source of support and care to the children. 149. The previous Term of Reference (1) has already dealt extensively with the difficulties encountered by CSC and the core group in trying to engage Lisa and her mother in the CP Plan. As was previously mentioned there should have been a more authoritative and robust case work approach by CSC and the core group in ensuring that the CP Plan was implemented and that the professional network retained control over events in the interests of the children’s safety and wellbeing. 150. Engaging Lee and his mother did not prove to be a problem for the core group. They were frequent attenders at core groups and CPR Conferences and were relatively open and honest in their dealings with professionals. Indeed, as commented upon by these two individuals in their conversation with the lead reviewer, for the most part they felt marginalised and not listened to by key professionals in the safeguarding process. As noted, they would have welcomed involvement in the assessments which could also have afforded them a voice in the proceedings and a sense of having been listened to. 151 In the event the key issues were the lack of a timely risk assessment of Lee’s propensity to violence on his partner and others, his mental health and their implications for the safety and wellbeing of Emma and Sarah during contact. 152. None of the core group agencies engaged with or purposefully sought to involve Tom in the child protection process despite the professional awareness that he had been part of Lisa’s household since mid-2012. In the words of the South Tees Hospital NHS Foundation Trust IMR author, Tom had become an ‘invisible’ male to the core group. Police checks and other intelligence showed that Tom had come to that agency’s notice on ten occasions. Tom had issues with alcohol and drugs, was involved in several incidents of domestic violence with his father and had previous matters of concern. Given that the children were on CP Plans this information should have been shared with CSC and the core group. As stated elsewhere, CSC should have completed a risk assessment of Tom in relation to the children’s safety and wellbeing as per the CP Plan. This was not done. Term of Reference 3 To what extent did agencies understand the risks presented to Emma in respect of the violent behaviour of the individual members of the family and significant others? 153 Lisa was never seen by professionals as a physical threat to her children, albeit she did have a record of violence towards her grandmother that never seemed to have been explored in any of the assessments. She was known by the Anti-Social Behaviour agencies (Coast and Country, Police PCSO) to have been intimidating on occasions to neighbours, particularly in the months leading up to Emma’s injuries in October 2013. However, the links 33 with the children were not made by these agencies and intelligence was not shared with CSC regarding possible safeguarding issues. A key issue not sufficiently professionally understood was the degree of domestic violence and abuse inflicted on Lisa from her partners, Lee and Tom (and latterly her father in August 2013) and its impact on Emma and Sarah’s emotional health and development. Lisa seemed to minimise the violence meted out on her which was mirrored by the lack of professional curiosity and follow up when incidents became known about. 154. CSC took appropriate protective action immediately after the birth of Sarah in January 2011 by not allowing her and Lisa to be discharged into the care of the maternal grandmother. The ensuing assessment by the student social worker correctly identified the maternal grandmother as not being a suitable person to care for Lisa and Sarah. However, there was little evidence to show that CSC had effectively assessed Margaret’s (the maternal grandmother) level of physical threat to the children, especially after the threatening incident with the neighbour in May 2012 which was witnessed by them. Nor was the potential impact of such violence on the children’s emotional health and development really understood. 155. The extent of the risks presented by Lee to both Lisa and the children were not sufficiently assessed and understood by agencies. The violent outburst at his mother’s house at the end of January 2011, soon after Sarah’s birth was not risk assessed by CSC. The Crisis Team had described him as, ‘ can be a very dangerous young man’ and a community forensic report of January 2010 had recorded that there were potential risks to his siblings, from a situational context, were he to live in the family home. Whilst passing on the latter information to CSC, the former was not shared with CSC. Likewise with Lee’s GP who had knowledge of his propensity to violence and his mental health record. Neither the TEWV nor the GP made any links between Lee’s behaviour and the implications for Emma and Sarah. In short, they did not ‘Think family, think child’. 156. The incident of late January 2011 resulted in the core assessment of March 2011 recommending that Lee, Lisa and Sarah should remain as a family unit but with support from appropriate services. In the opinion of the lead reviewer, this incident should have triggered a section 47 child protection enquiry into the potential threat from Lee to Lisa and Sarah. The assessment was undertaken by a student social worker who was supervised by a practice teacher and team manager. The assessment outcome raises questions about the quality of the supervision and managerial oversight of the student. 157. Lee was involved in further incidents of violence to his new partner, other adults and police officers following the breakup of the relationship with Lisa in April 2011. CSC made a correct decision not to allow Lee contact with Sarah and Emma pending a risk assessment. Because Pamela declined to make a complaint and denied any domestic violence, a decision was made by CSC to allow Lee to resume unsupervised contact with the girls. This was a very naïve and flawed decision that was not based upon a rigorous risk assessment and failed to determine the extent of Lee’s potential threat to his daughters during contact. 158. Thereafter, although Lee was open with CSC and the core group and certainly showed an interest and commitment to his children, he was not risk assessed for contact or the impact of the volatile relationship with Lisa, as set out in the CP Plans. 34 159. Previous mention has been made of the ‘invisibility/marginality’ of Tom who was not risk assessed despite reports of domestic abuse between him and Lisa, injuries with unconvincing explanations to her in February 2013 (the head laceration), four sets of injuries to Emma between April to October 2013 and a Police record of violence. There were also suggestions of cannabis misuse by him and Lisa that, the children may have been exposed to. The later care proceedings on the children and subsequent judgement (March 2014) found that Emma suffered significant harm whilst in her mother’s care. In addition, both Lisa and Tom (see paragraph 74 of the judgement) ‘had the opportunity to cause the injuries’ and that both adults failed to protect her (paragraph 75). CSC and the core group never had an understanding of Tom’s potential for violence against Lisa or the children, the potential impact of domestic abuse on Emma and her sister or an appreciation of them being exposed to possible substance abuse. 160. This case contained elements of the ‘Toxic trio’ (Ofsted; 2010) of domestic abuse, substance misuse and adult mental ill health; the interaction of which, could have significantly increased the level of risks to the children. There was no evidence that the professionals made this link in their assessments, thereby leading to an under appreciation of the potential risks of harm to the children. Term of Reference 4 Was the work in this case consistent with each organisation’s and the LSCB policy and procedures for safeguarding and promoting the welfare of children and with wider professional standards? Children’s Social Care 161. There were several instances where this agency’s practice was not consistent with existing LSCB policy and procedures. The first of these concerned the incident when Lee was violent in front of Sarah, Lisa and his siblings, at his mother’s house in late January 2011. He had reported to the Crisis and Home Resolution Team (CHRT) of hitting Lisa and pushing his mother during the incident. The case had just been allocated to a student social worker (overseen by a practice supervisor and team manager) to undertake a core assessment. This was completed in early March and concluded that a further period of support was needed because of the parent’s untested ability to care for Sarah independently. The parents and the baby were intending to move into their own accommodation in late February. In the lead reviewer’s opinion the assessment significantly under-estimated the risks to both Sarah and her mother from Lee’s violence. 162. This episode also raised questions about the efficacy or otherwise, of using student social workers to undertake complex child protection assessments. Whilst important for social work students to be able to partake in assessment work, it would seem more appropriate for them to undertake such work jointly and directly with an experienced social worker, rather than on their own, albeit under the supervision of a practice supervisor and team manager as in this instance. 163. Albeit mindful of hindsight bias, a strong case can be made that child protection action informed by a strategy discussion and a Section 47 enquiry should have been started in 35 early February. Such measures would have been warranted given the incident itself, the previous known record of violence of both parents, the father’s mental health background (with the Early Intervention Team), his alcohol misuse and his identified risk to professionals; he was subject to a ‘lone worker’ risk assessment. Further concerns should have been evident from the provision of the forensic services psychiatric report of January 2010 to SW9. Crucially, this had identified that he was a risk to children, albeit, indirectly; but posed a potential concern in the event of any volatility in the environment. The report had indicated that there was a need for a discussion with CSC should he move in to a family household where his siblings were present. This did not take place. 164. The absence of child protection action in February 2011 raises questions about the quality of supervision and management decision making. The decision not to proceed to child protection measures did not safeguard Sarah and was not consistent with CSC or LSCB safeguarding standards. 165. As pointed out by the CSC IMR, the completion of Emma’s pre-birth assessment in October 2011 was some four weeks late. It was limited in an understanding of the risks to Sarah and the unborn child due to Lisa’s refusal to engage, which in itself was a risk. It should have been started much earlier given the mounting multi-professional concerns for both children, Lee’s grievous bodily harm charge in July and Lisa’s disclosure of being pregnant in April. The ensuing strategy meeting and section 47 enquiry of October did not proceed to an Initial Child Protection Conference (ICPC) despite the conclusion of ‘Significant concerns’. CSC decided to continue with the Child in Need plan to give Lisa, ‘one last chance’. 166. In the lead reviewer’s opinion, this decision was overly adult focused and not sufficiently child centred; and did not sufficiently consider the impact of the (limited) known risks on Sarah and the unborn child. There should have been an ICPC in October which, amongst other things, could have made a co-ordinated post birth discharge plan for Emma. This omission and the late start on the limited pre-birth assessment did not safeguard and promote Emma’s wellbeing. 167. Neither Emma nor Sarah were ever seen by the social workers (SW1 and SW3) on their own or engaged with in play activity to get a sense of what they were like when not in the presence of their mother. Encounters with Lisa and the children tended to be descriptive and lacked analysis. Thus, there was little evidence of analysis by the workers on how well, or otherwise, the parents were working with the child protection plan and the implications for the children. 168. Clearly, there should have been some observations of the children undertaken without their mother present, perhaps whilst at the nursery and in conjunction with one of the early years workers. There should also have been more analysis on the impact of the adults’ behaviour on the longer term health and development of the children. This should have been picked up in management supervision. 169. There was no case work supervision recording by the team manager between late April and late August 2013 which breached agency and LSCB practice standards. This raises questions about the quality of case management oversight during the significant period 36 leading up to the serious harm caused to Emma in October 2013. For most of this time Emma and her sister had been subject to an ineffective Child in Need Plan. Tees, Esk and Wear Valleys NHS Foundation Trust 170. The agency had no direct involvement with Lisa or the two children. It was involved with Lee by way of a forensic assessment in January 2010 following concerns from his mother and a referral from his GP. As already mentioned, Lee was assessed as posing an indirect risk to children. A referral to CSC would be needed in the event that he moved into living with either parent and their younger children. The referral was closed in May 2010 as there was no role for the forensic team. There was no evidence of any follow up or sharing of the forensic assessment at the time with CSC to check whether he was in a household with children, albeit the report was sent to SW9 in February to assist with the core assessment. Whilst current expected practice would be to share information, this does not appear to be consistent with either the Trust or the LSCB’s safeguarding policies and procedures at that time. 171. During the relevant time frame, Lee was seen by the Criminal Justice Liaison Team (CJLT) twice and once respectively by the crisis team and access team. On none of these occasions was any consideration given to assessing the potential impact of Lee’s behaviour and mental state on Emma and Sarah, or on the child of his later partner, Pam. As the Trust IMR says, ‘there was limited understanding by Trust staff in adult mental health services of the need to be aware of and share information about the needs and risks to children – living with or in contact with parents/carers’. South Tees Hospital NHS Foundation Trust 172. The relevant services from this agency that had contact with the two children, their parents and Tom, were community midwifery and health visiting. By and large the service standards and safeguarding practice of the two services were consistent with the Foundation Trust’s own policies and that of the LSCB, albeit there were some instances of sub-optimal practice detailed below. Good practice was shown by the midwife (CM1) in making a child protection referral to CSC in early July 2011, (at week nineteen gestation, in line with procedures), because of concerns that the unborn child (Emma) might be at risk of neglect due to her mother’s non-attendance for ante-natal care appointments. 173. The agency IMR identified that it was unclear, what, if any handover of care took place between CM1 and CM2, as there was nothing recorded regarding this. Given the concerns this should have taken place either verbally or in written format. Also, HV3 did not record the details of Lisa’s new ‘boyfriend’ when told of his presence in late May 2012. HV3 could have challenged CSC in mid-July 2012 around the reports of Sarah’s top lip being red, bruises to Lisa’s arm (said to have been sustained from a Theme Park ride) and consideration of an early convening of the Review Child Protection Conference. 174. There was poor liaison between HV3 and the GP, an example being the lack of a follow up by the former when Emma was seen by the latter on the 20.05.13 for the small cut to her upper lip. Given that the child was still on a child protection plan and that this was the second injury in recent weeks, HV3 should have spoken with the GP to confirm his/her view of it being accidental in nature. Emma’s centile weight drop and Sarah’s static weight gain 37 observed by HV3 in mid-August 2013 did not raise any concerns and there was no plan to follow this up. 175. The Trust IMR opined that HV3 did not challenge Lisa sufficiently about her parenting and appeared to ‘normalise’ the neglect of the children. Lisa was seen by HV3 (and other professionals) as able to meet her children’s physical needs and to warmly interact with her ‘happy, sociable children’. However, she was deemed to have not considered their long term emotional development. NHS England Durham, Darlington and Tees Area Team 176. This agency delivered General Practice services to the children, their parents and Tom and involved three GP practices. However, as Tom was unassessed there was never a request to access his GP information to inform the assessment. Only GP practice 2 had midwifery clinics (provided by South Tees Hospital Foundation NHS Trust) run from the surgery. Child Protection Policy and Practice Guidance for GPs were circulated to practices in the Tees area in 2010 and were developed from the Royal College of General Practitioner’s guidance. However, since 2012, Safeguarding Children Procedures for all agencies have been web based and all GPs interviewed for the IMR were aware of procedures and able to access them. 177. The agency IMR analyses and identifies instances when GP safeguarding practice fell short of expectations in five key areas, these being; The recognition of adults with mental health issues and/or violent tendencies, linking them to children and considering parenting capacity and potential risks to children. This did not happen after the incident in late January 2011 when Lee became violent in his mother’s house in the presence of Lisa and Sarah. The need to ensure that relevant child protection information is effectively entered and coded onto GP clinical recording systems. Health professionals in the practice need to be aware of this and must be alerted when children are subject to child protection plans and other safeguarding measures. This was done by GP practice 3. The IMR author identified that ‘practices need to be aware of administrative factors to ensure its availability (i.e. flagging up major alerts on clinical systems such as System One) to clinicians’. Poor liaison and information sharing between GPs, health visitors, midwives and Children’s Social Care regarding Emma and her family. Only GP practice 2 held a meeting between the GP safeguarding lead, the health visitor and other health professionals, albeit this was before the birth of Emma. None was held on Emma and her sister by the other two GP practices during the timeframe in question, particularly whilst they were subject to child protection plans. The lip injury and small cheek bruise to Emma seen by GP14 on the 20.05.13 was not discussed with the health visitor and was not reported to the Child Protection Review Conference on the 22.05.13 which dis-continued the plan. Of concern was that GP14 did not reference in the consultation that Emma was on a child protection plan when seen for the injury, 38 however the GP had noted that the injury was consistent with the explanation. The IMR notes the need for GP practices to hold regular, structured multi-agency health meetings (GP, Health visitor, midwife, school nurse) facilitated by the practice safeguarding lead. The IMR also highlighted that only GP practice 2 had a practice policy (Local child protection policy and practice guidance for General Practice, November 2013). ‘Two of the General Practices involved showed a lack of thorough understanding regarding internal policies and procedures that are required to underpin good safeguarding children practice’. The IMR concluded that, ‘ having robust policies and procedures in place, which are understood and followed by all practice staff, is a corner stone of effective practice in Primary Care’), a finding that this Review wholly agrees with. Finally, the IMR found that there seemed to be a lack of understanding of the ‘pervasive and chronic nature of neglect which led to inappropriate inaction during significant consultations’, amongst some of the involved clinicians. Cleveland Police 178. Cleveland Police had no direct involvement with Emma until 19.10.13 when she was admitted to a local hospital with serious, unexplained injuries that triggered the current police investigation. A Police officer attended the Initial Child Protection Case Conference on 12.01.12 when Emma and Sarah were made the subjects of a child protection plan under the neglect category. 179. The Police and Coast and Country Housing dealt with several allegations of Anti-social behaviour episodes involving Lisa and Tom during the period in question. The Police also responded to reports of domestic abuse involving Lisa, Lee and latterly Tom. Lisa and Tom were cautioned for possession of cannabis in September 2013. Coast and Country Housing 180. Coast and Country Housing (CCH) provided housing and tenancy support to Lisa and her family and intervened on occasions in relation to reported episodes of anti-social behaviour by Lisa and others. The agency was present at the Initial Child Protection Conference in January 2012 and was a member of the core group. In addition to housing support it had a key role in providing relevant information to the Police, CSC and the core group regarding substance misuse behaviour and anti-social activity by the parents and other adults that had a potentially negative impact on Emma and Sarah. 181. The tenant adviser (TA1) attended the first three core groups between January to March 2012 and provided information relevant to the safeguarding of Emma and Sarah. However, due to staff leave there was no agency attendance at the first Child Protection Review Conference held at the end of March 2012. Moreover, no report was provided when it should have been. Apologies were sent by TA1 for her absence at the core group in late April but she did attend the fifth core group in May. Information relevant to the child protection plans was thus shared with the core group from January to the 21.05.12. 39 182. Thereafter, the link between CCH and the core group was broken and there was no further attendance at core group meetings, child protection reviews or involvement in the child protection plan. TA1 did not attend the sixth core group held on the 18.06.12 (she sent her apologies) and SW1 was asked to contact CCH. There was no evidence that she did. An invitation was received by CCH on the 06.08.12 to attend a Child Protection Review Conference (CPRC) set for the 15.08.12. 183. TA1 did not attend the CPRC despite CCH receiving the invitation; it is not known why she did not attend. The Conference Chair noted that CCH needed to be reminded of future core group dates and advised of the expectation that they attend all meetings. The social worker was to do this within one week. There was no evidence that this happened although on the 11.09.12 CCH (TA1) recorded a note to speak to SW1 but was unable to make contact with her. The date of the next CPRC was set for the 15.01.13. 184. Thereafter, TA1 was seconded to another post/service area from the 15.10.12. Her position was taken over by TA2 in September 2012. There is no evidence that a handover meeting was held although it would appear that TA2 received information on a housing application (21.09.12) that the children were on a child protection plan. 185. TA1 recalls contacting CSC (Seafield House) to inform them that any future invitations to meetings or minutes of meetings needed to be sent to the CCH district housing office for the attention of TA3. TA3 did not receive any invitations to core group meetings or case conference reviews. The Post Child Protection Plan/Child in Need Period 186. Given her non-co-operation with the child protection plans, there was very little chance of Lisa effectively co-operating with the Child in Need plan following the dis-continuation of the former on the 22.05.13. This proved to be the case. 187. She did not take Emma to the nursery in June, failed hospital and dental appointments and did not attend the multi-agency meeting on the 09.07.13 which effectively marked her dis-engagement with the Child in Need plan. 188. The Police and CCH became involved with the family between July to September 2013 regarding anti-social behaviour and reports of domestic abuse but did not pass on any information to the CSC. Attending Police Community Support Officers did not make the link between Lisa’s behaviour, possible domestic abuse with Tom and possible negative impacts on the children. CCH staff had not had any involvement with CSC since May 2012. 189. By the middle of August 2013 Sarah’s weight gain was static and Emma had dropped a centile, neither of which were picked up by professionals. The children were not attending any offered nursery provision and their progress was not being effectively monitored. No-one turned up for the multi-agency meeting of the 21.08.13. 190. The Child in Need meeting of the 10.09.13 noted the injury to Emma – the third since April - which was accepted and not followed through as a possible non-accidental injury. There were further anti-social and substance misuse episodes involving Lisa and Tom in September 2013 which were dealt with by the Police and CCH but were not shared with 40 CSC. Emma sustained a fourth injury – to her eye - in early October when no medical attention was sought or enquiries carried out. 191. Both children were seen by SW3 on the 10.10.13 who noted no concerns. Emma sustained serious non-accidental injuries and burns on or around the 19.10.13 whilst in her mother and Tom’s care. FAMILY VIEWS 192. Relevant family members were invited to give their views on the services received on the conclusion of Lisa’s trial and are set out below: (i) Father (F) and Paternal Grandmother (PGM) Summary of Main Issues Below is a summary of the relevant key issues/themes discussed in relation to the various agencies involved between mid-2010 and Oct 2013. 1. Father and Paternal Grandmother felt marginalised by agencies, particularly Social Care and were not treated as partners in the process: Throughout the period discussed both F and PGM repeatedly raised concerns and highlighted issues that they felt needed addressing by professionals however they weren’t listened to and received very poor responses. F – Raised concerns with Social Care regarding home conditions of the children, including lack of carpeting, drug use, bruising and general neglect. In respect of the allegation of drug use they were told that there was no evidence, however the house was ‘littered’ with evidence of drug taking. Both F and PGM felt that professionals were aware of this activity. PGM felt that the threshold set for the level of care was very basic. Neither F or PGM were involved in any of the assessments undertaken by Social Care. They were invited to and attended Child Protection reviews, which was the only time they had contact with other agencies. 2. Social Workers appeared to be intimidated by the children’s mother and maternal grandmother which prevented robust challenge: Both F and PGM felt that the social workers were scared of the mother and weren’t forceful or challenging enough with her. 41 They also thought that the social workers felt threatened by the maternal grandmother. 3. Workers had pre-conceived ideas of Father : Both felt that Father was marginalised due to his past, which they focussed on more than the concerns he highlighted. F felt he was not listened to by professionals until the injuries occurred. This resulted in the sole focus by agencies in terms of parental responsibility/capacity being on the children’s mother. F was not considered in assessments. Ultimately he felt that this resulted in him being denied access to his children. 4. Positive interaction has taken place with Police: Officers have been very supportive and kept both PGM and F up to date with Court etc. 5. Positive interaction with Health Visitor was highlighted. Lessons Identified Both F and PGM felt that the following lessons should be learnt by agencies: Professionals should listen more to Grandparents/Fathers and they should be included in assessments rather than focusing only on mother. They should be treated as partners in the process. Social Workers and others should be ‘on the ball’, particularly in respect of drug taking and should undertake more regular checks. (ii) The children’s mother (M) Summary of Main Issues Below is a summary of the relevant key issues/themes discussed in relation to the various agencies involved prior to Oct 2013. Health Visitor M said that the involvement from the Health Visitor throughout the period was very good and she was happy with the support she received. It was noted that the same Health Visitor was involved throughout the period. 42 Social Care M said that she had a number of social workers and admitted that she did rebel at times as she felt they were intruding. M said that they did explain why they were involved but she wanted to look after her children herself without interference. The lead reviewer asked about the child protection plan and what was expected of M as part of it. M said she found it hard and that the social worker was visiting a lot, making both expected and unexpected visits. She was not always in at the unexpected visits but did tell the social workers that if she wasn’t there she would be close by at her mothers and that they were welcome to visit her there but they declined to do so. In respect of the Child Protection Plan, M said that in addition to being expected to work with social services and the health visitor she had to take the children to the crèche. She confirmed that she did do this some days but that she had some concerns regarding one of the members of staff because her youngest daughter always seemed to have a full nappy when she went to collect her causing soreness. She did complain about this but was unsure of the outcome. M said that the reason why the children were on a child protection plan was explained to her and that it was due to her having too many different visitors to her house. She said she explained to the Chair of the meeting that it wasn’t like they thought and that she did stop them coming. The lead reviewer asked about the review meeting in respect of the Child Protection Plan and M said that at a meeting before Christmas (2012?) housing officers were in attendance and reported that there were no problems and Police also advised that they had no concerns. M met her new partner in May 2012 and he was spending a lot of time at her house. The children were taken off the Child Protection Plan in May 2013 and became Children in Need. The lead reviewer asked what had happened between May and October 2013. M advised that she saw the Social Worker a couple of times some were planned visits and others were unplanned. M said that she felt a weight had been taken off her shoulders when the child Protection Plan ended and that she felt she could be with her girls. She felt the level of support during this time was better that she was doing well and was taking the girls to the crèche. She was happier with the children being subject to Child In Need status rather than being on a Child Protection Plan. She felt that people were more ‘against’ them when they were subject to a ‘plan’ then when off it. She did not feel that the girls should have been subject to a Child Protection Plan for as long as they were, but did understand why it was necessary initially. 43 M said that the Chair at the review meeting had highlighted that M needed positive re-enforcement from professionals. A brief discussion took place regarding issues in August 2012 when Social Services were concerned regarding the care of the children and were considering care proceedings. M said she did recall this and remembered the Social Worker saying they would be removing the children but was unsure of when this was. M said that she made the changes required so this didn’t happen. M acknowledged that she sometimes struggled to get to appointments on time and did miss some appointments, particularly when her mum was without a car, but that she did look after her children. Due to some medical issues with her eldest daughter she did need to go to a lot of medical appointments which her mum supported her with when she was able. When this wasn’t possible she struggled to get to appointments on time due to issues with public transport. The lead reviewer raised the issue of concerns in relation to a number of young men being present in the house and M responded that they were helping her to decorate the house and that the children weren’t there at the time. Lessons Identified M said that lack of consistency from social workers had a negative impact. She explained that having them change so often meant that they never really got to know and understand her and the girls. This resulted in a reluctance to engage with new workers as she didn’t expect them to be around for long. (iii) Maternal Grandmother (MGM) Summary of Main Issues Below is a summary of the relevant key issues/themes discussed in relation to the various agencies involved prior to October 2013. Health Visitor MGM said that the relationship with the Health Visitor was very positive and that it was the same Health Visitor throughout the period. Social Care MGM reported that the relationship and interaction with the initial Social Worker was positive, in that she would praise and provide support to her daughter, M. MGM felt able to talk to her. She did feel that the Social Worker challenged M when appropriate but did so in a positive way. 44 MGM felt that support for M (as with all mothers) was essential. MGM advised that the relationship with social care deteriorated when there was a change in social worker. MGM did not know why the social worker was changed. She felt that the approach and attitude of the new social worker was negative and that she ‘told’ M what to do rather than discussing and working with her. MGM felt that there was no ‘direction’ or plan aimed at improving the situation and progressing it to a ‘’happy place’. The relationship between the new Social Worker was conflicting from the start and MGM did not feel that they ever formed a working relationship. MGM acknowledged that at times she might have been perceived as being aggressive when responding to such emotional situations. MGM did attend the core groups/Review Conferences to support her daughter. She said that agencies appeared to work together. Children’s Centres MGM felt that the experience with Sure Start couldn’t have been better. The staff appeared very nice and helpful and M could talk to them. Housing Interaction with housing officer in respect of ASB complaints was fine. Police MGM said that the interaction with the local police officer was very positive. Lessons Identified MGM expressed the view that grandparents such as herself should be involved more as she felt excluded from discussions and she would have contributed if given the opportunity. MGM also felt that there were ‘fixed ideas’ about her and she was labelled as aggressive, which affected relationships with professionals. CONCLUSIONS AND KEY LESSONS ToR 1 Conclusions 193. There was no evidence to suggest that Emma and her sister suffered actual significant harm whilst subject to their Child Protection Plans. The objectives and outcomes of the Plans were sound although they could have been ‘SMART’er. Lisa’s intransigence and opposition to the Plans made their implementation difficult. From this perspective, the child protection 45 plans, were to a degree, ineffective, given that the children missed out on consistently attending health appointments and Children Centre programmes which would have been to their benefit. In this sense, they did not adequately promote the children’s wellbeing. 194. There should have been a more authoritative and robust approach by CSC to case management involving the early use of the PLO/care proceedings process in line with the stated contingency plan. The optimum time for this was in August 2012 following the legal advice from the 09.08.12 meeting and agreement (but with no senior management input) to start care proceedings, bypassing the PLO process. CSC’s later decision not to proceed with this course of action was a missed opportunity to try and secure the children’s safety and wellbeing, albeit that there was no absolute certainty that a court would have agreed to care orders. 195. It would appear that the decision to initiate a short (one week) pre-proceedings option may have been influenced by the social worker’s lack of prior effective intervention with the family which, amongst other things, raises the question of management oversight and effective case supervision. There should have been a much longer period of time (say three months) for the PLO process to have run its course in order for Lisa to have shown that she was able to sustain any change over the longer term. 196. Poor (and lack of) recording was also identified as another issue, especially in regard to the lack of a clear audit trail around the rationale for decision making, especially in regard to starting care/PLO proceedings. 197. The Reviewing process correctly identified that many of the Plan’s objectives and actions consistently failed to be achieved with the needs of the children being unmet. The Assistant Director for Children and Families (People’s Services) should arrange for the development and use of a process of facilitated Complex Case Supervision for Core Groups when it is evident that there are significant difficulties in progressing The Child Protection Plan.’ The August 2012 CPRC, whilst apparently being informed of legal matters, did not record any discussion on this matter, which clearly should have happened. Thereafter, neither the core group nor the Conference Chair were kept informed by CSC of subsequent legal developments. They should have been informed by CSC of these matters which could have empowered the core group and Conference to support possible moves towards care proceedings or at least, a more robust approach to the PLO process. These could have been incorporated into the CP Plan. 198. The decision to discontinue the Child Protection Plans in May 2013 was flawed and should have been considered only after the completion of the risk assessments. Lessons 199. Child protection plans need to be SMART with clear, child focused outcomes and named individuals taking responsibility for the implementation of assigned actions. 200. Case management needs to be authoritative and robust when working with difficult to engage and non-cooperative parents/carers. Contingencies need to be clear and reverted to in a timely manner when parental non-compliance with CP Plans is encountered. 46 201. The PLO/pre-proceedings process needs to run for a reasonable time (say 2-3 months) to give parents/carers the opportunity to sustain change and demonstrate it to professionals. 202. CSC should record all legal advice and the rationale for decision making in regard to starting the PLO or care proceedings processes. All decisions regarding PLO/care proceedings should have the written approval and oversight of appropriate senior line managers (e.g. Service Managers). 203. Conference Chairs and core groups should be informed of the outcome of legal advice meetings with CSC. PLO pre-proceeding plans need to be integrated with existing Child Protection Plans and both need to be signed by parents/carers. 204. Child Protection Plans should only be discontinued if it is judged that the child is no longer continuing to, or is likely to, suffer significant harm and therefore no longer requires safeguarding by means of a child protection plan; and that all assessments have been completed. ToR 2 Conclusions 205. Child care professionals were able to engage with Lisa, Lee and his mother relatively well during the assessment period in 2011 but experienced increasing reluctance from Lisa to be involved in the Child in Need Plan. Her non-co-operation became more pronounced during the second pregnancy with Emma and minimal during the time of the Child Protection Plans of 2012/2013. Professionals failed to recognise this for what is was which contributed to the lack of authoritative practice. 206. Professional engagement with Lee was generally positive but risk assessments on the implications of his violent behaviour for the children were not completed in a timely way. 207. Tom was marginal to the core group professionals and was not engaged with. His presence in the family should have been risk assessed. 208. There was insufficient professional encouragement of Lee, his mother and arguably the maternal grandmother in their involvement in the assessment and planning processes and subsequent arrangements for the children. Lessons 209. There are three key learning points which arise from the above conclusions, namely, the difficulties of recognising and working with un-co-operative and hard to engage parents, the inclusion of males in ongoing child and family practice and the inclusion of grandparents. Regarding the first, it is understood that since March 2013 professionals in Redcar and Cleveland have been able to access guidance on working with un-cooperative families from the Tees Local Safeguarding Children Board website. Self-evidently these procedures would have been introduced towards the end of Emma’s child protection plan and would not have been available for most of it. However, this Review is keen to emphasise the importance of practitioners having a thorough knowledge of this aspect of working with families. It would 47 expect to see the topic on the RCSCB programme of professional learning and development opportunities. 210. Many previous Serious Case Reviews have identified the crucial importance of including male partners in the child protection/welfare process (e.g. the Baby P SCR 2008, Hamza Khan, 2013, Bradford SCB) and the tendency for them to remain largely ‘invisible/marginal’, as was the case with Tom. The learning here suggests that agencies in Redcar and Cleveland need to consider ways of ensuring that significant males (and others) in households where there are children about whom there are concerns, are involved in family assessments and risk analyses in a timely manner. 211. Finally, policy and practice needs to recognise the potential importance to children of including grandparents and other wider family members in the processes of case management and decision making by professionals and, when in the interests of children, actively promote such practice. ToR 3 Conclusions 212. Agencies had a poor understanding of the nature and extent of potential violence that the children were exposed to. This was both on an individual level with Lisa, Lee, Tom and the maternal grandmother and also regarding the violent interactional dynamic of the relationships between these individuals. Sarah’s aggressive behaviour noted at the Children’s Centre in November 2012 and January 2013 may have been a possible reaction to the atmosphere of violence experienced by her in the home. 213. The raised levels of potential risk to the children from the interaction of the ‘Toxic Trio’, which was not recognised by the professional network. Lessons 214. Where present, the impact of domestic abuse and violence from individuals on children and young people must always be factored in to all family/risk assessments where there are concerns that children are at risk of harm or abuse. 215. Professionals should be aware of the existence of the ‘toxic trio’ and, where appropriate, factor into all family/risk assessments their cumulative impact on children and young people. ToR 4 Children’s Social Care Conclusions 216. The assessment of February 2011 significantly underestimated the risks to Sarah and her mother from Lee’s violence. A strategy discussion and Section 47 enquiries should have been started in February 2011 and the episode was a missed opportunity to better understand the risk of harm to Sarah, and later on, Emma. 48 217. The quality of supervision and managerial decision making around this incident regarding the safeguarding of Sarah was not consistent with expected agency and RCSCB. 218. There was insufficient analysis of the impact of the parent’s behaviour on the longer term health and development of the children. 219. The children’s Child in Need plan from May to October 2013 was for the most part ineffective, due to Lisa’s continued non-cooperation. Case management oversight between May to October 2013 was below accepted agency standards. Lessons 220. No additional learning has been identified that is not already in this agency’s Individual Management Review. Tees, Esk and Wear Valleys NHS Foundation Trust Conclusions 221. The lack of timely information sharing with CSC and the absence of consideration for the children put them at potential risk of harm. Such practice was in breach of the Trust and the LSCB’s safeguarding procedures. Had the Trust been operating to the RCSCB safeguarding procedures it would have enquired whether Lee had contact with any children, identified any potential risks to them from him and proactively shared information with CSC. It should have been invited by CSC to the ICPC in January 2012. Lessons 222. The Trust reports that it has since taken action to address these deficiencies in its safeguarding practice. Training started in September 2013 on use of the Pre-Common Assessment Framework and the Procedure for Assessing and Responding to the Impact of Parental Mental Health on Children (PAMIC) tool. The Trust IMR reports that there has been a comprehensive training package disseminated to all of its services over the last year. Within the agency, ‘ there is a clear emphasis on the need for a family approach ensuring the needs of the child are considered when adults are receiving services from the Trust’. 223. The Trust reports that there has been an audit of the impact of the recent training to see if the needs of children are being considered. Positive evidence was reportedly shown both by the audit and a recent CQC inspection that children’s needs were being considered and addressed. However, this Review would suggest that the RCSCB needs to be assured that the Trust is operating safely in respect of the protection of children and is compliant with the Board’s policies and procedures. This would apply especially in regard to the recognition of child abuse and neglect, proactive and timely information sharing and referral to CSC. South Tees Hospital NHS Foundation Trust 224. It is recommended that South Tees Hospital NHS Foundation Trust work with NHS England area team to establish Safeguarding Children Multidisciplinary face to face meetings which should be held at least quarterly between General Practice and Health visitors, School Nurses and Midwives. 49 NHS England Durham, Darlington and Tees Area Team Conclusions 225. The evidence suggests that there were a lack of robust safeguarding policies and practice Guidance available in some of the GP practices involved in this IMR. In addition there were issues with regard to the communication systems between GP practices and the Local Authority Review Unit. Part of the problem at a strategic and developmental level seems to be associated with the lack of a Named GP for Safeguarding Children in the last two years and the resulting absence of Safeguarding Practice Lead meetings. Lessons 226. The IMR recommends (amongst other things) the appointment of a Named GP for Safeguarding Children by South Tees CCG and the NHS England (Durham, Darlington and Tees). This SCR is of the view that this should be progressed as a matter of urgent priority and notes that this was a recommendation from the Ofsted report of 20127 Moreover, the IMR findings and recommendations should be shared with NHS England Area Team (Durham, Darlington and Tees) and an action plan implemented without delay. NHS England Area Team should develop a system of audit relating to Primary care practice in Safeguarding children in order to provide assurance to RCSCB that Primary Care staff are contributing effectively to the safeguarding children process. Cleveland Police Conclusions 227. The evidence indicates that, for the most part, safeguarding practice by the Police was compliant with internal agency and RCSCB policies and procedures. The IMR does identify a lack of recording of information which was not compliant with expected practice. Also, there were some instances of intelligence reports regarding anti-social behaviour episodes by Lisa and Tom that did not consider the potential safeguarding implications for the children which were not acted upon sufficiently. 228. Reportedly, information by front line officers was not fully shared with specialist departments within the Police and with external agencies. The Panel identified that the potential risks to Emma and her sister from the adult’s behaviour may not have been fully understood by front line officers who dealt with instances of anti-social behaviour and Lee’s violence. There may have been a lack of awareness of the links between negative parental behaviour and the impact of this on the children. Lessons 229. These lessons have been identified in the Police IMR and are to be addressed in the action plan. 7 See Ofsted Report ( July 2012) ; Inspection of safeguarding and looked after children services; Redcar and Cleveland at page 8, ‘ Within six months….NHS Tees should recruit to the post of named GP for Redcar and Cleveland to ensure that primary care are represented at the RCSCB’. 50 Coast and Country Housing Conclusions 230. The lack of any Coast and Country involvement after the 21.05.12 detracted from the effectiveness of the child protection plans. The agency was a member of the core group and would have had useful information on the children’s welfare to impart at meetings. Whilst the social worker should have been more persistent in contacting TA1 ‘ a proactive approach could have been undertaken (by CCH) through contacting Redcar and Cleveland Children’s Services to request further meeting dates and scheduling them in relevant staff’s calendars’’. 231. Self-evidently, it is crucial that all core group agencies and their representatives understand their roles, responsibilities and importance regarding their involvement in the child protection process. In this instance there appeared to be a breakdown in communications between the core group, the key worker and CCH leading to the agencies non-attendance at core groups and Child Protection Review Conferences. The lead reviewer understands that this has been an issue with CCH in a previous SCR so it is even more imperative that action is taken to ensure that this agency maintains its consistent involvement in core groups and Child Protection Review Conferences. Lessons 232. CCH needs to ensure that it has in place effective systems and processes that provide for continuity of attendance and the provision of reports at child protection meetings when its staff are not able to attend meetings or where staff transfers occur. 233. There also needs to be an effective management process which monitors practitioner performance in regard to attendance, the provision of reports at child protection meetings and the overseeing of any emerging issues. 234. All of the above three learning points are identified in the CCH IMR and will need to be proactively and effectively implemented in a timely way. RECOMMENDATIONS 235. The following Recommendations are drawn from the conclusions and key learning points identified in the previous section. Within six months from the date of the approval of this Serious Case Review by the RCSCB the following Recommendations should be implemented by way of an action plan which will be produced and progress against this will be monitored by the RCSCB’s Learning Lessons and Improving Practice Sub Group. ToR 1 1. The Chair of RCSCB should be provided with evidence from the Assistant Director for Children and Families (People Services) that; 51 a) All Public Outline pre-proceedings, (1) Run for a minimum of two months (unless early removal is necessary due to the risks to the child) so as to give parents/carers a reasonable opportunity to achieve and sustain desired changes and demonstrate them to professionals, (2) Have SMART actions and child focused outcomes, (3) Be reviewed at timely intervals, (4) Ensure that all PLO/Pre-proceeding plans are integrated into any existing Child Protection Plans. b) Before dis-continuing a Child Protection Plan all assessments have been completed. c) Should ensure that all Child Protection Conferences (both Initial and Reviews) are fully informed of all decisions and outcomes of legal discussions held on children by the local authority. ToR 2 2. The Chair of the RCSCB should be provided with evidence from Board Members of Statutory Agencies where there are concerns about children, that they consider and engage with significant others (particularly males) in the household, where appropriate in family assessments and risk analysis. This should also include grandparents and other significant wider family members when in the interests of children. ToR 3 3. The Chair of the RCSCB should be provided with evidence that, where present, the impact of the ‘toxic trio’ (domestic abuse, adult mental health and adult substance misuse) on children and young people are included in all family and risk assessments. ToR 4 4. The Chair of RCSCB should seek evidence that the Assistant Director for Children and Families (People Services) has taken steps to be assured that the quality of first line management supervision and case work oversight of both Child Protection and Child in Need cases is consistent with agency standards. 5. The Chair of the RCSCB should seek evidence of adherence to the safeguarding practice of Tees, ESK and Wear Valley NHS Foundation Trust, particular relating to, (1) the impact of adults’ behaviour on children, (2) the timely and proactive sharing of information and appropriate referral to Children’s Social Care, is consistent with the standards of the agency and the RCSCB. 6. The NHS England Team should secure as soon as possible the employment of a named GP and it is recommended that once secured the initial priority should be on supporting practices to put in place robust internal policies and practice. 7. The NHS England Team should develop an audit programme for primary care which provides assurance to RCSCB that primary care staff are working effectively to safeguard children. 52 8. The Assistant Director for Children and Families (People Services) and the Chair of the RCSCB should seek evidence that processes are robust to ensure that Initial Child Protection Conferences, Child Protection Review Conferences and core group meetings are quorate, are held in a timely way and that appropriate agencies are invited and attend. 9. The Assistant Director for Children and Families (People Services) should arrange for the development and use of a process of facilitated Complex Case Supervision for Core Groups when it is evident that there are significant difficulties in progressing the Child Protection Plan. 53 APPENDIX 1 GLOSSARY ASB: Anti- Social Behaviour (Team) CCH: Coast and Country Housing CHRT: Crisis and Home Resolution Team CM: Community Midwife CiN: Child in Need CPRC: Child Protection Review Conference CPP: Child Protection Plan CSC: Children’s Social Care CREST: Substance Misuse Service EDT: Emergency Duty Team (Out of Hours Service) GP: General Practitioner H1: Hospital 1 H2: Hospital 2 ICPC: Initial Child Protection Conference IMR: Individual Management Review KPE: Key Practice Episode MARAC: Multi-Agency Risk Assessment Conference (Domestic Abuse) PAMIC: Parental Mental Health on Children (Tool) PCSO: Police Community Support Officer PLO: Public Law Outline RCSCB: Redcar and Cleveland Safeguarding Children Board SCR: Serious Case Review SW: Social Worker SWTM: Social Work Team Manager TA: Tenant advisor TEWV: Tees, Esk and Wear Valleys NHS Trust YOS; Youth Offending Service 54 55 APPENDIX 2 REFERENCES Anne Rawlings et al (2014): ‘Barriers to Learning from Serious Case Reviews’, Government Publication (DfE). Hill. T (2000): ‘Operations Management’, MacMillan Business Kahneman. D (2011): ‘Thinking, Fast and Slow’, Penguin Books Ofsted (2010): ‘Learning Lessons from Serious Case Reviews, 2009-2010’ (reference to the ‘Toxic Trio’) National Panel of Experts on Serious Case Reviews (2014): First Annual Report DfE (2013); ‘Working Together to Safeguard Children’ |
NC050376 | Child CA lived with both parents who had moved to Blackpool from Bolton. Both parents had a history of mental health problems, alcohol misuse and domestic violence. Mother and father had 15 children between them with no parental care for any of them before the birth of Child CA. 11 of the children had been subject to child protection procedures for neglect and emotional abuse. In April 2017, Child CA was found unresponsive in the home, and later died at hospital. The review followed the 'Welsh Model'. Learning points centred on information sharing; the application of pre-birth protocols; stronger leadership; and multi-agency arrangements to identify and support individuals and families with complex needs arriving to a new area with high levels of transience. Recommendations include: child protection assessment should be proportionate and plans should be specific, measurable, relevant and timely; frontline practitioners should receive regular and meaningful supervision; leaders should be able to demonstrate that they have a grip on cases assigned to their staff.
| Title: Serious case review: final report: Child CA. LSCB: Blackpool Safeguarding Children Board Author: Stephen Ashley Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Blackpool Safeguarding Children Board Serious Case Review FINAL REPORT Child CA Lead Reviewer: Stephen Ashley 2 Table of contents Section One – Introduction ................................................................................................ 3 1.1 What this review is about ……..……………………………………………………………...3 1.2 Why this review was conducted…………………………………………………………...3 1.3 How this review was conducted…….……………………………………………………..3 1.3.1 Methodology ......................................................................................................... 3 1.3.2 Practitioner’s Event ............................................................................................... 4 1.3.3 Family Engagement .............................................................................................. 4 1.3.4 Parallel investigations ........................................................................................... 4 1.4 How this report has been structured ........................................................................ 4 Section Two – The Story of Baby CA................................................................................. 4 2.1 Introduction ................................................................................................................ 4 2.2 The background of CA’s family ................................................................................. 4 2.3 The family move to Blackpool ................................................................................... 5 2.4 Agencies engage with the family pre-birth ............................................................... 6 2.5 The initiation of pre-birth child protection procedures ........................................... 7 2.6 The engagement of services post birth .................................................................... 7 Section Three – Analysis of Significant Issues ................................................................ 9 3.1 Introduction ................................................................................................................ 9 3.2 Significant Issues ....................................................................................................... 9 3.2.1 Significant issue one ............................................................................................. 9 3.2.2 Significant issue two……………………………………………………………………...9 3.2.3 Significant issue three ......................................................................................... 11 3.2.4 Significant issue four ........................................................................................... 14 3.2.5 Significant issue five ............................................................................................ 15 Section Four – Key Themes ............................................................................................. 17 4.1 Information sharing between professionals ........................................................... 17 4.2 The application of child protection procedures ..................................................... 17 4.3 Leadership ................................................................................................................ 18 Section Five – Key Findings ............................................................................................. 18 Section Six – Recommendations ..................................................................................... 19 Conclusion ........................................................................................................................ 19 3 Section One – Introduction 1.1 What this review is about This serious case review concerns a baby who, for the purpose of this review, is referred to as CA. CA lived in Blackpool with mother, known in this review as P1 and father, known in this review as P2. P1 and P2 moved to Blackpool in the summer of 2016. At the time of their move P1 was 4 months pregnant with CA. P1 and P2 had previously had considerable contact with Children’s Social Care in Bolton. P1 and P2 had 15 other children between them. In the case of P1 all her previous children had been the subject of child protection procedures and in the case of P2, 3 of his children and been the subject of child protection procedures and 1 had been adopted. In April 2017 CA was found unresponsive in a bedroom in P1 and P2’s flat. Attempts to resuscitate the baby were unsuccessful and the baby died at hospital. The cause of death is recorded as unascertained. A police investigation found no evidence that P1 and P2 were responsible for the baby’s death. 1.2 Why this review was conducted A case review panel was formed of professionals from Blackpool who were unconnected to the case; they followed guidance contained in Chapter 4 of Working Together 2015. They considered the facts of the case and agreed this case met the criteria laid down in Working Together 20151and Regulation 5(1) (e) and (2) of the Local Safeguarding Children Boards Regulations, for a serious case review to be conducted. The Independent Chair of Blackpool Safeguarding Children Board (LSCB) agreed and initiated this review. 1.3 How this review was conducted 1.3.1 Methodology An independent reviewer was selected to conduct the review. The panel requested that the reviewer should follow the ‘Welsh Model’ for conducting reviews.2 The reviewer, Stephen Ashley, has extensive experience in the compilation of high-level reports into child protection issues, having been a senior police officer for thirty years and having worked for Her Majesty’s Inspectorate of Constabulary. He has conducted several serious case reviews and is the independent chair of two safeguarding children boards. The lead reviewer is independent of Blackpool Safeguarding Children Board in accordance with Working Together 2015 chapter 4 (10). Relevant agencies were asked to complete timelines of their contacts with P1 and P2; these were combined in to a joint timeline. Further documents, including minutes from relevant meetings and assessments, were also obtained to form an evidence base. A number of working hypothesis were developed and these were tested against written evidence and at a practitioner’s event conducted with front line professionals. From this work, the significant 1 Working Together 2015 - Working Together March 2015 - https://www.gov.uk/government/.../working-together-to-safeguard-children 2 The ‘Welsh Model’ - This process consists of several inter-relate parts: Multi-Agency professional Forums to examine case practice, Concise Reviews in order to identify learning for future practice, and an extended review which involves an additional level of scrutiny of the work of the statutory agencies. 4 issues were agreed and analysed, from which a number of key themes emerged. The findings and recommendations were then developed. 1.3.2 Practitioner’s Event A practitioner’s event took place with front line professionals who had been engaged in the case. They discussed the working hypothesis and provide an insight into to why events occurred and not just what occurred. The practitioner’s event was well attended and provided significant detail in this case. Professionals are not named in this report. 1.3.3 Family Engagement Requests have been made by the lead reviewer to visit the parents. At the time of completion of this report the parents had not responded to this invitation. 1.3.4 Parallel investigations Lancashire Police investigated the death of CA and a report was submitted to the Coroner; as is standard practice in a case of this nature. There was no evidence that the parents were responsible for the death of the child. At the time of this report an inquest had not been held. 1.4 How this report has been structured Section two sets out the story of CA and highlights any significant issues. These issues are further analysed in section three. Section four describes the key themes and section five the key findings. The recommendations are in part six with a conclusion that is an evidence based summary of the case. Section Two – The Story of Baby CA 2.1 Introduction This section tells the story of CA and the family over the agreed period of the review. It begins with a short description of the family and their environment, providing some context around this case. The section is divided into sections relating to specific events within the timeframe. A brief description of what occurred during that period is detailed and significant issues are highlighted. 2.2 The background of CA’s family P1 and P2 moved from Bolton to Blackpool. P1 had been involved in a family dispute and had suffered domestic violence at the hands of her son. P1 had grown up in Bolton. P1 has reported how she and her siblings suffered physical and emotional abuse at the hands of her father, who is now deceased. P1’s description of her childhood is a painful one and she has talked to a social worker about the serious abuse and neglect she suffered. P1 first got pregnant when she was 16 years old and the father of the child was 31 years old. P1 had her second child by a different father when she was 19 years old. At age 20 she entered a new relationship that lasted 20 years and had 5 further children. All of these children were removed from her by social services, based on concerns 5 regarding neglect of the children and domestic abuse and alcohol misuse issues. In 2009 P1 began her relationship with P2. P1 gave birth to her eighth child that year. P2 had previously been in a long-term relationship that had resulted in the birth of 7 children. P2’s wife died in the early 1990s. P2 has described how he found it difficult to cope with his own 7 children and as a result 5 of his children lived with other family members and 3 of those were subject to a child protection plan and1 has been adopted. These children are now adults. The way in which P2 treated his children has caused a rift in his family. Following the birth of their son in 2009 there were a number of reported altercations between the couple and P1 contacted Children’s Social Care and said she could not cope. Proceedings were instituted and an interim care order in 2010 was followed by a full care order in 2011 and the child was adopted in 2012. It was established that the relationship had become unstable and despite numerous opportunities, alcohol misuse and poor parenting resulted in neglect of the child and as a consequence court proceedings followed. 2.3 The family move to Blackpool In July 2016 P1 and P2 moved from their home in Bolton to Blackpool. At this point P1 was 4 months pregnant. Children’s Social Care in Bolton received a referral from midwifery regarding the fact that P1 was pregnant and were also informed the couple had moved to Blackpool and as a result made a referral3 to Blackpool Children’s Social Care (BCSC). The move to Blackpool appears to have been motivated by a desire to move away from their family, in particular P1’s son, who had subjected P1 to domestic violence. There is little recorded action from Blackpool Children’s Social Care (BCSC), despite the history of the family, and the potentially high risk to the unborn child; including all elements of the toxic trio of parental mental health, alcohol misuse and domestic violence. The case was allocated to an inexperienced newly qualified social worker for the completion of a pre-birth assessment. The social worker was told that a legal planning meeting (LPM) should be considered. The move to Blackpool was for family related reasons but there is no family connection to Blackpool. This is not an uncommon position and there is a disproportionate level of immigration to Blackpool. Blackpool is a town with a large amount of low cost housing and is perhaps perceived as a holiday town and a place that may be suitable to make ‘a new start’. Consequently, Blackpool finds itself welcoming families from all over the country and Europe. Many of these families bring with them difficult issues that have developed over many years. Many of these families have had previous contact with agencies in the areas they had previously resided in. It is not uncommon that agencies in Blackpool should find that a family with complex issues arrives without warning and requires immediate assessment and support. Given this history of immigration, agencies should understand and be prepared to deal with these issues. 3 Referral - The referring of concerns to local authority children's social care services, where the referrer believes or suspects that a child may be a Child in Need or that a child may be suffering, or is likely to suffer, Significant Harm. Significant issue one Blackpool is a town with higher than average levels of transience. Agencies need to ensure they can deal effectively with new arrivals to the town and meet their health, safeguarding and social needs. It is the responsibility of front line professionals to acquire the historical information they need to provide the right level of service and protection to families. 6 When P1 and P2 arrived in Blackpool maternity services engaged with P1. Information was requested from Bolton midwifery and a conversation took place between the two areas. As a result, a specialist midwife was allocated to P1. Because of P1’s medical condition, care for P1 was shared by community midwifery and specialist midwifery services. Midwifery were aware that BCSC had received a referral. BCSC did not appear to have received a substantial briefing from children’s services in Bolton. This is understandable given the case was not open to them at this time and they had followed procedures by making a referral. It was late September before Blackpool social services contacted Children’s Social Care in Bolton and asked to view the files of P1 and P2. 2.4 Agencies engage with the family pre-birth At the beginning of September 2016, a referral was made by midwifery to the ‘Baby Steps’ programme4. This is a commissioned support programme managed by the NSPCC and is for pregnant mothers. This programme allocates a Family Engagement Worker (FEW) to the family. The allocated FEW was made aware of the family’s previous history and that BCSC would be able to provide further details. Numerous attempts were made by the FEW to contact P1 but contact was sporadic as either she did not attend appointments, or was not at home when the FEW attended. In September, a MARAC5 was held as part of a transfer from Greater Manchester Police and several actions agreed; including informing midwives of the previous episodes of domestic abuse by P1’s son and consideration of a Clare’s law6 application for P2. It is unclear what the motivation for this application was, given the MARAC process concerned P1’s son and there was only one reported incident between P1 and P2, when the police were called to an argument between the couple that had resulted in no further action. This application was made but no disclosures were made. It is unclear whether BCSC engaged with the Multi-Agency Risk Assessment Conference (MARAC) process and exactly what information was shared. There was no evidence of domestic abuse by P2 against P1. At the beginning of October, the social worker received supervision from a team leader. The social worker was tasked to complete a Child and Family Assessment (CAFA) and family genogram. This request had first been made at the end of August but had not been actioned. The social worker was also tasked to arrange an initial child protection conference 8 weeks prior to birth and “consider” whether a legal planning meeting was required. This followed procedures laid down in the Pan Lancashire Multi-Agency Pre-birth Protocol (2012 revised 2014). This protocol was fully updated and a new protocol was formally adopted in March 2017. In summary, there is clear evidence that P1 received a specialist midwifery service (referred to as universal plus) enabling her health risks to be considered. There is little evidence of a coordinated response and whilst midwifery services were aware of the complex needs of the family, despite receiving an early referral, Blackpool children’s services failed to engage with Bolton children’s services until September 2016 and so there was a lengthy delay in the information sharing process; either between areas or with other front line professionals. 4 ‘Baby Steps’ programme - Baby Steps is an educational programme designed to support Mums and Dads to be able to manage the emotional and physical transition into parenthood. 5 MARAC - This is a forum to assess and manage the risk of adult perpetrators of domestic abuse. 6 Clare’s Law - the Domestic Violence Disclosure Scheme (also known as ‘Clare’s Law’) commenced on 8 March 2014, across England and Wales. Under the scheme an individual can ask police to check whether a new or existing partner has a violent past. This is the ‘right to ask’. If records show that an individual may be at risk of Domestic Violence and Abuse from a partner, the police will consider disclosing the information. A disclosure can be made if it is legal, proportionate and necessary to do so. 7 2.5 The initiation of pre-birth child protection procedures Throughout the autumn, the family engagement worker continued to try and engage with the family. This had limited success and P1 continued to avoid appointments with the Baby Steps programme. An assessment7 was commenced at the beginning of August but was not completed until the end of November 2016. A strategy meeting8 was held on the 3rd November 2016 but this did not involve partners and appears to have taken place in order to comply with procedures and provide the trigger for convening an Initial Child Protection Conference9 (ICPC). In fact, the first case conference took place in mid-December the day after CA’s pre-mature birth. The Pan-Lancashire Multi-Agency Pre-birth Protocol is not referred to by any of the agencies and was not followed. Whilst legal proceedings had been discussed on several occasions, no legal planning meeting took place until nearly a month after the birth of CA. 2.6 The engagement of services post birth CA was born prematurely at Blackpool Hospital delivery suite in mid-December 2016. This should have been anticipated given records have shown that in previous pregnancies P1 had given birth pre-maturely. The following day an initial child protection conference was held. The parents were consequently not present at this initial conference and were not represented. The conference was attended by two health professionals but not a representative of the Baby Steps programme. The plan stated that a social worker visit would take place every four weeks. In fact, the first visit took place on 6th January 2017. That visit was unannounced and found that there was evidence that bottles were sterilised, but the communal area of the flat complex smelt strongly of cannabis. There was considerable support arranged by health professionals and plans for discharge were discussed with BCSC at a discharge planning meeting on 19th December. CA was discharged from hospital according to normal practice and community midwives visited P1 and CA. CA had been discharged on 20th December and was seen three times at home by 7 Assessment - Assessments are undertaken of the needs of individual children to determine what services to provide and action to take. 8 Strategy meeting - A Strategy Meeting (sometimes referred to as a Strategy Discussion) is normally held following an Assessment which indicates that a child has suffered or is likely to suffer Significant Harm. The purpose of a Strategy Meeting is to determine whether there are grounds for a Section 47 Enquiry. 9 ICPC - An Initial Child Protection Conference is normally convened at the end of a Section 47 Enquiry when the child is assessed as either having suffered Significant Harm or to be at risk of suffering ongoing significant harm. Significant issue two There was no handover package between Bolton and Blackpool social care. Support services were put in place for the family but this was not co-ordinated by agencies who failed to share appropriate information. P1 was able to avoid contact with services. Significant issue three The application of child protection procedures in the pre-birth phase was inconsistent and failed to comply with statutory guidance. Significant issue four Legal planning was considered but was not put in place quickly enough. It failed to provide the contingency that may have been required in this case. 8 health professionals prior to 6th January 2017. In that week, a health visitor visited the flat four times. Safe sleeping was discussed with P1 and it was noted the flat was very hot but there were no further concerns. On the 12th January, an emergency request was made to the Families in Need (FiN) team to provide support. This request coincided with a legal planning meeting that was conducted on that day. The legal planning meeting highlighted a number of issues around the procedures that had been adopted up to that point and requested a number of actions be undertaken by BCSC. Whilst there were no grounds for removal of CA it was considered there may be grounds for an application to the courts for a Care Order10. A week after this meeting a senior managers’ meeting took place. They acknowledged that legal proceedings should have been in place before birth and put in place very clear expectations of future activity including the Public Law Outline11 process. At this point, there was considerable activity put in place around the family. Family support workers from the Families in Need team were visiting daily. On the 16th January, a core group meeting12 took place. This meeting achieved little but it is of note that the parents complained they were being visited too frequently. Family support workers continued to undertake regular visits throughout January. At the end of January, the family were allocated a new social worker. During February, the family were visited weekly by a health visitor and at least six times by a family support worker. A number of support packages were also arranged for the family. On 14th February, a core group meeting was held. Several issues were discussed including housing issues and support packages that might be put in place. Individuals were allocated specific tasks and this meeting was an improvement on previous core group meetings. On 3rd March the first review conference took place. The relevant professionals were present or provided reports. Professionals presented a positive picture of the parents and the improvements they had made. Whilst the parents were able to self-report regarding mental health issues and alcohol misuse, actions were in place to ensure these claims were substantiated. It was agreed CA would remain on a child protection plan while the PLO was completed and to ensure that the parents were able to maintain their levels of care. A core group meeting followed this meeting. It was agreed the P1 would be referred for a SPOA assessment and that relapse prevention work would be conducted by the FIN. There would be a four-week parenting course made available, and the parents were seeking a change in accommodation. At the beginning of April CA was found by P1 and was described as “floppy”. CA was taken to Blackpool Hospital but attempts to resuscitate CA failed. CA was declared deceased on 3rd April 2017. 10 Care Order - A Care Order can be made in Care Proceedings brought under section 31 of the Children Act 1989 if the Threshold Criteria are met. 11 Public Law Outline - The Public Law Outline sets out streamlined case management procedures for dealing with public law children's cases. The aim is to identify and focus on the key issues for the child, with the aim of making the best decisions for the child within the timetable set by the Court, and avoiding the need for unnecessary evidence or hearings. 12 Core Group meeting - Core Groups are made up of professionals from differing agencies, including the Lead Social Worker who are responsible for implementing and monitoring the Child Protection Plan. Significant issue five Following the birth of CA statutory child protection procedures were not applied in a consistent and effective way. The quality of the child protection plan in this case was poor. A legal planning meeting prompted senior management engagement and a step change in support and oversight took place. 9 Section Three – Analysis of Significant Issues 3.1 Introduction This section provides an analysis of each of the significant issues. From this analysis the key themes have been developed. 3.2 Significant Issues 3.2.1 Significant issue one Blackpool is a town with higher than average levels of transience. Agencies need to ensure they can deal effectively with new arrivals to the town and meet their health, safeguarding and social needs. It is the responsibility of front line professionals to acquire the historical information they need to provide the right level of service and protection to families. The higher than average levels of transience that occur in Blackpool, mean that services in the town need to be structured in a way that means they can effectively deal with both families accessing universal services and those with more complex needs. Professionals expressed a view that the position of P1 and P2 is not an unusual one, and front line professionals regard it as one of the outstanding features of their working lives. However, professionals should expect to provide services to new arrivals as they would any other resident in Blackpool. It is a professional’s responsibility to ensure they gather the required historical data around a family whatever the circumstances of arrival in the town. Clearly, structures need to be in place to identify those families arriving in Blackpool who need significant support. The recently introduced Early Help Hub would appear to be the most effective place in which to deal with those families that do not meet the threshold for statutory intervention. There is clearly much work being undertaken to support those families once their need has been established, but multi-agency arrangements should be in place to take a more pro-active approach in identifying troubled families and putting in place support at the earliest opportunity. The issues around ‘new arrivals’ are dealt with in section 4. 3.2.2 Significant issue two There was no handover package between Bolton and Blackpool social care. Support services were put in place for the family but this was not co-ordinated by agencies who failed to share appropriate information. P1 was able to avoid contact with services. Key Point One - There was no formal handover between Bolton and Blackpool Children’s Services When the referral was received by BCSC a social worker was allocated to the case and an assessment process began. Supervision took place with the social worker who was told to complete an assessment and genogram. The supervisor also stated that the case should be subject to a legal planning meeting prior to birth. These requests are in accordance with agreed pre-birth protocols. The social worker was an ASYE (Assessed and Supported Year in Employment) and was inexperienced. 10 This case was not ‘open’ to Bolton Children’s Social Care and so they passed a referral to BCSC. In the circumstances, it is understandable that Bolton did not take any further action. If a strategy meeting had been called then an invitation should have been extended to them. The allocated social worker did however go to Bolton and review the files relating to the family, but not until late September. There is no explanation as to why this took so long. Key Point Two – Midwifery services worked swiftly to ensure P1 received the correct level of medical care and support Midwifery services did contact their counterparts in Bolton and received information regarding P1, including her previous contacts with children’s social care and her medical history. As a result, she was referred to specialist midwifery services. Midwifery followed policies and were quick to respond. Midwifery services referred P1 to the Baby steps programme which is commissioned on behalf of the Better Start Partnership. It is led by midwives and health visitors with NSPCC family engagement workers supporting health, who are the clinical lead. The correct level of support was put in place by health professionals to reduce the risks to P1 and her unborn child. Key Point Three - Pan Lancashire Pre-birth Protocols were not followed The pan-Lancashire multi-agency pre-birth protocol provides a clear process to be followed by all agencies to minimise the risk of harm to the unborn child. The protocol was not followed. At no stage did a multi-agency meeting take place concerning the family. At the practitioner’s event, it was agreed that it would have been useful for this to have occurred. A number of professionals commented on the fact that they did not know who the allocated social worker was and limited attempts to contact her had failed. It was agreed that professionals who were dealing with P1 should have escalated the matter to ensure BCSC were fully engaged and to agree a coordinated approach. Key Point Four – No multi-agency meetings took place and professionals were left with an information deficit The Family Engagement Worker (FEW) was new in her role. Whilst she had received basic information concerning P1 and her previous history, she had not received a comprehensive briefing from midwifery services and whilst she had attempted to contact the social worker, she got no response. As a result, the FEW was not aware of the high level of risk P1 posed to her unborn child. At the practitioner’s event the FEW acknowledged that she had not fully understood this risk and had been too willing to accept reasons given P1 not to meet. Given the high risk P1 posed the FEW should have been more fully briefed by the social worker and the relevant health professionals. Midwifery services should have escalated this case when they received no response from BCSC. In summary; midwifery services understood the risks to mother and baby and put in place the right levels of support to ensure her medical needs were met. The FEW was correctly asked to engage with P1 but her inexperience and lack of a comprehensive briefing resulted in a level of naivety around P1’s failures to attend appointments. The inexperienced social worker failed to instigate any form of multi-agency meeting and in hindsight professionals accept this should have been escalated. The issues around formal child protection procedures are dealt with in section 3.2.3. The failure to follow the agreed Pan-Lancashire 11 Protocol resulted in a lack of information sharing between services. A lack of coordination by agencies allowed P1 to avoid contact when she wanted; without consideration as to how her living with the toxic trio would impact on her ability and willingness to engage. 3.2.3 Significant issue three The application of child protection procedures in the pre-birth phase was inconsistent and failed to comply with statutory guidance. Key Point One – An inexperienced social worker was allocated to a high-risk case Following a referral, a social worker was allocated to the case. The social worker was qualified and was an ASYE (Assessed and Supported Year in Employment) but was inexperienced. This meant the social worker was qualified but in the first year of employment and should have been receiving close supervision and support. This was not necessarily an issue if the social worker had significant previous experience in social care. In this case, the social worker was inexperienced. The only reason suggested as to why such an inexperienced social worker was allocated to this case was put forward at the practitioner’s event. Social workers said at the event that BCSC is undergoing significant change. There has been an increase in the number of social workers but recruiting qualified, experienced social workers is recognised as a significant problem both locally and nationally and there is not the capacity to allocate experienced social workers to each case. Supervisors have to make difficult choices when allocating cases. However, given the high-risk nature of this case it was not appropriate to allocate an inexperienced social worker, and having done so there was should have been greater supervision and support provided to that individual. Key Point Two - The Pan Lancashire Multi-Agency Pre-birth Protocol was not followed P1 and P2 had numerous issues around mental health and alcohol misuse. P1 had a history of neglect of all her previous 8 children who had been subject to child protection procedures. P2 had 7 children, 4 of who had been the subject of child protection procedures. Between them the couple had had 15 children and no longer had parental care of any of them. Given the multitude of issues facing P1 and P2 and their history of neglect, this was always going to be a difficult and complex case. It is difficult to understand why an ASYE would be allocated in the primary role of providing protection to the unborn child in these circumstances. Six of the seven risk factors identified in the Pre-birth Protocol were present in this case. This case was always going to be high risk. As a result of this significant risk of harm, the Pan-Lancashire Multi-Agency Pre-birth Protocol (pre-birth protocol) should have been followed. There is no evidence in this case that the protocol was implemented or referred to at any point, despite the issues being apparent at an early stage. There has been no explanation as to why there was no strategy meeting on receipt of the referral. The basic facts of the case clearly determined that a pre-birth assessment was required and that a strategy meeting13 should have been held to determine whether a section 47 investigation was required. There is no explanation as to why this did not occur. 13 Section 47 strategy meeting - Under Section 47 of the Children Act 1989, if a child is taken into Police Protection is the subject of an Emergency Protection Order or there are reasonable grounds to suspect that a child is suffering or is likely to suffer Significant Harm a Section 47 Enquiry is initiated. 12 Key Point Three – The pre-birth assessment was poor and failed to follow statutory guidance The pre-birth assessment began on 3rd August 2016 and was completed on 29th November 2016. This was two weeks prior to the ICPC. The assessment is poor in quality and lacks detail. It does not refer to any other agencies and is not compliant with statutory guidance. It is not credible to suggest it could have taken 4 months to complete and contains information that could have been obtained in the immediate period following the referral to BCSC. It was not shared with other agencies and would, in any case, have been of little use to other professionals. The assessment concentrates on the status of the family in 2016. It does not deal with any detail around the previous issues P1 and P2 had whilst in Bolton. Given the social worker had visited Bolton on 21st September this is inexplicable. Both P1 and P2 had a history with Children’s Social Care that stretched back over 20 years, but there is little reference to previous issues. This was particularly relevant given P1 and P2’s previous child had begun life living with them, but their level of care had rapidly deteriorated post birth, until the child was removed and later adopted. This undue concentration on present circumstances, as opposed to historical patterns of behaviour, is often referred to as ‘start again syndrome’ and can result in a failure to fully appreciate indicators of risk that remain present. The FEW from Baby Steps was not contacted and yet she would have been able to describe the way in which P1 and P2 were avoiding contact. The midwifery service did not provide an input despite there being concerns regarding mother’s health. The assessment was based on two visits conducted by the social worker and a brief synopsis of the family history. There is no meaningful assessment of the alcohol and mental health issues that had previously affected P1 and P2 and no mention of domestic abuse issues, even though there had been a MARAC and a Clare’s Law application had been made. There is no explanation as to why this assessment was poor. The inexperience of the social worker was clearly a factor, as were the heavy workloads being experienced by social workers at this time. The assessment should have been seen by a supervisor. In addition, P1 and P2 had significant experience of dealing with professionals. Front line professionals all described the way in which both P1 and P2 expressed their determination to “get it right” with this baby. They regularly acknowledged the mistakes they had made previously, but stated their determination to bring this baby up themselves. Professionals saw evidence that P1 and P2 wanted to comply and were determined to keep their baby. This seemingly led to an over-optimism on the part of professionals in which present positives were emphasised at the expense of historical patterns of behaviour. There is no doubt that both P1 and P2 were experienced enough to present themselves in a way that would be seen as positive by professionals. It is a fact that both P1 and P2 had far more experience in the child protection system than many of those professionals they were dealing with, albeit from a different perspective. This case has highlighted the need for comprehensive and proportionate assessments and clear supervision of cases. Key Point Four – Statutory guidance was not complied with regarding pre-birth conferences A strategy meeting should have taken place once it was established that the unborn child would be at significant risk of harm. The first strategy meeting was conducted on the 3rd November, which followed a supervision meeting with the allocated social worker 2 days 13 previously. The strategy meeting took place between the social worker and her manager. It did not follow statutory guidance or agreed protocols. The result of the meeting was that an initial child protection conference was arranged to take place on 15th December. This ICPC would have been when P1 was 36 weeks pregnant. The meeting should have taken place at the 30-week point. The ICPC was quorate and took place the day after CA was born. This was 4 weeks prior to the estimated date of delivery. The case was considered without parental representation (for obvious reasons) and it was agreed that CA would be placed on a child protection plan in the categories of neglect and emotional abuse. It seems that little thought went in to this categorisation. The chair had emphasised the need not to base any conclusions on past history but actually the only concerns were around the mental health and alcohol misuse by the parents and neglect was not in itself discussed. Professionals at the practitioner’s event commented that the ICPC was concluded very quickly. It is clear from the minutes that the report from the social worker was the main focus of the meeting. The police provided a report that contained details obtained from the Police National Computer but the police had not been involved with P1 and P2 since their arrival in Blackpool. A Children’s Centre manager was present but had not seen the family, so was, in effect, in an information gathering role. A midwife reported that CA had been born the previous day. The family GP was invited but did not attend. The information placed before the conference lacked a solid evidence base. Health professionals had been engaged with P1 throughout her pregnancy and were aware of her history. They were able to comment on her health needs. The police had not had contact. The conference based its decision on the social worker’s report. This lacked evidence and was compiled without reference to key professionals, including the FEW. There was no mention of GP services or whether P1 or P2 had engaged around mental health issues. Given that the GP would have had access to historical medical records this was a gap in information sharing that reduced the effectiveness of the ICPC. One professional commented that at the conference a comment was made that the attendees should not get “bogged down by the history”, and the couple’s history was not explored in any depth. There is no simple explanation as to why the statutory guidance was not complied with. The inexperience of the social worker and a lack of supervision were contributory factors. In addition, no other professionals escalated the case to ensure it received closer attention, which would have been expected in the circumstances. One health professional acknowledged that she regrets not doing so, but with everything else she was doing escalation slipped down the list of priorities. The FEW was inexperienced and the Baby Steps programme was a new service that had not reached maturity in terms of its processes and procedures. Both the FEW and her manager have acknowledged that they should have escalated the case and are sure that developments since this case, in terms of training and policy development, ensure that the case would now be escalated. The ICPC took place later than it should and, because of CA’s premature birth, took place after she was born. Given the earliest date of delivery was estimated as 18th January 2017 the meeting was in effect scheduled for a month prior to CA’s birth. The ICPC complied with guidance but could not be described as effective. The attendees relied on the social worker to supply a report, and whilst there was sufficient information to agree that the unborn child should be placed on a child protection plan, the meeting lacked effective engagement with relevant professionals and minutes of the meeting reflect a brief meeting with little challenge or meaningful discussion. There is a simple question worth asking. What difference did this failure to follow guidance make? 14 P1 was not a healthy mother, but her health needs were closely monitored by health professionals. The specialist attention she required was provided to her and she was monitored throughout her pregnancy, including through routine enquiry about domestic abuse. In terms of P1 and her unborn baby, health needs were met. Statutory guidance required an initial strategy meeting to be held. This would have given professionals the chance to discuss the case and share information. Effective plans could have been put in place to monitor the family. This would have provided a far more accurate picture of the family and the risks a new baby would face. The ICPC should have provided a solid foundation for the work that would be required following the birth of CA. It did not do that; although it achieved its primary function of agreeing CA should be placed on a child protection plan. It is not possible to know whether the failure to comply with statutory guidance during the period of P1’s pregnancy had an adverse effect on CA. However, it did set a tone for the work that was to follow and the failure to comply was not only poor practice but hindered an effective response and support to this family. 3.2.4 Significant issue four Legal planning was considered but was not put in place quickly enough. It failed to provide the contingency that may have been required in this case. Key Point One – instructions to put in place legal planning meetings were not followed The supervisor of the allocated social worker instructed her to put in place a legal planning meeting on 26th August 2016. This position was reiterated in a supervision meeting at the beginning of October. On the second occasion the social worker was told to “consider” a legal planning meeting. By the time of the ICPC no legal planning meetings had been arranged. The first legal planning meeting was held on 12th January 2017. A Public Law Outline was put in place on 2nd February. There is no explanation as to why the social worker did not arrange an earlier legal planning meeting or why supervisors did not insist that it was put in place. The matter was not considered at the ICPC. At the first core group on 19th December the social worker insinuated it was arranged. It had not been. In addition to the inexperience of the social worker, she was also absent with periods of sickness; but this issue should have been picked up by her supervisors. Key Point Two – Effective legal planning was a catalyst for intensive intervention and support It is clear from the timelines in this case that the legal planning meeting on 12th January 2017 is the catalyst for step change in how the family were being regarded. This meeting involved a number of managers and it lays out a significant level of work that is to be conducted. P1 and P2 were at this meeting and were legally represented. This was the first time that clarity around the expectations for the parents was laid out. Legal planning meetings and a public law outline should have occurred far earlier in the pregnancy. There is no reasonable explanation as to why this didn’t occur. A supervisor established immediately after referral that a legal option should be considered and may have 15 been required. When a legal planning meeting took place it was the catalyst for a change in focus and more effective process was put in place. 3.2.5 Significant issue five Following the birth of CA statutory child protection procedures were not applied in a consistent and effective way. The quality of the child protection plan in this case was poor. A legal planning meeting prompted senior management engagement and a step change in support and oversight took place. Key Point One – Following discharge from hospital an effective child protection plan was not put in place Following the ICPC on 15th December a child protection plan was written. A core group was held on 19th December and a series of visits to the family was agreed. The child protection plan is dated 19th December. It states that a legal planning meeting had been held. This was not correct and would have misled other professionals when it was discussed at the core group. It would also potentially have given them a false sense of security. It seems more likely that the legal planning meeting referred to is a meeting that took place to complete the legal planning pro-forma. The child protection plan contains a number of immediate actions that should have already been in place. It specifically states: “Contact health visitor and see if she can offer further supports/visits check if mother is registered with GP in Blackpool – try and obtain consent from her to contact GP to check what medication/support she is accessing for her mental health no evidence alcohol misuse has been addressed only parents self-reporting. Can we get any testing and speak to parents again about engaging with relapse prevention support. Check if they engaged previously with an agency. If they say they have, get details contact them. Do a referral for Family Group Conference See if Mother would like a referral to Home Start SoE to be completed –XX kindly offered to assist with this Referral to be made to FIN – contact them today and request support until it can go on to panel Court records from Bolton – legal will request these.” These actions are all logical but have an appearance of being a list of ‘to dos’ rather than clear SMART actions put in place as a result of thoughtful multi-agency discussions. The plan is unprofessional and lacks details. It does not contain named individuals or clear timescales. This lack of detail and grip is further exacerbated by the timing. It was approaching the Christmas period when professionals acknowledged it would be more difficult to arrange action. CA was discharged from hospital with P1 on 20th December. Midwives had conducted a discharge planning meeting, including BCSC, and agreed a series of visits to the family. These were followed through. A community midwife visited on 21st December and a health visitor on the 23rd December. It had been agreed that a social worker would visit on the 22nd December. There were no social worker visits until 6th January when an unannounced visit 16 took place. Health professionals conducted visits as expected and had attempted to coordinate with BCSC. There is no explanation as to why BCSC did not conduct visits, although the social worker did record that on 5th January they had been unable to gain access. The level of support provided to the family by health professionals over this period was sufficient and ensured that CA was being properly cared for. Whilst there was some concern around the hot temperatures in the flat, safer sleeping arrangements were discussed with the parents and there were no concerns raised. The actions from the child protection plan quoted above are described as; “steps that need to be taken immediately to protect this child”. This included contacting the Family in Need team to provide intensive support. In the three weeks over the Christmas period there is no evidence that BCSC put in place any of those steps. Key Point Two - The legal planning meeting initiated a more intense response On 12th January 2017, the first legal planning meeting took place. This laid out specific actions for both parents and agencies. It is also the case that on the same day the Family In Need team were provided with an emergency referral and immediately began work. This team visited the family on the 12th January and made a further 20 home visits prior to the end of January. They visited at various times and on some occasions twice in a day. This was extremely good practice and ensured that a true picture of the family could be compiled. There seems no doubt that the legal planning meeting heightened concern about the action that had taken place previously. A senior manager was also notified about this case. On 16th January, a core group meeting was held. P1 and P2 complained that they were being visited too regularly by the FIN team. There was no one present from the FIN team. Both P1 and P2 were offered various avenues of support but these were declined. On 19th January, a meeting of senior managers from BCSC took place. A more experienced social worker was allocated to the case. On 31st January, this social worker took full control of the case. Key Point Three – Following management intervention the case was handled with more urgency and professionalism The legal planning meeting had led to intervention by senior managers. A senior social worker took over the case. The FIN team maintained intensive visits. By February a public law outline had been put in place and was being enacted. At a core group meeting in mid-February there are clearly defined actions in place to support the family. In March a review conference took place. Whilst there was no health representation at the meeting (the family was not invited), reports were submitted. It is clear from the minutes that significant progress had been made with the family. At this meeting, all the professionals believed CA was being well cared for and they had no current concerns. The social worker indicated that P1 and P2 were complying with requests and the public law outline. Whilst progress had been made it was agreed that CA would remain on the child protection plan whilst various actions were completed and to demonstrate that the care they were providing could be consistently maintained. In summary; the low-level work that had taken place during the pregnancy of P1 largely continued following the birth of CA. Midwives and health visitors conducted their visits and ensured they followed plans to maintain the health of mother and baby. BCSC allowed the case to drift over the Christmas period. The involvement of senior managers following the 17 LPM saw an immediate change. It seems at this stage, for the first time, BCSC acknowledged the high risk the family posed, and put in place both preventative and support measures. They also put in place a senior and experienced social worker to move the case forward. At the time of CA’s death BCSC had control of this case and were managing it appropriately. Section Four – Key Themes 4.1 Information sharing between professionals P1 and P2 arrived in Blackpool from Bolton. Given P1 was pregnant it was to be expected that health services would provide a handover and to some extent at least this did occur. Despite an early referral from Bolton CSC it was over 8 weeks before a social worker attended Bolton to view social care files. Given P1 or P2 had not engaged with Bolton CSC for 5 years the onus was on Blackpool to pro-actively engage. On arrival, health were aware of a basic history of P1 and P2 and midwives had exchanged information. No strategy meeting was called so the available information was not collated. Because of this lack of information sharing, no joint plan was agreed. Throughout P1’s pregnancy health and BCSC worked in their own silos. No joint meetings occurred in the first 4 months the family were in Blackpool. There is no evidence this put any person at risk, but it is poor practice. The lack of information sharing during the pregnancy meant that clear multi-agency plans were not in place when CA was born. It is relevant that even though P1 had given birth pre-maturely in a number of her other pregnancies this information was not shared with other professionals. The lack of a joint approach continued in the first weeks following the birth of CA. Health conducted their work and BCSC made plans but the failure to share information meant that there was not a coordinated approach. This was critical over the Christmas period. Whilst the lack of information sharing and coordination did not put CA at an identifiable risk, it did mean that comprehensive planning was not in place and this meant that appropriate plans were not in place when CA was born. 4.2 The application of child protection procedures There was little understanding of the Pan Lancashire Multi-Agency Pre-birth Protocol by any of the professionals in this case. This is of concern. The document has been in place since 2012 and was reviewed in 2014. A new document was agreed in March 2017. Work needs to be undertaken to ensure the new protocols are embedded into practice across all agencies. No agency called a strategy meeting when they became aware of P1 and P2. Whilst professionals accepted they could have done so, this was left to the social worker who did not follow procedures. A pre-birth assessment took several months to complete and was of poor quality. As a result, there were not strong plans in place when CA was born, professionals were ill informed and had not been able to express their views of the case. A strategy meeting (which also is recorded as a section 47 investigation) did not take place until the social worker had been told by a supervisor to book an ICPC. It is apparent that the strategy 18 meeting was only recorded as a means of showing procedures were being followed. In fact, no other professionals attended or were asked for reports. This was poor practice. An ICPC was held but was brief in nature and some key professionals were not present. The lack of substantiated information could have been a real cause for concern, but the chair agreed to put CA on a child protection plan despite the lack of information available. The child protection plan that was developed following the ICPC was poor. It had a number of steps that needed to be taken immediately, but none of these took place prior to 2017. Following management intervention in January 2017 the standard of reports and intervention improved immeasurably. Given the current work that is taking place at BCSC and the action plans in place following recent serious case reviews, there are no additional recommendations in this area. 4.3 Leadership An inexperienced social worker was allocated to this case. Given the historical concerns, it is difficult to understand why such an inexperienced social worker was put in place. To add to the situation her supervision was sporadic. Eventually a management intervention saw a more experienced social worker put in place. Other agencies were aware that a more coordinated approach would be useful but did not take the lead themselves and continued to concentrate on the actions required by their own agency. No one questioned the drift that occurred in this case until a management intervention in January 2017. The case could have been escalated, but in any event the case conference chair should have questioned the quality of the assessment and child protection plan. All aspects of this case contained drift and a lack of grip: suggestions for support not progressed; failure of parents to make themselves available were not questioned; key documents not completed or taking excessive time to complete; and poor quality assessments and plans. This lack of leadership cannot be addressed by action plans. The LSCB should satisfy itself, through its current audit programme, that child protection plans are being properly and professionally managed. Section Five – Key Findings CA died from an unascertained cause but there is no evidence that the death of CA was attributable to her parents. Professionals could not have prevented the death. This case has demonstrated several areas for improvements in child safeguarding across agencies in Blackpool. Whilst some agencies demonstrated good and expected practice, further work is required. Namely: information sharing; the application of escalation procedures; the application of pre-birth protocols; 19 stronger leadership; multi-agency arrangements to identify and support individuals and families arriving in Blackpool with complex needs. These issues should be addressed by agencies as a matter of urgency. Section Six – Recommendations Recommendation One The Safeguarding Children Board should assure itself that all agencies have systems in place to deal with families, including those with additional needs, arriving in Blackpool. Recommendation Two The LSCB should, assure itself that front line practitioners are aware of, understand and are applying, the pan-Lancashire pre-birth protocol. Recommendation Three The LSCB should assure itself that child protection assessments are proportionate and that plans are specific, measurable, achievable, relevant and timely. Recommendation Four The LSCB should assure itself that front line practitioners receive regular and meaningful supervision and that leaders are able to demonstrate they have a grip on cases assigned to their staff. Conclusion P1 and P2 moved to Blackpool to escape the difficult life they had in Bolton. Both had a significant history of mental health, alcohol misuse and domestic violence issues. P1 had 7 children from previous relationships. All those children had been the subject of child protection procedures; for reasons of neglect and emotional abuse. P1 no longer retained legal responsibility for any of those children. P2 had 7 children by a previous relationship and 4 of them were subject to child protection procedures. P2 had no legal responsibility for his children. The couple had a child between them in 2009 that was subject to child protection procedures for reasons of neglect. This child has now been adopted. P1 was 4 months pregnant when the couple arrived in Blackpool. CA was born in December 2016 and sadly died from an unascertained cause in April 2017. There was no evidence that the death was attributable to the actions of her parents. Professionals had some concerns about the way in which partners worked together in this case to protect CA and asked for the case to be reviewed under child safeguarding legislation. This review has found that there were a number of areas where child safeguarding procedures in Blackpool need to improve. On their arrival in Blackpool, health services provided P1 and her unborn baby with the support she needed and continued with the right level of support throughout her pregnancy. Health practitioners failed to escalate the case 20 when they received no response from children’s social care. Child protection protocols were not followed and strategy meetings were not held. This would have ensured a coordinated approach to the family. Pre-birth assessments were poor and no consideration was given to legal proceedings to support professionals’ work; until CA had been born. Information was not always shared between agencies and plans were not made to ensure CA would be properly protected. Following the birth of CA, the child was placed on a child protection plan, but the plan was poor and did not do enough to reduce risks to CA. Following a management intervention, a month after the birth of CA, correct procedures were implemented and plans were in place to support CA and the parents to ensure the baby was properly protected. Agencies in Blackpool need to improve the way they work together and ensure that child protection procedures are understood and implemented. There was a lack of leadership in this case. |
NC047730 | Death of a nine-year-old boy, Alex, who was drowned in the bath in December 2014. His grandfather was later convicted of his murder. Alex had had little involvement with agencies other than some support at school. Alex's maternal grandfather lived with or near the family for the duration of Alex's life and had significant mental health problems; adult mental health services provided constant contact with him and his family over a long period of time. He murdered Alex as part of his campaign to return to hospital care, following discharge from an acute inpatient mental health hospital ward. Key findings include: a lack of robust risk assessment and care planning to protect family, carers and the public at the point of discharge from the inpatient facility. Recommendations: the mental health management team in acute wards must ensure processes for risk assessment at all stages of treatment and discharge to take account of carers and their families; improvements to care pathway/treatment plans so that all patients are clinically assessed prior to transfer; there should be a named consultant responsible for each patient's care and discharge; adequate safeguarding children training to be embedded in all practices.
| Title: Serious case review relating to Alex: date of birth: 7th January, 2005: date of death: 23rd December, 2014: overview report. LSCB: Lincolnshire Safeguarding Children Board Author: Ceryl Teleri Davies Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 SERIOUS CASE REVIEW Relating to Alex Date of birth: 7th January, 2005 Date of death: 23rd December, 2014 OVERVIEW REPORT Prepared by:- Ceryl Teleri Davies Independent Author Date: 8th December, 2016 2 CONTENTS 1. INTRODUCTION 1.1 Summary of the circumstances leading to the Serious Case Review 1.2 Context to the Serious Case Review 1.3 The Serious Case Review process 1.4 The Terms of Reference 1.5 Independent Panel and Independent Overview Author 2. SUMMARY OF THE FACTS AND FAMILY INFORMATION 2.1 Family history 2.2 Overview of the integrated chronology of events and agency involvement 2.3 Summary and conclusion of the Integrated Chronology 2.4 Information from the family 3 ANALYSIS Analysis: The Agency Narrative Reports & Themes 4 LEARNING Learning on the fringe 5. CONCLUSION 6. IMPLEMENTATION OF THE LEARNING 6.1 Recommendations 6.2 What’s changed?: LPFT 6.3 Progressing Recommendations and dissemination of learning Appendix 1: ANR Recommendations 3 SERIOUS CASE REVIEW OVERVIEW REPORT: ALEX 1. INTRODUCTION Table 1: Summary of family members:- Key Relationships to Alex Mother Father Sister Maternal grandfather Maternal grandmother Mother’s partner 1.1 Summary of the circumstances leading to the Serious Case Review The Lincolnshire Safeguarding Children Board (LSCB) agreed on the 17th of February, 2015, to commission a Serious Case Review (SCR) into the death of Alex, a white British boy, who it was understood, died on the 23rd December, 2014. The inquest was open and adjourned at the time of Alex’s death, and formally closed on the 2nd December, 2015, following the completion of the criminal trial. Alex was 9 years old at the time of his death. He was drowned in the bath of his home by his maternal grandfather whilst under his care and supervision. Alex was taken to Hospital and was pronounced dead. On the police’s attendance a disclosure was made by maternal grandfather, resulting in his arrest on suspicion of the murder of Alex. At this time it was made clear by other family members that Alex’s death had been a deliberate act by maternal grandfather. The family had to reconcile with the sudden loss of Alex and the knowledge that this loss was due to the actions of a key member of their family. 1.2 Context to the Serious Case Review There are several aspects that make this SCR exceptional. Firstly, there is limited history of inter-agency involvement with Alex and his sister, with the majority of services surrounding maternal grandfather and not the child subject to this review. The focus of the multi-agency working was with maternal grandfather, primarily to address his mental health and offending 4 behaviour. Therefore, the majority of the agency analysis focuses on the multi-agency care and support offered to maternal grandfather as the perpetrator. It should be noted that the LSCB gave detailed consideration to whether a child or adult review process should be followed, with a multi-agency decision concluding that the child SCR criteria had been triggered. Secondly, there was limited agency concerns raised regarding the care of both children. Alex presented as a typical child receiving low level support, primarily focused on his educational needs. Therefore, Alex did not present as a vulnerable child, to the contrary, he presented as a happy, caring and lively child. Over several years, maternal grandfather experienced fluctuating mental health needs, with a long offending history, for many years in the context of alcohol dependency. In summary, prior to Alex’s death in December 2014, maternal grandfather was admitted in July 2014 to an acute inpatient ward for review of his medication and assessment of his cognitive state and remained as an inpatient, however, with hindsight he should have been discharged home at a much earlier stage. When maternal grandfather was discharged from the care of this unit in December 2014, the discharge was completed in a manner that did not consider best practice, policy or procedure. The role of the Treating Consultant Psychiatrist is now clear upon the completion of Lincolnshire Partnership NHS Foundation Trust’s (LPFT) Agency Narrative Report (ANR) and a Root Cause Analysis investigation (RCA); however, this issue was unclear at the point of discharge and was not aligned to or consistent with a planned multi-disciplinary Care Programme Approach process. There will be discussion around some useful learning and recommendations for practice development as there is evidence to suggest that there were key missed opportunities, in particular regarding the completion of robust risk assessments focused on public protection. However, it needs to be highlighted that the only individual responsible for the tragic death of Alex is maternal grandfather. The evidence indicates that he was violent, abusive and highly manipulative. Maternal grandfather made the decision to undertake this act and as a result has now been found guilty and convicted of murder. The degree of his violence towards Alex could not have been predicted or prevented by professionals or members of his family. 1.3 Serious Case Review Process 1.3.1 As outlined, the LSCB agreed on the 17th February, 2015, to commission a SCR into the death of Alex. The scope of this SCR was to cover the timeframe from the 1st July, 2013 to the date of Alex’s death on the 23rd December, 2014. The rationale for this review period was 5 due to a SEN review resulting in Alex progressing to School action plus due to a change in his educational needs. 1.3.2 Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires LSCBs to undertake reviews of serious cases in accordance with procedures as set out in ‘Working Together to Safeguard Children’ (HM Government, March 2015). The Serious Case Review criteria apply to all children, including those with a disability and are set outlined in Regulation 5 of the Local Safeguarding Children Boards Regulations (2006): (1) The functions of a LSCB in relation to its objective (as defined in section 14(1) of the Act) are as follows – (e) Undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1) (e) a Serious Case Review is one Where – (a) Abuse or neglect of a child is known or suspected; and (b) Either – (i) The child has died; or (ii) The child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the Child. Working Together 2015 states that SCRs and other case reviews should be conducted in a way which; recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and 6 makes use of relevant research and case evidence to inform the findings. 1.3.3 The Agency Narrative Reports: The authors of the ANRs which analyse their agency involvement with the family were senior practitioners or senior managers, who had not had direct contact or management involvement with Alex or his family. 1.3.4 On the 25th February, 2015, the National Panel and Ofsted were notified of the decision to commission a SCR. 1.3.5 The scoping meeting was convened on the 1st April, 2015, to establish the Terms of Reference, process and timeline. 1.3.6 It was agreed that there would be no engagement with the family until the criminal process had concluded. During the trial in November 2015, maternal grandfather changed his plea to ‘guilty’ and was subsequently sentenced to a minimum of 22 years in prison. Maternal grandfather originally pleaded diminished responsibility, but during the trial he changed his plea to guilty following the psychiatric assessment which noted his responsibility for this crime. It was agreed following the trial that transcripts of the expert medical assessments should be obtained to inform the review process. Following the presentation of expert evidence during the criminal trial, LPFT decided to commission an independent forensic report. Therefore, their ANR was reviewed to take account of this independent report. 1.3.8 The family interviews were completed on the 16th May, 2016. 1.3.10 The SCR panel meetings were held on the 1st April 2015, 22nd May 2015, 21st October 2015, 4th February, 2016, 7th April 2016, 13th July 2016 and 2nd December 2016. 1.3.11 On the 8th December, 2016, the LSCB Strategic Management Group convened to sign off the final SCR Report. 1.4 The particular questions outlined within the Terms of Reference are summarised below:- 1. Resources Policies and procedures To examine the referral/assessment input and discharge/closure mechanism alongside the decision making processes to establish if agency input was sufficiently resourced and robust enough to meet the needs of Alex and his family. Did the policies and procedures of agencies reflect the relevant legislation and guidance available at that time, and were they adhered to? 7 2. Risk Management To examine the risk management process to establish where appropriate risk assessment tools were used as per internal and external polices and procedure. 3. Information gathering, sharing and defensible decisions To ensure that decisions made were informed by the information available, evidenced based, and the risk and protective features were appropriately balanced. Was there effective and timely information sharing between the respective agencies and the family? To consider whether there were opportunities for inter and intra-agency working that were missed at the time of agency input into the family. 4. Competencies training development To identify whether the agencies staff in this case had the required competencies and confidence to carry out their role, and to identify any relevant training or development need that may improve future practice. 5. Line management advice and guidance To establish whether staff in this case sought, and were given, appropriate levels of supervision, advice and guidance during the decision making processes when working with this family 6. Culture To identify within the agencies whether there were issues of an organizational culture which prevented objective assessment of presenting concerns and needs when working with the subjects. Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability of the child and family? Were these explored and recorded? 7. Communication To establish if the inter and intra-communication processes were efficient and effective and involved the family. Was the voice of the child heard through agencies engagement with the family? Based on the nature of agency involvement with this family, a decision was undertaken to focus on a ‘mixed’ methodology including, agency narrative, review of case files, formulation of an inter-agency chronology, staff interviews and family interviews. However, the LSCB was also mindful that if any agency considered that there was any relevant 8 information outside this timescale, it would be included in their ANR. A review of each agency report and the terms of reference are outlined within section 3 of this report. 1.5 Independent Panel and Independent Overview Author 1.5.1 The membership of the SCR Panel was agreed by the SCR Subgroup, which consisted of senior managers and/or designated professionals from the key statutory agencies, who had no direct contact or management involvement with the family. 1.5.2 The Serious Case Review Panel members were:- AGENCY ROLE Independent Chair of the SCR panel Children’s Services Manager, Action for Children & Chair Children services Service Manager Youth Offending Service Head of Service Lincolnshire Police Quality Auditor and SCR Author Clinical Commissioning Groups Consultant Nurse Safeguarding Children and Adults Lincolnshire Partnership NHS Foundation Trust Consultant Nurse Safeguarding & Mental Capacity Humberside, Lincolnshire, North Yorkshire (HLNY) Community Rehabilitation Company NPS- Lincolnshire Lincoln and Gainsborough CRC Team Manager LCC Education Representative Team Leader Inclusion and Attendance United Lincolnshire Hospital Trust Named Nurse for Safeguarding 1.5.3 Independent Overview author The Independent Overview Author is Ceryl Teleri Davies has compiled the Overview Report and contributed to the Integrated Action Plan produced by the Lincolnshire Safeguarding Children Board. The author is a qualified Solicitor and Social Worker, with a Master’s degree in both work areas, a postgraduate diploma in Community and Criminal Justice, and qualifications in Mental Health. She has extensive practice-based experience across social care, criminal justice and mental health services, including work on a multi-agency basis to 9 support children, young people and vulnerable adults at practitioner, middle and senior management level. Ceryl Teleri Davies is not employed by any of the LSCB Agencies. 2. SUMMARY OF THE FACTS AND FAMILY INFORMATION 2.1 Brief Family History 2.1.1 Alex lived with his mother and sister in a two storey terraced house, bordered by other identical properties, and located within a densely populated residential area close to a city centre. As expected of a city centre, the area is surrounded by local amenities, shops and good transport links. The picture that emerged from agency records and the records of meetings with the family members is one of a supportive network of maternal family members all living within the local area. 2.1.2 For several years maternal grandfather was involved in incidents which required police intervention, it is evidenced that he regularly committed crime and had both alcohol and mental health related problems. Over the years, maternal grandfather’s mental well-being and behaviour resulted in him spending increased time in various mental health settings on a voluntary basis. He resorted to violence and abuse on several recorded incidents against people other than his family and he also caused difficulties for maternal grandmother (his ex-wife) with his persistent, often uninvited presence. For much of her adult life, despite being divorced from maternal grandfather for some 28 years, she continued to offer continued support. 2.2 Overview of the integrated chronology of events and agency involvement 2.2.1 The aim of this section is not to reproduce the full integrated chronology, but to highlight significant events to illustrate an account of what is known in agency records. The following extracts from the integrated chronology are the overview author’s view of the significant practice events which occurred prior to Alex’s death. An outline of the fringe learning will be provided in section 4 of this report. 10 2.2.2 The Terms of Reference stipulated the time frame to be examined as from the 1st July, 2013, to the date of Alex’s death on the 23rd December, 2014, essentially a period of approximately 17 months prior to Alex’s death. 2.2.3 In summary, the emerging picture revealed that Alex dearly loved his family. He remained within one primary school; his progress reports presented a picture of an enthusiastic young boy who was able to form positive relationships with children and adults. He faced some challenges in school, but was offered support via Special Educational Needs (SEN)1 input, including a targeted support plan. On the 9th December, 2014, Alex’s proposed statement of educational needs was issued. One of his school progress reports described him as a “kind and caring boy, who has many friends and has developed a fantastic attitude to learning”. The picture is of a young boy who had good attendance, positive peer relationships and an enthusiastic approach to learning, but who sometimes found it challenging to cope with the pace of learning and environmental distractions. 2.2.4 Maternal grandfather’s mental health records reveal a significant degree of diagnostic uncertainty, with several psychiatric diagnoses, including anxiety, recurrent depression, personality disorder and bipolar affective disorder. However, in October 2013 he was described as “very well” and not reporting any phenomena consistent with affective or psychotic problems, or self-harm/suicidal/homicidal ideation. Maternal grandfather was concordant with prescribed medication. He was described as “reconciled with family’” and currently living in warden supported housing. 2.2.5 In April 2014 maternal grandfather voiced his concern when Clomipramine (his anti-depressant at the time) became unavailable across the UK. The GP and maternal grandfather both separately alerted LPFT to this information however, the response was insufficient. The psychiatrist advised the GP to commence an alternative anti-depressant. In what would appear to be a result of human error no Psychiatrist outpatient appointment was arranged to review the new antidepressant. On the 16th 1 Special educational provision is the additional or different help given in school to children with special educational needs. 11 April, 2014, the GP surgery contacted a staff grade doctor to inform them that maternal grandfather had contacted the Integrated Community Mental Health Team (ICMHT) because of his anti-depressant being stopped. The staff grade doctor advised a type and dose of anti-depressant to be prescribed on an interim basis until maternal grandfather received a review appointment. This was followed through by the GP and the GP went on to increase the dose of anti-depressant, but it was not recorded by the staff grade doctor and no follow up appointment was offered to maternal grandfather. There then followed a decline in his mental health over a three-month period ultimately leading to hospital admission. This information is key as prior to the discontinuation of Clomipramine maternal grandfather had been discharged from Trust services and had been stable and well for 18 months. If he had been reviewed as planned by a Consultant Psychiatrist within the community, soon after the 14th April, 2014, then it is likely the newly prescribed anti-depressant would have been amended if required. This review could also have initiated the ‘fast track’ mechanism for maternal grandfather to receive support from the Trust’s ICMHT services during a period of medication transition. If this review had taken place, maternal grandfather’s deterioration within the community may have been slowed or prevented. 2.2.6 In July 2014 during a home visit, maternal grandfather presented as shirtless and unkempt. His mood appeared mildly agitated as he highlighted his inability to cope with living independently. He presented as both subjectively and objectively depressed, self-neglectful and socially isolated. It is noted that there were morbid thoughts but no suicidal ideation, intent or risk to self or others was deemed present. He highlighted that he was estranged from his daughter. An urgent out-patient appointment was arranged for maternal grandfather with the Home Treatment Team to offer support in the interim period. On the 29th July due to increased concerns, continual decline and a clinical impression of maternal grandfather as suffering a severe depressive episode, a decision was made that his risks could only be managed within inpatient care. However, despite his presentation as severely depressed as soon as he was admitted to hospital, his symptoms disappeared as he had obtained what he wanted, i.e. admission. He did not require this form of care and there is evidence that some of his behaviour was goal directed to prevent his discharge, including complaining of anxiety or tightness in his head, verbal aggression, resisting plans to move him on and rolling around on the floor. There is no evidence that these 12 maladaptive behaviours were related to a mental illness but rather were related to his goal to get his own way. Despite this, his period in some form of inpatient care continued until December 2014. 2.2.7 On the 27th August, 2014, maternal grandfather was rude and abrupt to another vulnerable patient on the ward. When approached to explain his behaviour, he became hostile, shouted and swore at LPFT staff. He later received a call on the patient phone, at which point he was again hostile and swore at staff and refused to take the call. This example illustrates the nature of maternal grandfather’s behaviour towards others. 2.2.8 On the 12th September, 2014, mother rang the ward to enquire about maternal father; he refused to talk to her. He was often dismissive of his family despite their continued support and attempts to maintain contact with him. Mother was advised that he did not wish to talk to her, at which point she became tearful and upset. He does mention his daughter on several occasions to LPFT staff, in particular that he was worried about her. The following day maternal grandfather was transferred to an open rehabilitation ward due to pressures on acute bed availability. 2.2.9 On the 22nd September, 2014, maternal grandfather was seen and reviewed by his Treating Consultant Psychiatrist in the company of a Staff Nurse. He discussed pressure in his head and that he would like a change in medication and wished to remain in inpatient care. The Doctor discussed with maternal grandfather about first having some blood tests, ECG and MRI to check for any physical conditions prior to reviewing his medication. Maternal grandfather stated he did not want any tests done but wanted his medication changed and stated “you are not listening”. He reacted by jumping out of his chair and attempted to strangle the Psychiatrist with both his hands. On police attendance the victim and staff at the unit did not wish to make any complaint, but explained that the unit’s facilities were unsuitable for maternal grandfather. At the scene, maternal grandfather was detained under Section 136 of the Mental Health Act and taken directly back to the previous hospital’s Section 136 suite for an assessment. Maternal grandfather was admitted informally back on to the acute 13 inpatient unit. The Psychiatrist who was assaulted later contacted the police stating that she wished to make a complaint and was now off work as a result of this incident. As a result of the official complaint of assault, a crime of Common Assault was raised, which was later superseded by the murder charge. 2.2.10 From the 29th September, 2014, discharge planning was discussed with maternal grandfather. During this period he continued to state that he did not feel ready to go home, as he wanted to go into residential care. It is noted that mother had stated that she wished for maternal grandfather to live nearer to them. Maternal grandfather held the belief that his daughter and ex-wife were going to clean his home on a regular basis if he returned to live in the community. He had previously refused contact with both women and it appears that he had now selected to re-engage with them on his terms, further demonstrating his manipulation. He also stated that once he was discharged from hospital, mother was going to visit him more regularly to help him stay on top of the cleaning, however, it appears that mother had not agreed to undertake a ‘deep clean’ or indeed regular cleaning of his home. 2.2.11 On the 17th October, 2014, mother and maternal grandmother visited maternal grandfather in hospital; they both stated that his housing situation was of concern. He refused to see either of them, but agreed that they could attend for the ward round on the 23rd October, 2014. On the 19th October, 2014, maternal grandfather began to discuss his wish to self-discharge as he wanted to leave the ward. He also stated that he wished to live with maternal grandmother, but she refused his request as she did not feel able to cope with managing his needs. On the 25th October, 2014, maternal grandfather asked to be placed in seclusion so that he could shout and vent some frustrations. Once in seclusion he laid on a mattress. Maternal grandfather later advised that the police were required as he was not well. He explained that he should not be on the ward, appeared annoyed and hostile, swore at staff and stated that they did not understand. On 30th October, 2014, mother informed the unit that maternal grandfather had re-established contact with her in the last few days. 2.2.12 During early November 2014 mother and maternal grandmother began to clean maternal grandfather’s home and offered support to assist him resettle in the 14 community. Maternal grandfather initially refused to leave the ward and asked again whether or not he could stay with his ex-wife. On the 24th November, 2014, mother telephoned the ward to express her concerns regarding her father’s planned discharge from hospital as she felt he was not well enough and required a lot of input. Later that day he returned from unescorted voluntary leave with mother and maternal grandmother to the ward, but had initially refused to return. He also repeatedly asked mother if he could stay with her for a few days, but was advised that she did not have the room for him. Both women expressed concerns that maternal grandfather may ‘up the ante’ of his attention seeking behaviour to get his own way as he liked being in hospital and did not like his home. This demonstrates the family’s insight into maternal grandfather’s manipulative behaviour. He left the ward that afternoon again on unescorted voluntary leave and attended mother’s home; she agreed that he could stay overnight. 2.2.13 On the 25th November, 2014, maternal grandfather returned with mother and maternal grandmother where he was agitated, his family were clearly distressed and asked to leave the ward. Maternal grandfather then assaulted a male nursing assistant by punching his head. Maternal grandfather was placed in the de-escalation room as he was becoming increasingly aggressive. The police were advised that he was an informal patient and not acutely unwell. Maternal grandfather was arrested for Common Assault, taken into custody, and bailed to return to Lincoln Police Station. Later the same day the Psychiatrist spoke with mother and maternal grandmother and they expressed concern about maternal grandfather hurting someone. They were informed about the assault on the nursing assistant earlier that day and also informed about the previous assault on a staff member. There is no evidence in agency records that the details of that previous assault were shared with the family. The LPFT ANR also reflects that on this date, mother and maternal grandmother reported concerns to the acute inpatient unit that maternal grandfather posed a risk to others. The example of threatening others with a knife was given to staff and concerns raised about vulnerable residents at his accommodation. Both raised concerns about him whilst on unescorted voluntary leave and that they were frightened of him turning up at their properties. They also identified the presence of his grandchildren at his daughter’s home, but that they did not think that he would harm his grandchildren. All of these factors represented a change in risk status, as staff had been made aware that maternal 15 grandfather now had access to his grandchildren and they perceived a risk to the family and public. He was now a proven risk to LPFT staff from two separate assaults. If this information had been considered and assessed then the risk assessment should have been updated. 2.2.14 On the 6th December, 2014, maternal grandfather told the Trust staff that he would not be able to survive outside of hospital and again complained about pains in his head. He was offered reassurance that he would not be discharged if professionals were not confident that this was the right option. Maternal grandfather did not appear to accept this and stated that he held a belief that he is a “one off case”. Despite his recent assaults on staff, his non-adherence with his discharge plan and continuous resistance to discharge and re-settle in the community, his risk of harm to himself and others was assessed as ‘low’. 2.2.15 On the 9th December, 2014, a comprehensive multi-disciplinary ward review was undertaken, which noted the concerns from the family and discussed maternal grandfather’s risk to others, with the decision reached that he was not suitable for early discharge. Therefore, the plan of the MDT was to discharge maternal grandfather only following a period of further leave. 2.2.16 On the 10th December, 2014, maternal grandfather attempted to assault a nurse whilst discussing the planned home leave for that day. Trust staff believed this triggered the assault, rather than any physical or mental health concerns. Maternal grandmother attended the ward to collect him for planned leave but was advised not to take him as on a previous occasion he had attempted to physically assault her. The police attended and spoke to maternal grandfather, however stated that they could not arrest him as he had not actually committed an assault. He later became aggressive again and attempted to throw a table at staff members whilst stating that he wanted to be arrested. It was then decided that maternal grandfather should be discharged from the ward due to the number of violent incidences towards staff when leave from the ward or discharge was discussed, with the Treating Consultant Psychiatrist stated that the incidences were not due to his mental health. There were no concerns with regards to his capacity and there was no evidence of acute mental illness during his admission to the unit. As a result a decision was reached to discharge him due to level of risk to 16 staff. That same day there was a plan recorded that the police would attend the following to prevent a breach of a peace. Also, the community mental health follow up was arranged to his home address. 2.2.17 On the 11th December, 2014, Police officers attended to prevent a breach of the peace. Despite a comprehensive review of this case for the ANR, there was a lack of clarity regarding the authorisation of maternal grandfather’s discharge. The Root Cause Analysis (RCA) completed and the RCA Panel have now established the Treating Consultant Psychiatrist on the day of maternal grandfather’s discharge. It appears that the process of discharge was contrary to the Trust’s Clinical Care Policy and was undertaken due to the concerns regarding the escalating violence towards staff and as he did not require a placement within an acute inpatient unit. It appears that there was a breakdown in communication, and a lack of consistency in decision making, in particular the clarity of the role of the Treating Consultant Psychiatrist. Whilst there was a full risk assessment completed prior to discharge it failed to identify any wider risks other than to LPFT staff. He was discharged to his home address, but subsequently arrived at mother’s property where he stayed the night and later refused to leave. Mother became concerned due to her family and work commitments. It was agreed that maternal grandfather was to stay with maternal grandmother over the Christmas period, but not indefinitely. 2.3 Information from the Family 2.3.1 To enable the family to participate in the review, the SCR timescale accommodated the parallel criminal proceedings. Father had elected not to be part of this review process. Mother and maternal grandmother were invited to participate in the SCR and on the 16th May, 2016, the overview author met with both women. Due to the nature of this SCR, listening and gathering the views of the family was essential. Not only did this meeting allow the author to fully understand the context of Alex’s life, but also assisted in placing him in the forefront of this review. 2.3.2 It is pertinent to note that throughout this review process, mother and maternal grandmother have presented themselves with the upmost dignity. Both women began 17 by explaining the sense of loss felt by the school and community as a whole. However, the support of the school has been of great comfort to them, with great praise for the school’s efforts, support and guidance. Indeed, they described how the school have been ‘exceptional’ and did ‘everything to help Alex’. Alex was described as a lively, happy, inquisitive and unique boy who did not ask for anything. Mother described that he was very kind and would openly share whatever he had. Essentially, his ‘special spark’ was loved by all. 2.3.3 Maternal grandfather had often shared time with them as a family, including attending family holidays. They were of the view that maternal grandfather would not harm a member of their family. They both explained how he had often been verbally abusive, but never physically violent towards them. They described the exceptional and harrowing impact of Alex’s death on them as a family, not only the loss of Alex, but also the fact that this loss was a result of maternal grandfather’s actions. 2.3.4 Firstly, they expressed how LPFT staff members did not listen to their views, in particular regarding the quality of services offered to maternal grandfather. They explained how they repeatedly raised concerns regarding maternal grandfather’s deteriorating mental health, with a junior doctor responding that ‘they could cross that bridge when they come to it’. These concerns included increased agitation, his inability to cope, a significant decline in his self-care skills and personal hygiene. As family members, they felt that they had the knowledge and understanding of maternal grandfather’s needs to be able to voice their concerns. 2.3.5 Secondly, they raised concerns regarding the consistent sharing of information with them. The key example provided was regarding maternal grandfather’s discharge, in particular as they had been advised that he would not be discharged. They continued to be unclear regarding the accountability of this decision and the actual identity of the Treating Consultant Psychiatrist who undertook the decision to discharge him. They question the purpose of his escorted discharge into the community by a police officer. Also, they query why information was not shared with them regarding his assault by attempting to strangle a Doctor, in particular as it was known that there have young children within their family. They feel that a key piece of the jigsaw was 18 missing here regarding the adequate communication of risk and safeguarding concerns, not only to them as family members, but also to the wider public. 2.3.6 Thirdly, they described several occasions when they were treated by the LPFT staff members. They felt that information was not shared with them until the point when a request was received for them to clean his flat in preparation of his discharge home. Communication was then focused on the length of time it would take them to clean his flat. In addition, they were left for 3 hours waiting to attend a ward round without any form of communication with them as his family. As maternal grandfather was an adult deemed to have mental capacity, the flow of information shared with the family would be dependent on his wishes and feelings. The Trust could only share information with the family when maternal grandfather agreed and therefore he could dictate the degree of their involvement. However, it cannot be known if the family would have responded differently if the abusive episodes towards staff on the ward would have been shared with them. 2.3.7 They felt that they clearly voiced their concerns regarding his presence at their home and his continual request to live in either of their homes. They felt that he was discharged without the appropriate plan or communication with his family; he also did not have the appropriate supply of medication. During the post discharge home visit, maternal grandmother explained that he did not speak. Maternal grandmother was advised that she could receive the required medication from the crisis team, but the crisis team did not attend the arranged appointment and she had to collect his medication. Instead, the crisis team telephoned maternal grandfather and did not mention his lack of medication. Therefore, their key question and concerns focus on the quality of the care and treatment plan and the preparation for his discharge. As a result of this review, they are eager that constructive lessons are learnt, to focus on service developments and good practice. 2.3.8 The family voiced that maternal grandfather was very much part of their family and often attended family holidays. The family loved maternal grandfather, despite the emotional burden he placed on them; they continued to offer him care and support as a family. However, they were not fearful of him either on an individual level or on behalf of the children. Despite the exceptional impact of this loss on their family, their 19 sincere description of Alex animated his characteristics in such a heartfelt and dignified manner. 3. ANALYSIS: THE AGENCY NARRATIVE REPORTS (ANRs) & THEMES All the ANRs addressed the Terms of Reference of the SCR. The ANRs were informed by agency records, procedures and as required interviews with key professionals. All reports were helpful in drawing clear analysis of agency involvement and any lessons to be learnt. The SCR Terms of Reference identified several themes to be examined:- Resource, Policies and Procedures; Risk Management, Information gathering, sharing and defensible decision, Competencies training development, Line management advice and guidance Culture, Communication. 3.1 LINCOLNSHIRE PROBATION TRUST: With regards to maternal grandfather’s offending history, the Lincolnshire Probation Trust was involved with maternal grandfather from the 22nd July, 2011 until the 21st January, 2013 whilst he was subject to an 18 month Community Order for an offence of affray. The Order contained supervision requirement and a 6 month mental health treatment requirement. At the time of this offence for affray, maternal grandfather was living in supported accommodation and the offence involved him threatening an elderly female victim with a knife when she refused to give him what he wanted (a cigarette and a cup of tea). Evidence suggests that this Community Order progressed well, with the mental health treatment requirement expiring on the 21st February, 2012. Whilst this Community Order was successfully completed, maternal grandfather had made threats to other residents at the supported living accommodation and as a result was on his final warning in terms of residing at this address. The police attended and spoke to both parties, it was felt that the threats were not genuine and he was not convicted for this offence. At the end of this Community Order it is noted that maternal grandfather had achieved a significant degree of stability and was assessed as posing a medium risk of serious harm to the public. According to probation records he was abstinent from alcohol, was complying 20 well with his mental health treatment/medication and had a good relationship with his daughter and grandchildren. The Probation Trust had no further contact with maternal grandfather following the expiration of this Order on the 21st January, 2013. 3.2 THE POLICE: Lincolnshire Police is an organisation employing approximately 2000 staff, around 1100 of which are Police Officers. Within Lincolnshire Police, the Public Protection Unit (PPU) has responsibility for a number of aspects of policing, not least of which is Child Abuse Investigation, but in this regard it is limited to intra familial abuse and offences committed by persons in positions of trust. Other sexual offending against children is investigated by mainstream Criminal Investigation Department (CID) Detectives, supported where appropriate by PPU staff. The PPU is a specialist unit of highly trained staff and is responsible for the management and investigation of crimes involving: Safeguarding Adults; Safeguarding Children; Sex and Dangerous Offender. The Public Protection Unit can also advise on investigations of Domestic Abuse, Honour Based Violence and Forced Marriage. To provide an accurate picture of the level of police involvement with maternal grandfather, details beyond the scope of the terms of reference require consideration, as between April 1996 to December 2015 there were 92 recorded incidents of police attendance involving maternal grandfather. These incidents cover a variety of crimes and occurrences, ranging from concerns for safety, mental health issues, suicide attempts, anti-social behaviour, theft, arson, drink related offences, public order offences, criminal damage and assaults. Thirty-two of these relate to theft from shops and drink related offences; many of the thefts were committed whilst in drink, where aggression was shown towards staff or members of the public. There were also a number of assaults and Public Order Offences which were committed whilst under the influence of alcohol. In addition, there are recorded incidents of maternal grandfather reported missing, where he was dealt with by way of Section 136 of the Mental Health Act. There are also recorded incidents of maternal grandfather as the victim of assault. There were several occasions when the police attended maternal grandfather’s accommodation to undertake a welfare check due to concerns raised regarding his 21 whereabouts, wellbeing or presenting mood. Therefore, this was a citizen who was well-known to the police due to his persistence offending and often chaotic lifestyle. On the 22nd September, 2014, whilst inpatient within NHS mental health rehabilitation centre, maternal grandfather assaulted a Psychiatrist. The allegation was that maternal grandfather had grabbed hold of the doctor around her throat, whilst saying that voices have told him to do so. On the police attendance the victim and staff did not wish to make any complaint, but explained that this particular NHS facility was unsuitable for maternal grandfather. As a result, maternal grandfather was lawfully detained under Section 136 of the Mental Health Act and assessed. This was a missed opportunity for Trust staff and the Police to share information and work together effectively. Maternal grandfather had assaulted a member of Trust staff and was removed from the unit by the Police. At this point, it would have been pertinent to assess maternal grandfather’s mental capacity in relation to the assault. This would have established the appropriate decision making for responding to maternal grandfather. There is no evidence that the Trust completed a formal capacity assessment or took the lead with the Police to suggest that a capacity assessment was required in relation to this assault. The assaulted Psychiatrist later changed her mind and just under a month after this assault contacted the police. She stated that she was off work as a result of the attack and wished to make an official complaint. A crime of Common Assault was raised and efforts were made to interview maternal grandfather. A decision was later undertaken that it was ‘not in the public interest’ to proceed as by then he was charged with Alex’s murder. This incident demonstrated the actual and potential risk of harm maternal grandfather presented. Whilst the degree of his violence was not predictable, a ‘pause and a review’ and re-assessment of his needs by LPFT may have assisted in analysing his risk of harm to others. Prior to Alex’s death, maternal grandfather was dealt with by the Police as a result of attacks on staff within the acute inpatient ward. Firstly, on the 25th November 2014, whilst maternal grandfather was an inpatient, the police received a report from the Trust stating that maternal grandfather had assaulted a male nursing assistant by punching him in his head. The police attended and initially assisted staff to remove maternal grandfather from the ward to a separate room as he was becoming increasingly aggressive. Maternal grandfather was arrested for Common Assault, taken into custody, and bailed to return to Lincoln Police Station. A decision was later undertaken not to charge maternal grandfather for this assault as it was not deemed to be in ‘public interest’ to pursue this further as by this time he was already charged with murder. Secondly, on the 10th December, 2014, maternal grandfather 22 attacked another member of Trust staff, and had been restrained by staff and taken to his room. Whilst in the medical room in the company of a staff member receiving his medication, maternal grandfather pushed aside the medicine trolley, raised both his fists and went towards the staff member. He was taken hold of and restrained before any assault took place. The police attended and spoke to maternal grandfather who apologised to the member of staff and was advised to calm down. Maternal grandfather had been assessed as having capacity and being well enough for discharge and as he was due to leave inpatient services, the staff on the ward believed that this had triggered the assault. The final Police involvement prior to Alex’s death was on the 11th December, 2014, when they were asked to attend to prevent a breach of the peace on maternal grandfather’s discharge from inpatient care. To summarise, maternal grandfather was well known to Lincolnshire Police as detailed in the comprehensive history of police involvement. However, despite this documented knowledge of maternal grandfather’s behaviour and the impact his behaviour had on others, the police had no direct involvement with Alex or maternal grandfather’s family (with relation to maternal grandfather’s behaviour). Resources Policies and procedures: - All incidents attended were assessed and if necessary crimed, with any subsequent arrests dictated by the procedures and guidelines of the Police and Criminal Evidence Act 1984 (PACE). Over the years, maternal grandfather has been arrested on several occasions, none of which had any direct connection with Alex or his sister. With regards to maternal grandfather, Section 136 of the Mental Health Act was initiated on 2 occasions relating to maternal grandfather, firstly, in 2009 and subsequently in 2014. As previously outlined, there was a missed opportunity for joint working between the Trust and Lincolnshire Police to assess and establish capacity in relation to this offence. Risk Management: - No relevant matters identified. Information gathering, sharing and defensible decisions: - The decision to crime incidents and arrest as a consequence was correctly based on the information and evidence the officers had at the time. Competencies training development: - All required training, guidance and support were provided by the Police, with broader and specific training development offered and encouraged. 23 Line management advice and guidance: - All officers are trained in Children’s Safeguarding risk assessing and PACE. It would appear that all necessary training, development, advice and supervisory guidance for staff were implemented appropriately. Culture: The Police are clear within their ANR that there are no presenting cultural issues of concern. Whilst this may be the case, as outlined below there needs to be a focus on shifting the culture of jointly working with LPFT to address assaults and violence suffered by them in the course of their employment. Communication: Overall, there were several examples of good timely communications between the Police and other agencies involved with the family. There was also a lack of joint working with LPFT when dealing with the violent/abusive treatment of their staff. On a positive note, a key outcome of this review is an agreement to facilitate joint working between the Police and LPFT regarding the dealing of violent incidents against LPFT staff. 3.3 EDUCATION: SCHOOL From the 13th October, 2008, Alex attended a local mixed primary school with approximately 240 students on roll. His nursery progress reports commented that he “had settled well at nursery, that he was enthusiastic when playing, a very quiet boy but who was confident around adults”. In his Reception Class, Alex was described as “being a very enthusiastic child”, who showed a keen interest in all aspects of his classroom activities and a real desire to want to do well in tasks he was set. He showed great motivation to learn and a willingness to try new activities. He was further described as a young boy who was developing a wider group of friends and showed a full range of feelings whilst having a clear understanding of right and wrong. His attendance was 96% in Reception class and he received praise for making a positive contribution to the year group. By Year 3, continued to be described as a “polite, caring and capable boy” who was naturally inquisitive and well liked within the class. A confident reader and a capable mathematician who lacked focus at times when left to work independently. It is clear from the school reports that Alex engaged well with all of his subjects, taking part in class trips and workshops. He was described as a child with “exceptional enthusiasm”, who had the ability to be a great all-rounder enjoying other achievements at school such as tennis, football and taking part in a chess tournament. The Head Teacher at the time (2012/13) stated that: "Alex is a lovely lad with a fantastic smile". 24 In February 2013 Alex was referred to receive additional support in school, but this referral was nothing out of the ordinary in supporting children in schools. A range of support strategies were discussed with the school and implemented to support Alex with his learning. Alex’s attendance in Year 4 was 91% and his report describes him as being “lovely, funny and extremely entertaining”. However, the report also describes that he sometimes struggled to cope with the high demands of the work in Year 4, but continued to be extremely inquisitive and ask some fantastic questions. He found Maths to be the easiest lesson as he particular liked shapes. Alex described that when he ‘grew up’ he would like to be either a policeman or a computer programmer. To achieve this, Alex stated he would need to get “A grades and be good at school”. From July to September 2014, there were continued discussions around Alex’s educational needs and the requirement of a statutory assessment of his educational needs. In December 2014 a draft statement of educational needs was issued with specific targets agreed for Alex. His end of term progress report in 2014 noted that he was a “capable child who at times struggled with the high demands of work in Year 4”. There is evidence that the school offered several forms of support packages throughout Alex’s education, which was clearly echoed by the family as they felt that the support offered and provided by the school had been exceptional. Resources Policies and procedures: - Prior to July 2013, Alex’s needs had been assessed and managed internally by the School, using School Action and School Action Plus support. This method of support allows schools to increase or reduce resources when there is some improvement or change in progress. This is the correct process that all schools adopt when assessing and addressing a child's needs in school. The records held by the school do not appear consistently detailed. The introduction of Educational Health Care Plans will go some way in ensuring that records are detailed. A referral to the Educational Psychology Service was promptly made and the evidence collated to apply for a statement of special educational needs. The referral for assessment was received by the Lincolnshire County Council on the 23rd July, 2014, and the Proposed Statement was issued on the 9th December, which was 13 days outside the deadline. There is no further information held to explain this delay. 25 Risk Management: With regards to Alex’s progress in school, his needs were assessed using the appropriate methods as part of ongoing assessment of his development and progress. Support was offered by internal and external agencies in a task orientated manner, with a transparent picture of Alex’s needs fully gleaned when the Statutory Assessment of his needs was completed and reviewed. Information gathering, sharing and defensible decisions: There appears to be continuous communication regarding Alex’s educational needs, which were well known. Alex’s progress was monitored, with the required assessments and observations completed. Competencies training development: All required training, guidance and support were provided by the school, with broader and specific training development offered and encouraged. Line management advice and guidance: - Alex had access to a teaching assistant and additional support as per his assessed educational needs. Culture:-The school was aware of how to identify and meet the needs of Alex. The family praised the school’s culture, support and guidance throughout. Communication: - The records indicate that the school showed a good level of engagement throughout and liaised effectively with mother throughout. His voice is also effectively captured throughout their meetings, which illustrated his personality, likes and dislikes. 3.4 PRIMARY HEALTHCARE: GP SURGERY The relevant family members were registered with two separate GP Practices in Lincolnshire. Alex, mother, maternal grandmother and sister were registered with one Practice, whilst maternal grandfather was registered with another Practice. With regards to the children, Alex’s sister attended the surgery on an infrequent basis for minor illnesses only, but Alex was not seen by the GP during the scoping period of this review. Alex was up to date with 26 his immunisations and vaccinations, with no concerns expressed by the GP regarding either child’s health or wellbeing. Maternal grandfather’s GP records indicate that he was deregistered from the practice on the 26th September, 2014, with a rationale recorded that he had left the area, following the receipt of information that he was no longer resident at his address. It appeared that an administrative error occurred resulting in maternal grandfather’s records being closed and subsequently deducted from the GP list. However, the records never left the GP surgery because the transference process of records is in response to a new GP requesting the notes from the existing GP. There being no request, the records stayed on file and could be re-opened at any time. This is an established process, whereby this was a human error as opposed to systems failure, however, this did not have any impact in this particular case. There is nothing within the GP records suggesting that maternal grandfather had a prolonged episode without access to his anti-depressants or any other prescribed medication. The contact that maternal grandfather had with the GP and the prescription of medication was within normal and expected practice. In fact, the GP demonstrated good liaison with LPFT throughout. When the GP became aware that Clomipramine, the anti-depressant that maternal grandfather was initially prescribed was no longer available, advice was sought in a timely manner from a specialist who provided an alternative anti-depressant to be prescribed. The records show that this was actioned with immediate effect via an urgent referral, ensuring that there was no gap in provision of anti-depressant therapy. The report provided by the GP relating to the other adults of the family provides an overview of involvement with the GP. Each individual family member was managed by the GP regarding their health and wellbeing, which includes no reference to Alex either directly or indirectly. GP Primary Care Resources Policies and procedures: - As detailed within the fringe learning (see section 4.), the matter regarding the referral management system will be addressed following a review of this system and the audit of the process. Risk Management: - It is good practice to respond to parental concern, however, despite an electronic system implemented to trigger a reminder to refer, the referral as requested by 27 mother for Alex to receive a Paediatrician assessment was not actioned. Despite this, there was no direct impact on Alex. It is positive that the GP Practice is reviewing their referral management system. Information gathering, sharing and defensible decisions: - As outlined, there was limited contact between the GP and Alex as he did not attend for any appointments during the review period. Competencies training development All relevant processes for arranging training and development of GP practice staff were implemented. Line management advice and guidance:-No relevant information, concerns or learning identified. Culture: It is apparent that the GP practice knew the family well and had developed a relationship over a period of several years. The agreement to action a referral request in the absence of an actual consultation suggests confidence and a lack of formality that develops within trusting relationships. The GP’s acceptance to make a referral in the absence of a face to face contact would strengthen the evidence of a developed professional relationship between the GP and this family. Communication: - The long standing relationship with the GP and the family suggests the GP was aware of the health and wellbeing issues regarding the adult family members. As Alex did not see the GP or experience significant health concerns within the scope of this review, his voice is obviously not evident. 3.5 UNITED LINCOLNSHIRE HOSPITAL NHS TRUST (ULHT) ULHT had very limited contact with the family. On the 3rd September, 2014, a letter was sent to mother confirming that an appointment had been made for Alex to be assessed by a Community Paediatrician on 22nd September, 2014. Upon researching ULHT’s involvement with Alex, the ANR Author reported a lack of clarity in relation to the informal processes currently in place between the Community Paediatrics Team (employed by ULHT) and the 28 Community Health Trust (LCHS) for the arrangement of appointments and storing of clinical records. However, this did not appear to have a particular impact in this case. 3.6 LINCOLNSHIRE PARTNERSHIP NHS FOUNDATION TRUST (LPFT). The Trust was established on 1st June, 2002, when social care and health services, formerly provided by Lincolnshire County Council and Lincolnshire Healthcare NHS Trust, were brought together to create a new mental health and substance misuse services for adults. The Trust was authorised as a Foundation Trust on 1st October, 2007. Lincolnshire Partnership NHS Foundation Trust (LPFT) provides a range of health and social care services for people of all ages. The Trust provides care and treatment for a local population of some 735,000 people within Lincolnshire. In addition to this SCR, an internal Root Cause Analysis (RCA) investigation was commissioned by the Chief Executive of the Trust. The aim was to undertake a multi-disciplinary review of the care and treatment provided to maternal grandfather and to identify whether there was any aspect of the care and management that could have minimised the likelihood, prevented the event, or minimised the death of Alex. Maternal grandfather accessed the Trust’s mental health services frequently between the years of 1997 and 1999. He was again in frequent contact between 2005 and 2014. He received services from multiple specialities including a single contact with the Trust forensic team in 2006, Primary Care, Crisis Home Treatment, Integrated Community Mental Health Team, Psychology and Psychiatric out-patient services. He had twelve admissions to acute or rehabilitation in-patient units between 2007 and 2014. A variety of psychiatric diagnoses including anxiety, recurrent depression, personality disorder and bipolar affective disorder were made during maternal grandfather’s contact with the Trust, with these diagnoses primarily given in the context of his alcohol use. Maternal grandfather had reported that he had been abstinent from alcohol since 2009. Maternal grandfather’s anti-depressant medication was consistently prescribed by the GP until the 16th April, 2014, when the GP practice manager communicated with the secretary of an LPFT psychiatrist stating that maternal grandfather had rung the ICMHT as he had not received his Clomipramine (which the GP practice were unable to obtain due to manufacturing issues within the UK). The LPFT psychiatrist advised the prescription of 29 Venlafaxine (anti-depressant) by the GP until maternal grandfather obtained a review appointment. This prescription was continued until the 21st July, 2014, when a telephone communication between the GP and maternal grandfather identified maternal grandfather’s increasing symptoms of depression. The GP referred maternal grandfather to the older age community mental health team for a dementia assessment and completed an urgent referral to the ICMHT. Maternal grandfather was seen by the psychiatrist on the 29th July, 2014, and is admitted informally to an acute inpatient unit. The period when maternal grandfather’s anti-depressant medication was changed signified a key period of decline in his mental wellbeing. If he had been reviewed as planned by a Psychiatrist within the community, soon after the 14th April 2014, then it is likely the newly prescribed antidepressant would have been reviewed by the Trust and amended if required. This review could also have initiated the ‘fast track’ mechanism for maternal grandfather to receive support from LPFT during a period of medication transition. If this review had taken place, his deterioration within the community may have been slowed or prevented. Mother and maternal grandmother stated that they did not have prior concerns for the safety and wellbeing of her two children when in the care or company of maternal grandfather. As expected, in his role as maternal grandfather, he spent time in the company of his daughter and his grandchildren and attended family holidays. However, whilst they feel that he may not have necessary been a risk to the children, they did raise on the 24th November, 2014, that he may ‘up the ante’ in some way to get his own way as he liked being in hospital and did not like his home. On 25th November they also highlighted what the Trust’s RCA panel considered to be public safety concerns. Not only does this demonstrate the family’s insight into maternal grandfather’s manipulative behaviour, but also that they did raise general concerns with LPFT staff on at least two occasions. During the family interview on the 16th May, 2016, both women reiterated this view and their reflections that they felt that not all the necessary information regarding maternal grandfather’s risks were adequately shared with them as his family. Following on from this point, there are also issues relating to the care and treatment offered to maternal grandfather, which was another concern raised by the family. For example, they believe that he was discharged in an unplanned manner, without even the clarity of the professional functioning as the Treating Consultant Psychiatrist who sanctioned this discharge. Listening and addressing the concerns raised by the family around maternal grandfather’s deterioration, and completing a comprehensive risk assessment with the 30 required professional curiosity may have provided the opportunity for family members to further share the details of their concerns and their experiences shaping their perspective. On several occasions maternal grandfather appeared irritable, agitated and neglected his hygiene. During his inpatient period he repeatedly complained of tightness in his head. However, as the court transcripts of the expert witness testimony illustrates there were no identified physical or mental health concerns identified to trigger these headaches. In fact, the expert view demonstrated that maternal grandfather was manipulative. During his inpatient period, maternal grandfather appeared fixated with his wish to move into residential care as he felt he could not cope with living on his own and felt “lonely”. Alternatively, he wanted to be placed within a maximum security hospital as he felt he had a personality disorder. He commented that he would be better as long as he was “locked up” and that he “should be taken away”. The chronology illustrates the journey of maternal grandfather’s declining mental wellbeing between April to July 2014, the pressure this placed on his family and his manipulation of the situation, which was not assisted by the services he was offered during this period. There was a lack of defensible risk assessments to inform the discharge planning process and to fully consider and analyse the risks that he posed to others. A review of the Trust’s safeguarding screening tool about children was not undertaken, which resulted in superficial and ill-informed risk and vulnerability management. There were several incidents when there were sufficient triggers to warrant a more comprehensive review of the risk assessment to others, for example, on the 25th November, 2014, when there was a missed opportunity to review and evaluate all of the known information following another assault on a Trust staff member. In fact, this information contextualises mother and maternal grandmother’s concerns that he would “up the ante” and be a risk to others. Within this dynamic, rather than considering the wider risk to the public which includes Trust staff, the safety of the wider public was not identified. Whilst it is now accepted that maternal grandfather did not require inpatient care, this was not the view shared by the LPFT Psychiatrist two days prior to maternal grandfather’s discharge. On 9th December, 2014, there was a comprehensive multi-disciplinary ward review (MDT) led by the Treating Consultant Psychiatrist, where the plan for discharge after a period of leave was planned. This Psychiatrist was new to this post and had recently taken over as maternal grandfather’s inpatient Treating Consultant Psychiatrist. The expressed fears and concerns of his family and maternal grandfather’s risk to others was discussed and reviewed. 31 Maternal grandfather’s family were recorded to be ‘concerned, as he had previously made threats towards them, adding to his risk of violence’. A risk assessment update to ‘risk to others’ was recorded as ‘low currently but previous severe assaults indicate potential risks for future’. It is recorded that maternal grandfather was not suitable for early discharge. There was no formal meeting to review his risk prior to discharge despite significant concerns and evidence of his risk of harm to others. It should also be borne in mind that concerns were raised by his family regarding maternal grandfather’s behaviour and the potential vulnerability of other residents. Also, maternal grandfather’s use and manipulation of his daughter and ex-wife demonstrated his attitude towards both of them and his selfish tendencies despite their unconditional support and assistance. Whilst the Trust staff appeared willing to engage mother and maternal grandmother to assist maternal grandfather to return home, it appears that their concerns went unheard and become ‘invisible’ in the scheme of returning maternal grandfather home and thus removing him from the unit. On 12th December, 2014, mother rang the maternal grandfather’s social worker and informed her that he had arrived at her house and she had allowed him to stay for one night, and on that day she did not know what to do as he was refusing to leave. Mother did not feel she could manage him in her home due to family and work responsibilities. The Trust staff attempted to come up with a plan and rang her back, at which time maternal grandmother was planning on assisting him to return home. On 14th December the Trust community staff rang mother and she confirmed that maternal grandfather was temporarily staying with maternal grandmother. On 15th December a home visit was agreed with maternal grandmother for the 16th December, but she was unavailable and so agreed home visit for the 18th December. On the 18th December a face to face seven-day follow-up appointment was undertaken and completed by the Crisis and Home Treatment Team and Integrated Community Mental Health Teams from maternal grandfather’s home area at maternal grandmother’s home. There is no evidence of a robust review of risk despite his change in circumstances from the intention to live at home to staying with his family despite the known history of incidents whilst on acute inpatient ward. However, this was a joint home visit with a social worker and a nurse present due to the potential risk to professionals. Between the 18th December and 21st of December, three telephone calls were made to maternal grandfather as attempts to offer him face to face visits. All three calls went unanswered until the 22nd December when contact was made by telephone with a Crisis Nurse. Maternal grandfather was discharged unseen after he declined to see the Crisis team and denied any risk to self or others. Therefore, the follow-up visit 32 failed to robustly evaluate the known risks posed to the family and the wider community. The lack of focus on defensible risk management did not consider maternal grandfather’s history, in particular his pattern of recent violent behaviour and the risks to the wider public. Resources Policies and procedures: - The policies, procedures, good practice and statutory guidance for all staff were up to date. Therefore, the missed opportunities identified were not a result of a lack of procedures, knowledge or resources, but were rather environmental and cultural in nature. This illustrates that simply noting a contractual or strategic commitment to safeguarding is insufficient if the culture in this case does not support the operationalisation of this into everyday practice. Throughout maternal grandfather’s treatment there was a general lack of robust consideration of risk management and effective multi-agency working in line with the Trust expectations, policies and procedures in this case. Risk Management: Robust and effective risk management tools were implemented to assist clinical staff to undertake defensible risk assessment. However, the risk assessments completed throughout maternal grandfather’s mental health care did not defensibly measure his actual or potential risk to others. Risk assessments were ineffective in analysing maternal grandfather’s historical and presenting behaviour to inform a robust risk management plan for the wider public. The evidence reflects insufficiently robust risk identification, assessment and review processes which represented a common factor that influenced core decision-making processes throughout maternal grandfather’s care. Reiterated below is the key finding of the RCA which found, “..that that there were missed opportunities to fully assess and manage the clinical presentation and associated treatment and risk processes. This led to subsequent failures to provide consistent and robust care and risk management plans, by both individual practitioners and the broader multi-disciplinary team. This resulted in a level of decision-making and care delivery that fell short of the standard of care expected by the Trust”. Despite assaults on two staff members and two other attempts there continued to be a lack of due regard to the requirement to consider the wider risk to others. In light of this, maternal grandfather continued to demonstrate his abusive and violent behaviour with limited consequences considered. Therefore, despite actual evidence of violence and harm, concerns voiced by his family that he would ‘up the ante’ to get his own way and a change in his circumstances, maternal grandfather’s presenting needs and risks were not sufficiently re-33 assessed or evaluated. Trust staff had observed his attitude and behaviour towards his family, in particular his manipulative tendencies. Despite all of these concerning variables, his risk to the wider public and family were not analysed. The quality of the risk assessment further deteriorated prior to maternal grandfather’s discharge from inpatient care. This is evident on the 9th December, 2014, when a comprehensive multi-disciplinary ward review led by a Consultant Psychiatrist noted Maternal grandfather’s “risk to others’” as “low currently but previous severe assaults indicate potential risks for future” and confirms that he was unsuitable for early discharge. It is questionable whether the presenting evidence and risk equated to “low risk”, in particular as the assaults were repeated and recent. Also, no additional specialist advice, for example, advice on risk from the Trust specialist community forensic team which are routine risk management steps/processes to be accessed when evaluating this degree of actual and potential risk of harm. However, despite the decision that maternal grandfather would not be discharged until after a further period of home leave, two days later he was indeed discharged from the acute inpatient ward to the community. What is of concern and illustrates the practice and culture of this inpatient setting in this case is the lack of a robust risk assessment of the risk to the wider community, whilst the risk to the inpatient ward staff was evaluated. Assessing the risk to staff members in itself is not an issue, however, assessing the risk to staff and ignoring the wider risks is of concern. Whilst the evidence now reflects that maternal grandfather was in the incorrect placement (i.e. inpatient care), it remains unclear why he remained in this placement for this length of time, in particular as this is a scarce resource. Following his discharge, there was a lack of evaluation of the information received directly from maternal grandfather and his family around his refusal to leave their homes and his demands to stay in their homes, as well as a time when he had refused to return to the unit. The 7 day follow up visit in the community following discharge lacked the robust approach required to consider the impact of this violent behaviour and indeed his manipulation of his family members, this was based on the updated discharge risk assessment information which had not considered wider public risks. There was a lack of professional curiosity to review the information beyond the superficial presenting needs as the outcome of this visit was noted as raising “no particular concerns”. This is despite the lack of any form of robust risk assessment, his recent abusive and violent behaviour whilst an inpatient, and the professional 34 judgement on the 9th, December, 2014, that he should not have been discharged at this time. The context of his behaviour was an established pattern of recent aggression to LPFT staff, assaults (the attempted strangulation of a Psychiatrist) and the in the author’s view the lack of value of the family’s contribution and the wider knowledge of their knowledge of his behaviour. The professional foresight, instinct and drive to evaluate maternal grandfather’s risk assessment to others in a fluid and dynamic manner was missing at the point of discharge and essentially led to a lack of consideration of risk management by using multi agency public protection processes. Information gathering, sharing and defensible decisions The issues regarding the lack of defensible information sharing was not due to policy, procedures or training as the required systems were implemented. The evidence demonstrates that not all decisions made by Trust staff in relation to the care of maternal grandfather, were fully informed by or made after consideration of all available information and evidence. Instead, they were based upon risk assessments that did not analyse wider risks to others. As a result, the risk and protective factors for working with maternal grandfather and his family were not balanced effectively against one another. If the risk assessment process had been completed effectively, there would have been consideration of the risk to the wider community. There is evidence that the Trust shared information with the Police, GP and indeed with the family when maternal grandfather eventually consented. Despite this, the lack of acknowledgment of the concerns that the family says they shared impacted on the quality of the information shared and how this information was operationalised to ensure the risks to others were robustly managed. Key decisions were undertaken without the foundation of a robust assessment informed by multi-agency information, which is evidenced by the fact that he was within the incorrect placement to meet his needs for a period of 4 months. There was also poor recording of the decision making between the ward consultants and the ward team upon discharge on the 11th December, 2014. Competencies training development All the required training and development were offered on a continuous basis to the Trust staff. However, at the time of Alex’s death; out of the 29 staff working on the acute inpatient ward only 14 (48%) were compliant with their mandatory safeguarding children level 3a, which included domestic abuse competencies. The Trust has implemented a new clinical risk framework after having consulted with a number of 35 key national policies and publications on best practice in assessing and managing risk. The new risk framework focuses clearly on risk to others and prompts staff to consider safeguarding screening tool information when assessing risks. It also reminds staff that they need to complete and update their safeguarding screening tools in light of their risk assessment and management plan. All the acute inpatient unit staff have been trained on this new risk assessment model and it is fully embedded. Line management advice and guidance: - The Trust RCA panel found, “concerns in relation to management and supervision in terms of leadership, accountability, assurance and managing of staff competency within clinical areas”. Of concern to the panel was, “an absence of evidence supporting sufficient presence and oversight” particularly in relation to the acute inpatient unit. This was in terms of, “ward level managerial input and accountability for clear practice leadership, engagement and quality assurance/service monitoring”. The panel found a, “failure of effective and robust ward level management overview and supervision of service quality and decision making processes”. This lack of management oversight is evident, as even basic practice guidance was not followed. Culture: There were issues in relation to organisational culture in this case that affected the objective and robust assessment of the presenting concerns and needs of maternal grandfather. Once the clinical formulation and associated risks had been decided at the point of admission i.e. that the mental health problem was not acute and the presenting need was social in nature, no alternate formulation was then considered or appropriate discharge arrangements undertaken. Therefore, the professional judgement was static, rather than fluid and dynamic. This perception was most evident on the acute inpatient ward, as staff did not deviate when presented with information and behaviours that potentially conflicted with the existing clinical view. When dealing with acute mental health illness this should not be the case. This was of serious concern given that the foundation of a risk assessment relates to the fact that risk is dynamic, with the review of risk assessments a prerequisite to successful risk management. This flawed view of maternal grandfather’s risk to others focused solely upon his risk to Trust staff and failed to anticipate the potential for maternal grandfather to be a risk to his family or the wider community. This included a lack of adherence to Trust Policies and Procedures as outlined across the agency report in relation to risk assessment, information sharing and communication. 36 This demonstrated an endemic culture in this case that prevented objective, responsive and analytical assessment and care planning. This culture proved crucial and functioned as a blockage to good practice as contact with maternal grandfather was clouded by a static judgement. There was evidence of a staff culture of maternal grandfather ‘being the same as he always was’, which is destructive when aiming to work within an environment where it is essential that risk is seen as dynamic. It was unhealthy and risky practice to regard maternal grandfather’s escalating violence and abuse as presenting the ‘same as he always was’. Communication: - The same themes noted within the risk management and information sharing sections are applicable here. Essentially communication, information sharing and risk assessments were ineffective. The several examples of poor communication are outlined within the ‘missed opportunities’ e.g. the poor communication during the discharge planning stage. Not only were the risk assessments inaccurate and flawed, but opportunities to communicate on a multi-disciplinary and a multi-agency basis remained unidentified and unexplored. The Trust missed the opportunity to hear the voice of the family and to adopt a multi-agency approach focused on strength based principles or ‘Think Family’. This flaw was evident by a lack of robust assessment throughout maternal grandfather’s treatment. There was no wider evaluation or prediction of risk beyond the superficial, even when maternal grandfather was voicing his own concerns/fears about his behaviour and intention to harm others. The overwhelming lack of communication is evident in the decision to discharge maternal grandfather following a professional judgement indicating otherwise and a following two assaults and two attempted assaults on Trust staff. Not only did the judgement to discharge lack a robust professional rationale, it appears that this was to the consideration of the protection of Trust staff. Whilst it was correct to consider the risks to staff members, the risks to his family and the wider community should also have been reviewed. There was also a comprehensive breakdown in communication, when even the role and responsibility of the Treating Consultant Psychiatrist was unclear. 4. LEARNING ON THE FRINGE During this review one example of learning on the fringe was captured. On the 9th November, 2013, there is a written request by mother asking the GP to undertake a referral to the Community Paediatrician. The GP stated that he would undertake a referral despite having no 37 direct contact with Alex. There is no evidence that a referral was undertaken by the GP. The GP acknowledged that the referral had not been actioned by him, and states that the only explanation can be due to an oversight on his behalf. Although a face to face contact did not occur between the GP and Alex, a task had been generated by the reception staff within Alex’s record to advocate that a referral was required. This should have drawn to the attention of the GP to the need to respond to the request to undertake the referral. There appeared to be an electronic and administrative trigger to ensure that referrals were completed in a timely manner. However, due to human error and competing work pressures, this system did not appear to be a robust mechanism for referral management. The GP is the gatekeeper of access to health services and accordingly, referral to specialist health services is a major component of their work. If this referral had not been proactively actioned by others, this specialised support and guidance may not have been implemented to assist Alex. This GP Practice is currently developing a referral management system to address this issue. Best practice would also be to audit the revised referral process to quality assure its robustness. 5. CONCLUSION The only individual responsible for the tragic death of Alex is maternal grandfather. The evidence indicates that he was violent, abusive and highly manipulative. He prioritised his needs above everyone else and went to great lengths to get what he wanted. Based on his history and escalating violent behaviour, maternal grandfather should have been assessed as a risk of harm to others. Robust professional practice and the required degree of curiosity may have led to the identification of the risk of serious harm to others. Whilst the risk of serious harm to adults was predictable, the risk to children or indeed his family was not evident. However, maternal grandfather was an informal patient and there were no grounds identified to detain him within this setting. Equally so, it is questionable whether or not he should have been placed within an acute inpatient setting at all during this period. Whilst it may have been the appropriate decision to admit him to this unit, within 6 days of admission he was assessed to have no cognitive impairment and not to be significantly depressed. Whilst several agencies provided services to this family, the key focus of this review is on the services provided to maternal grandfather by LPFT. There were several missed opportunities for LPFT to respond differently. These missed opportunities demonstrate a lack of defensible judgement and professional foresight. Specifically, the risk assessment and discharge planning process were flawed to the degree that maternal grandfather was discharged without 38 a full analysis and risk management plan of risk to others. These learning points demonstrate a culture in this case that was focused on the needs of the staff members, which filtered through all core aspects of their work associated with the role of the Treating Consultant Psychiatrist, risk assessment, care management, assessment and review. Whilst little will be of comfort to mother or maternal grandmother, it should be acknowledged that they attempted on two recorded occasions to voice their concerns. This needs to change with a focus required on promoting the voice of carers and their families. The overarching culture of each organisation should be focused on an approach grounded in principles focused on a holistic strength based approach, where the needs of all family members are considered in a visible manner. However, it should also be acknowledged that not all risks can be prevented, but robust risk assessments can manage and mitigate risk factors. To summarise, there are several key points of learning for LPFT. Firstly, the lack of competent practice and professional curiosity resulted in a lack of robust risk assessment. The discharge planning lacked any form of basic defensible risk assessment, planning or analysis of the presenting risks to the wider public. Secondly, the culture within this particular inpatient ward in relation to this case perpetuated an ethos focused on a lack of ownership, in particular in establishing the Treating Consultant Psychiatrist. Thirdly, despite the presence of comprehensive policies, procedures and training; the organisational culture functioned as a barrier to assessing maternal grandfather in a dynamic manner. Finally, these learning points resulted in the lack of visibility of the family’s needs and the safeguarding concerns that required managing on a multi-agency basis. Therefore, the flow of practice from the planning, assessment, to his discharge, lacked the required professional curiosity, governance and management oversight to recognise his risks and listen to the voice of this family. In conclusion, I wish to reiterate that the responsibility for Alex’s death lies with maternal grandfather, who demonstrated a callous unconcern for the feelings of others, who is manipulative and would do anything to achieve what he wanted, which was to be locked up and cared for. By the time of his discharge on the 11th December, despite the nature of the practice informing this discharge, it was evident that he should have already left acute inpatient care. Despite his actions and wish to remain in hospital, there was no reason for him to remain in the hospital, as he was not suffering from any mental illness. However, there were limited indicators of the risk he posed to specifically to children and the degree of his violence towards Alex could not have been predicted or prevented. By his own admission during the trial process, once within the community, when he perceived his daughter thwarted 39 his desire to be allowed to stay with her in her home, he cruelly took Alex’s life. His action to kill Alex occurred 11 days following his hospital discharge and clearly did not take place in the presence of psychosis or another severe mental illness. Although it is agreed that he does have a diagnosis of personality disorder, this did not impair his decision making at this time. Given the nature of this act no agency or any member of his family could have predicted or prevented such an outcome. This was not as a result of any mental health illness; maternal grandfather made the decision to undertake this particular action and as a result has now been found guilty and convicted of murder. 6. IMPLEMENTATION OF LEARNING 6.1 Recommendations by the Independent Overview Report Author Recommendation 1: GP: Primary Care In order to evaluate the suitability of applying the GP ANR recommendations (see appendix, section 3) to the whole of the GP community in Lincolnshire, an audit sample to be undertaken across a cross-section of GPs. As these recommendations relate to core aspects of a GP’s role, the findings from this audit should inform the extent of the requirement to disseminate this learning across the GP community. Recommendation 2: Police and LPFT The police and LPFT to establish an agreement to address the required standard of practice, communication and timescales when addressing the violence and abuse to LPFT staff within the workplace. In particular, a process needs to be formulated to address cases when staff do not wish to make a complaint when assaulted in the workplace. Recommendation 3: LPFT 3.1 LPFT to consider at service transition points, there is clear evidence in the clinical notes with regards to the offer of advocacy and support to both patient and carer to ensure they are offered choice and control over their care arrangements. Specifically: • At admission; • At transfer to rehabilitation services; • At discharge to CMHTs. 40 3.2 The process of disseminating the importance of the comments/complaints process/policy to be reviewed and re-launched to all staff members. 3.3 An audit to be undertaken of the 7 day review following discharge from inpatient care to focus on the quality of the recording, the outcome of the visit, the consideration to risk and vulnerability management and the needs of the family as a whole. 6.2 What’s Changed?: LPFT In light of the context of this review, the focus of this section is on reviewing the change and developments in LPFT. The internal Trust RCA identified 30 recommendations, which were themed and incorporated under the following headings: Professional Practice Risk Assessment and Procedure Care Pathway, Treatment/Care Plans Staff Management Performance Management Ensuring Performance Compliance (audit, monitoring and supervision) Raising Policy Awareness Amendments to Policy Community Mental Health Team Operational Policy Pharmacy/Medical Advice Since the recommendations were shared, a ‘ward improvement plan’ has been designed which incorporates all the actions that were under the headings above. This plan is working to effect and embed extensive positive change. A copy of this improvement was shared with the LSCB business manager and the independent author of the Serious Case Review for the purpose of providing assurance against the ward related concerns that were detailed within the LPFT ANR. During this improvement process there has been a complete restructure of the Trust’s operational services. Some of the improvements completed include the assigning of a Team Manager to oversee the improvement plan, the development of an acute care pathway model with associated treatment pathways based on NICE guidance, the completion 41 of a skills gap analysis of the clinical team, the employment of a Delayed Transfer of Care social work post, and the implementation of initiatives from Triangle of Care toolkit to better engage Carers with decision making. 6.3 Progressing Recommendations and dissemination of learning 6.3.1 As the commissioner of this SCR, the LSCB will monitor the progress of the resulting recommendations and action plan. 6.3.2 Any future related inter-agency training and learning events will incorporate the key learning and good practice examples from this SCR. 6.3.3 The key messages will be presented and shared with statutory partner during a LSCB meeting. 6.3.4 Each agency safeguarding lead will disseminate key lessons to be learnt within their own agencies. 6.3.5 Key messages will also be disseminated at the LSCB sub-group meetings. Ceryl Teleri Davies Independent Overview Author 8th December, 2016. APPENDIX 1: Recommendations from the ANRs The ANRs have provided evidence of actions already undertaken in response to individual agency recommendation. These recommendations have been identified by each ANR author in their own reports and have been signed off at a senior level within the respective agency. The Board accepts responsibility for overseeing and ensuring their implementation. 1. POLICE No recommendations outlined within the Police ANR. 2. EDUCATION: 42 No recommendations outlined within the Education ANR. 3. GP: PRIMARY CARE: Recommendation 1: The GP practice should review the process for referrals and develop explicit policy/practice guidance within 3 months from date of request. The policy should be compliant with the guidance; Delegation and Referral (GMC 2013) and include: • The distinction between the rationale of making referrals following face to face consultation and in situations where this may be overridden. • The timeliness of referrals from consultation to actioning. • The practice responsibility regarding DNA (non-attendance at the appointment) including where safeguarding concerns / vulnerability are identified • The referral outcome reporting. Recommendation 2: The practice should provide assurance of a robust quality assurance process to ensure early identification of administration errors / time delays in: • Executing referrals. Recommendation 3: The GP practice where maternal grandfather was registered should provide assurance of a robust quality assurance process regarding: • Deduction of patients in accordance with available Guidance (Removing Patients from the Practice list –Medical Protection Sept 2013. 4. UNITED LINCOLNSIRE NHS HOSPITAL TRUST:- Recommendation 1: Community Paediatrics Business Manager, Community Paediatricians and Information Governance representatives from ULHT to work with relevant LCHS colleagues in order to formalise the current administrative and storage arrangements for the ULHT Community Paediatrics function. Estimated timescale for completion of Formal agreement is 31st March 2016. Recommendation 2: Community Children’s Team Matron to devise a function to ‘alert’ Professionals to the existence of additional Nursing Documentation. Timescale for completion is 31st January 2016. 4. LPFT:- Recommendation 1: Professional Practice Fast Track Protocol: There is a thorough review of the Fast Track Protocol and process to include: 43 Ensuring trigger and response cascades are robust; Allowing effective return to service for service users; Adequate controls and safeguards to ensure medication reviews are undertaken as required; A provision for timely access to consultant advice; A process for identifying a care coordinator (lead professional), for previously discharged service users returning under fast track going directly into acute/in-patient services. Recommendation 2: Risk Assessment and Procedure o For the ward consultant, team leader, ward manager and identified risk champion for a particular Ward to fully engage in the roll out of the Trust’s new clinical risk assessment training programme and associated CQUIN. o In-patient consultants, team leaders, the CRHT leaders and ward managers of a particular ward and a rehabilitation centre to ensure, through management supervision, that all staff fully understand and meet the required standards of the new Trust Clinical Risk Assessment Protocol For Ward consultants, team leaders and ward manager to ensure appropriate forums for discussing clinical risk, such as ward MDTs and CPA reviews, take account of perspectives of all relevant parties: patient, family, carers. There needs to be a shared understanding of formulation of risk, explicitly recorded and disseminated. For these teams there is a detailed quality impact review of the new risk assessment process within 2 months of this report. Ensuring key issues and actions are completed and the new procedure fully embedded. Recommendation 3: Care Pathway, Treatment/Care Plans The acute service medical and management team review and develop a clear and robust ward review pathway/protocol/process, aligned with the named nurse model. The quality and content of the information presented must: Support safe and effective clinical decision making; Be clearly documented in the clinical record; Include/be supported by empirical data/formal assessment outcomes specific to clinical need; 44 Reflect the level of clinical complexity at presentation, using standardised condition specific assessments when indicated; Record a clear clinical rationale where service user statements/decisions are not aligned to their care plan. That at service transition points, there is clear evidence in the clinical notes with regards to cross team discussion/agreement. Specifically: At admission; At transfer to rehabilitation services; At discharge to CMHTs. To include reasons for admission/discharge/transfer and differing clinical opinions. That all patients, at admission, are classified as requiring CPA and associated processes. To be reclassified as non-CPA a formal review must be undertaken. That the full care pathways between Trust acute, rehabilitation and CMHT are fully reviewed. Specifically: All patients are clinically assessed prior to transfer; Service and medical management to be assured that stated standards are being met. Recommendation 4: Staff Management o That the named nurse model, as applied to acute Mental Health ward setting is reviewed against alternative current best practice nursing models based on national bench mother’s partnering evidence. o A named consultant responsible for a patient’s care should be clearly identified and known to the patient and ward staff at all times. To include annual leave and locum cover, and points of transfer. o That the professional/medical leave policy and process is reviewed, formalised and disseminated through all management and clinical lines; and that medical cover arrangements on a particular Ward are reviewed and the required levels of cover provided to maintain safe practice, at all times 45 o For a particular Ward to have a substantive ward manager appointed as soon as possible, to provide strong, visible and stable leadership and management presence. o Formal performance management and/or disciplinary processes should be considered in issues relating to failures in the following domains: Clinical risk assessment processes; Trust policy in relation to CPA standards; Discharge and liaison standards; Safeguarding pathways and processes. Recommendation 5: Ensuring Performance Compliance (audit, monitoring and supervision) o That ward consultants, team leaders and ward managers ensure all staff are compliant with CPA training. o Team leaders ward managers and medical managers ensure a process for monitoring the quality of assessment and care planning is recorded through management supervision of named nurses (or equivalent). o That there is an audit of MDT review entries within 2 months of this report to ensure standards are met, specifically: Clinical rational recorded where there is non-alignment between service user and care plan; Inclusion of formal reviews of medication; There is a review of the MDT ward review process to ensure earlier identification of service users for review; to better support full attendance and engagement of external parties. This review is audited after 2 months of this report to ensure issue is addressed. Recommendation 6: Raising Policy Awareness o All in-patient staff confirm their awareness of the requirements of the Trust’s Assessment and Care Planning Policy and, specifically: 46 Care plans are created collaboratively; Care plans are derived from appropriate assessments. o The full MAPPA process to be reviewed and embedded to improve service awareness, access and use. o That the Trust’s policy for Assessment and Care Planning (including CPA) is re- issued in a lessons to be learned learnt report across the Trust. o Ward consultants/doctors and ward managers ensure that recording of MDT meetings, including ward rounds and CPA review, is done in line with Trust policy. o All ward staff are up to date with mandatory safeguarding policy. Recommendation 7: Amendments to Policy: The following Trust policies are reviewed: Clinical Care Policy discharge/transfer procedure; admission procedures; timescales for CPA transfer; clinical risk screening; reviewing clinical risk assessment. To ensure service specific review of risk occurs at key transition points. All in-patient and community staff to confirm their awareness of the amended policy. CMHT Operational Policy is reviewed and revised to ensure: Alignment with Clinical Care Policy; Service eligibility criteria for teams are clear; Internal referral processes and routes are agreed and stated; The ICMHT referral form is included in the policy; Information on service interface is added – section 7; These are agreed and disseminated between all in-patient and community services. Recommendation 8: Pharmacy/Medical Advice The role of routine pharmacist in relation to MDT decision making is reviewed. 47 Recommendation 9: Safeguarding 15.1 The Trust measure the use of the safeguarding screening tools across all services against the Safeguarding Policy to ensure that they are being accurately and routinely completed and reviewed. 15.2 For the Named Doctor to review the junior doctor’s training provision specific to Trust services and in line with the Trust’s safeguarding training matrix and intercollegiate competencies (2014). 15.3 A joint training session will be attended by the Trust’s Safeguarding Champions and Risk Champions to highlight the issues identified within the RCA and ANR; including how risk is dynamic and requires reassessment in a family situation with lessons on how to embed this learning developed and led by Trust Champions, monitored by the risk and safeguarding governance systems. The Consultant Nurse for Safeguarding and the Named Doctor for Safeguarding Children will develop and lead this session. |
NC52459 | The sexual abuse of an 11-year-old girl, and grooming of her 8-year-old sister, by their mother and her boyfriend over a 12 month period prior to April 2020. Learning is embedded in the recommendations. Recommendations include: schools should consider how they monitor and review the concerns logged on their child protection online management system, there should be an automatic review built in when a certain number of concerns are logged within a specific period; safeguarding leads within schools should ensure that any referral to another agency is always followed up and that the nature of the response is recorded at the time; health services need to ensure that all transfers in families where children are at risk are accompanied by appropriate documentation, management review and a visit; when a concern is raised with health services by another agency, consideration should be given to a visit being undertaken by a health visitor rather than relying on what was seen at a visit some weeks or months earlier; children and young people services should ensure that at the point of referral, any extensive history is carefully considered within the multi-agency safeguarding hub as part of effective decision making on what action to take; and children and young people services should set any retracted compliance regarding a common assessment framework within the context of the family history and consider stepping up for a social work assessment rather than simply accepting that nothing can be done as parental co-operation is withdrawn.
| Title: Local children’s safeguarding practice review: Young People F: overview report. LSCB: Suffolk Safeguarding Partnership Author: Chris Burton Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. This report is the property of Suffolk Safeguarding Partnership and is confidential. Its contents may only be shared with appropriate representatives of the relevant agencies for the purposes of completing the Local Children’s Safeguarding Practice Review Process. Local Children’s Safeguarding Practice Review Young people F Overview Report DATE 26/04/2021 Author: Chris Burton – County Safeguarding Manager Page 3 of 14 Contents 1. Introduction ..................................................................................................................................... 5 2. Scope of Review ............................................................................................................................. 5 3. Organisational Context ................................................................................................................... 6 4. Key Findings ................................................................................................................................... 7 5. Recommendations Emerging from this Review ............................................................................. 9 6. Action Plan .................................................................................................................................... 11 7. Glossary of Terms......................................................................................................................... 13 8. Appendices ................................................................................................................................... 13 Appendix 1: Terms of Reference .................................................................................................. 13 Appendix 2: Attendees at Information Gathering Event............................................................... 13 Page 5 of 14 1. Introduction 1.1 It is always shocking when long term sexual abuse of children emerges in the absence of any obvious indicators – nothing said by the child and no apparent distress or even unease, no alarm bells heard by school, health or CYP. Professionals have to acknowledge the unpalatable reality that in some instances the shocking abuse such as in this case may not be experienced by the child as terrifying and that there may paradoxically be some positive and affectionate feelings for the abuser. 1.2 That is the context within which the abuse of these girls occurred, only emerging when the wife of the abuser found explicit images of the girls on his phone in April 2020 and immediately called the police. These and other videos, indicated that her husband was conducting an affair with the mother of the two girls in question, abusing the older girl and preparing to do the same with the younger child. It became clear during the police investigation that the children’s mother was instrumental in preparing the girls to be abused by her lover and complicit in the physical and sexual harm experienced by them both. 1.3 The abuse continued for a period of at least 12 months prior to April 2020. During this time, F1 the eldest girl now aged 11 had been sexually assaulted on several occasions, so seriously that the perpetrator was convicted of rape. Her sister F2, now 8 was in the process of being physically and emotionally prepared by her mother for a similar pattern of sexual abuse. The perpetrator was known to the two girls as a friend of their mother who was kind and affectionate to them with a daughter in the same class as F1. Aspects of the preparation that the mother had put them through were not without discomfort and both physical and emotional pain – both adults received a 22 year prison sentence, the maximum permitted by law. 2. Scope of Review. 2.1. During the Care Proceedings in respect of these girls, the family court judge requested information as to what steps the local authority had taken [if any] to investigate and identify why the abuse suffered by these children was not picked up sooner either by them or by any other agencies involved with the children and what changes if any might be made to any procedures/process to help prevent serious abuse in respect of children in the future being missed. The response by the Chair of the Suffolk Safeguarding Partnership effectively set the scope of this review, namely: 2.2. To determine whether or not there were any indicators that were missed during the 18 months to 2 years prior to April 2020 2.3. To question what links were made between individual concerns that arose, mother’s history and the broader context of what became known during the 10 years since the family moved to Suffolk 2.4. To highlight the ‘lived experience’ of these children and determine what might have been done for this to have become apparent to professionals in the months and years before the abuse was discovered 2.5. To evaluate the role of agencies both before the abuse was discovered and afterwards 2.6. To consider whether a lack of professional curiosity was a factor in dealings with this family during their time in Suffolk 2.7. To understand whether there is any further learning and development needed to distinguish the identification of neglect and the implications for children 2.8. Interviews were conducted with relevant staff: - Investigating police officer and Inspector from the Child Protection Unit - Headteacher and Safeguarding lead from the school Page 6 of 14 - Healthy Child Programme Lead - Allocated social worker - Current foster carer 2.9. Chronologies from Health and Education, Police interview transcripts with the girls and detailed records from CYP were examined as well as the details of the concerns logged on the school’s CPOMS (Child Protection Online Management System) since the girls first attended. 3. Organisational Context 3.1. The answer to the understandable question about how this could have been missed is simply that there were no obvious indicators to suggest the nature and extent of the abuse they suffered. However, there were factors in the history of this family which might have elicited a greater degree of professional curiosity, with a subsequent linking of apparently disconnected events and a willingness to at least consider the unthinkable. These links were not made. No single agency, other than the school, had any consistent overview of these children. 3.2. There are three main phases to organisational and professional links with this family – firstly 2010 to 2016 – CYP and some Health involvement. When the family first moved to Suffolk, a period of CP Planning for F1 in another county had recently ceased. There was no Health handover visit when the family arrived, something that would happen now. 3.3. However, F1 was once again made the subject of a CP Plan in Suffolk from June to November 2011, category of neglect. There was significant involvement and assessment during 2011 and `the case was closed immediately after F1 was removed from a plan 3.4. CYP received several referrals in the following years: - Oct 2013: Concern from mother’s half-sister that stepfather was coming to stay for a week in the household and was a Schedule 1 offender; - May 2014: Concerned neighbour reporting smelly children and various men coming and going. HV reported that when she had visited in February house and children were ‘clean and tidy’; - November 2015: Allocated for SW assessment due to concerns about domestic violence and physical chastisement. None of the above resulted in any clarity about what had been done and whether the home had been visited or the children seen. A further unspecified MASH referral was made in April 2016 with an information and advice outcome. 3.5 A second phase from 2016 – 2020 when the local primary school recorded a range of concerns and incidents with some involvement from Early Help in 2019 when a CAF had to be abandoned after mother withdrew her agreement. There were some referrals for specialist health appointments but with no specific outcome. It was in the latter stages of this phase that the girls were being abused – school staff who knew them well are horrified and distraught that they did not consider the possibility of harm as they saw no sign. On one occasion, F1 missed the first part of the school day for a visit to the dentist, returning for lunch after suffering penetrative sexual abuse by the male perpetrator. No one talked to her about the ‘dental appointment’, as there was nothing about her presentation on that Page 7 of 14 day to cause worry and yet…. she had been the subject of a catalogue of queries and concerns about personal hygiene, cleanliness, poor clothing and her mother had refused a CAF after initially agreeing. 3.6 A third phase from April 2020 ‘till the present, when the abuse was uncovered and the children removed. It is this period that has shown exemplary multiagency work starting with the Police/CYP joint investigation and characterised by an unwavering focus on the children’s view of their world and how it has been impacted by the abuse they suffered 4. Key Findings 4.1. Main observations as follows: • Although there was no single indicator that would have suggested these children were being abused, agencies had information that was not systematically evaluated – multiple single occurrences or concerns were not linked over time, nor did frequently recurring doubts trigger any more formal review of each individual concern. An example of this is an excess of 30 concerns being logged by the primary school over a three-year period without an evaluation of what this might mean for the lived experiences of the girls; • When the police and social worker visited the girls’ family home, the physical standards were poor – dirty bedding, few clothes, an older father who simply sat continually downstairs, unable and/or unwilling to do anything to meet their needs. No professional had entered the house for some months; • Staff within the school were available to the girls should they have wished to speak about what was happening at home, but did not consider that there might be a need to engage them carefully and pro-actively to get an understanding of their world and their experience of it; • An absence of professional curiosity, information being fitted within the pre-conceptions of professionals and an overly optimistic view of what might be happening for these girls; • Both health and CYP had historic information from before the family moved to Suffolk that indicated: - The mother of the girls had suffered sexual abuse and physical harm from her own parents and been a looked after child in the latter years of her childhood - She had low cognitive functioning and identified herself as having a degree of learning disability - She had married a man 41 years her senior after initially having a relationship with his son - Her eldest daughter F1 had been on a CP Plan for neglect as a baby in another county All of these elements were never fully pulled together, even though there was a further CP in Suffolk during 2011. • No one agency made the link between this history and what were seen simply as sporadic low-level indicators of neglect at various points from 2011 to April 2020. Yet there were other concerns - a CP referral in 2013, two reports of domestic incidents, and an allegation that mother hit F1 in 2015, concern expressed by a neighbour about different men being seen entering the house • Referral to MASH might have been the mechanism that prompted this scrutiny of individual concerns with the historic context but this was not the outcome of the referrals that were made Page 8 of 14 • Neglect is an overused term especially the phrase ‘low level neglect’. A classification of low may conceal a high adverse impact for a child. The classification is sometimes used as a justification for professional inaction and more seriously can blunt the impetus for exercising appropriate and proportionate professional curiosity. The assumption was made by the school that when the at times poor hygiene and grubby presentation of the girls improved, this was a positive indicator. In fact, it was the result of the girls being cleaned and physically ‘groomed’ before the abuse began. • These girls were not able to verbalise their lived experience during the time that the abuse occurred, at least not to those professionals who they saw most often. However, no one considered that it might be helpful to encourage them to say more about life at home • It was only after the abuse had been discovered that these girls have been able to talk about what their life was like. • No one agency had the complete picture about this family. When they first moved from Herts in 2011, F1 had only recently been removed from a CP plan – this information informed the CYP response and there was a short further period of Child Protection and the case was shortly thereafter closed. • There was no formal review of the health records as they were transferred (which would happen now). • It was only the police investigation that revealed the extent of the abuse suffered by these children. However they have only begun to be able to express the nature of their experience over the period of months since they have been placed elsewhere. This is not unusual as many children can only disclose once they feel safe enough to do so. 4.2. The only aspect of this case that is positive is the response of agencies after details of the abuse emerged in April 2020. 4.3. From the point of the at which the girls were supported when their mother was arrested and they were removed to a safe environment, excellent work has been done in trying to help uncover the extent of what happened and then supporting them and their carers. 4.4. The transcripts of the initial joint interviews show a sensitivity, a responsiveness and a willingness to suspend disbelief and enter into the world of these children. The commitment to the girls from both the investigating police officers and their social worker has been unwavering. 4.5. The social worker who is working with the girls has demonstrated both a thorough knowledge of the family history and how this can better inform responses to their present trauma. 5. The ‘lived experience’ of the girls 5.1. The children are now placed together – F1 is struggling in a range of ways e.g. soiling. Only at points when she appears content will she speak a little about the abuse. Her carer believes that she loves and misses her mother as well as the perpetrator to some extent. She also describes their concern and worry for their father. F1’s younger sister doesn’t talk about what happened. The foster carer describes a ‘turbulent period’ in the months since they arrived in November of last year, ‘if one is on track then the other is not’. 5.2. The impact on both girls is incalculable – specialist support is available both to them and the foster carers whose insights are invaluable in helping these girls to process what has happened. The female carer describes how F1’s smearing and urinary incontinence somehow makes her feel closer to the perpetrators – in a sense she welcomes the discomfort (the abuse was accompanied by incontinence) and her current soiling becomes self- harm. Page 9 of 14 5.3. The girls have expressed a wish to remain where they are and have taken the name of the family. As the carer described it……..’they are part of our family and this is their forever home. There is no one else for them – we are it!’ 6. Recommendations Emerging from this Review 6.1. It is clear from the body of this report that there were no specific instances when a clear indication of abuse was missed. However, there is learning which all agencies can take from the pattern of events after the children moved to Suffolk: - Forty years ago Tony Morrison coined the phrase ‘professional dangerousness’ (Dangerous Families – Tavistock 1981) to highlight the way in which professionals can behave in a way which ‘colludes with or increases the dangerous dynamics of the abusing family. Sadly, this is still a feature of professional thinking as is demonstrated in this case. The SSP should consider delivering a Partnership learning event which builds on the need to:- o Talk with the child o Exercise professional curiosity o Understand the experience of the child not simply the adults’ point of view o Beware of the parent who habitually visits school, clinic or office as a possible strategy to discourage professionals visiting the home o Access or develop a comprehensive chronology and learn from what is known. This is an important counter to professional optimism and also the ‘start again’ syndrome when a family moves to another area or service o Assess if in any doubt – do not assume it is simply how this family lives o Deep dive into reasons for variable/disguised compliance o Clarify all routes for expressing concerns – not simply MASH – contacting the relevant service manager and safeguarding manager o Avoid assuming that another agency or professional will have an overview of risk o Challenge decisions by agencies that do not follow on from the evidence-base in a referral o Understand the implications of professional uncertainty for how cases are managed and workers supported o Embed authoritative practice which can effectively challenge parents when needed o Understand the dangers of silo thinking 6.2. Schools should consider how they monitor and review the concerns logged on their CPOMs system. There should be an automatic review built in when a certain number of concerns are logged within a specific period. 6.3. Safeguarding leads within schools should ensure that any referral to another agency is always followed up and that the nature of the response is recorded at the time. Any perceived failure in responsiveness should be escalated within the school and the Headteacher can then contact a senior manager within the receiving agency Page 10 of 14 6.4. Health need to ensure that all transfers in of families where children are at risk are accompanied by appropriate documentation, management review and a visit. 6.5. When a concern is raised with Health by another agency, consideration should be given to a visit being undertaken by a health visitor rather than relying on what was seen at a visit some weeks or months earlier 6.6. CYP should ensure that at the point of referral, any extensive history is carefully considered within the MASH as part of effective decision making on what action to take 6.7. CYP should set any retracted compliance regarding a CAF within the context of the family history and consider stepping up for a social work assessment rather than simply accepting that nothing can be done as parental co-operation is withdrawn. Page 11 of 14 7. Action Plan The following Action plan has been developed by the review group to implement the recommendations made in this report. Theme Action No. Action Lead Responsible Progress / notes Voice of the Child 1. Family Engagement 2. 3. 4. Identifying Neglect 5. 6. 7. 8. Professional Curiosity 9. 10. 11. 12. 13. 14. Page 13 of 14 8. Glossary of Terms CCG NHS Clinical Commissioning Group GP General Practitioner JPUH James Paget University Hospital LH Lound Hall Nursing Home MASH Suffolk County Council Safeguarding Multi-Agency Safeguarding Hub – central point through which all safeguarding referrals are made SCC Suffolk County Council SSP Suffolk Safeguarding Partnership Pt acronym often used in clinical records for ‘patient’ ‘SystmOne’ NHS clinical notes recording system used by GP practices 9. Appendices Appendix 1: Terms of Reference Appendix 2: Attendees at Information Gathering Event Endeavour House Ipswich Suffolk, IP1 2BX 01473 26 55 00 ‖ www.suffolksp.org.uk |
NC049415 | Sexual abuse of a 15-year-old adolescent by her older brother in 2015. Child H1 had made a previous disclosure at age 12. Child H1 lived with her parents and Sibling 1 and Sibling 2. She had a history of temporary school exclusions, and reported being bullied at school; episodes of missing from home; self harm and suicidal ideation; non-attendance at CAMHS; and reports to the police about her behaviour in the community. In 2015, mother informed children's services that H1 had disclosed sexual abuse by Sibling 1 18 months earlier. Section 47 enquiries were made, and Sibling 1 was accommodated, but later moved back home. Learning identified includes: when Early Help is delivered without holistic access to information and there is no plan with agreed outcomes, it is a challenge to monitor the impact of the intervention; it is important that efforts are made to understand why young people are engaged in behaviour described as "risk taking" and "challenging"; it is essential that practitioners recognise cultural influences on children and families from diverse communities. Identifies good practice around use of multi-agency resources and information sharing between the nurse practitioner and the school nurse. Recommendations include: to audit and monitor how the voices of children and young people inform assessments and interventions.
| Serious Case Review No: 2018/C7028 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. 1 Child H1 SCR FINAL JULY 2017 Local Safeguarding Children Board Serious Case Review - Child H1 (July 2017) This Serious Case Review was commissioned by the Independent Chair of the Local Safeguarding Children Board (LSCB) in July 2016 following a recommendation by the LSCB Case Review Sub Group. The circumstances regarding the serious harm of a child with concern about the way in which agencies worked together met the criteria for a Serious Case Review in accordance with Working Together to Safeguard Children (2015)1. Incident which resulted in the Serious Case Review In June 2015 Child H1 disclosed that she had been sexually assaulted by Young Person 1 (YP1)2. H1 had made a previous disclosure that she had been sexually abused by her older brother Sibling 1, H1 was 12 years old at the time and Sibling 1 was 14 years old. The family received support from Early Help Services and H1 was subject to a Child Protection Plan and subsequently an Interim Care Order was granted by the Court. At the time of the Review H1 had returned home to live with her parents. The Family The family comprised of H1, Mother, Father, Sibling 1 aged 14 years and Sibling 23 aged 13 years4. Sibling 1 became a looked after child following the disclosure that he had sexual abused H1 and has lived in a foster placement apart from a brief period when he returned to the family home. H1, Sibling 2 Mother and Father live in the family home. The family identify as belonging to an ethnic minority and lived mainly in Local Authority 1 during the timeline of this Review. Legal Context . Regulation 5 of the Local Safeguarding Children Board (LSCB) Regulations 2006 sets out the functions for LSCB’s. This includes the requirement for LSCB’s to undertake Reviews of serious cases in specified circumstances. Regulation 5 (1) (e) and (2) set out a LSCB's function in relation 1 Working Together to Safeguard Children (HM Government, 2015) 2 H1 was aged 12 years 9 months and YP 1 was 16 years 9 months at the time 3 Sibling 2 has a diagnosis of Dyspraxia and learning difficulties 4 Age of siblings at the time H1 disclosed the sexual abuse by Sibling 1 2 Child H1 SCR FINAL JULY 2017 to Serious Case Reviews, namely: 5. (1) (e) undertaking Reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1) (e) a serious case is one where: (a) Abuse or neglect of a child is known or suspected; and (b) Either (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. Methodology An intensive multi-agency Child Practice Review (CPR)5 was identified as the most appropriate and proportionate model to conduct the Review. The CPR process supports practitioners to reflect on cases in an informed way and the Review report focuses on learning and practice improvement. The CPR methodology provides a learning tool for Local Safeguarding Children’s Boards to use when it is important to consider how agencies worked together. The role of Safeguarding Boards is to engage and contribute to the analysis of case issues, to provide appropriate challenge and to ensure that the learning from the Review can be used to inform systems and practice development. In so doing the Board may identify additional learning issues or actions of strategic importance. These will be included in the final report of the Review or in an action plan as appropriate. This Review has been conducted in accordance with the principles for Serious Case Reviews set out in Working Together (2015), which: Recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight Is transparent about the way data is collected and analysed Makes use of relevant research and case evidence to inform the findings Working Together (2015) states that Serious Case Reviews should Identify improvements in the way that agencies work together for the prevention of death, serious injury or harm to children and to consolidate good practice Clearly identify what lessons are to be learned both within and between agencies and within what timescale they will be acted on and what is expected to change as a result. 5 The CPR is also referred to as the ‘Welsh Model’ for more information see; Protecting Children in Wales Guidance for Arrangements for Multi-Agency Child Practice Reviews (Welsh Government, 2012). http://www.sewsc.org.uk/fileadmin/sewsc/documents/Published_SCR_CPR/Child_Practice_Review_ Guidance_-_Welsh_Government.pdf 3 Child H1 SCR FINAL JULY 2017 The Review Process A Review Panel comprising of managers from relevant agencies was established in accordance with the guidance. The panel was chaired by a senior manager from Children’s Services. Dr Catherine Connor, an independent Lead Reviewer, was commissioned to work with the panel and to author the final report. A timeline of significant events with a brief analysis of agency involvement was provided by each organisation. Agency timelines were merged to produce an interagency timeline of key events which was reviewed and analysed by panel members with reference to the agreed Terms of Reference for this review. The Review Panel sought to identify factors which influenced the actions of practitioners and agencies and further understanding about how multi-agency systems impacted on this case. Good practice was recognised and opportunities for inter and intra agency learning and practice improvement were highlighted. Fourteen Practitioners who had direct involvement with H1 and the family attended a Learning Event to further understanding of the factors which influenced decision making and practice during the timeframe for this Review. Practitioners said that they appreciated the opportunity to reflect on this case and identified opportunities to change and improve practice. The views of Practitioners will be presented throughout the Review. Practitioners attended a second meeting with the Lead Reviewer to comment on a draft report of the Review findings and initial analysis. Family involvement The Lead Reviewer and Chair appreciated the willingness of H1, Mother and Father to participate in this Review6. The focus of discussions with the family was to understand how H1, Mother and Father had experienced the intervention and support provided by agencies and whether, from their perspective, there had been missed opportunities to provide support. It was evident that H1, Mother and Father were very upset and angry about intervention by Children’s Social Care (CSC) which had resulted in H1 being subject to an Interim Care Order and removed from the family home. Although H1 had returned to live at home at the time of the meeting with the Lead Reviewer and Chair, it was a challenge to focus the discussion on the involvement of agencies and practitioners during the provision of Early Help support and the implementation of Child Protection processes. H1 was very clear about the fact that she had been bullied at School and did not think this had been taken seriously by staff. H1 said that she wanted to attend full time education and she was very dissatisfied and unhappy with the one hour per day timetable that was provided whilst at School 3. H1 spoke highly of the Child Sexual Exploitation (CSE) Team Practitioner and it was evident that this relationship was valued by H1. The views of H1, Mother and Father will be reflected throughout this Review. 6 H1 met with the Lead Reviewer and Chair separately from Mother and Father. 4 Child H1 SCR FINAL JULY 2017 Review timeframe The timeline agreed by the Review Panel for consideration was from August 2013, the beginning of support by Early Help Services, until April 2016 when H1 was made subject to an Interim Care Order. The timeline was divided into three periods: August 2013 – March 2015 Initial referral to the Local Authority Families Team until H1 disclosed sexual abuse by Sibling 1 April 2015 – September 2015 Multi-agency response to the disclosure by H1 that she was sexually abused by Sibling 1 until the Initial Child Protection Conference (ICPC) October 2015 – April 2016 Provision of multi-agency support and intervention to implement the Child Protection Plan until H1 was subject to an Interim Care Order Use of a systems perspective throughout the analysis will provide an opportunity to understand the complex sequence of events and explore the factors which influenced the way in which agencies worked together to safeguard H1. Circumstances resulting in the Review Key Period 1 - August 2013 - March 2015 Initial referral to the Local Authority Families Team until H1 disclosed sexual abuse by Sibling 1 During this period H1 was on the roll of four schools (two primary and two secondary) and received three five day exclusions and a further one day exclusion. H1 was also reported missing from home on two occasions and was admitted to hospital overnight for observation and assessment on two occasions due to self-harm and suicidal ideation. Mother consented to work with the Local Authority Families Team in August 20137. Two months later Sibling 1 was arrested for Breach of the Peace following what was described in the Police report as an unprovoked attack on Sibling 2. H1 was 11 years at the time and witnessed the incident. The Police made a referral to CSC and information was shared with Health. In October 2013 there were emerging concerns about the inappropriate behaviour and language of H1 towards other children and unauthorised absence at Primary School 1. In November 2013 7 The family were identified for support as part of a data exercise based on poor school attendance linked to the Troubled Families Initiative. The Families Team are part of Children’s Services in Local Authority 1, but include practitioners from other agencies, and provide interventions to children and families under a number of initiatives, both at early help and statutory levels of intervention. 5 Child H1 SCR FINAL JULY 2017 the Families Team Practitioner recorded that Mother had a black eye, issues with people in her community, was fearful for her family and planned to move to Local Authority 28. The Families Team Practitioner provided Mother with contact numbers to obtain advice and support. Efforts were made by School 1 to locate H19 during a period of absence in January 2014. Confirmation was received that H1 was attending School 2 in Local Authority 2 and records were transferred. Two months after starting at School 2 H1 had 15 unauthorised absences and it was recorded that H1 found it difficult to settle and that other pupils made reference to her ethnicity. H1 was readmitted to School 1 in March 2014 following a return to Local Authority 1. H1 received support from the Behaviour Team and a mentor at School 1. Mother informed school that she was considering home education however H1 told teachers that she wanted to remain at School 1. The Pupil Welfare Officer (PWO) informed CSC that the family had been known to Local Authority 2 in 2013. In March 2014 Mother informed the Police and CSC about serious threats of a sexual nature allegedly made by a friend of Sibling 1 towards Mother and H1. It was decided by CSC that additional needs and concerns could be addressed by the Families Team. In May 2014 Father advised the PWO that unauthorised absences were due to Mother taking H1 out of the area. It was recorded that advice and guidance were provided and the case was closed to the Pupil Welfare Service. A member of the public informed the Police that Sibling 1 had made threats to harm another young person. No further action was taken at the request of the child’s mother who stated that they were frightened of repercussions from the family of H1. This information was shared with the Families Team practitioner. In May 2014 Mother informed School 1 that she was waiting for an appointment with Child and Adolescent Mental Health Services (CAMHS) however Mother and Father did not respond to a letter to arrange an initial consultation and H1 was subsequently discharged. In June 2014 following concerns expressed by Mother that H1 was associating with older boys the Families Team practitioner completed one to one work with H1 to explore sexual health and healthy relationships. H1 was excluded from school for the first time at 11 years of age in July 2014. The exclusion letter from School 1 to parents noted that; the attitude of H1 towards staff has become completely unacceptable, particularly in recent weeks. The first multi-agency meeting took place the day after the school exclusion. This was recorded as a Troubled Families Review meeting and was attended by the Families Team practitioner and colleagues from the Pupil Referral Unit. School 1 were not aware of the meeting. In August 2014 the Nurse Practitioner (at the GP Practice) made a referral for H1 to CSC and was 8 This represented a move of well over 100 miles 9 School 1 made repeated phone calls to the family and other schools in an attempt to locate H1 6 Child H1 SCR FINAL JULY 2017 advised by letter from the Duty Team that needs would be met by the Troubled Families Service10. At the same time Mother had informed CSC that Sibling 1 continued to be violent towards Sibling 2 and was refusing to attend school. It was recorded that no further action was required as the case was open to the Families Team. In September 2014 H1 transitioned to secondary education and attended School 3. During the first week H1 was excluded for what was recorded as persistent disruptive behaviour. On the same day Mother received a fine following prosecution due to the persistent absence of Sibling 1 from school. Mother reported H1 as missing from home for the first time in September 2014 this was allegedly due to being grounded by parents following the exclusion from School 3. H1 returned home after a couple of hours, a safe and well check was conducted by the Police and a Multi-Agency Safeguarding Hub (MASH) referral was submitted 11 . Mother informed the Families Team practitioner that Father had found H1 with a group of young males however this was denied by H1. Mother was advised by the Families Team practitioner to contact the Police should H1 go missing from home again. In October 2014 H1 was admitted to hospital overnight after presenting with deliberate self-harm and suicidal ideation. Mother and Father informed staff at the hospital that they were concerned that they could not keep H1 safe at home and they planned to take her to stay with her Aunt in a different Local Authority area12 whilst they attended to other family issues. A discharge summary in GP records details the information that was provided to parents about available support and action to take to keep H1 safe. H1 received a further exclusion from School 3 in November 2014 for what was recorded as a violent assault on another pupil. A multi-agency meeting was held due to concerns about the poor school attendance of Sibling 1, Sibling 2 and H1. Following a managed move to School 4 H1 started a trial period in December 2014, however H1 returned to School 3 in February 2015. H1 received one hour of education each day on a one-to-one basis in the library at School 3. It was recorded that Mother and H1 were very unhappy with this provision and both stressed their disagreement with the very limited provision of education in discussion with the Lead Reviewer and Chair for this Review. During this time period the Nurse Practitioner worked proactively to share information and raise concerns with other agencies 13 and parents about the non-attendance of H1 at CAMHS. In January 2015 Mother was given a food voucher after informing the Families Team practitioner 10 Troubled Families is a national programme of targeted intervention for families with multiple problems and delivered by the Families Team in local authority 1 11 The MASH in Local Authority 1 only accepts Police referrals and is the means by which information about Police concerns can be shared with key partners (including Children’s Services) and multi-agency information collated to enable more informed decision making. Referrals are used by Police Officers to report children or adults with vulnerabilities and graded as high, medium or standard risk. This grading is used to prioritise responses. 12 This was the neighbouring local authority and the aunt’s address was around 10 miles from the family home. 13 The Nurse Practitioner liaised with the School Nurse, Families Team Practitioner, School 1 and 3, CSC, Pupil Welfare Service and CAMHS 7 Child H1 SCR FINAL JULY 2017 that the family had no food. A case note in CSC records states that H1 was reported missing from home for a second time however there is no evidence that this was reported to the police. Records indicate that during a home visit in February 2015 H1 disclosed to the Families Team worker that she had been self-harming due to bullying at school. One week later H1 was admitted to the adolescent unit for assessment after presenting at hospital for the second time with low mood and evidence of self-harm. H1 informed medical staff that she was having problems with pupils and teachers at school. H1 received a further exclusion from School 3 in March 2015 following a physical assault on another pupil. Two days later H1 disclosed that she had been sexually abused by Sibling1. Key Period 2 March 2015 – October 2015 Multi-agency response to the disclosure by H1 that she was sexually abused by Sibling 1 until the initial Child Protection Conference In March 2015 Mother informed CSC that H1 disclosed14 that she had been sexually abused 18 months previously by Sibling 1. Following a Strategy Discussion15 between the Police Public Protection Unit and CSC a joint home visit was made during which H1 repeated the disclosure. Immediate safeguarding needs were addressed, Mother and Sibling 1 left the family home and H1 and Sibling 2 remained with Father whilst further enquiries were made. A High Risk MASH referral was submitted and a criminal investigation commenced. Mother and Aunt refused to support the investigation, declined to provide statements and Mother would not provide permission for H1 to take part in a video interview16. Following Section 4717 enquiries H1 and Sibling 2 were closed to CSC18 and Sibling 1 was accommodated19 as Mother and Father had made serious threats to harm him. In April 2015 the Families Team Practitioner informed the Social Worker for Sibling 1 that he had been seen at the home address. At a multi-agency meeting Professionals20 shared concerns that H1 was not being safeguarded as Sibling 1 was known to be going to the family home when H1 was present. H1 attended hospital following a physical assault by an 18 year old. It was recorded that H1 informed paramedics that she was being bullied at school and that she wished she was dead. CSC records indicated that no further action was taken as the case was said to be a 14 H1 made the disclosure to Aunt 15 A Strategy Discussion is held when a child has suffered or is likely to suffer Significant Harm. The purpose of a Strategy Meeting is to determine whether there are grounds for a Section 47 Enquiry. 16 Achieving Best Evidence Interview (ABE) to progress a joint child protection investigation 17 Under Section 47 of the Children Act 1989, if there are reasonable grounds to suspect that a child is suffering or is likely to suffer Significant Harm, a Section 47 Enquiry is initiated. This is to enable the local authority to decide whether they need to take any further action to safeguard and promote the child’s welfare. 18 Closure summary stated that Families Team would provide parenting support and H1 would be referred to CAMHS 19 Under section 20 of the Children Act 1989 which allows a child to be accommodated by the local authority, but it must be agreed to by those with parental responsibility. 20 School staff, the PWO and Families Team practitioner 8 Child H1 SCR FINAL JULY 2017 criminal matter. H1 spoke to the Nurse Practitioner from the GP Practice about feeling unsafe at home21 and with the consent of H1 the Nurse Practitioner shared this information with the School Nurse to provide an opportunity for H1 to receive support in school. H1 told the Nurse Practitioner that she wanted to attend school. At the same time Mother informed the Nurse Practitioner that H1 was too upset to attend school and requested a sick note. The Nurse Practitioner noted the discrepancy between the views of Mother and H1 regarding school. In April 2015 H1 received a further school exclusion from School 322 Mother did not attend a reintegration meeting and informed School 3 that H1 was having flashbacks, not sleeping and was afraid to leave the house. However H1 was not at home when the PWO visited to offer support and did not attend school until September. The School Nurse informed the Nurse Practitioner from The GP Practice that H1 had been excluded from school following the physical assault of a peer, the Nurse Practitioner recorded23 that it was important to understand the cause of H1’s behaviour. In addition the School Nurse advised that Mother had continued to state that H1 was too distressed to attend school and the Nurse Practitioner recorded a concern that H1 was being intentionally socially isolated. In May 2015 Father attended hospital following an overdose. Father was discharged from the Primary/Intermediate Care Mental Health Team (PIMHT) in June due to lack of engagement. In June 2015 H1 made a second disclosure24 of sexual assault by YP1. H1 also disclosed that she had sexual intercourse when 10 years old with YP 2, now aged 15 years. A MASH referral graded as high risk was submitted and information was therefore shared with other agencies. A Strategy Discussion took place between a Police representative from the multi-agency CSE team25 and a manager from CSC. It was agreed that a joint Section 47 enquiry with completion of a Child and Family Assessment (CAFA) was required. Home tuition was in place at this time, H1 had not been in school since March 2015 and attendance was 35%. Following this second disclosure the Families Team practitioner made a referral to CSC. H1 took part in a Police interview which resulted in the arrest of YP 1 and also the arrest of Sibling 1 in July 2015. Sibling 1 was released on Police Bail for an AIM26 assessment to be carried out by the Youth Offending Service with conditions not to communicate with H1 or attend the family home. 21 H1 said that the doors were always unlocked and Sibling 1 was allowed freely into the house. 22 For threatening behaviour and verbal abuse 23 Recorded within GP Medical Notes 24 H1 disclosed to Aunt, Mother was informed and reported the disclosure to the Police 25 The CSE Team in Local Authority 1 consists of CSC, Police, Health and Education practitioners. The focus of work is to safeguard vulnerable children and young people under the age of 18 who are sexually exploited and to identify, target and prosecute associated offenders 26 In accordance with the LSCB Harmful Sexual Behaviour policy 9 Child H1 SCR FINAL JULY 2017 H1 attended the local sexual health service in July 2015 accompanied by the Families Team practitioner. Shortly afterwards a joint home visit27 was made by the Families Team practitioner and the CSE team social worker who advised Mother that she would be undertaking an assessment. Mother shared concerns about H1 contacting males by phone from her bedroom and said that H1 had been returned by the police at 2.30 one morning as she was walking the streets. It was recorded by the CSE team social worker that concerns were substantiated but H1 was not judged to be at risk of significant harm or at risk of Child Sexual Exploitation and a Child in Need plan was proposed. A Child and Family Assessment was not completed. Less than a week following the conclusion of the Section 47 enquiries H1 was reported missing from home by Mother and found two days later by police in London. A Strategy meeting took place to discuss the missing from home episode and following a further Section 47 Enquiry it was decided that the case met the criteria for an Initial Child Protection Conference. In the course of Section 47 Enquiries H1 was interviewed28 about pictures of a sexual nature that had been found on her laptop. H1 insisted that she had taken the pictures herself however there were concerns about H1 being vulnerable to exploitation. Mother informed the social worker for Sibling 1 that prior to running away H1 was in the company of adult males and she was not sure how to keep H1 safe at home. Mother requested that H1 was taken into care and stated that she overemphasised what had happened between her and Sibling 1. It was recorded in a Case Note by CSC that Mother was advised that she had a legal duty as parent to safeguard H1 and a multi-agency meeting would be arranged to identify support and intervention. During a home visit by CSE team social worker and health practitioner H1 was seen alone and with parents. H1 requested to be taken into care and disclosed physical abuse by Mother but did not want to make a statement to the police. H1 also reported that Father had responded inappropriately when H1 was threatening to self-harm. H1 also told the Families Team practitioner on a separate home visit recorded to have taken place on the same day that she was unhappy at home, scared of things kicking off and made threats that she would run away. An Initial Child Protection Conference took place in September 2015 and H1 was made subject to a Child Protection Plan under the category emotional abuse with a secondary category of sexual abuse and Sibling 2 was subject to a Child Protection Plan under the category of emotional abuse. Key Period 3 October 2015 – April 2016 Provision of multi-agency support and intervention to implement the Child Protection Plan until H1 was subject to an Interim Care Order In October 2015 Sibling 1 received a Youth Caution for the offence of sexual abuse of H1. It was noted in the record of a telephone discussion between the police and Social Worker for Sibling 1 27 Part of the Section 47 Enquiries 28 By the Police and CSE team social worker 10 Child H1 SCR FINAL JULY 2017 that a written agreement would be put in place between CSC, Mother and Father to ensure that H1 and Sibling 1 were not left alone together. In a separate discussion between the Police and CSC on the same day it was recorded that Mother planned to move Sibling 1 back into the family home and a Child and Family Assessment was required to ascertain the risk that Sibling 1 posed to H1. H1 received support and advice with contraception during this period however Mother was not in agreement with this. The case was closed to the Families Team in October 2015 as Mother was very unhappy with the report submitted by the Families Team practitioner for the ICPC and refused to work with her. There were ongoing concerns regarding school attendance, H1 was excluded from School 3 due to an alleged physical assault on a member of staff. Mother refused to send H1 to school for a reduced timetable and H1 requested a return to mainstream schooling. Reports were submitted to the Police about the behaviour of H1 in the community which included a disability hate incident. It was recorded in minutes of a Core Group that the escalation in the behaviour of H1 was linked to the return home of Sibling 1. This view was shared by Practitioners who attended the Learning Event. H1 was initially discussed at a MACSE29 meeting in October 2015, information was shared, current risks discussed and actions agreed. H1 was discussed regularly at MACSE meetings during the time considered by this Review, not all discussions were recorded. At a meeting in November 2015 between Mother and the social workers for Sibling 1 and H1 Mother self-reported that she was managing the risks by moving the bedrooms apart and making sure that H1 and Sibling 1 were not left alone together. It was recorded in the multi-agency chronology that there had been no progress with the CP plan that had been in place for two months. At the Review Child Protection Conference in November 2015 Sibling 2 was stepped down from a Child Protection Plan and H1 remained subject to a plan under the category of emotional abuse as it was thought that she was no longer at risk of sexual abuse/exploitation. In December 2015 the social worker for Sibling 1 became the allocated social worker for H1. H1 was reported as missing from home in January 2016 and was located by Police at a friend’s address. A high risk MASH referral was submitted as H1 was considered vulnerable to CSE and this information was shared between CSC, Health and School 3. At a Core Group attended by Mother and Father in January 2016 professionals expressed concern about lack of case management by the local authority. Further disagreement between professionals was noted in the minutes of a Core Group in February 2016. At this time H1 was said to be living between her parents and aunt as she struggled with boundaries being put in place at home. Information was received from the CSE team practitioner about the use of social media which risked increasing the vulnerability of H1 and Mother repeated 29 Multi-Agency Child Sexual Exploitation (MACSE) meetings are a forum in which practitioners review and co-ordinate their response to high risk victims, offenders and locations. 11 Child H1 SCR FINAL JULY 2017 that she was worried about H1 having contact with older males. H1 was admitted to hospital on two occasions in February 2016 following incidents of self-harm and auditory hallucinations. A high risk MASH report was submitted as there were concerns that the mental health of H1 had deteriorated. Information was shared with CSC, School 3, and Health. H1 absconded from hospital and refused to return. H1 was not supported by Parents to attend a follow up CAMHS appointment following discharge from hospital. A Practitioner from the CSE team visited H1 to discuss the recent hospital admission. Mother continued to disagree that H1 should receive any contraception although H1 had requested a service. Mother had an argument with H1 about the provision of contraception and was subsequently admitted to hospital following an overdose. H1 was said to have smashed up her room and Mother discharged herself from hospital the following day. H1 ran away from home with a knife in March 2016 and Mother alleged that she had been allowing boys into her room at night. H1 told the police about anxieties regarding the living situation at home and said that she was having flashbacks of the abuse by Sibling 1 and said that the relationship with her mother was very difficult. H1 said that she would continue to run away from home. At the MACSE meeting in March 2016 it was recorded that a CSE team Police officer and social worker would liaise to progress to a Legal Planning meeting30 due to escalating risk and no change in circumstances for H1. H1 was reported as missing from home at the beginning of April 2016 and some weeks later was admitted to hospital overnight having taken an overdose with intent to self-harm. H1 was arrested at the hospital for a public order offence. A telephone strategy discussion took place to consider a Police Protection Order if H1 was reported missing before a suitable placement could be sourced. An Interim Care Order was granted by the court in April 2016. ANALYSIS: Practice & Organisational Issues Identified Four thematic areas emerged during this Review and the analysis focussed on key practice issues within each area identified to maximise learning for the Local Safeguarding Children Board. The Family; voice of the child, parenting capacity Early Help; early intervention and support , application of thresholds Multi-Agency Work; Information sharing, strategy discussions, Section 47 Enquiries and assessment, child protection processes, Missing from Home, School attendance and escalation of concerns 30 A Legal Planning Meeting is held to discuss the way forward in a particular case, where an application for a legal order may be required. 12 Child H1 SCR FINAL JULY 2017 Cultural influence The Family Voice of the child H1 spoke to different professionals during the timeframe for this review31. H1 told the Families Team practitioner and hospital staff about bullying at school and problems with teachers. H1 said that she wanted to attend full time education however frequent exclusions and changes of school made this difficult. As episodes of self-harm and missing from home incidents increased the heightened emotional distress of H1 was evident and H1 told hospital staff that she self-harmed because she couldn’t cope and she made disclosures to practitioners about wanting to die. H1 presented at hospital with auditory and visual hallucinations which H1 said had been triggered by visits of Sibling 1 to the family home32. It was not evident how the views of H1 were assessed or shared and there was little evidence that the voice of H1 had any influence on the provision of intervention and support. H1 told the Lead Reviewer and Chair that she put on an act of being ‘hard faced’ to protect herself and that she felt judged by people because of past behaviour. H1 said that she did not trust anyone and was trying to forget the things that had happened in the past. There was little evidence of a multi-agency approach to consider the holistic needs of H1 and the family and limited consideration was given to develop a deeper understanding of how past experiences specifically the sexual assault by YP1 and sexual abuse by Sibling 1 may have impacted on H1. There has been extensive research on the impact of sexual abuse on children some of which has been summarised by the NSPCC.33 Sexual assault has immediate and long-term consequences that can be devastating for the physical, emotional and relational health of the victim (Bloom34). The emotional distress of H1 as evidenced by incidents of self-harm, episodes of missing from home and other risk taking behaviour of increasing seriousness was addressed with limited effectiveness by agencies. The behaviour of children can be a clear indicator of their emotional state and on occasions H1 presented as very needy at School 1 and School 3. Whilst efforts were made to support H1 at school these focussed on the management of behaviour. Efforts to support H1 by the Families Team and Schools 1 and 3 were not coordinated and as school exclusions continued and risk taking behaviour escalated it was evident that interventions had limited impact and were not effective. 31 The views of H1 was recorded by the Nurse Practitioner, CAMHS, CSC and Families Team practitioners 32 Practitioners within CSC, Early Intervention, Police, PWO, CAMHS, School and the GP were all aware at some time during this Review that Sibling 1 visited the family whilst H1 was there following the disclosure of sexual abuse. 33 www.nspcc.org.uk/preventing-abuse/child-abuse-and-neglect/child-sexual-abuse/signs-symptoms-effects/ 34 Understanding the Impact of Sexual Assault: The nature of Traumatic Experiences. Bloom, S. from Sexual Assault: Victimization across the Lifespan: edited by A. Giardino, E. Datner, and J. Asher. GW Medical Publishing, Maryland Heights, Missouri, 2003 (PP. 405‐432) 13 Child H1 SCR FINAL JULY 2017 There appeared to be a lack of professional curiosity within all agencies to understand the cause of H1’s behaviour and this was not explored in a systematic way that addressed the influences of school, peers and family on H1. In the absence of an effective Early Help assessment it is not possible to state with confidence what H1 was attempting to communicate by her behaviour. Learning points from previous SCRs have highlighted the importance of recognising behaviour as a means of communication and the implications of doing so for practice. (Ofsted (2011) p1835, Sidebotham P. Brandon M. (2016) p11836). Although the wishes and feelings of H1 had been shared directly with practitioners these were not reflected consistently in records or considered within assessments and issues were frequently reported from the perspective of Mother. Professionals did not share a clear understanding of H1’s wishes and feelings and there were missed opportunities to respond constructively in a way that validated the views of H1 and may have reduced the distress experienced. Parenting Capacity Practitioners had a limited understanding of the capacity of Mother and Father to support H1 which contributed to an over-optimistic view of the ability of parents to appreciate risk and recognise the necessity to safeguard H1. Omission to complete a parenting assessment was acknowledged by the Review Panel and Practitioners at the Learning Event as a significant oversight and missed opportunity to learn about how Mother and Father parented H1, Sibling 1 and Sibling 2. Mother and Father both stressed in discussion with the Lead Reviewer and Chair that they would ‘do anything’ to support H1 and said that they had been ‘crying out for help’ to assist with the difficulties that they had experienced with all the children. These comments by Mother and Father were inconsistent with reports that H1 had not been supported to attend CAMHS appointments and on occasion Mother refused to support the attendance of H1 at school and actively encouraged H1 to remain at home. In addition Mother and Father37 refused to cooperate with CSC at times. Police were unable to interview H1 following the disclosure about sexual abuse by Sibling 1 as Mother refused to give permission and neither she nor Aunt would cooperate with Police enquiries. There was a view expressed by some professionals at the learning event that H1 appeared to have been blamed at times for making the disclosure and causing trouble for Sibling 1, this appeared to be supported by a record within CSC which noted that Mother informed the Social Worker that she had over emphasised the incident that occurred between H1 and Sibling 1. There was no evidence that consideration was given to the impact of this response on the wellbeing and safety of H1. In October 2015 Mother informed the Police that Sibling 1 would be returning home following the 35 The voice of the child: learning lessons from serious case reviews Ofsted 2011 36 Sidebotham P., Brandon M. et al Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011- 2014 London: Department for Education 2016 37 Father refused to allow entry or discuss concerns with a social worker on one occasion when Mother and Children were not present 14 Child H1 SCR FINAL JULY 2017 withdrawal of Bail conditions. In discussion with the Lead Reviewer and Chair, Mother said that she had been asked to take Sibling 1 home and she felt backed into a corner to agree, however there was no evidence within case notes or minutes of meetings to support this view. At the Learning Event Practitioners stated that Mother had undermined the placement of Sibling 1 whilst in foster care38. Whilst practitioners stated that they were aware of Mother’s actions to interrupt the stability of placement for Sibling 1 this knowledge did not inform assessments or influence the intervention and support that was offered to the family. In the absence of a comprehensive parenting assessment there was limited understanding of the factors which influenced the response of Parents to specific incidents39. There were concerns about Mother and Father not acting in the best interests of H1 on occasions, however the reasons for this were not explored and no effective challenge was made. It was acknowledged by the Review Panel, Practitioners at the Learning Event and detailed in agency records that the response of Mother and Father may have been influenced by their particular culture. The influence of ethnicity and culture on intervention provided is discussed later within this analysis. Sibling 1 was accommodated for his own safety due to the physical threats made against him by Mother and Father. Recording of Section 47 Enquiries in March 2015 noted that there were clear concerns relating to the disproportionate response of parents to the behaviour of Sibling 1. However, there was no evidence that this response was explored with Parents and a further opportunity to gain insight into their understanding and parenting capacity was not taken. At the Learning Event and Review Panel meetings professionals stated that there was a combination of factors that contributed to this response. Practitioners described the presentation of Mother and Father as very forceful and it is possible that staff were intimidated. There was an over-optimistic view within agencies, unsupported by evidence, that parents were able to protect H1. Whilst Father had periods of absence from the family home there were times when he was active and influential in the care of the children particularly with regard to school attendance. Minutes of a Core Group in September 2015 noted that “Father should be approached to discuss the issue of him becoming actively involved in decisions regarding H1”. In meeting with the Lead Reviewer and Chair it was evident that Father had at times been actively involved and influential in the provision of care and support for H1. There was limited effort by professionals however to engage Father consistently and the records of all agencies focussed on interaction with Mother. A summary of learning from serious case reviews by the NSPCC40 highlighted the important role that men play in the lives of children. Whilst the necessity of working proactively to involve Father was recognised as a need this was not reflected in the support and intervention provided. Limited engagement with fathers is a well-rehearsed theme within Serious Case Reviews 38 Sibling 1 was said to have made significant progress whilst in foster care 39 Disclosures by H1 of sexual abuse by Sibling 1 and incidents when H1 was excluded from school, self-harmed and went missing from home. 40 Hidden men: learning from case reviews , NSPCC 2015 15 Child H1 SCR FINAL JULY 2017 nationally. Despite recognition of the benefits of father inclusive health and family services, services are still heavily weighted in favour of mothers, and appear slow to change 41. The influence of the family’s culture on the involvement of Father will be addressed later in this analysis. The parental relationship was not assessed although there were indicators of family arguments42 and at the Learning Event Practitioners stated that Mother had alleged that Father did not support with the children. The early help assessment noted that Mother initially reported that she and Father had separated and then resumed their relationship in 2015. In discussion with the Lead Reviewer and Chair there was no reference to difficulties within their relationship and Mother and Father presented as united in the care of H1. Mother said that Father was fully supportive and gave examples when he had been physically active in seeking the whereabouts of H1 when she was missing from home. Mother and Father experienced challenges with their own emotional wellbeing and both were hospitalised overnight on separate occasions during the timeline considered for this Review43. The impact of parental mental health on H1, Sibling 1, and Sibling 2 was not considered effectively although it was noted in the early help assessment that “Mother’s mental health does impact on the children, Mother has a lack of understanding around the self-harming of H1 and rules and boundaries are inconsistent”. There is extensive research evidence that demonstrates the impact of parental mental health problems on children. A Social Care Institute for Excellence guide to parental mental health and child welfare (SCIE 2011) 44 highlights key recommendations for practice which include: assessment of the whole family effective planning to meet the individual needs of each family member. As evidenced within this Review the process of assessment was not adequate, planning was not effective and the needs of H1 and other family members were not holistically addressed. The need to improve the quality of parenting assessments was identified by an internal review undertaken by Children’s Services in early 2017. The parenting assessment template is under review and training for Practitioners has been planned. 41 http://www.fatherhoodinstitute.org/wp-content/uploads/2014/10/Burdett-Report-Final-Version-June-18-2014.pdf 42 The records of Sibling 1 and Sibling 2 were not reviewed in detail, however at the Learning Event Practitioners shared information about historical parental conflict and concerns of Mother that Sibling 1 was behaving like his father. Parental conflict was not identified as a significant concern during the timeline considered for this Review. 43 Father took an overdose at the time H1 made the second allegation of sexual abuse and Mother took an overdose following an argument about H1 receiving a contraceptive implant. 44 Think child, think parent, think family: a guide to parental mental health and child welfare SCIE 2011 p.6 16 Child H1 SCR FINAL JULY 2017 Early Help Services Early Intervention and Support The early help framework in place in Local Authority 1 during the review timeframe provided a continuous assessment tool (form) to assess and plan early help interventions that also served as the referral form for higher tier interventions, if necessary. The framework emphasised the expectation that local agencies should work together to provide early help assessments and interventions for children and families. The Families Team provides intensive family support and intervention in homes and supports the delivery of early help in Local Authority 1. It is important to note that whilst Families Team had significant involvement with the family of H1, the delivery of early help remains the responsibility of all agencies involved with children, young people and their families. Initial support and intervention by the Families Team focussed on improving school attendance and preventing anti-social behaviour. It quickly became apparent that issues were more extensive and complex and included the violent behaviour of Sibling 1, additional needs of Sibling 2 and the emotional wellbeing and increasingly challenging behaviour of H1. There was little evidence that consideration was given to these additional areas of concern as they emerged specifically the vulnerability of a child with disabilities known to be at risk of violence from a sibling. The early help assessment for H1 was incomplete and it was unclear how changes would be evidenced and monitored. H1 was assessed to have complex needs, described in the LSCB Threshold Document as “Children whose vulnerability is such that they are unlikely to reach or maintain a satisfactory level of health or development”. There was reference within the assessment to H1 being frightened in case Sibling 1 returned to the family home however there was no analysis of risk or plan to ensure that H1 was effectively safeguarded. In discussion with the Lead Reviewer and Chair, Mother likened meetings with the Families Team practitioner to having chats over a cup of coffee which were supportive at times but did not lead to change. At times the intervention by the Families Team practitioner was not robust enough to address emerging concerns. It was unlikely that discussions about healthy relationships with the Families Team Practitioner were an adequate response to Mother stating that H1 was associating with older males. There was insufficient managerial oversight to monitor the effectiveness of interventions or increase in risk. In the absence of a clear plan to address the complex needs it was difficult to identify any improvement or deterioration in the level of health and development needs of H1. During this Review Practitioners were open about some historical challenges with the delivery of intervention and support to families by the Families Team which was said to lack effectiveness and focus. Various factors contributed to the limited impact of early intervention and support which included inadequate and incomplete assessment, poor information sharing and ineffective multi-agency partnership working. Working Together 2015 states that an early help assessment carried out for an individual child and their family should be clear about the action to be taken and services to be provided (including any relevant timescales for the assessment) and aim to ensure 17 Child H1 SCR FINAL JULY 2017 that early help services are coordinated and not delivered in a piecemeal way45. It was acknowledged by Practitioners at the Learning Event and the Review Panel that there have been significant improvements in the delivery of intervention by the Families Team which includes the introduction of an improved management structure and a case management system. There was an increased confidence expressed by the Review Panel and Practitioners in the effectiveness of the revised assessment, planning and Review processes used by the Families Team. Support provided by Families Team practitioners must now relate to an agreed plan focussed on outcomes with clarity about how the work will make a difference for the child and family. Whilst there have been positive changes to systems and processes it was evident that some challenges remain. It was acknowledged during discussions at the Learning Event and meetings of the Review Panel that there was limited appreciation and understanding between the Families Team and CSC regarding the responsibility and contribution of each service area. It was evident from information provided for this Review that limited integration and lack of cohesiveness between the Families Team and CSC had a direct impact on the quality of intervention and support provided to the family of H1. Whilst there has been an improvement of professional relationships between the Families Team service and CSC and examples of good practice were evident, it is important that further development is encouraged to promote consistent and effective partnership working to focus on the needs of children and families. There was an opportunity for practitioners from the Families Team and CSC to work together on a parenting assessment and this may have improved coordination and increased the effectiveness of subsequent interventions. The provision of Early Intervention and Support was at times confusing for the family, Mother complained that too many professionals were involved and more importantly the needs of H1, Sibling 1 and Sibling 2 and risks they were exposed to were not identified or appropriately assessed. The need to integrate Families Team and CSC services has been identified in previous reviews and audits in Local Authority 1. Communication days have taken place between the managers of the Families Team service and CSC to develop greater cohesiveness between the services and to facilitate cooperation and coordinated working practice. Further events are planned with Practitioners to progress this development. Application of Thresholds It was acknowledged amongst Panel members and Practitioners during the Learning Event that there were significant errors of judgement regarding the application of thresholds for H1. Agencies worked independently, intervention was reactive and each new concern appeared to be managed in isolation. It was a challenge for practitioners to assess the needs of H1 and the family and this was made more difficult due to the lack of a chronology within case records. 45 Working Together, 2015 p 14 18 Child H1 SCR FINAL JULY 2017 A pattern emerged in which new concerns or incidents were reported to CSC, information was shared with the Families Team Practitioner and the case closed to CSC as it was considered that support needs and risk could be managed by the Families Team. It was the consensus of all professionals involved in this Review that the decision to close the referral for H1 in 2015 following the disclosure against Sibling 1 was not based on a thorough assessment of need or risk. There was limited communication between CSC and the Families Team and a lack of clarity about the decision making process which resulted in the judgement that the Families Team could manage risk and provide effective intervention in response to new information of increasing concern regarding the wellbeing of H1. Mother and Father did not contribute to a plan nor did they have an understanding about how support and intervention to address emerging needs would be provided. In the absence of an assessment and the attendant lack of communication it was not evident that there was a shared understanding of emerging needs amongst professionals and Mother, Father and H1. In addition it was not possible to have confidence that the Families Team had the capacity, skills or the agreement of parents to provide and sustain effective intervention. Internal audits undertaken by CSC have identified inconsistent management of decision making following an initial contact with CSC. It is known that discussions take place and there are constructive professional relationships to enable rapid consideration of cases, however this was not evidenced sufficiently within this Review. Following the referral to CSC by the Families Team practitioner in September 2015 it was decided that the threshold had been reached for consideration at an ICPC. The Independent Chair of the ICPC expressed concern that the case had not been referred earlier and it was recorded that the threshold for child protection intervention had been met earlier. Whilst there was consensus among professionals that H1 and Sibling 2 were made subject to a CP plan there was evidence that thresholds continued to be inappropriately applied. A Review Child Protection Conference took place eight weeks after the ICPC and Sibling 2 was stepped down from a CP plan without a full assessment of risk or need and the category of Sexual Harm was removed from the CP Plan for H1. Practitioners at the Learning Event stated that this was a unanimous decision made by all professionals at the meeting, however given the information that was known at the time it is evident that this decision was flawed and should have been challenged by the Independent Reviewing Officer (IRO). The decision made at the Review Child Protection Conference was contradicted by the Police two months later. A high risk MASH referral was submitted due to H1 being considered a high risk of Child Sexual Exploitation when missing from home. There was limited collaboration between 19 Child H1 SCR FINAL JULY 2017 agencies and inconsistent assessment of the level of risk and intervention required. There was no evidence that Think Family46 principles were considered by practitioners to inform intervention. The needs of H1, Sibling 1 and Sibling 2 were considered separately and it was recorded that that Sibling 2 and H1 were exposed to unassessed risks. Whilst much work was taking place to support H1 and the family this was fragmented, lacked coherence and appeared to be reactive to incidents of increasing seriousness. It was clear from agency records and information shared at the Learning Event that Practitioners worked hard to support the family and work was time consuming, challenging and reactive with little opportunity to reflect on practice. Practitioners expressed an appreciation for the reflective learning opportunity afforded by participation in this Review47. During the course of this Review, the Local Safeguarding Children Board has agreed a new Threshold Document with increased clarity about levels of need, assessment of risk and provision of support and interventions. Training will be offered across the multi-agency partnership and effective and consistent implementation will be monitored by the LSCB. Multi-Agency work Information Sharing The first multi-agency meeting took place the day after H1 was excluded from School 1 for the first time in July 2014. School 1 were not invited and were unaware of the serious incident that had taken place at the family home48. There was no opportunity for School 1 to consider how this experience may have impacted on H1 before excluding her from School. Practitioners acknowledged at the learning event that they did not fully understand or appreciate the role of CAMHS. Practitioners were not aware of the duty phone line and consultation service offered by CAMHS prior to making a referral.49 H1 was referred to CAMHS by the GP and the Families Team Practitioner and referrals were subsequently closed due to non-attendance. The GP Practice recorded that H1 alleged not to have known about the appointments and was very upset to have missed them. Letters to inform that a CAMHS referral had been closed were forwarded to the GP and referrer. An early outcome of this Review is that all school nurses (even if they are not the referrer) will receive a copy of the discharge letter from CAMHS which will state the reason for discharge from the service. This information will provide School Nurses with greater opportunity to support and encourage young 46 Think Family means securing better outcomes for children, young people and families with additional needs by co-ordinating the support they receive from children’s, young people’s, adults’ and family services. www.education.gov.uk/publications/eOrderingDownload/Think-Family.pdf 47 Practitioners said they would work to reflect on their work more frequently with colleagues and would appreciate a procedure to enable this. 48 The abuse on Sibling 2 by Sibling 1 49 The Families Team practitioner made a referral to CAMHS for H1 to receive bereavement counselling which is provided by other agencies. This would have been identified in a telephone consultation prior to an inappropriate referral being made. 20 Child H1 SCR FINAL JULY 2017 people to attend appointments with CAMHS. Examples evident during this Review of limited information sharing included: school were not informed of the first incident when H1 was missing from home; the Families Team practitioner was not aware that Mother had refused to engage with the Police investigation following the disclosure by H1 and agencies were not aware that the Pupil Referral Unit had assessed it necessary to have two people present when delivering home tuition due to Mother becoming aggressive towards staff at school. Had a multi-agency meeting taken place it is likely that this information would have been shared and intervention provided in a more holistic way. The Nurse Practitioner proactively shared information about H1 not attending CAMHS and concerns that H1 was being intentionally socially isolated by Mother with the Families Team practitioner and the Pupil Welfare Officer. There was no record to evidence whether this information was shared with other agencies or addressed with Mother and H1. In the absence of a clear plan to inform support and intervention it was a challenge for practitioners to assess the value and relevance of new information as it was shared. Medical records noted details of a telephone conversation between the Nurse Practitioner and School Nurse regarding abuse by H1 on another pupil in which the Nurse Practitioner stressed the need to understand the factors that may be influencing behaviour of H1. This was the first example within the timeline of a professional stating explicitly that it was important to understand why H1 was behaving in the way rather than reacting to the immediate incident. Strategy Discussions, Section 47 Enquiries and Assessment Following the disclosure that Sibling 1 had sexually abused H1 a Strategy discussion took place between the Police and CSC and S.47 enquiries were made. Intervention initially focussed on the physical separation of H1 and Sibling 1. Following Section 47 enquiries H1 and Sibling 2 were closed to CSC Sibling 1 was accommodated due to parental threats of harm. Recording of S.47 enquiries was limited and the impact of the sexual abuse on the emotional wellbeing of H1 was not considered. Intervention focussed on the immediate risk and need to separate H1 and Sibling 1 and the emotional wellbeing of H1 was overlooked. It was acknowledged by the Review Panel that the recording of the Strategy Meeting following a second disclosure by H150 was not to the required standard and contained limited contextual information and few details of the discussion. Health partners were not involved in the Strategy Meeting. It was decided to undertake a CAFA as part of S.47 enquiries, although there was no record of what was discussed to inform this decision. The decision following the Strategy Discussion to undertake a CAFA was not actioned. The delay was eventually identified by a manager and the assessment progressed with urgency. It would appear that previous managerial 50 H1 alleged sexual assault by YP 1 and under age sex with YP2 to Aunt, Mother was informed and reported the disclosure to the Police 21 Child H1 SCR FINAL JULY 2017 oversight had not been adequate or this would have been addressed earlier. H1 was reported as missing from home by Mother in August 2015 and was found by Police two days later in London. The Strategy Meeting following this incident was well attended and evidenced good information sharing about the specific incident. A high risk MASH referral was submitted by the police and a return home interview was completed. Agency records noted that H1 was at high risk of CSE. It was recorded in the outcome of the S.47 enquiries in September 2015 that H1 was seen and spoken to alone however there was no detail about what H1 said during the discussion, information about previous concerns was incomplete, reference was made to self-harm and missed CAMHS appointments, however there was no information about missing from home episodes and school exclusions. It was acknowledged by members of the Review Panel and by Practitioners at the Learning Event that recordings of the strategy discussions and S.47 Enquiries did not adequately evidence the extent and quality of effective multi-agency discussion and co-working. The Review Panel acknowledged that the inconsistent quality of S47 enquiries had also been identified at recent reviews and audits of the front door. Training has taken place and learning communicated back into teams. A new and more effective template for S.47 enquiries and Strategy Meetings is being developed by CSC Senior Managers. Child Protection Processes Parents did not attend the first Core Group and minutes of the meeting evidence some information sharing, however there was limited discussion about the CP plan. It was recorded that the social worker for H1 would liaise with the social worker of Sibling 1 about his potential return to the family home, however there was no record in CSC Case Notes that a discussion took place. Whilst professionals expressed concerns about the possible return home of Sibling 1, these were not escalated and no action was taken to ensure that H1 would be appropriately safeguarded. It was recorded in the multi-agency chronology prepared for this Review that Core Groups were infrequent, ineffective and did not confirm the detail of the Child Protection Plan outlined at the ICPC. Since 2016 CSC Managers have received a fortnightly report regarding the completion of statutory visits to enable clear oversight, challenge and support to ensure that visits are within the required timescale. It was acknowledged by the IRO at the Learning Event that poor practice should have been challenged more robustly. Limited managerial oversight and absence of reflective practice contributed to a lack of appreciation about the vulnerability of H1 which may have been linked to lack of understanding 22 Child H1 SCR FINAL JULY 2017 about the risks associated with sexual abuse in families. Yates51 describes an intuitive decision making process influenced by a practice mind set of ‘siblings better together’ when working with families in which sibling abuse has occurred. This mind set comprises three underlying perspectives: children as vulnerable and intending no sexual harm to others; sibling relationships as non-abusive and of intrinsic value; and parents as well-intentioned protective. These perspectives encourage a focus on immediate safety rather than emotional harm, and could be said to extend Dingwall et al.’s52 ‘rule of optimism’. There is a danger of the victim child becoming lost. The decision making process regarding H1 and Sibling 1 focussed on actions to ensure the immediate safety of both. There was very little attention given to the emotional harm experienced by H1 who was not effectively safeguarded and it could be stated that her needs were lost in the protection process. There was a delay by Managers to authorise Statutory visits and lack of challenge when visits were out of timescales. In addition records of some visits were confusing and inconsistent with a lack of clarity about who was spoken to and whether the child had been seen. Some CSC supervision records evidenced initial reflective discussion about the case although this did not lead to any change in the intervention provided. In December the social worker for Sibling 1 (Social Worker 1) became the social worker for H1 in response to information from the family and other professionals about difficulties in contacting the social worker for H1. This appears to have been a decision led by Social Worker 1 with limited managerial oversight. It was clear from information shared at the Learning Event that Social Worker 1 received a limited handover and was required to undertake statutory visits and core groups as a priority. At the Learning Event Social Worker 1 stated that it was a challenge to manage the case given the varied and complex needs of all the children. Social Worker 1 focussed on re-establishing a positive working relationship with the family in order to implement the CP Plan. The third core group took place in January which resulted in a further period of unassessed risk between Sibling 1 and H1 as they lived in the same house for two months and the behaviour of both escalated significantly during this time period. Mother and Father attended the core group in January 2016 (the first in three months) and concerns were expressed by parents and other professionals about the lack of case management by CSC. School records indicated that H1 was in the care of aunt53 however this was a family arrangement and CSC had not been informed that H1 was not at home. It would appear that managerial oversight during this time was not rigorous enough and there was insufficient 51 Yates, P. (2017); ‘Siblings as Better Together’: Social Worker Decision Making in Cases Involving Sibling Sexual Behaviour, The British Journal of Social Work 52 Dingwall, R., Eekalaar, J. and Murray T. (1983); The protection of children: state, intervention and family life, Oxford: Blackwell. 53 It had been recorded by the IRO following the ICPC that H1 should spend minimal time with Aunt 23 Child H1 SCR FINAL JULY 2017 oversight to effectively safeguard H1, Sibling 1 and Sibling 2. At a meeting in November 2015 between Mother and the social workers for Sibling 1 and H1 Mother self-reported that she was managing the risks by moving the bedrooms apart and making sure that H1 and Sibling 1 were not left alone together. Mother did not appear to understand the requirements of the Child Protection process and said that she was unaware of home visits and core group meetings. There was no record that Mother and Father had been provided with a copy of the CP plan or the dates of meetings. There was a significant omission to safeguard a young person which was not identified at practitioner or managerial level, or by the Independent Reviewing Officer. It was reported in the timeline for this Review that there had been no progress with the CP plan during the first two months. Use of a written agreement between CSC and Mother and Father to ensure that Sibling 1 and H1 were not left alone was not appropriate or adequate to ensure the safety of H1. There was no clarity about how the written agreement would be monitored or what the consequences would be should conditions be breached. There is considerable evidence that written agreements provide a false sense of assurance to professionals. It is unlikely that the written agreement was of benefit to H1 who told professionals that she did not feel safe in the house when Sibling 1 was present. Records of the Core Group in February 2016 inappropriately detail disagreement between professionals about intervention and support which resulted in further fragmentation of the safeguarding process. It would have been more constructive and in the best interests of H1 had the professionals had a pre-meeting to discuss different views about how to proceed. Mother attended this Core Group which did not progress an assessment of risk or review how Mother and Father were managing to safeguard H1. Given the ongoing concerns and unassessed risk it was difficult to understand the decision to remove Sibling 2 from a CP plan and to remove the category risk of sexual harm from H1 who remained subject to a CP plan under the category risk of emotional abuse. It was evident that much work had been completed by the CSE team however there had not been a sufficient time lapse to confirm whether the information and support provided had led to a sustained change in the behaviour of H1 and reduction in the risk of CSE. It was recorded within the Review Child Protection conference minutes that H1 was not at risk of sexual exploitation and also that Sibling 1 was an unassessed risk. These statements are contradictory and illustrate a lack of coherence in the recording of child protection processes. At the Learning Event Practitioners spoke about high caseloads and rapid turnover of staff which was unsettling for the workforce. The need to embed the early help framework and improve managerial oversight, monitoring of practice and quality of assessments have been identified as issues within this Review. It is important that any actions from this review build on the work currently in progress to improve service delivery for children and young people in Local Authority 1. Response to Missing From Home H1 was reported a missing from home on 4 occasions during the course of this Review. It was 24 Child H1 SCR FINAL JULY 2017 known that there were also times when Mother and Father did not report H1 as missing. H1 went missing from home for the first time in September 2014. Mother informed the Families Team practitioner H1 had been missing from home and found by her father with older males although this was strongly denied by H1. There was no evidence that this information was shared in supervision by the Families Team practitioner who advised Mother to contact the police should H1 go missing again. There was a lack of understanding about the H1’s vulnerability and the potential risk of CSE whilst missing from home. A second missing from home episode was reported in January 2015. It was unclear who had made the report and there was no further information about how this was managed or whether the information was shared with other agencies. The missing from home episodes suggest that there was little or no improvement in behaviour management and escalation of risk as whilst missing H1 was vulnerable and at risk of CSE. Records indicate that H1 went missing in response to the boundaries imposed by parents as a consequence for being excluded from School 3. H1 returned within three hours and a safe and well check was conducted by the Police. A MASH referral was not made and therefore information about H1 missing from home was not shared with CSC, Health or School. It appears that this incident was treated in isolation and the Police Officer may not have been aware of the context regarding school exclusions and CAMHS referrals. There were some examples of good practice following missing from home episodes. There was evidence of multi-agency cooperation between the Police and the CSE team. H1 had a good relationship with staff from the CSE team it was thought that she would be more likely to make a disclosure about where she had been and who she had been with to CSE team practitioners. In addition it is likely that H1 would have felt more supported having the return interviews conducted by people that she was familiar with. Previous audits have identified that submission of MASH referrals as a contact generates work with limited outcome. Managers are reviewing procedures and practice to enable more efficient and effective processing of MASH referrals. School attendance Poor school attendance for H1 and Sibling 154 was a long standing concern for professionals. H1 experienced much disruption in educational provision due to school exclusions, refusal by Mother to allow attendance55 and movement to different areas. School 1 provided support to H1 and made significant efforts to locate H1 and share information with School 2 when the family moved area. The Pupil Welfare Service provided intervention and support to enable H1 to attend school or an alternative provision following exclusion. Mother received a fine due to Sibling 1 not attending school and Minutes of a Core Group in October 54 Initially Sibling 2 had poor attendance however this was resolved following a change of school and improved travel arrangements to facilitate attendance 55 Due to a reduced timetable or alleging that H1 was too distressed to attend school 25 Child H1 SCR FINAL JULY 2017 2015 noted professional concerns that cultural difference was sometimes used as an excuse for not attending education. It was identified during this Review that attendance procedures were not rigorously or consistently applied by School 3. There were specific concerns about the use of recording codes when H1 was accessing educational activity off-site or within another establishment and when excluded. It is essential that attendance is appropriately recorded to ensure that the whereabouts of children is known and can be checked. This is of particular importance for those children known to be vulnerable and at risk. School 3 is under new management and attendance procedures have been reviewed. Centralised systems have been introduced and there is greater control over registration procedures. A meeting is planned between Senior managers of School 3 and CSC to discuss the learning from this Review and ensure that changes are implemented effectively and consistently. Escalation The LSCB has an agreed escalation process, which is covered throughout LSCB training. The procedure is not implemented consistently; although, as noted by members of the Review Panel, concerns are discussed among practitioners and across agencies and, at times, senior managers in CSC are contacted directly to resolve an issue. There was consensus amongst Practitioners that H1 was at risk due to Sibling 1 being allowed back into the home when H1 was present. Whilst there was a clear concern that H1 was not being safeguarded, limited action was taken to reduce the risk to H1. It was evident from CSC records that professionals had some concerns about the management of this case by CSC. Core groups and statutory visits were out of timescale, however professionals did not escalate concerns further than sharing information with the Social Worker for Sibling 1. Whilst these concerns were valid it was not appropriate for professionals to express disagreements in meetings with Mother and Father present. Given the challenge to engage Mother and Father in the child protection process this was an opportunity to progress multi-agency work and address prior drift. It is important that all agencies and practitioners recognise their duty to cooperate in activities to safeguard children. As the Child Protection Plan for H1 had been in place for four months with little progress and increased concerns this should have been escalated through the appropriate channels. Practitioners at the Learning Event were aware of the formal escalation process and said that they would implement this in the future following the reflection on practice during this Review process. An issue resolution was raised by the Safeguarding Service Manager regarding Sibling 2, as 13 days following the ICPC there was no record of the CP Plan on the relevant case records. Implementation of the escalation process has been highlighted in other reviews and audits, resulting in an updated process being adopted. This review endorses recommendations previously made to promote the effective use of the escalation process across all partner agencies of the LSCB. 26 Child H1 SCR FINAL JULY 2017 Cultural Influence Agency records referenced that the family of H1 were from an ethnic minority community however there was no evidence that meaningful consideration was given to the ethnicity and culture of the family during the intervention and support provided. It was recorded in the S.47 Report following the disclosure of abuse by Sibling 1 that the family were from an ethnic minority community and Parents were worried about their community hearing about the sexual abuse as this would bring shame on the family. The record also included the fears of Sibling 1 about a community backlash. There was limited evidence that the anxieties of the family were considered or impacted on assessments and intervention provided. The Review Panel noted that the culture of the family was not adequately taken account of in assessments and interventions. Records indicated that H1 complained of being bullied as a consequence of her ethnicity at School 2, although this was not substantiated. It was not evident what action had been taken to address the allegation or whether support had been offered to H1. In discussion with the Lead Reviewer and Chair H1 said that she was bullied but nothing was done about it. Issues within the their community led to movement of the family; in November 2013 a Families Team Practitioner recorded that Mother spoke about disagreements with people in their community and planned to move to Local Authority 2 as she was fearful for her family due to repercussions within the community. On their return to Local Authority 1 in 2014 Mother informed the Families Team practitioner that they experienced racial abuse in Local Authority 2 and decided to return. In June 2015 Mother informed the Families Team Practitioner that the family were planning to move due to the shame felt due to H1 associating with older boys. The impact of these cultural stresses on the family was not effectively addressed by practitioners. In discussion with the Lead Reviewer and Chair, Mother stated that in her culture education was not prioritised. It was the view of some Practitioners at the Learning Event that culture was used by Mother to support non-attendance at school. However, Mother also stated that she was not happy when H1 was on a reduced timetable and the ambivalence of Mother towards H1 attending school was not addressed. The different views expressed by H1, Mother and Father about school were not explored and there was a missed opportunity to gain a greater appreciation of Parental views and cultural influence regarding attendance at education. In addition it was likely that the negative view of Mother regarding H1 receiving sexual health support was influenced by her cultural background, however this was not explored. Practitioners at the Learning Event were clear that their knowledge of the family’s particular culture was limited and this was shared by some members of the Review Panel. 27 Child H1 SCR FINAL JULY 2017 Practice issues Changes that have taken place during the process of this review School School 3 is under new management and attendance procedures have been reviewed. Centralised systems have been introduced and there is greater control over registration procedures. Health School Nurses are informed when a young person has been discharged from CAMHS Good Practice Identified During this time period the Nurse Practitioner at the GP Surgery worked proactively to share information and raise concerns with other agencies and parents about the non-attendance of H1 at CAMHS. It was recorded that information was shared in a timely way and H1 was seen by the School Nurse and offered an open appointment. The CSE team practitioner and Police completed joint Section 47 enquiries as it was thought more appropriate for someone already working with H1 to obtain a disclosure – this was good practice and evidence of good use of multi-agency resources. School 1 worked proactively to identify where H1 was located when she did not attend school This was good practice by School 1 to ensure the safety of H1, the lead for children missing from education in Local Authority 1 was informed and supported efforts to confirm the whereabouts of H1. On return to School 1 H1 was reintegrated into the class she had previously left in to support established relationships. Following the specific disclosures of sexual abuse H1 told the Nurse Practitioner about feeling unsafe at home because the doors were always unlocked and Sibling1 was allowed freely into the house. The Nurse Practitioner, with consent of H1, shared this information with the school nurse to ensure that H1 had support in school. Learning and Recommendations Learning Point 1 When Early Help support is delivered without a holistic assessment to inform a plan with agreed outcomes it is a challenge to monitor the impact of intervention. Practitioners may develop a false 28 Child H1 SCR FINAL JULY 2017 reassurance about the effectiveness of their support to children, young people and families. Question for the Board How can the Local Safeguarding Children Board seek assurance about the quality of Early Help assessments and ensure that intervention is making a difference for children and families? Learning Point 2 Without a holistic (multi-agency) assessment, factors which increase or decrease risk within the family, community and environment may be overlooked and make it more difficult to assess and evidence the appropriate level of need for a child or family. Recommendation 1 The Local Safeguarding Children Board should review assessment tools to ensure that information required to evidence decision making regarding the level of need/risk is easily accessible. Learning Point 3 The development of positive relationships between agencies and professionals at all levels is important to promote multi-agency cooperation and effective intervention when supporting children and families. Absence of partnership working can result in duplication of resources and agencies working in isolation with limited impact. Recommendation 2 The Local Safeguarding Children Board should actively promote the development of constructive professional relationships between the Families Team and CSC. Recommendation 3 The Local Safeguarding Children Board should consider the development of an annual event to celebrate good practice and promote partnership working. Learning Point 4 In the absence of a parenting assessment it is a challenge for Practitioners to have clarity about the capacity of parents to understand safeguarding concerns and confidence in the ability of parents to protect children. This may result in practitioners having unrealistic expectations of parents and the vulnerability of children could increase. Recommendation 4 The Local Safeguarding Children Board should undertake an audit of parenting assessments to monitor quality and ensure that training is implemented across the workforce. 29 Child H1 SCR FINAL JULY 2017 Learning Point 5 It is important that efforts are made to understand why young people may be engaged in behaviour described as ‘risk taking’ and ‘challenging’. When the focus of intervention is on behavioural change it is possible that underlying emotional distress could escalate and risk taking behaviours increase. Question for the Board How can the Local Safeguarding Children Board ensure that all partners recognise that young people may be communicating distress through their behaviour and ensure that intervention is focussed on support to understand and reduce distress rather than change behaviour? Learning Point 6 When children and young people speak directly to Practitioners it is not sufficient to record what has been said. If the voice of young people does not inform assessments and subsequent interventions it is likely that they will not feel listened to, intervention may not be appropriate and challenges could escalate. Recommendation 5 The Local Safeguarding Children Board should audit and monitor how the voices of children young people inform assessments and interventions. Learning Point 7 It is essential that practitioners recognise the cultural influences on children and families from diverse communities. An ability to demonstrate cultural competence will enable practitioners to intervene with respect when required to promote the best interests of children and young people. Question for the Board How can the Local Safeguarding Children Board ensure that the practice of all partners is culturally sensitive and focussed on the needs and best interests of children and young people? Learning Point 8 In addition to ensuring the immediate safety of children following sibling abuse it is important that consideration is given to their emotional wellbeing and risk assessments are completed in a timely way to ensure the safety of all. Recommendation 6 The Local Safeguarding Children Board should satisfy itself that when action is required to ensure the immediate safety of children and young people consideration is given to their emotional wellbeing and support is provided in a timely way. 30 Child H1 SCR FINAL JULY 2017 Learning Point 9 Appropriate recording of Strategy Meetings and S.47 Enquiries is essential to evidence decision making processes and multi-agency actions to address identified risks. Recommendation 7 The Local Safeguarding Children Board should seek assurance that the templates used to record Strategy Meetings and S.47 Enquiries facilitate the effective recording of information to evidence multi-agency discussion, information sharing and agreed action to safeguard children and young people. Learning Point 10 Omission to use formal procedures to escalate safeguarding concerns may result in children and young people being subject to unnecessary risks. Recommendation 8 The Local Safeguarding Children Board should promote and monitor the use of the escalation process. Learning Point 11 When Early Help support is provided by a single agency (the Families Team) the efforts of other agencies (schools) to support young people may take place in isolation. Multi-agency partnership work to provide Early Help support to families and young people can become fragmented and lack effectiveness. Question for the Board How can the Local Safeguarding Children Board ensure that the provision of Early Help for children and families is coordinated, effective and recognised as the responsibility of all agencies? 31 Child H1 SCR FINAL JULY 2017 Statement by Reviewer I make the following statement that prior to my involvement with this learning Review:- I have not been directly concerned with the child or family, or have given professional advice on the case. I have had no immediate line management of the practitioner(s) involved. I have the appropriate recognised qualifications, knowledge and experience and training to undertake the Review. The Review was conducted appropriately and was rigorous in its analysis and evaluation of the issues as set out in the Terms of Reference. Reviewer Catherine Connor (Signature) Date June 2017 Chair of Review Panel (Signature) Date July 2017 |
NC50855 | Death of a 15-year-old young person. Cause of death attributed to acute morphine poisoning and aspiration of gastric contents. Young Person (YP) lived with their mother, sister and grandfather, and was described as bright and articulate. YP had experienced sleeping difficulties over a number of years, had been self-medicating with cannabis to help them sleep and experimented with other drugs sourced on the internet; engaged with a number of internet drug forums. Known to Child and Adolescent Mental Health Services (CAMHS) since April 2012. Ethnicity or nationality not stated. Practice and organisational issues identified include: the benefits of multi-agency coordination through Early Help processes to support YP and their family; threshold for referral to Children's Social Care; impact of transformational change on services; lack of clarity amongst professionals about interventions that CAHMS could offer; Substance Misuse Services for Young People and CAHMS situated in different providers; importance of communication with fathers; importance of systems that enable communication of risk where more than one professional is involved in an organisation; professional awareness of patterns and sources of young people's drug use; safety when experimenting with drugs. Areas of good practice identified include: support and commitment by YP's school and GP. Recommendations include: development of an awareness raising and educational campaign about young people who use and supply drugs; guidelines to strengthen professional knowledge about referral thresholds and pathways for young people who abuse or procure drugs.
| Title: Re: child practice review SILR14B. LSCB: Derbyshire Safeguarding Children Board Author: Patricia Field Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Derbyshire Safeguarding Children Board Child Practice Review Report Re: Child Practice Review SILR14B Concise Review √ Review Process This serious incident learning review was commissioned by the independent chair of Derbyshire LSCB on 5th November 2014, in agreement with the recommendation of the Serious Case Review Sub Committee that the circumstances surrounding the death of young person did not indicate a need for a Serious Case Review (Section 9 of Working Together to Safeguard Children (Department of Education March 2013)), but that lessons could be learnt by organisations involved. Circumstances resulting in the review Subject of the review: Young person (YP): Aged 15 years (deceased) On , the local ambulance service was called to the home of a young person (YP) who had been found suddenly and unexpectedly collapsed and unresponsive at home in their bed in the morning. Life support was initiated on the scene and continued in hospital, but, sadly attempts at resuscitation were unsuccessful The circumstances resulting in the death of the young person (YP) have been established by the coroner who gave a narrative verdict at inquest which included: “YP’s death being contributed to by a number of agencies, due to no safeguarding referral being made”. which included: The immediate cause of death was: 1a aspiration of gastric contents 1b acute morphine poisoning YP was fifteen years old at the time of their death. The YP lived with their mother, older sister and grandfather. The YP had had difficulty sleeping over a number of years and had been known to Child and Adolescent Mental Health Services (CAMHS) since April 2012 and had taken to self medicating with cannabis, which the YP felt helped them to sleep. Over the review period, the YP started to experiment with a range of other drugs, which they sourced on the internet – including a range of “legal highs”. The YP also engaged with a number of internet drug forums where the YP communicated about drugs. Despite a close knit peer group, the YP had significant anxiety, including social anxiety and depression and the YP felt that the drugs that they used had a beneficial effect on their well-being. There is evidence that towards the end of the review period, the YP had experimented with heroin. 2 The YP was an extremely bright, articulate young person, who achieved well in school, with aspirations to become a doctor, and who had an intellectual interest in the drugs that they used and researched their potential effects. The YP was engaged with a number of agencies, who were trying to support the YP with regard to their mental health, general well-being and their drug use. There is evidence that the YP partially hid their drug habit from some individuals. Legal Context: A Serious Incident Learning Review was commissioned by Derbyshire Safeguarding Children Board, following agreement at Derbyshire Safeguarding Children Board Serious Case Review Panel in accordance with Working Together to Safeguard Children (Department of Education 2015). Regulation 5 of the Local Safeguarding Children Boards Regulation 2006 sets out the functions for LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) set out an LSCB's function in relation to serious case reviews, namely: Working Together to Safeguard Children (Department of Education 2015) also stipulates that LSCBs should consider conducting reviews on cases which do not meet the SCR criteria. Whilst this case was deemed not to meet the threshold for a Serious Case Review it was agreed that a Serious Incident Learning Review should take place in line with the principles of learning and improvement set out in Chapter 4 of Working Together to Safeguard Children (Department of Education, March 2015). The methodology used was the Child Practice Review process (Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Government, 2012). This is a formal process that allows practitioners to reflect on cases in an informed and supportive way. Documenting the history of the child and family is not the primary purpose of the review. Instead it is an effective learning tool for Local Safeguarding Children Boards to use where it is more important to consider how agencies worked together. The detail of the analysis undertaken of the case is not the focus of the reports which are succinct and centre on learning and improving practice. However, because a review has been held, it does not mean that practice has been wrong and it may be concluded that there is no need for change in either operational policy or practice. The role of Safeguarding Boards is to engage and contribute to the analysis of case issues, to provide appropriate challenge and to ensure that the learning from the review can be used to inform systems and practice development. In so doing the Board may identify additional learning issues or actions of strategic importance. These may be included in the final child practice report or in the action plan as appropriate. Methodology: Following notification of the tragic death of the young person in this case and agreement by the chair of the Derbyshire Safeguarding Children Board to undertake a Child Practice Review, a Review Panel was established in accordance with guidance. This was Chaired by Amanda Clarke, 5. (1) (e) Undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1)(e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 3 Board Manager for Derbyshire Safeguarding Children Board and included representation from relevant organisations within Health, Education, Police, Youth Offending Service and Social Care. Dr Patricia Field, Designated Doctor for Derbyshire County was commissioned to work with the panel and to undertake the review. . All relevant agencies reviewed their records and provided timelines of significant events and a brief analysis of their involvement. These were considered by the panel and provided opportunity for panel members to raise questions and clarify understanding of the circumstances of the case and of the separate services provided. The agency timelines were merged and used to produce an interagency timeline. This was carefully analysed by the reviewing officer with the Panel and informed of the areas of interest that required further exploration and consideration. The process also allowed for the identification of the key practitioners required to attend a learning event in order to understand the detail of the single and interagency practice in this case. The Chair of the Panel and reviewing officer met with the father, and had e mail communication with the mother to gain an understanding of their experiences of the services offered. This valuable insight in to their experiences was shared with the Panel and with practitioners attending the learning event. Account was taken of the views of the parents when writing the report and recommendations. The learning event was held on and was attended by 17 professionals who had had significant involvement with YP, in addition to the Reviewer who facilitated the session, the Chair of the Panel and the minute taker. The learning event was organised in line with Welsh Government guidance (Child practice Reviews Organising and Facilitating Learning Events, December 2012) and the event was recorded by the minute taker. Following the learning event, the reviewer collated and synthesised the learning to date for discussion with the Panel. Practice issues originally identified by the Panel were re-examined in the light of the findings of the review. This provided opportunity to identify issues requiring further clarification with practitioners or managers. In reviewing the findings, the Panel gave consideration to what could be done differently to further improve future practice. The Reviewing officers will meet again with the family to provide them with a copy of the review when completed and agreed by the Derbyshire Safeguarding Children Board. Learning from the full report may be made publically available after consideration by the Serious Case Review Sub Group and the Board ANALYSIS: Practice & Organisational Issues Identified The YP and their family, predominantly the YP’s mother, were engaged with a number of universal and specialist services during the period of this review, including school, the GP, CAMHS and Young People’s Substance Misuse Service. Scrutiny of the timeline, information shared and reflections at the panel meetings and the learning event have highlighted areas of good practice and also provided an opportunity for wider learning to emerge about the ways in which services work together: The following is an analysis of the issues identified: 1. The benefits of multi-agency coordination through Early Help processes to support YP and their family “Early Help” is the vehicle through which all professionals who work with children and their families assess need and deliver services as early as practicable in the child’s journey in order to ensure 4 optimum outcomes for children and to prevent an escalation of need. Early help requires a collaborative approach from all agencies, including schools, with the active involvement of children, young people, families and carers The start of every Early Help Assessment is the meaningful conversation that every professional who works with children and their families holds with the child and family about their strengths and challenges, in order to work out what services are required. Some services maybe provided or arranged through individual partner agencies, but many will require the involvement and shared assessment and planning of a number of agencies, and pathways through universal and targeted services Working Together 2015 is very clear that local agencies should work together to provide early help assessment and effective services for children who may benefit from them. In Derbyshire, the Common Assessment Framework was in place for much of the time period under review. This was replaced by the Early Help Assessment in 2014 – a very similar process, but with simplified paperwork. The Early Help process does not appear to be well embedded in the daily practice of the children’s workforce in Derbyshire. This is in line with findings in a number of other areas, highlighted in the Ofsted Report on the thematic inspection “Early Help: Whose Responsibility?” published in March 2015, No. 150012 YP was a young person who may have benefited from the coordinated approach that underpins Early Help processes. Individual professionals worked extremely hard to support the YP, and there was evidence of interagency communication, but this did not bring all those involved to a collective view of the needs of the YP and their family, and, often, professionals were working in professional isolation. Engagement of all involved through an Early Help Assessment would have enabled better information sharing and engagement of the YP and their family in a more holistic assessment of need and planning of services. It may have enabled the support of the school nurse, whose offer of help to the YP had declined. A team around the family approach and joint care plan would have helped to reduce the professional isolation and sense of powerlessness felt by some professionals when there seemed to be no way forward 2. Threshold for referral to Children’s Social Care (CSC) The YP was never referred to CSC by any professional during the period of the time line, despite agreement from the professionals from all agencies at both the panel meetings and the leaning event that the threshold had been met on a number of occasions, for example, when YP was excluded from school for supplying drugs, on the occasion that the YP presented to the emergency department (ED), with evidence of ingestion of drugs and alcohol and when the YP disclosed that they were using some of their father’s medication. There a number of reasons that might have underpinned this: • Self harm is a term used to describe a situation when somebody intentionally damages or injures their body. It is a way of coping with or expressing overwhelming emotional distress. There is a lack of clarity amongst professionals about the threshold for referring young people who have self harmed to Children’s Social Care, a significant number of whom are at risk of significant harm due to abuse or neglect – and about the likely outcome of a referral. A significant number of these young people are at risk of significant harm due to abuse or neglect and are more likely to have poor outcomes. (Ref: On the edge – NSPCC 2014). It does not appear that staff used their own agency specialist safeguarding professionals for guidance when uncertain about whether to refer. • Professionals had a perception that a referral was likely to be rejected, implying that the threshold would not have been met. Again, the expertise of local safeguarding professionals 5 was not used. There was limited consideration of the use of the escalation policy in circumstances where a referral may have been made and then rejected. • Young people who use or procure recreational drugs for others are often not seen as at risk of significant harm and therefore a safeguarding issue – but may rather be seen as making a lifestyle choice as opposed to being a vulnerable young person. This meant that on the occasion of when the YP supplied drugs to another young person, no multi agency strategy discussion was held. This has been highlighted in a recent Derbyshire learning review (SILR14A). The current Derby and Derbyshire Safeguarding Children Boards’ Threshold Guidance (available on the Safeguarding Board website), would suggest that YP would have met the threshold for support as a Child in Need, and may have accessed support via the Multi-Agency Team. Referral would have acted as a central point for collating concern from different agencies, which would have built a fuller picture than that held by any one agency. • YP was described as a “Grade A” student; the YP was articulate and appeared to be in control of their situation, and to have a good relationship with their parents. It is likely that the absence of neglect and the YP apparent rationalisation of their drug use influenced professional decision making with the result that the focus was on the YP’s narrative, rather than on whether thresholds were met. 3. The impact of transformational change on services In the current economic climate, services need to change and modernise in order to meet their fiscal targets. It is well recognised that times of reorganisation within services can increase risk. It is important that a risk assessment is undertaken at these times, which takes account of the views of the clinical staff providing the service. This is also relevant if there are protracted absences from a team. Nationally, funding for CAMHS services has been under review. The local CAMHS service was delivered in the context of a recognised underfunding for CAMHS nationally. There is evidence from NHS Benchmarking data that this underfunding is significantly worse in that particular service compared to national and regional funding levels and as such has a significant impact on CAMHS capacity and is likely to have contributed to the shortfall in service. This has been raised with Commissioners and is now on the shared risk register. In addition, Commissioners have committed significant resources to the service in order to reduce risk. This was against a background of transformational change in both clinical and administrative staff that resulted in a loss of posts. At the same time, some long term study leave and a high level of stress and sickness absence reduced resource within the Team further. The service provided to the YP and their family from the Child and Adolescent Mental Health Service (CAMHS) Team fell short of that expected, as a consequence of both professional and organisation issues: • There were delays in access to the service, resulting in some high risk cases being unallocated, and also in the process of referral of the YP to the drugs service • There was delay in referral and lack of availability of cognitive behavioural therapy. • There was a lengthy delay in sending letters out to the GP and a lack of communication with the GP when the YP failed to attend appointments • Supervision is recognised as a key element of safeguarding. Over the time period of the review, there were 3 separate managers, along with a shortfall in supervision for clinical staff, in terms of frequency, consistency and quality of supervision. • The staff member most involved with the YP was not a permanent member of staff, but was a member of the bank staff. Bank staff work flexibly on an ad hoc basis, specifically for a 6 named Trust, as needed, but are not permanent staff members. At the time of the review, bank staff did not have the same access to training. This has now been rectified. Since the time period of the review, some administrative changes have been put in place, including digital dictation so that letters are now sent out within 10 days. 4. Clarity about services offered by CAMHS There was a lack of clarity amongst other professionals about interventions that CAMHS could offer, the thresholds and timescales used to determine level of urgency of referrals, (12 weeks is not unusual for a routine referral) and also a lack of knowledge about local alternative sources of mental health support for young people. This gave rise to a sense of frustration at times, when professional expectations were not met. 5. Mental Health Services for young people who use drugs. The YP was recognised by both professionals and the YP’s parents to have high levels of anxiety and sleep difficulty and there was a strong feeling that the YP drug taking was, at least in part, a form of self-medication that enabled them to cope. However, Substance Misuse Services for Young People and CAMHS are situated in different providers, and young people with both mental health problems and drug use are predominantly under the drugs service. This meant that the YP was unable to access mental health services at the same time as address their drug use – and it was felt that until this happened the YP would not be able to reduce their drug use. There was also a lack of clarity from CAMHS on this issue. Although CAMHS were of the view that YP remained an open case, to contact them as required, this was not the impression given to YP’s parent, YP themself and the GP, who clearly felt that the YP had been discharged from CAMHS. Partnership work is currently ongoing between the CAMHS and the Young Person’s Substance Misuse Service to develop closer working relationships and to draw up a protocol that will help to support young people with both mental health problems and drug use. 6. Hidden fathers A number of local and national reviews have highlighted the importance of professional communication with both parents, and the NSPCC have produced a recent summary (March 2015) of the learning from national reviews with regard to “Hidden Men”. There was a sense that the YP deliberately withheld information or minimised their drug use when communicating with their father, who was largely unaware of it until a month or so before his child’s death. There was only limited professional communication with YP’s father from all agencies and, and as a result, he felt marginalised both before and after YP’s death, in a situation where he had frequent contact with his child and felt he may have been able to provide support. 7. The importance of systems that enable communication of risk where more than one professional is involved in an organisation There were a number of organisations where several professionals were involved in the care of YP. In the GP practice, a number of GPs provided care and risk was difficult to communicate – this was a particular issue over the prescribing of codeine to YP, who, at the start of the timeline was being seen by a number of different GPs. The YP was being prescribed codeine to treat headaches. Codeine is an opiate drug, often used for pain relief, but is not recommended as first line for tension type headaches in children. It can be a drug of abuse because of the overall sense of calm and feelings of pleasure that it induces and it should not be prescribed to those who are likely to abuse it. 7 The GP practice have now put in place brief daily practice meetings to raise awareness of and to facilitate information sharing about vulnerable patients seen recently. This is in addition to monthly multi disciplinary meetings. Previous reviews have also advocated the use of record flagging to highlight risk. 8. Professional awareness of patterns and sources of young people’s drug use It is well recognised that young people’s IT skills and awareness of new phenomena such as “Legal Highs” are generally well ahead of parental and professional knowledge. Examination of YP’s computer and phone indicated that they had been very sophisticated in their use of the internet and in accessing the “Dark Web” and the YP had successfully concealed traces of their on line activities. The “Dark Web” refers specifically to a collection of websites that are publicly visible, but hide the IP addresses of the servers that run them. , but it is very difficult to work out who is behind the sites and they cannot be located using search engines. This makes safeguarding children and young people in this arena a challenge. YP’s school have already undertaken some awareness raising with staff and parents since YP’s death. The school has reviewed the content of its personal, social, health and economic curriculum, and its staff training, and has bought in to the Amy Winehouse and Addaction drug and alcohol awareness resilience programme. The school has also run an information evening for parents, which was well received and there is a plan to extend awareness to other head teachers locally. 9. Safety when experimenting with drugs YP died overnight, with evidence that he had taken some drugs late beforehand. YP’s father was of the view that there should be a very strong message to young people that experimenting with drugs was highly dangerous. Taking recreational drugs does pose a significant risk of serious harm or death. This applies to both “legal” highs and illegal drugs. Young people must never be given the message that drugs are safe, and they must be made aware of the risks, but there may be circumstances when an approach to harm reduction needs to be made, particularly around the use of drugs when alone, or at night. The Young People’s Substance Misuse Services do provide information to service users on harm reduction, including less risky ways to use drugs. Practice issues A number of practice issues were highlighted by individual organisations as a result of the learning review. These will need to go through the governance arrangements of those organisations, to monitor, for example: • Derbyshire Healthcare Foundation Trust: Emphasis on the importance of accurate, documented and updated risk assessments that are analysed to inform care plans. • Derbyshire Healthcare Foundation Trust: Ensuring access to supervision. • Royal Derby Hospital: Better documentation of conversations about patients. Good Practice Identified A number of areas of good practice were identified during the review, by the panel, by professionals at the learning event and also by the mother of YP, where professional commitment resulted in an 8 enhanced service: 1. YP’s school were unwavering in their support of YP – in their efforts to persuade the YP to engage with CAMHS, in their commitment to keep the YP engaged in sometimes difficult circumstance, rather than adopting a more punitive approach, and in the arrangements that they made so that the YP could go on an extended school trip abroad. This was recognised by YP’s parents (and indeed, as reported by the YP’s mother, by the YP themself). 2. The YP’s GP who saw the YP predominantly in the last few months of their life was tenacious in her commitment to liaise with other organisations (particularly school, the drugs service and CAMHS) and in her efforts to secure services on the YP’s behalf, in circumstances where these proved difficult to access. Again, this was recognised by YP’s mother. The two examples above highlight the importance of persistence and of not giving up on young people, who can be difficult to help and who may be engaging in risky behaviour, even in the face of apparent rebuff. This can at times require some risk assessment by the professional – for example in the decision to take the YP abroad, and also in not permanently excluding the YP from school when the YP had supplied another young person with drugs. 3. YP’s school hold a fortnightly multi agency meeting to share information and consider vulnerable children. This enables information sharing about vulnerable children, so that professionals can be alert to vulnerable children, to potential safeguarding issues and are able to plan the most appropriate support or intervention. 4. YP’s drugs worker was prompt to supply a safe storage box to the YP’s mother, to enable safe storage of the grandfather’s opiate medication. This is given to methadone or other drug users, but not routinely in this situation – but it was good practice to reduce the risk of YP abusing their grandfather’s medication 5. YP’s drugs worker was prompt in contacting the GP as soon as she was aware that the YP was obtaining codeine on prescription. Conclusion Scrutiny of practice as a result of this serious incident learning review has provided an opportunity to consider areas of good practice in addition to ways in which services may be improved. It is not always easy to steer adolescents who are involved in risk taking behaviour on to a safer course. It is, therefore, important that agencies work collaboratively with each other and with young people and their parents and carers in the assessment of need and the provision of services. Even with this in place, it is not possible to state with certainty that the outcome would have been different, although this remains a possibility. The following recommendations, based on the learning from this case, have been made: 9 Recommendations In order to promote the learning from this case the review identified the following actions for Derbyshire Safeguarding Children Board and its member agencies: 1. Derbyshire LSCB should ensure that this report is made available to local practitioners to inform practice and widen learning. Intended outcome: That local practitioners will assimilate the learning from this report, in order to better support young people in similar circumstances 2. Derbyshire LSCB should ensure the development of an awareness raising and educational campaign about young people who abuse or supply drugs, both legal and illegal, for professionals, parents and young people. This should include use of the internet and referral thresholds and pathways and should also highlight the dangers of drug use, especially at night or when alone Intended outcome: Professionals, parents and staff will be better informed about some of the ways in which drugs can be sourced, the nature of the drugs and risks associated and feel confident that they know the possible steps to take if faced with a concern. Young people will be more aware of the risks of drug use which may prevent their involvement with both illegal and legal drugs. 3. Derbyshire LSCB should develop and disseminate guidelines to strengthen professional knowledge about referral thresholds and pathways for young people who abuse or procure drugs. This should include circumstances when young people present to Emergency Departments, to other health settings and in schools and other settings. Intended outcome: To enable multi agency involvement with young people who are known to be using or procuring drugs and to reduce professional isolation. To strengthen professional confidence in Emergency Departments and other settings in knowing when to refer to Children’s Social Care when young people present 4. Derbyshire LSCB should review the strategy and implementation of Early Help to ensure that it is embedded in the professional practice of all partner agencies. This should include effective audit arrangements that ensure the robust monitoring of the quality of early help assessments, and the planning, management oversight and outcomes for children, Intended outcome: To ensure that the children’s workforce in all agencies is aware of its responsibilities to ensure that early help is provided within and between organisations, with the aim of improved holistic assessments for children and young people with additional needs and formulation of multi-agency support plans, to improve outcomes for children and enable a shared understanding of risk. Additionally, to reduce professional isolation, particularly when cases appear “stuck” 5. Derbyshire LSCB should continue through training and policy to promote communication with both parents (including in Early Help assessments and planning) when there are significant concerns about the wellbeing of children Intended outcome: To ensure that parents who are not the main care giver (usually fathers) have a voice when there are significant welfare concerns for their child 6. Derbyshire LSCB should seek assurance from all Board members, via the Chief Officer’s group, that when undergoing transformational change, or when there is a significant imbalance between capacity and demand, a risk assessment is undertaken that ensures mitigation of significant risks to children and young people. Risks that cannot be mitigated 10 should be reported to the Chair of Derbyshire Safeguarding Children Board and Children’s Trust Board Intended outcome: To reduce risk to children during periods of transformational change, to ensure staff are adequately supported during these times of change and to avoid the unintended consequences as a result of a service change that is usually part of a measure to improve efficiency 7. CAMHS should produce guidance for other professionals that highlights: • referral criteria, including thresholds and response times for urgent, soon and routine referral • referral proforma • how to access advice from a CAMHS professional • alternative sources of mental health support for young people Intended outcome: To improve quality of referrals to CAMHS and to clarify for other professionals and agencies how and when the service may be accessed 8. The partnership working that is taking place between CAMHS and the Young Person’s Substance Misuse Service should continue to develop a protocol to enable the mental health needs of young people who use drugs to be met. Intended outcome: To better support young people who have the dual pathology of drug dependence and mental health problems References • Working Together to Safeguard Children H M Government March 2015 • Hidden men: learning from case reviews Summary of risk factors and learning for improved practice around ‘hidden’ men NSPCC March 2015 • Derby and Derbyshire Safeguarding Children Boards’ Threshold Guidance • On The Edge – NSPCC 2014 Statement by Reviewer REVIEWER Dr. Patricia Field (Designated Doctor for Derbyshire County) Statement of independence from the case Quality Assurance statement of qualification I make the following statement that prior to my involvement with this learning review:- • I have not been directly concerned with the child or family, or have given professional advice on the case. • I have had no immediate line management of the practitioner(s) involved. • I have the appropriate recognised qualifications, knowledge and experience and training to undertake the review. • The review was conducted appropriately and was rigorous in its analysis and evaluation of the issues as set out in the Terms of Reference. 11 |
NC50684 | Death of a 16-year-old girl in January 2014. Elizabeth was killed by a 16-year-old friend X at his home in Surrey. In October 2014 he was found guilty of murder and sentenced to life imprisonment with a minimum term of 25 years. Bromley Safeguarding Children Board (BSCB) did not initiate a serious case review about Elizabeth whose home address was in Bromley until March 2017. Elizabeth was known to Child and Adolescent Mental Health Service (CAMHS) as a result of anxiety, low self-esteem and self-harming; there was concern about alcohol and drug misuse, a reported overdose and unsafe sexual practices. In October 2013, Elizabeth transferred to School 2 in Surrey to study for 'A' Levels where her relationship with her killer began. Ethnicity or nationality of Elizabeth is not stated. Findings identified include: a report by Elizabeth concerning an incident within the family, set in the context of other difficulties, justified it being considered a safeguarding issue and responded to accordingly; counselling services could have categorised her reports of sexual activity as exploitative and initiated a referral to children's social care; no formal means existed in BSCB for unexpected child deaths to be reported to the LSCB on a case by case basis. Recommendations include: the named GP should circulate to practices the new Vulnerable Adolescents Strategy and associated protocols; training to include professional curiosity and safeguarding risk assessment when young people present with anxiety; to complete an audit on the quality of information sharing within and between partner agencies.
| Title: Serious case review for publication ‘Elizabeth’. LSCB: Bromley Safeguarding Children Board Author: Fergus Smith Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. BROMLEY SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW FOR PUBLICATION ‘ELIZABETH’ FERGUS SMITH 16.07.18 Contents 1 INTRODUCTION 1 1.1 Trigger event & need for serious case review 1 1.2 Summary of known background 1 1.3 Conduct of the review: notifications & scope 3 2 ELIZABETH’S STORY 6 2.1 Involvement with safer schools officer & ‘Counselling Service 1’ (substance misuse) 6 2.2 CAMHS involvement 7 2.3 Support from ‘Counselling Service 2’ 11 2.4 Subsequent contacts with Health / Education providers 12 3 RESPONSES TO THE TERMS OF REFERENCE 15 3.1 Family history 15 3.2 Assessment & decision making 17 3.3 Vulnerability to sexual exploitation, mental health / substance misuse issues 18 3.4 Organisational or resource factors 19 3.5 Domestic violence in Elizabeth’s relationships ? 20 3.6 Organisational responses following death of Elizabeth 21 4 CONCLUSIONS & RECOMMENDATIONS 23 4.1 Conclusions 23 4.2 Recommendations 23 CAE 1 1 INTRODUCTION 1.1 TRIGGER EVENT & NEED FOR SERIOUS CASE REVIEW 1.1.1 On 24.01.14, 17 year old Elizabeth was killed by a 16 year old friend ‘X’ at his home in Surrey. In October 2014 ‘X’ was found guilty of murder and given a life sentence with a minimum of 25 years. 1.1.2 In August 2016 Bromley Safeguarding Children Board (BSCB) was asked by its Surrey counterpart to explain why it had not initiated a serious case review about Elizabeth whose home address was in Bromley. The BSCB independent chairperson at that time and BSCB members had not previously been aware of the case. 1.1.3 In December 2016 after consideration of the information available at that time and in spite of some dissenting views, the then chairperson of its standing ‘serious case review panel’ had determined that the statutory criteria for initiating a serious case review (SCR)1 were not met (there having been no suspicion of abuse or neglect preceding Elizabeth’s death). That determination did not reflect the level of vulnerability which was subsequently identified and which is summarised in this report. 1.1.4 By March 2017, a newly appointed BSCB independent chairperson, in discussion with the Board’s ‘SCR sub-group’, decided that emerging indicators of Elizabeth’s vulnerability and subsequent murder meant that exploring her experiences of services would generate useful learning and provide an opportunity for Elizabeth’s ‘voice’ to be heard. He determined therefore, that a SCR would be completed. 1.2 SUMMARY OF KNOWN BACKGROUND PERPETRATOR X 1.2.1 X who lived at home with both parents and one of his 3 siblings had a history of self-harm and anxiety symptoms. Following concerns expressed by his mother to the family’s GP, X had been referred to his local ‘Child & Adolescent Mental Health Service (CAMHS) in 2012 when aged 15. X was provided with systemic psychotherapy for a year. 1.2.2 In February 2013, X was diagnosed as having an ‘autistic spectrum disorder’ (ASD). Because his self-harm and anxiety-related symptoms had appeared to improve, X had been discharged from CAMHS in October 2013 and had no further contact with that service before he killed Elizabeth 3 months later. 1 Regulation 5 Local Safeguarding Children Boards Regulations 2006 requires Safeguarding Children Boards (LSCBs) to undertake reviews of ‘serious cases’ in accordance with procedures in Working Together to Safeguard Children HM Government 2015. A ‘serious case’ is one in which, with respect to a child in its area, ‘abuse or neglect is known or suspected and the child has died [as in this case] or been seriously harmed and there is cause for concern as to the way in which the local authority, LSCB partners or other relevant persons have worked together to safeguard her/him’. CAE 2 1.2.3 NHS England2 commissioned an independent investigation into the care and treatment of X in Surrey. In its report which was shared with SCR panel members, it formulated 10 recommendations for the current provider of CAMHS in Surrey (Surrey and Borders Partnership NHS Foundation Trust (SaBP). ELIZABETH Routine review 1.2.4 When Bromley’s Child Death Overview Panel (CDOP) undertook in 2014, its routine review of the death of a child resident in the borough, it appeared Elizabeth’s involvement had been predominantly with universal services e.g. school and GP. Further research by Bromley’s Safeguarding Children Board in late 2016 and enquiries during the course of this review indicate that this mistaken conclusion had been a consequence of: Miscommunication with the school which (in the event that it had received such a request) could have provided relevant information Information from the GP Practice which did not confirm Elizabeth’s previous involvement with CAMHS The one-off involvement of a Metropolitan Police Service (MPS) ‘safer schools officer’ in late October 2010 (Elizabeth was then 14) not having been available to and in consequence not shared by, Surrey Police 1.2.5 Details of the involvement of CAMHS and other agencies have been evaluated during the course of this SCR and are summarised in section 2 of this ‘publication report’. School 1 had reported that in her ‘year 11’ (2012-2013) Elizabeth had been unhappy in her tutor group and felt that her friends thought of her as ‘weird’. The school had responded by arranging for Elizabeth to register attendance in ‘Student Support’. Elizabeth, who was described by school 1 as kind and thoughtful was considered to be lacking in confidence with few friends. She was known to have a part-time job and her family was regarded as caring and supportive. 1.2.6 Elizabeth had mentioned to school staff, a boyfriend she visited and with whom she indicated she was happy. Her mother was known to be aware and had raised no concerns about him. No evidence has been identified to indicate that either parents or school should have been wary of that relationship. 1.2.7 Available GP records indicated nothing exceptional about Elizabeth’s use of the Practice (though pre-2011 records had been transferred to NHS England during the process of switching to electronic records). 2 NHS England leads the National Health Service in England, sets the priorities and direction of the NHS and encourages and informs the national debate to improve health and care. CAE 3 Preliminary research for the serious case review 1.2.8 With parental agreement, Elizabeth’s earlier medical records were accessed and revealed nothing of relevance to the SCR. 1.2.9 Elizabeth’s Primary School was also contacted for this review and recalled a happy, quietly confident girl with a dry sense of humour and a small circle of friends. There had never been any safeguarding or other concerns during her 6 years there. Checks with several other agencies with which Elizabeth might potentially have been involved in Bromley and Surrey (hospitals, NHS 111 and Ambulance Services) revealed no contact with the young person. 1.3 CONDUCT OF THE REVIEW: NOTIFICATIONS & SCOPE 1.3.1 The BSCB chairperson notified the Department for Education (DfE), regulatory body Ofsted and central government-appointed ‘National Panel of Independent Experts’ (NPIE) of the decision to complete a SCR which was completed between July and October 2017 in accordance with terms of reference reproduced in section 3. The purpose of a SCR is to identify required improvements in service design, policy or practice amongst local or if relevant, national services. SCRs are not concerned with attribution of culpability (a matter for a criminal court), nor cause of death (the role of a Coroner). 1.3.2 The period of review was 01.09.10 (when a rising 14 year old Elizabeth began ‘year 9’) to her death. Any emerging information pre-dating September 2010 and believed to be relevant has also been considered. An independent report was commissioned and it was agreed that upon receipt of material, author Fergus Smith would: Collate and evaluate it Facilitate meetings with family and professionals Draft, in consultation with the selected serious case review panel a narrative of agencies’ involvement and an evaluation of its quality, as well as conclusions and recommendations for action by Bromley’s Safeguarding Children Board, member agencies and (if relevant) other local or national agencies CAE 4 AGENCIES CONTRIBUTING INFORMATION 1.3.3 The following were asked to supply a chronology and an evaluative report of respective involvement: Bromley Healthcare (school nursing - no records traced) Bromley Urgent Care Centre (UCC) (a one-off contact) Metropolitan Police Service MPS (confirmation of a one-off involvement) Relevant Bromley & Surrey Schools (education / initiation of pastoral care) Bromley Counselling Services ‘1’ (drug and alcohol misuse) & ‘2’ (community well-being service for children and young people) Oxleas NHS Foundation Trust (provider of local Child & Adolescent Mental Health Services CAMHS) Bromley GP Services (routine family healthcare) 1.3.4 In addition to the above sources the author sought and obtained information from the school-based ‘Counselling Service 3’ where Elizabeth undertook an introductory session some days before her death, a sexual health worker whom Elizabeth consulted in early 2011 and the lead author of the NHS England-commissioned report. CAE 5 SERIOUS CASE REVIEW PANEL Bromley Healthcare: Named Nurse Bromley Healthcare: Designated Doctor Bromley Clinical Commissioning Group (CCG): Designated Nurse Bromley Public Health Programme Lead (Substance Misuse) London Borough of Bromley Children’s Social Care: Head of Service, Quality Improvement London Borough of Bromley: Head of Access & Inclusion, Education Metropolitan Police Service: Review Officer Addaction (previously Bypass): Contracts Manager London & South NHS England: Head of Investigations Oxleas NHS Foundation Trust: Head of Safeguarding Children Oxleas NHS Foundation Trust: Associate Director CAMHS Surrey Safeguarding Children Board: Partnership Support Manager Surrey County Council: Schools & Learning – Education Lead for Vulnerable Learners + BSCB Business Manager 1.3.5 Panel members provided professional challenge to an initial draft report. When agreed by Bromley’s Safeguarding Children Board, a copy of this final report will be sent to the national panel of experts (NPIE), regulator Ofsted and to the Department for Education (DfE). INVOLVEMENT OF PROFESSIONALS & FAMILIES 1.3.6 The parents of Elizabeth and those of X had been informed by the LSCB chairperson of his decision to initiate a SCR. Despite the family’s ongoing grief, Elizabeth’s mother was able to offer clarification and comment about her experiences of services provided and feedback on the findings of this report, which were shared prior to publication. For that, the panel is very grateful. Efforts were also made to seek the views of Elizabeth’s father. Her mother had reported that he remains too distressed, sees little value in the exercise and does not wish to become involved. That observation has been confirmed by a member of the extended family (herself a senior manager in a Mental Health Trust with substantial professional experience of individuals’ responses to trauma and by the Police ‘family liaison officer’ (FLO) who supported the family at the time of the incident). 1.3.7 The author is also grateful to the parents of X who agreed to meet him and contributed what information they could. CAE 6 2 ELIZABETH’S STORY 2.1 INVOLVEMENT WITH SAFER SCHOOLS OFFICER & ‘COUNSELLING SERVICE 1’ (SUBSTANCE MISUSE) 2.1.1 On 05.10.10, a Metropolitan Police ‘safer schools officer’ was alerted by ‘school 1’ to a concern that on more than one occasion Elizabeth (aged 14) had been visiting a named year 9 boy from a local boys’ school, drinking alcohol and taking ‘poppers’3. The boy had also reportedly taken (a by then deleted), ‘inappropriate’ image of Elizabeth (reportedly a video taken of an inebriated Elizabeth – nothing of a sexual nature was indicated). The officer was told that parents had been informed but neither they nor Elizabeth sought formal action. He agreed to speak to the boy on the next visit to his school. Mother has reported that she had not received confirmation of the outcome of those events. Comment: albeit over 3 years before her death, the above incident offers the first known example of Elizabeth’s vulnerability. 2.1.2 Information from the GP Practice has revealed nothing of significance in Elizabeth’s records. A local provider of alcohol and substance misuse advice (Counselling Service 1) had been working with Elizabeth during 2010 though the GP Practice remained unaware of that. The agency’s involvement had been triggered by a referral from mother on 25.11.10, itself prompted by concerns about her daughter’s behaviours. INITIAL ASSESSMENT 2.1.3 Mother and daughter were involved in an initial assessment by Counselling Service 1 where Elizabeth acknowledged past use of substances, some self-harming and suicidal thoughts. Concerns were shared with mother who felt (for reasons not captured in records), that a referral to CAMHS was not required at this time. Comment: disappointingly, records fail to capture Elizabeth’s own view of CAMHS involvement; all involved staff have moved to other employment and it has proved impossible to locate them and explore memories; given the inevitability of staff turnover, it is critical that records are coherent and complete. 2.1.4 At Elizabeth’s first one to one session (she was then 14 years 3 months old) unspecified (i.e. detail not apparent) ‘unsafe sexual practice’ and a perceived pressure to engage in intercourse were discussed. Following a missed appointment, the worker consulted her manager who confirmed a need to refer to CAMHS. Contact was made next day. Meanwhile the worker initiated contact with the Sexual Health Services and an appointment was made for early 2011. Agencies’ responses to this point were cautious and appropriate, albeit with some significant inadequacies of record-keeping. 3 ‘Poppers’ is a slang term given broadly to the chemical class called alkyl nitrites, that are inhaled for recreational drug purposes, typically for the ‘high’ or ‘rush’ that the drug can create as a consequence of vaso- dilation; possession of alkyl nitrites is not illegal though their supply can be an offence. CAE 7 REFERRAL ON TO CAMHS BY ‘COUNSELLING SERVICE 1’ 2.1.5 Prompted by Elizabeth’s self-harming (scratching arms and burning herself with a lighter) and thoughts that life was not worth living, the Counselling Service recommended family therapy and counselling. Its later records refer to self-esteem being low and being upset by the break-up of a sexual relationship begun ‘in order to keep the [unnamed] boy happy’. Elizabeth was deemed to be vulnerable because she was easily influenced by others and keen to please (thus potentially coercible). No record has been found of liaison with school or other agencies. Though unspecified forms of ‘stress and anxiety’ were reported within her family, Elizabeth did not want information shared with her parents. The subsequent referral to CAMHS indicated that Elizabeth’s current sexual partner was of a similar age to her. Comment: Counselling Service 1 was wholly dependent upon Elizabeth’s account; without the involvement of other agencies it could not be confident about the age of her sexual partner; more professional curiosity might have revealed additional useful information. 2.2 CAMHS INVOLVEMENT 2.2.1 Elizabeth was discussed at a multi-professional CAMHS meeting in mid-December 2010 and a decision made to accept the referral. When the allocated clinician made initial enquiries of the referrer s/he was told of the concern that Elizabeth had some difficulty in understanding social situations and was potentially vulnerable to sexual exploitation. Previously reported thoughts of self-harm or suicidal ideation were said to have ceased in the past week. 2.2.2 An initial appointment was offered and Elizabeth attended with her mother. The results of that session were later discussed in a further team meeting and in the clinician’s supervision. In discussion with the referrer it was thought that Counselling Service 1 should continue to work with Elizabeth on misuse of drugs and safe sex and that subject to her agreement, a referral to Counselling Service 24 would be justified. ONGOING INVOLVEMENT OF ‘COUNSELLING SERVICE 1’ 2.2.3 Elizabeth continued to make good use of the service offered by the counselling service. In early January 2011 mother reported to the worker that Elizabeth had been taking (un-recorded quantities of) ‘over the counter’ medication and had 3 bottles of vodka hidden under the bed. It is uncertain whether advice on required action if the recommended daily dose were to be exceeded was given. At her scheduled session next day the worker discussed these concerns with Elizabeth. An email request was sent 2 days later by the worker seeking a session with ‘sexual health practitioner 1’. Following an initial meeting involving the worker, sexual health professional, mother and daughter, a one to one session for Elizabeth was provided. 4 ‘Counselling Service 2’ is a long-established local charity offering free, confidential counselling to young people and families (and would currently be described as a ‘community well-being’ service). CAE 8 2.2.4 The highly experienced sexual health practitioner, though mindful of the potential risk of sexual exploitation, found no evidence to reinforce that concern. She was clear that Elizabeth was ‘Fraser competent’5 . Only by virtue of there being an accompanying and caring mother was the referral in any manner different from many others. Comment: Greater curiosity about the number or nature of the sexual relationships as well as a more formally recorded assessment of Fraser competence would have been helpful. 5 Nearly 30 years ago, a Mrs Victoria Gillick challenged Department of Health guidance which enabled doctors to provide contraceptive advice and treatment to girls under 16 without their parents knowing. In 1983 the judgement from this case laid out criteria for establishing whether a child under has the capacity to provide consent to treatment; the so-called ‘Gillick test’. It was determined that children under 16 can consent if they have sufficient understanding and intelligence to fully understand what is involved in a proposed treatment, including its purpose, nature, likely effects and risks, chances of success and the availability of other options. If a child passes the Gillick test, he or she is considered ‘Gillick competent’ to consent to that medical treatment or intervention. However, as with adults, this consent is only valid if given voluntarily and not under undue influence or pressure by anyone else. Additionally, a child may have the capacity to consent to some treatments but not others. The understanding required for different interventions will vary, and capacity can also fluctuate such as in certain mental health conditions. Therefore each individual decision requires assessment of Gillick competence. If a child does not pass the Gillick test, then the consent of a person with parental responsibility (or sometimes the courts) is needed in order to proceed with treatment. The ‘Fraser guidelines’ specifically relate only to contraception and sexual health. They are named after one of the Lords responsible for the Gillick judgement but who went on to address the specific issue of giving contraceptive advice and treatment to those under 16 without parental consent. The House of Lords concluded that advice can be given in this situation as long as: He/she has sufficient maturity and intelligence to understand the nature and implications of the proposed treatment He/she cannot be persuaded to tell her parents or to allow the doctor to tell them He/she is very likely to begin or continue having sexual intercourse with or without contraceptive treatment His/her physical or mental health is likely to suffer unless he/she received the advice or treatment Advice or treatment is in the young person’s best interests. Health professionals should still encourage the young person to inform his or her parent/s or get permission to do so on their behalf, but if this permission is not given they can still give the child advice and treatment. If the conditions are not all met, however, or there is reason to believe that the child is under pressure to give consent or is being exploited, there would be grounds to break confidentiality (Fraser guidelines originally just related to contraceptive advice and treatment but, following a case in 2006, they now apply to decisions about treatment for sexually transmitted infections and termination of pregnancy) http://www.cqc.org.uk/guidance-providers/gps/nigels-surgery-8-gillick-comptency-fraser-guidelines CAE 9 2.2.5 Prompted by a report about difficulty in social situations and ‘concrete thinking’, the possibility of Asperger’s Syndrome6 was considered by CAMHS. It was though, concluded that a formal assessment would be unnecessary because Elizabeth showed significant empathy toward others in distress. REPORTED OVERDOSE & POTENTIAL SAFEGUARDING ISSUE 2.2.6 Mother accompanied her daughter to a second CAMHS appointment in mid-February. Elizabeth complained of having no privacy and reported taking 4-5 (unidentified) tablets so as to ‘feel better’, not to kill herself. She did not want her mother to be told of this action. Based upon the rationale that the risk to health was low, no stated intention of repeating the action and a need to facilitate ongoing engagement with counselling, mother was not informed. 2.2.7 The need to strike a balance between the needs and rights of child and parent was clearly recognised and appropriately debated in a multi-disciplinary meeting. The reasoning for the decision to withhold was also clearly recorded. Though well-intentioned, the decision effectively denied a parent considered to be caring and committed, information of potential relevance to her ability to support her daughter. Comment: the decision was not ‘unreasonable’. It was though in the author’s view, toward the end of the spectrum of what could be described as ‘reasonable’ e.g. what could not have been predicted was the extent to which Elizabeth might use the support offered by her counsellor. 2.2.8 Elizabeth also reported an incident at the family home which was later shared with and caused distress to her mother. The potential safeguarding incident was discussed at a team meeting and a consensus formed that a referral to Children’s Social Care was not required unless there was any recurrence. That judgment (the rationale for which was not apparent in records) was shared with mother. The known vulnerability of the family would have justified at this time (assuming parental consent) a referral to Children’s Social Care. 2.2.9 The clinician liaised with school 1 and was told Elizabeth was a ‘vulnerable girl with good enough peer relationships but easily led’. Systemic family therapy was again recommended. In the opinion of the clinical psychologist submitting a report to the SCR (and one with which the author concurs), that offer was an appropriate response to a not uncommon experience of tension (especially during adolescence) within the complex relationship of a mother and daughter. 6 Asperger’s Syndrome is defined by the World Health Organisation (WHO) defines Asperger Syndrome (AS) as one of the autism spectrum disorders (ASD) or pervasive developmental disorders (PDD), which are a spectrum of psychological conditions characterised by abnormalities of social interaction and communication. CAE 10 ONGOING SUPPORT FROM COUNSELLING SERVICE 1 & CASE CLOSURE BY CAMHS 2.2.10 Joint clinician / sexual health practitioner sessions were provided. ‘Positive relationships’ were explored and advice about sexually transmitted diseases and contraception provided. In mid-February, Elizabeth spoke of feeling depressed but by the end of that month she reported feeling better and agreed to family therapy with her mother at CAMHS. She also reported ‘putting things on hold’ with her boyfriend, which was understood (whether accurately or not is uncertain) by practitioners to mean deferment of a further sexual relationship. 2.2.11 By mid-March either Elizabeth and/or mother decided not to take up family therapy. Records do not make it clear whether that had been a joint decision though it had been articulated by mother (poor record keeping is a recurring issue). The view of the worker at Counselling Service 1 was that the counselling available from ‘Counselling Service 2’ would be more effective. 2.2.12 Records indicate her parents [sic] were considered to be caring, protective and supportive. In spite of tension between them, a real warmth of relationship had been observed between mother and daughter. Whilst there is evidence to support this view of mother, it is unclear on what basis the conclusion could be reached with respect to Elizabeth’s father who remained un-involved with CAMHS or other sources of support. 2.2.13 On the basis of the above understanding, it was agreed that CAMHS would close the case and this was done in mid-April 2011. In the (sadly accurate) view of the allocated clinician, Elizabeth remained vulnerable to encountering problematic peer relationships and to continuing under-age sexual activity (which might or might not be exploitative or harmful). Clinical outcomes that were recorded at the outset and end of the assessment indicated improvement and confirmed that Elizabeth was unlikely to meet any diagnostic criteria for a mental health disorder. 2.2.14 A letter to the GP confirming case closure was either not sent or perhaps not uploaded until 14.11.11. It contained no detail of any assessment or treatment from CAMHS. The term ‘vulnerable’ was included in the letter but not coded onto the Practice’s IT system where it might have informed any future consultations. Prior to the receipt of the closure letter, the GP Practice had remained unaware of Elizabeth’s involvement with CAMHS and never received confirmation of the use of either local counselling service. Record-keeping and inter-agency communication should have been better. CAE 11 2.2.15 At her penultimate Counselling Service 1 appointment in May 2011 Elizabeth reported being well and abstaining from alcohol. She said she was enjoying a youth club and was more assertive especially with boys, reported no self-harming and had not been feeling low. At what was intended to be a final appointment in June her self-report was again largely positive. Because of a delay in ‘Counselling Service 2’ offering an initial appointment, 2 more sessions were offered by and attended at Counselling Service 1. At her final session, she reported being ‘substance free’, no longer self-harming and getting on better with her mother. 2.3 SUPPORT FROM ‘COUNSELLING SERVICE 2’ 7 2.3.1 In the view of the clinical psychologist’s report to this review, the choice of individual counselling was a helpful one for Elizabeth who needed to better understand social situations, improve self-esteem and assertiveness. In the absence though of family therapy, it was recognised that family-related difficulties might remain unchanged. There remained little professional awareness of Elizabeth’s father or the quality of their relationship. The referral letter sent to Counselling Service 2 included many though not all identified key risks (self-harm, overdose and the potential safeguarding incident outlined in para. 2.2.8 were omitted). Comment: the areas of risk omitted represented a serious failure of communication. 2.3.2 The closing notes of the Counselling Service 1 involvement reflected the records of 13 sessions attended by Elizabeth. Elizabeth reported that she had found the support useful and had ceased to self-harm. She reported an improved relationship with her mother in whom she said she felt more able to confide. No safeguarding issues were identified during the very limited period of contact with ‘Counselling Service 2’ (4 sessions were offered and 3 attended during June / July 2011). For the purpose of this review, the closed case file was reviewed and the counsellor whom Elizabeth had consulted was interviewed. Notes were described by the author of the submitted individual management review as clear and congruent with the account provided. 7 Counselling Service 2 is a third sector organisation delivering a single point of access for children and young people with emotional and mental health difficulties that impact upon their well-being; when Elizabeth was seen, the agency was much smaller and offered counselling to 11-23 year olds. CAE 12 2.4 SUBSEQUENT CONTACTS WITH HEALTH / EDUCATION PROVIDERS HEALTH 2.4.1 Elizabeth presented herself at an Urgent Care Centre (UCC) in March 2012. She reported having taken an emergency contraceptive pill supplied by a local pharmacist and was feeling sick. The identity and age of the sexual partner was not captured though mother has advised the author that he was marginally older than her then 15.5 year old daughter. Comment: the pharmacy and UCC should have sought to establish the age of Elizabeth’s sexual partner. Royal Pharmaceutical Society (RPS) guidance has been updated since that time and can be sourced from https://www.rpharms.com/resources/quick-reference-guides/protecting-children-and-young-people#children. 2.4.2 In January 2013 in an otherwise unremarkable presentation at an out of hours (OOH) GP service with a minor viral illness, a comment was passed to the GP Practice about ‘stress in Elizabeth’s school 1’. Aside from routine presentations for physical illnesses, in December that year, Elizabeth presented herself to the GP complaining of ‘tiredness and anxiety’. She reported that she was receiving counselling ‘at school’. Blood tests that were initiated proved to be normal. In the view of the ‘named GP’ who evaluated the service provided by Elizabeth’s GP Practice, responses were logical and proportionate. EDUCATION Transfer to ‘School 2’ for ‘A’ levels: general progress 2.4.3 Elizabeth’s mother has confirmed that her daughter’s transfer in September 2013 to study for ‘A’ levels reflected a wish for a ‘fresh start’. Information provided by ‘school 2’ to Surrey’s LSCB and shared in late 2016 with Bromley’s Board confirmed a good attendance level of about 96% with a very few half-days of always authorised, absences. Because no pastoral information was received, staff remained unaware of Elizabeth’s previous use of external agencies (such information was reportedly transferred to a Croydon-based college which Elizabeth attended for only a day before her move to school 2 – those records were actively pursued during the course of the SCR by Bromley’s Education staff but remain untraced). Comment: the loss of pastoral records represents a serious failure in information transfer and a recommendation has been made in section 4. CAE 13 2.4.4 Though there exists no reason why it would or should have prompted concern, it is unclear precisely when teachers became aware of Elizabeth’s (believed by mother and family, as well as the parents of X and the Police to be non-sexual) relationship with her killer. If staff had been aware that X posed a threat to other pupils (no evidence has emerged from this or the NHS England report to suggest that they were) there would have been at least the possibility of a proactive response. 2.4.5 Elizabeth had told her mother of the friendship at half-term in October 2013 and mother has informed the author that she had been planning to contact X’s mother to introduce herself, as might any parent in a similar situation. Her intention had not been prompted by any specific concern. Initial counselling appointment 2.4.6 About a week before her death, Elizabeth, having been referred by a member of the school’s ‘leadership team’ in mid-December 2013, was seen for an initial assessment session by a school-based counsellor8. That counsellor was contacted by the author and the arrangements that had been made for and the conduct of, what would be Elizabeth’s only session shared. 2.4.7 Elizabeth had sought reassurance through counselling with respect to the pressure she felt in relation to social relationships and academic demands. She made no reference to any unwelcome pressure to be sexually active and spoke positively of her boyfriend X whom she did not identify by name. Whilst acknowledging and describing (accurately) previous difficulties Elizabeth denied current misuse of substances. Her presentation and account of her history and present circumstances prompted no concern on the part of the counsellor with whom Elizabeth agreed to meet weekly. Nothing in the routine referral for counselling or response provided, justifies any recommended service improvements. AGENCY RESPONSES FOLLOWING DEATH OF ELIZABETH 2.4.8 In addition to the questions about what might have been done better preceding Elizabeth’s death, concerns had been identified about the following responses after it: Information from the GP for the CDOP process was incomplete and misleading There was insufficient awareness amongst Safeguarding Children Board members about the murder of Elizabeth The debate about the requirement for or desirability of a SCR seems to have taken place outside of a formal process, without direct involvement of all those whose role e.g. designated doctor / nurse justified them offering advice to the independent chairperson of the Board 8 The school-based service was a well-established ‘not for profit’ youth counselling service which engaged self-employed accredited (British Association for Counselling and Psychotherapy) counsellors; it provided a confidential school-based counselling service in Surrey and other local authority areas. CAE 14 Records within Bromley Education Service had not (at the time this SCR commenced) been updated to capture either Elizabeth’s further education provider nor untimely death 2.4.9 This SCR has identified a number of ways in which, in spite of all the efforts of professionals and family, the vulnerability of a young woman such as Elizabeth might be better recognised and responded to. CAE 15 3 RESPONSES TO THE TERMS OF REFERENCE 3.1 FAMILY HISTORY What agencies did Elizabeth engage with, or not engage with, during her adolescence and did she have any particular vulnerabilities? Were any safeguarding issues identified in respect of Elizabeth? If so, were they acted upon appropriately and in a timely way by all agencies 3.1.1 Aside from essentially unremarkable use of primary and secondary mainstream schools and GPs, Elizabeth engaged well in adolescence with targeted services focused upon substance misuse and wider mental health needs (poor record-keeping / information sharing served to constrain the benefits). No records confirming any involvement with school nursing services in either Bromley or Surrey have been traced. 3.1.2 Vulnerability to social (and potentially sexual) exploitation was appropriately identified by professionals in Counselling Service 1 and CAMHS and reasonable responses initiated. Prompted by a referral from a responsible parent, ‘vulnerability’ was recognised with respect to: Substance misuse (alcohol and ‘poppers’) Sexual exploitation by individual boys Complex relationships at home 3.1.3 Staff at school 1 in close co-operation with Elizabeth’s mother also recognised and responded to perceived vulnerabilities by instigating additional support (the detail of how this was done remains uncertain, in consequence of the loss of pastoral records). It appears that school 2 was also sensitive to and acted upon Elizabeth’s discerned / declared needs (though had her pastoral records been available, the nature or extent of those needs could have been better evaluated). 3.1.4 It remains uncertain which pastoral records were passed over to the college in Croydon at which Elizabeth was (extremely briefly) ‘on roll’. School 2 did not receive any pastoral information that might have been forwarded by either establishment. This systemic weakness has informed a recommendation in section 4. 3.1.5 Recognition by Counselling Service 1 staff of Elizabeth’s acknowledged vulnerability appropriately triggered involvement and a joint approach with the Sexual Health Service and later with CAMHS. 3.1.6 The comprehensive report of CAMHS work makes it clear that Elizabeth’s needs were understood and that careful and sensitive discussions were completed with the young woman and her mother. It is also clear that good use was made of the combined expertise of the members of the multi-disciplinary team, though the decision to withhold information from mother was justified by the narrowest of margins. CAE 16 Safeguarding issue 1: reported overdose 3.1.7 CAMHS records confirm that there was a very considered response to Elizabeth’s report of having ingested 4-5 tablets. In close consultation with the multi-disciplinary team and her colleague in Counselling Service 1, the following factors were considered: Risk of harm from the overdose Risk of repeating the behaviour Elizabeth’s wish for privacy / reduced parental intrusion and her express wish that her mother not be informed Need to facilitate ongoing assessment / treatment Confidence in mother as a source of protection for Elizabeth from individuals or substances to which she might remain vulnerable 3.1.8 The conclusion arrived at was that the wishes of then 14.5 year old Elizabeth should be respected (her mental capacity and ‘Gillick / Fraser competence’ - see footnote 5 - was not doubted) The rationale for that conclusion was reproduced in the CAMHS report supplied and in the view of the author was, by the narrowest of margins, justified. Safeguarding issue 2: incident within the family 3.1.9 Elizabeth’s report of an incident at home prompted an exploration with Elizabeth alone and then together with her mother. At a subsequent multi-disciplinary meeting, further thought was given to the implications of the reported event and whether a referral to Children’s Social Care was justified. Though most of the CAMHS records of engagement with the family are clear, they do not describe sufficient detail nor the rationale for not seeking the involvement of Children’s Social Care. 3.1.10 In the view of the author, Elizabeth’s report set in the context of her other known difficulties justified it being considered a safeguarding issue and responded to accordingly. CAE 17 3.2 ASSESSMENT & DECISION MAKING What assessments were completed, and were they timely and of adequate quality? Were the decisions and actions that followed assessments appropriate? Were Elizabeth’s views and wishes sought and taken into account in assessments and planning? Was the level and extent of agency engagement and intervention with Elizabeth and her family appropriate 3.2.1 Elizabeth engaged well with Counselling Service 1 where it was appropriately determined that (in addition to advice on matters of sexual health) she should be referred to CAMHS. 3.2.2 CAMHS completed during its relatively brief 3 month involvement (and not withstanding comment made in para. 3.1.9), a sufficiently thorough and timely assessment of need and liaised with relevant other agencies such as the referring Counselling Service 1, school 1 and later the recommended provider of counselling – Counselling Service 2. Actions taken were consistent with assessed need. 3.2.3 Elizabeth’s views and feelings were clearly centre-stage during her involvement with Counselling Service 1 (to the extent that her mother felt somewhat excluded and remained un-informed of her daughter’s overdose). Elizabeth’s views were also sought by the CAMHS clinician though on some occasions, her explicit opinion e.g. with respect to agreeing to family therapy are not distinguishable from those of her mother. This may reflect incomplete record keeping rather than any failure to heed Elizabeth’s views and the decision taken to maintain confidentiality with respect to the overdose offers evidence that her wishes were awarded a real importance (though her capacity to make decisions that were truly in her interest, could be challenged). 3.2.4 Observations by CAMHS and by school 1 staff of the mother- daughter relationship noted it to be warm and caring, albeit strained as Elizabeth went through adolescence and sought to address some individual developmental challenges. 3.2.5 The motivation of both mother and daughter to address their reported difficulties is evidenced by their positive use of counselling and school-based support. Even in hindsight, the level and extent of targeted agency involvement appears to have been proportionate to the apparent need and consistent with the wishes of mother and daughter, albeit diminished by inadequate recording. The wishes and feelings of Elizabeth’s father remained unknown and should have prompted greater professional curiosity. CAE 18 3.3 VULNERABILITY TO SEXUAL EXPLOITATION, MENTAL HEALTH / SUBSTANCE MISUSE ISSUES Was information known by any agency about ‘child sexual exploitation’ (CSE), mental health issues or substance misuse? If so, was appropriate consideration given to how these impacted on Elizabeth? What information was shared with Elizabeth’s family? Was Elizabeth deemed Fraser competent? 3.3.1 Counselling Service 1 discerned and responded sensitively when Elizabeth acknowledged that she was sexually active and referred to succumbing to pressure to be so, by her then boyfriend. Neither the counsellor at that agency nor the subsequent CAMHS clinician categorised her reports of sexual activity as ‘exploitative’ and did not therefore initiate a referral to Children’s Social Care. Had they done so, it might have prompted a more holistic appreciation of influential factors and individuals. 3.3.2 Awareness of and sensitivity toward the phenomenon of exploitation has risen significantly since 2010/11 and the current government definition for application by professionals is that CSE9 is: ‘A form of child sexual abuse. It occurs where an individual or group takes advantage of an imbalance of power to coerce, manipulate or deceive a child or young person under the age of 18 into sexual activity (a) in exchange for something the victim needs or wants, and/or (b) for the financial advantage or increased status of the perpetrator or facilitator. The victim may have been sexually exploited even if the sexual activity appears consensual. Child sexual exploitation does not always involve physical contact; it can also occur through the use of technology’. 3.3.3 Elizabeth appears to have been open about her circumstances and made good use of counselling opportunities provided. Her accounts across time and agencies were only of a small number of serial rather than any contemporaneous relationships and she reassured at least one counsellor about having developed the confidence to cease a reported sexual relationship. Whilst doubt must remain, there is insufficient evidence to conclude that Elizabeth was a victim of CSE (though the risk of it was greater than the average female of her age). 3.3.4 As alluded to above, Elizabeth’s ‘Gillick or Fraser competence’ was never doubted by involved professionals, though might usefully have been spelled out formally and explicitly in their records. 9 The relevant professional guidance in 2010/11 was the non-statutory ‘Safeguarding Children and Young People from Sexual Exploitation 2009. CAE 19 DID AGENCIES COMMUNICATE EFFECTIVELY & WORK TOGETHER TO SAFEGUARD & PROMOTE THE CHILD’S WELFARE? Were there any cross border issues, and if so, how were they addressed? Was race, religion, language, culture, socio economic class, ethnicity or disability a factor in this case and was it considered fully and acted upon? 3.3.5 There was a close and helpful liaison initiated by CAMHS with Counselling Service 1 and school 1. 3.3.6 If the GP Practice had been made aware at an earlier stage of the involvement of other sources of support (Counselling Service 1), its clinicians would potentially have been able to contextualise better, any future consultations by Elizabeth. 3.3.7 The records completed whilst Elizabeth was at school 1 were all reportedly transferred to the Croydon-based college but were not in turn passed over (or anyway were not received by) school 2 in Surrey. 3.3.8 The ethnic origin of the mother and daughter (neither disabled) was captured. It remains uncertain to what extent any Faith or class-related issues were contemplated or debated. The absence of any direct involvement of father or Elizabeth’s sibling precluded the development of an appreciation of how the family as a whole, functioned. 3.4 ORGANISATIONAL OR RESOURCE FACTORS Were appropriate management / clinical oversight (supervision) arrangements in place for professionals making judgments in this case? 3.4.1 It is clear from the records maintained by Counselling Service 1 that the involved worker appropriately sought and was provided with significant management advice that shaped her responses to the family. 3.4.2 Records of Bromley CAMHS also confirm that its judgements were mediated by means of debate in multi-disciplinary teams as well as by individual supervision. The extent of recorded involvement with Counselling Service 2 was too limited to enable any comment beyond noting that the independent evaluation of it offered no criticism of the level of management or clinical oversight. 3.4.3 There was a significant amount of multi-disciplinary debate within CAMHS and a helpful link made by Counselling Service 1 with the Sexual Health Service. Whilst the feedback to the GP Practice by CAMHS was inadequate, there has emerged no evidence of a lack of supervision or any reluctance to share relevant information across agencies. The decision to withhold some information from mother has been evaluated elsewhere. CAE 20 3.5 DOMESTIC VIOLENCE IN ELIZABETH’S RELATIONSHIPS ? What was the nature of the relationship with the perpetrator who killed Elizabeth? Where was Elizabeth living at the time of her death? Was this information known to the key support services? 3.5.1 Mother’s account of her daughter’s previous intimate relationships suggests that Elizabeth had to a degree, experienced ‘coercive control’ from 2 Bromley-based boyfriends (one thought to have been a non-sexual relationship). No explicit evidence exists and mother reported none with respect to a 3rd from East Sussex. That relationship reportedly ended after the incident that triggered emergency contraceptive treatment. 3.5.2 The (understood to be non-sexual) relationship with the individual who murdered Elizabeth was relatively new and had been made known to her mother only at the half-term (October 2013). Mother was aware of some unusual features e.g. that the young man was sitting exams at home rather than at school and that a claim that his parents owned the property in which the family lived, was false. She had no grounds on which to suspect any physical risk to her daughter and had been planning to make contact with the boyfriend’s mother when the tragic event occurred. 3.5.3 Mother’s account confirms information that emerged during the murder inquiry about where Elizabeth was living i.e. that although a grandmother lived in a nearby village, Elizabeth was living at home and attending school 2 daily. Aside from school staff and mother, it remains unknown whether any other parties were aware of the relationship. Even if they had, it is by no means clear that the relationship (given no communicated suggestion of X posing a risk to others) would have prompted any response. CAE 21 3.6 ORGANISATIONAL RESPONSES FOLLOWING DEATH OF ELIZABETH What information was shared following Elizabeth’s death and why was a Serious Case Review not considered at that time? What information was shared between Surrey and Bromley LSCBs? Did Bromley’s child death, rapid response and case review processes work? What were the barriers? Were the parallel processes (coroner and police investigation) clear? Have these now been resolved? FRAMEWORK IN PLACE AT TIME OF ELIZABETH’S DEATH 3.6.1 Until 2016 the Bromley Safeguarding Children Board ‘serious case review sub-group’ met only when an SCR was being undertaken for a specific case. No formal means existed for unexpected child deaths to be reported to the LSCB on a case by case basis. This means that there are no formal minutes of any meeting where Elizabeth might potentially have been discussed and a formal recommendation made to the independent chairperson. 3.6.2 An email trail between the then ‘designated doctor’ for child deaths, chair of CDOP and ‘head of quality assurance’ indicates differing opinions about the need even for a ‘rapid response meeting’. Documents traced during this SCR confirm that the case had been debated at a February 2014 meeting of Surrey’s SCR Sub-group at which members were clear about Elizabeth’s ‘ordinary residence’. The then respective independent LSCB chairs were considering some form of ‘peer review’ but for reasons that neither Bromley nor Surrey’s LSCBs have been able to confirm, this idea was not progressed. 3.6.3 Elizabeth was discussed at CDOP meetings in March, June, September and December 2014 but the absence of formal links to a SCR sub-group or the Board (as well as non-receipt of information sought from school 2) meant that her case was not referred beyond that forum. Initial decision 3.6.4 The formal decision not to hold a ‘rapid response meeting’ (which remained unknown to most of the Board) was made by the then ‘designated doctor for child deaths’ and was apparently based upon: A (mis)-understanding of Police advice that the rapid response process could not be carried out alongside homicide enquiries Acknowledgment that statutory guidance provided by Working Together to Safeguard Children 2013 emphasises that any responses ‘must not prejudice criminal proceedings’ An apparent absence of safeguarding issues and Reassurances that the family’s support needs were being addressed by Police and others CAE 22 3.6.5 What emerges from the NHS England report is that the needs of the victim’s family were unintentionally overlooked, so that the assumption indicated by the latter bullet point was mistaken. 3.6.6 The additional impact of not holding a rapid response meeting was that there was no further scrutiny of Elizabeth’s vulnerabilities or any safeguarding issues. Following the established process would have established at an earlier stage that she was known to CAMHS and drug and alcohol-related services. Challenge from Surrey LSCB & current arrangements 3.6.7 Prompted by a response from the NPIE about the NHS England-commissioned report regarding the young man X, Surrey’s LSCB contacted Bromley LSCB in August 2016 asking why no SCR had been undertaken. The absence of minuted formal meetings meant that the business manager (in post only for a year) was unable to provide an explanation / rationale. Further enquiries established that Elizabeth had been known to Oxleas NHS Trust and to Counselling Service 1. This prompted further scrutiny of the case. 3.6.8 Enquiries completed by the chairperson of CDOP confirmed that rapid response meetings should still be initiated when there is a homicide enquiry and is now embedded practice for unexpected deaths. In addition, the business manager now attends the CDOP and all rapid responses and presents all unexpected child deaths to the quarterly Serious Case Sub-Group. Extra-ordinary SCR meetings are also held if there is a complex case with information gaps and possible safeguarding issues. For these reasons, no recommendation for system improvement is necessary. CAE 23 4 CONCLUSIONS & RECOMMENDATIONS 4.1 CONCLUSIONS 4.1.1 Some aspects of Elizabeth’s experiences and agencies’ responses to them indicated a heightened level of vulnerability and some potential advantage might have been gained had there been more information exchange and multi-agency communication. 4.1.2 This SCR was focused upon Elizabeth’s experiences of service delivery (as opposed to those of her killer). Nothing has been found to indicate an acute physical risk to Elizabeth from another person and no alternative responses by any of the agencies with which she (or her family) were involved could have served to predict or prevent her murder. 4.1.3 Opportunities for improvements in the way services recognise and respond to vulnerability (in particular record keeping and its communication) have been identified and inform the recommendations below. 4.2 RECOMMENDATIONS BROMLEY GENERAL PRACTITIONERS 4.2.1 With the aim of increasing the proportion of children coded ‘vulnerable’ on GP electronic records and number of GPs using safeguarding risk assessment tools: The named GP should circulate to Practices the new ‘Vulnerable Adolescents Strategy’ and associated protocols produced by Bromley’s Safeguarding Children Board Training at the GP academic half-day in January 2018 should include the challenge of professional curiosity and safeguarding risk assessment when young people present with anxiety, importance of transferring information about vulnerability from received letters to codes on the internal system, importance of completing ‘feedback forms (currently labelled ‘form B’s) following the death of a child BROMLEY HEALTHCARE 4.2.2 Bromley Healthcare should check and provide the Safeguarding Children Board with an assurance that the record-keeping of school nurses is of an acceptable standard. CAE 24 OXLEAS NHS FOUNDATION TRUST (CAMHS) 4.2.3 The Trust should reinforce by means of learning events, current expectations that where there are safeguarding concerns consideration should be given to consultation with the Trust’s Safeguarding Team or Children’s Social Care and the rationale for decision-making and actions recorded on clinical records. 4.2.4 An audit should be completed on the quality of information sharing within and between partner agencies (in particular identification of risk). 4.2.5 Guidance on patient confidentiality and the guidance on information sharing and the duty to do so when significant risks are identified, should be circulated to all clinicians. 4.2.6 The roll out of the ‘Sexual Health Risk Assessment Tool’ should be completed by means of a presentation at a ‘level 3’ training day with follow-up information at team meetings and other appropriate forums. BROMLEY & SURREY COUNCILS 4.2.7 Taking account of the current statutory guidance in ‘Keeping Children Safe in Education’, and (from 25.05.18) the European General Data Protection Regulation (GDPR), both Councils should: Review the lawfulness, reliability and effectiveness of the arrangements by which any pastoral / child protection-related records maintained by schools are / will be transmitted (and duplicates maintained) to further education providers Take any necessary action to ensure that potential reviews do not slip between geographic boundaries and that associated decision-making is independent of agency-sensitivities and subject to an effective methodology and decision-making process Overview publication draft E Bromley 16.07.18 GLOSSARY / ABBREVIATIONS Abbreviation Meaning ASD Autistic Spectrum Disorder BSCB Bromley Safeguarding Children Board CAMHS Child & Adolescent Mental Health Service CCG Clinical Commissioning Group CDOP Child Death Overview Panel CSE Child Sexual Exploitation EMIS A patient database accessible to many primary care practitioners GDPR (European) General Data Protection Regulation IMR Individual management review LSCB Local Safeguarding Children Board NPIE National Panel of Independent Experts OOH Out of Hours RPS Royal Pharmaceutical Society SaBP Surrey and Borders Partnership NHS Foundation Trust SCR Serious Case Review |
NC048183 | Serious injuries sustained by a 5-week-old female child. Child N sustained extensive non accidental injuries which left her with life long disabilities. Child N had 6 admittances to A&E in the first 5 weeks of life. By the sixth admittance, non accidental injuries sustained over a period of several weeks were identified. Child N's mother was known to CAHMS as a teenager and received treatment for depression. Child N's father experienced emotional abuse and neglect in his childhood and was on the Child Protection Register on two occasions. Father was previously sectioned under the Mental Health Act. Both parents were charged with allowing and causing significant harm to a child, and recieved custodial sentences. Issues identified include: there should have been greater consideration of safeguarding as an alternative explanation for Child N's symptoms; practitioners need to take into account the history of admissions; practitioners did not challenge the parent's explanation of the injuries; need for better sharing of information in terms of parent's mental health difficulties; indications of possible neurological trauma and a potential brief seizure soon after admittance were not taken in to account. The SCR was carried out within a Root Cause Analysis Framework. Recommendations include: ensuring processes are in place within the acute hospital trust for clinician case accountability, clinical overview and follow up for individual children when non-accidental injury is a possible diagnosis; reviewing how joint working can be improved between the acute hospitals, the multi-agency safeguarding hub and children's social care when non-accidental injury is suspected particularly in relation to children under 4 months old.
| Title: Serious case review: Child N: overview report. LSCB: Northamptonshire Safeguarding Children Board Author: Amy Weir Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 | P a g e Northamptonshire Safeguarding Children Board Serious Case Review Conducted Under Working Together to Safeguard Children 2013 Child N Overview Report Lead Reviewer: Amy Weir MA MBA CQSW June 8th 2015 (final) 2 | P a g e Final 19.12.2016 SCR Child N Date of birth: February 2014 Date of serious incident: March 2014 Ethnic origin: White UK LIST OF CONTENTS 1. INTRODUCTION AND BACKGROUND TO THE REVIEW 3 2. REVIEW PROCESS 3 3. SUMMARY CHRONOLOGY 3 4. CASE HISTORY OR NARRATIVE OF KEY EVENTS & EVALUATION OF THE WAY AGENCIES WORKED 6 5. CHILD N’S EXPERIENCE 14 6. THEMATIC ANALYSIS 15 7. FINDINGS 17 8. CONCLUSIONS 19 9. RECOMMENDATIONS 20 10. NEXT STEPS – PROGRESS REPORT AND LEARNING 20 Appendices Appendix A - Family and Significant others and Genogram Appendix B - Scope and Full Terms of Reference Appendix C. Membership of the Northamptonshire SCB Serious Case Review Panel Appendix D - List of References 22 23 26 27 3 | P a g e Final 19.12.2016 1. INTRODUCTION AND BACKGROUND TO THE REVIEW 1.1 This Serious Case Review (SCR) was commissioned following serious injuries sustained by a young child when she was aged five weeks old. It considers the circumstances in which these serious injuries occurred and whether the services, which were received by the family from a range of professionals, provided the best response required to address her needs. 1.2 All names have been anonymised and the child is known as Child N within this review. Child N was born in February 2014. When she was five weeks old, she was rushed to hospital in a “floppy” state. Her condition rapidly deteriorated and resuscitation, intubation and ventilation were required. It was subsequently identified, through X-Rays and scans, that she had sustained bilateral subdural haemorrhages, two rib fractures, a leg fracture and a wrist fracture; the medical evidence is that these injuries had been sustained over a period of several weeks. As a result of these findings, a police investigation was initiated as the injuries were believed to be as a result of non-accidental injury. Her parents were arrested and were charged with allowing and causing significant harm to a child. 1.3 Child N has survived these injuries and she has made some limited recovery but it is clear that she will suffer lifelong disabilities and will never make a full recovery. A Serious Incident Review was undertaken at the hospital following the identification of Child N’s injuries. Care proceedings for Child N have now been concluded. Both parents were charged with causing or allowing harm to a child and both parents pleaded guilty. Sentencing took place on 7th December 2016 and both parents are now serving custodial sentences. 1.4 These factors led to the decision on 5th June 2014 by the Chair of the Northamptonshire Safeguarding Children Board (NSCB) to undertake a Serious Case Review. The Working Together 2013 criteria for commissioning a SCR were met as follows: “The child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.” 2. THE REVIEW PROCESS 2.1 This review has been conducted with due regard to the principles of fairness, impartiality, thoroughness, accountability, transparency and above all with a focus on the child, Child N. Consideration of her interests and experience have been the central focus of the review. The significance of the serious injuries she suffered and of the long term impact on her has affected all those involved in the review. 2.2 The time period covered within this Serious Case Review is from May 1st 2013 to 31st May 2014. Any additional historical information relevant to the review going back beyond these dates (e.g. within the parents’ own childhoods) has been fully considered in the review. 2.3 Moira Murray and Amy Weir, who are experienced independent safeguarding experts, were appointed Independent Reviewers. A Panel of Senior Managers was formed to support the process. The Panel was chaired by Moira Murray, and Amy Weir wrote this report with the support of the SCR Panel. Further information about the Reviewers and the Panel is set out in the appendix. 2.4 The full Terms of Reference for the review are appended to this overview report. Critical points in the case were considered in the SCR. Possible reasons for actions taken at the time and learning and improvements needed have been identified, including the significance of these insights for current practice. 4 | P a g e Final 19.12.2016 These findings will inform the NSCB’s Learning and Development Plan and they will be embedded in local practice through that plan. 2.5 This investigation has examined key documents and spoken to key staff and practitioners, directly and indirectly through the involvement from each agency of experienced Senior Managers, who have had no direct involvement in this case. Local practitioners have been brought together to consider, discuss and comment on the findings of the review. The root cause analysis “fishbone” approach to identifying key contributory factors has been used. The aim of this has been to gain an understanding of how the interaction between various factors influenced the way practitioners responded to Child N and her family. 2.6 Child N’s Mother and Father have been contacted to inform them that this review was being undertaken. They have also been asked whether they would like to contribute to the review. At the time of writing, they had declined to participate as they are preoccupied with the care and criminal proceedings which were in process. Both parents then pleaded guilty to the criminal charges and declined to contribute to this process. 2.7 The critical points considered are: What information, prior to and following Child N’s birth, was known about the mental health of both her parents? Was this information effectively shared between agencies? A safeguarding 2 (SG2) form was completed by the Midwife, was this document shared effectively with other agencies? What early intervention services were provided to support the parents and protect the unborn child? In early March 2014, Child N was brought to the Emergency Department of Hospital A and was admitted with a painful right leg. No obvious fracture was identified and she was discharged two days later. Were the X-rays taken at that time reviewed by a Paediatric Radiologist? Was a differential diagnosis considered? Why was a referral not made to Children’s Social Care at that time? Child N had six admissions to hospital over a period of 5 weeks from the time of her birth until she was admitted to hospital with life threatening injuries. Was a chronology made of these admissions and were health professionals alert to the safeguarding concerns presented? What was the process for paediatric review of the case and was it consultant led? 2.8 The possible reasons for actions taken or not taken at the time were considered: What factors contributed to practice decisions at the time? What could have been improved? Was consideration given to differential diagnosis and the possibility that Child N may have been subject to non-accidental injury or “Fabricated or Induced Illness” given the large number of hospital admissions in such a brief period? It is known that in the past that Father had been subject to Child Protection plans and that he had fathered a child with a mother who was 15 years old when she gave birth. What information was known to agencies about Father’s history and his parenting capabilities? What level of safeguarding children training had professionals involved with Child N and her parents undertaken, and how did that training inform decisions taken at the time? 2.9 The significance of these insights for current practice. If the same event occurred now, what factors would influence the response? What learning and improvements have already been implemented? What is working well now and what still needs to be improved? 5 | P a g e Final 19.12.2016 3 SUMMARY CHRONOLOGY Date Event 8th Feb 2014 Child N born. 10th to 11th Feb 2014 In Hospital - Jaundice admitted to Hospital A, treated. 12th to 14th Feb 2014 In Hospital – Re-admitted to Hospital A with jaundice. Feeding problems. 6th to 8th March 2014 Hospital admission: Parents called 111 mentioned Child N having leg pain for 2 or 3 days and they also mentioned previous bruises. They were advised to contact out of hours GP – they again mentioned painful leg but not bruising and they were asked about any possible injuries. Seen with a limb injury by out of hours GP in early hours who considered possible medical cause (including dislocation of hip) as well as non-accidental injury as a possibility and he referred to Hospital Paediatrician. Mother spoke of her own congenital hip dislocation at birth. GP noted this but also possible leg break, perhaps non-accidental injury. Baby in pain when touched. 05:40 Admitted to Hospital A Paediatric Ward. Paediatric and orthopaedic staff involved. Initially both non-accidental injury as well as medical causes were considered. Mother’s congenital hip problems were to be ruled out prior to referral to out of hours’ Social Worker, if non-accidental injury remained a concern. 6th March X-Ray and 8th March, ultrasound on hips and knees, nothing abnormal was seen. Health Visitor informed by phone of event. Tests for infection showed none was present. 8th March 2014 Child N reviewed on ward - fracture or infection ruled out; safeguarding concerns not obviously revisited. Discharged from Hospital A. Parents advised to return if concerned and further scan to rule out hip dislocation to be completed on 13th March. Health Visitor contacted. 9th to 10th March 2014 In Hospital – 999 Breathless / apnoea incident observed by parents at home. Parent said baby went blackish purple in the face and stopped breathing for a few seconds. 23:37 Re-admitted to Hospital A Paediatric Ward with apnoea after a feed - stopped breathing. Health Visitor informed who then called mother on 10th March. 10th March 2014 After observations, no further apnoea incidents seen; stable so discharged at 14:00 Parents shown how to carry out basic life support. Cardiac Echo Test to be completed at Outpatients. Letter to be sent to the Health Visitor. 12th to 15th March 2014 Admitted to Hospital: 999 call - Father said to have found baby unresponsive, no appetite, vacant eyes, won't stop crying and was going limp. Call handler felt baby sounded in distress and in pain, and heard piercing screaming on 999 call. 19.45 Transferred to Hospital A. Ambulance staff found baby floppy/ unresponsive, apparently in pain, fast heart rate and low temperature. Admitted and given fluids and antibiotics for suspected infection. 21:30 Admitted to High Dependency Unit at Hospital A. 13th March 2014 Repeated blood samples and lumbar puncture. 09:55 Reviewed by Consultant - reflux medication, antibiotics, chase for cardiac ECHO, chest X-Ray and head ultrasound; the possibility of an intra-cranial haemorrhage was mentioned. 6 | P a g e Final 19.12.2016 14th March 2014 Reviewed – continue treatment. 21:00 Father reported that baby had an episode of “going black in the face”, “monitor showed heart greater than 200 and oxygen saturation at 70%”. No staff saw this. 15th March 2014 Staff Nurse noted that Child N was having brief episodes of staring to the left and eyes flickering whilst feeding; this was also observed by Senior House Officer. Nothing further noted. 12:00 Reviewed on ward round – chest X-Ray showed “patchiness” of left lung but decision made that well enough to discharge with antibiotics. 12:20 Consultant saw parents and advised them to get more support from Health Visitor. 19:30 Blood cultures negative so discharged. 17th March 2014 GP saw mother for feeding problem - reflux - and discussed recent admission to hospital. Mother said baby now much better now. 18th March 2014 Health Visitor 6 week developmental check at GP surgery. Child N gaining weight, mother gentle with baby and good eye contact. Mother said she was on anti-depressants and said felt low when baby was unwell. Father raised no concerns but said he was epileptic and asthmatic. Baby on antibiotics for chest infection. 20th March to 10th April 2014 In Hospital: 999 – limp and high pitch cry. 13:00 Injuries identified. Admitted to Hospital A, but then transferred out of county to Hospital B as her condition rapidly deteriorated. Critical condition and thought unlikely to survive. Parents’ behaviour inappropriately jovial and lacking concern. Abuse considered and referred to CYPS in Northants but referral apparently not responded to immediately. Further referral made into the MASH on the afternoon of 20th March by Hospital A following further information from Hospital B. 21st March 2014 Hospital B carried out Specialist Imaging and informed Hospital A that Child N had an inter-cranial bleed which was potentially a result of abuse. Police involved and parents arrested. 4. NARRATIVE OF KEY EVENTS with EVALUATION OF THE WAY AGENCIES WORKED 4.1 Prior to Child N’s Birth: What information, prior to and following Child N’s birth, was known about the mental health of both her parents? Was this information effectively shared between agencies? What was known and was this shared appropriately? 4.1.1 There is a considerable amount of relevant information in the records of various agencies about Child N’s parents. However, it is clear that this was not fully sought or identified by all agencies in the management of the case. The professionals involved with Child N’s parents only identified low levels of concerns until Child N’s non-accidental injuries became clear in mid-March. Both of Child N’s parents were brought up in Northamptonshire. Some agencies had kept the historical information about the parents but, for example, in Children’s Social Care, the full information no longer appeared to be available or readily accessible. 4.1.2 Both parents had very frequent contact with their GPs over the years. Significant information about both parents was available in the GP records. In particular, there was information about Father, which identified that he experienced emotional abuse and neglect in his own childhood. 7 | P a g e Final 19.12.2016 This, together with some of the information about his Mental Health Service contacts, would, if known to professionals during the pregnancy and during Child N’s first few weeks of life, have been very likely to raise concerns that he might be unable to parent his own child safely. However, much of this GP information was only available in the historical paper records still held by the practice but not used in routine care. In particular, in relation to childhood safeguarding concerns for Father, these were only reflected in the electronic record through a single reference to the Father being on what was then the Child Protection Register. 4.1.3 Information about the Father’s mental health history was also available within NHFT Adult Mental Health records. This was made available to the review. 4.1.4 As mentioned above, Child N’s Father had been, throughout his childhood, the subject of concerns about his safety and care. Two older siblings had been removed from the care of his parents by another Local Authority. Father and his Brother were on the Northamptonshire Child Protection Register on two occasions 1987-88 and 1995-96; this was as a result of physical abuse from his mother and of having been left with strangers by his parents whilst they went away on holiday. Father found it difficult to cope at school, was described as having emotional and behavioural difficulties and exhibited some unpredictable, dangerous and cruel behaviour. In 2001, Father was admitted to hospital for a psychiatric assessment as result of concerns about his challenging behaviour. 4.1.5 In 2006, Father had sex with a 15 year old who became pregnant; Father has a daughter with whom he has no contact following concerns about his inappropriate behaviour. In 2007, he was sectioned under the Mental Health Act following an argument at home and because he reported hearing voices. He was released a day later but was expected to have continuing contact with Mental Health Services; however, he missed most of his appointments and was discharged. Father was prescribed anti-depressants at times by his GP and had reported hearing voices from an early age which reportedly sought to control him and had caused him to be violent. 4.1.6 Child N’s Mother was known to Child and Adolescent Mental Health Services (CAMHS) as a teenager. In 2006, her mother reported that Mother was “out of control” and making threats to harm herself. Mother was subsequently diagnosed as having Attention Deficit Hyperactivity Disorder (ADHD) and given medication to control this. She wanted to go to college and, before Child N’s birth, was a student at a local University though she did not apparently get through her first year. She had experienced anxiety and depression for several years and received treatment from her GP and Mental Health Services for depression. After she met Father she became pregnant and they both stated to professionals that Child N was born as a planned pregnancy. 4.1.7 At the Midwife booking in July 2013, both parents revealed their history of depression and of involvement with Mental Health Services. However, they did not share their full history of childhood difficulties nor that Father had another child. It is possible, if contact had been made by the Midwife or the Health Visitor with Mental Health Services, that Father’s own troubled childhood, having been on the Child Protection Register, and the fact that he had fathered a child, may have come to light. Was the information shared appropriately and acted upon? 4.1.8 Both the parents disclosed some information about their mental health histories when Mother booked with the Midwife early in her pregnancy. The potential for increased vulnerability was appropriately recognised. The level of concern did not reach a safeguarding threshold where, for example, information held by other services might be shared without parental consent. 8 | P a g e Final 19.12.2016 In the Health Visitor Service, the history of mental health concerns caused the case to be classified at Level 2, “Universal Plus”, potentially requiring additional services or support. Approximately 10% of the health visiting caseload in Northamptonshire is managed at this level. 4.1.9 Several previous case reviews nationally and locally have found that Universal Health Services often fail to establish a full picture of the concerns and vulnerabilities for prospective or new parents, which are available within all the person’s health records. The history of fathers is also often insufficiently explored. There are a number of possible reasons for this: Recording templates and practice standards do not strongly support or promote the routine exploration of issues such as the parental relationship and parents’ own childhood experiences. It appears that, as both parents presented no active concerns during the pregnancy, no further detailed enquires were made. The parents appeared to behave appropriately and seemed very committed to the pregnancy, made good preparation for the baby and provided good physical care to Child N when she was born. Current practice expects that midwives can access GP records for mothers, their primary clients. Universal access to fathers’ records (bearing in mind that fathers may be registered at a separate GP practice) is not current practice. A pilot process is currently underway within Northamptonshire to see whether a universal approach to seeking consent to review the records of the father or partner is practical. Multi-disciplinary team (MDT) review meetings (typically including GPs, HVs and Midwives) had been established, or were being developed, in both GP practices, with the aim of sharing concerns and monitoring progress for vulnerable families. This is recognised good practice in primary care safeguarding. The GP IMR suggests that GP Practice A may have considered Mother’s case at their developing MDT. However, Mother then registered at Practice B (where Father had always been registered). There was no clear expectation in the handover that the case be discussed at practice B’s MDT, and this never happened. However, the concern level in this case would only have been increased if the MDT led to the opportunity to review Father’s GP record. As noted above, inactive concerns and, in particular historical welfare concerns for parents, are often summarised very briefly. Identifying historical concerns for the entire caseload, or even the approximately10% of the caseload recognised as having additional vulnerabilities, will be dependent on record systems which effectively summarise and highlight such concerns within the records. 4.1.10 The limited information which the Midwife and also the Health Visitor had – that both parents reported a history of mental health problems – was never shared with the Paediatricians assessing Child N during her hospital admissions and nor was fuller information sought. 4.1.11 There was no established process on the paediatric ward to obtain any information on parental vulnerabilities from the maternity records. Communication with the Health Visiting Team during Child N’s admission with a painful right leg was not effective in communicating concerns. The possibility of non-accidental injury, which was recognised at the start of the admission, was not communicated to the Health Visiting Team. The contact on this occasion seems to have been treated by both services as a routine notification. There may have been an expectation on the part of the hospital that the health visiting team would share any information about their vulnerability, but this did not happen. Information about Child N’s multiple admissions was not shared with the Health Visiting Team in a consistent and timely way. In particular, the Paediatric Liaison Service was not functioning effectively at this time and there was a lack of clarity about its role and what was being provided. 9 | P a g e Final 19.12.2016 4.1.12 The Midwife rightly saw the parents as vulnerable and likely to need additional support; she completed a Health Safeguarding Notification (Form SG2) to signify that there would be a need for additional support. This was shared with the Health Visitor and the GP; it was also reviewed some weeks later and a plan made for support. However, none of these professionals appear to have considered making contact with Mental Health Services directly to check out what the Midwife had been told about the parents’ contact with those services so that the full details of their history were not known; the Health Visitor works in the same NHS Trust as Mental Health Services but this contact was not considered or made. Although it is not a defined expectation that health professionals should explore a parent’s mental health history with Mental Health Services, it would have been good practice and would have provided highly relevant information in this case. For the most part, the GP, Health Visitor and Midwife did work well together to share information prior to Child N’s birth but they did not see the need to seek the further information which would have been available. 4.1.13 As the history set out above shows, there was significant and relevant history in relation to the likely parenting capacity of both parents and possible vulnerabilities. Unfortunately, the level of safeguarding concern was not reached which might have led to referral to children’s social care. The fact that Mother and Father themselves withheld some relevant information and seemed to be coping and committed to the baby also is likely to have led professionals to take an optimistic and less enquiring approach. 4.1.14 Were effective Early Intervention Services provided? The Midwife identified the likelihood of the family needing additional support and linked effectively with the Health Visitor and the GP. The GP saw Mother and Father and “oversaw” the pregnancy. 4.1.15 Plans to refer the family to a Children’s Centre do not seem to have been progressed. The context was that no specific concerns were identified or noted about how they were coping and planning for the birth of the baby; they seemed to be highly committed to the pregnancy and responded appropriately when seen for ante-natal screening and were preparing for the birth of the baby. This is likely to have led to this referral for Early Help not being regarded as a high priority and it might even have been seen as unnecessary. 4.2 After Child N’s birth 4.2.1 After she was born, Child N was admitted to hospital on six different occasions during the first five weeks of her life. Child N was in hospital on two occasions during February 2014 - 10th to 11th and 12th to 14th February – both these admissions related to her being jaundiced. This is a common condition post-birth and her parents appropriately sought and received medical advice. On 6th March 2014, Child N was brought to the Emergency Department of Hospital A, following a referral from an out of hours GP; she was admitted with a floppy and painful right leg; she was discharged on 8th and admitted again on 9th March before being discharged again on 10th March. She was next admitted to hospital from 12th to 15th March after a 999 call from her Father saying she had stopped breathing for a period and was unresponsive. Child N was also admitted to the hospital on 20th March when she was unresponsive and floppy and her condition quickly deteriorated to being critical. 10 | P a g e Final 19.12.2016 Were the responses to Child N’s hospital admissions appropriate and were effective services provided? 4.2.1.1 Admission March 6th to 8th 2014 The first significant admission was on 6th March. Child N’s parents phoned the NHS 111 telephone advice service late on the evening of 5th March. The summary record of this contact indicated that this problem had been a concern for a few days, and the parents had previously noticed some bruising. Parents were advised to take Child N to a GP, which they did. The out of hours GP would have had all this information including the bruising comment. It is not clear whether this information, which should have further raised concerns about possible non-accidental injury, was passed on to the hospital when Child N was admitted in the early hours of the 6th March. The out of hours GP provider has recognised that while arranging hospital admission was appropriate, safeguarding concerns should have been flagged to the patient’s usual primary care team for follow up. An immediate referral to Children’s Social Care could have been considered, and they have provided assurance that such referrals are made regularly. Both the GP and the admitting Paediatric Registrar appropriately recognised that non accidental injury was a possible explanation for Child N’s painful leg. It was reasonable to consider possible medical explanations for the painful leg, but the conclusion that this was due to Developmental Dysplasia of the Hip (DDH), typically a non-painful condition, was inappropriate, but was undoubtedly influenced by Mother’s own description of her history of DDH. Physical examination did not show any bruises or other external injuries, X-rays did not show any clear signs of fractures, and hospital staff had no concerns from their observation of the parents and the care they gave to Child N. Child N’s painful leg should have been recognised as unexplained in such a young, immobile baby, and still potentially having been the result of non-accidental injury. We now know the fracture was present but was not picked up; if this had been seen, further steps could have been taken including a specialist paediatric review of the X-Rays, and a referral to Children’s Social Care. There is a new NSCB Bruising Protocol which would now support a referral if the problem was recognised as a possible unexplained injury in a very young, immobile infant. Even if no further action to refer was taken at this time, a safeguarding flag in relation to an unexplained concern might have influenced thinking at Child N’s subsequent admissions. Various tests were ordered and completed and a thorough medical assessment was made of Child N’s condition without delay. Initially, as the out of hours GP had recommended, non-accidental injury as well as medical causation for her leg pain was considered. When Child N was examined, she had no visible injuries identified on X-Ray. She was discharged two days later without any further consideration of the possible safeguarding concern. We now know that subsequent X-Rays viewed by a specialist have shown a fractured tibia below the knee, and this is the most likely explanation for Child N’s leg pain. Specialist review has identified subtle evidence of a possible fracture on the films taken during this admission on 6th March. The specialist consulted stated that the tibial fracture was “due to a forceful grab and yank type injury” involving the use of force well beyond normal handling. However, it is clear that this subtle abnormality at this stage could have been missed by Paediatricians and general Radiologists. 4.2.1.2 Admission 9th to 10th March Having been discharged on the 8th, Child N was re-admitted on the 9th of March. Her parents reported a “blue episode” at home. Child N‘s parents dialled 999 late in the evening saying that she had had a breathless / apnoea incident. Her Father said her face had been blackish / purple and she had stopped breathing for a few seconds. Child N appeared “well” on admission. 11 | P a g e Final 19.12.2016 Tests were arranged to rule out infection. It was thought that Child N might have experienced an apnoeic episode (stopped breathing) at home; this is a relatively common problem in very young babies with a range of possible causes; the working diagnosis of reflux (of stomach contents into the oesophagus, also common in young babies) was reasonable. No X-Rays were taken during this admission. The previous concerns and issues do not seem to have been reviewed and non-accidental injury was not considered. No further apnoea episodes were observed in the hospital. The health visitor was notified of the admission when Child N was discharged the next afternoon; a further medical test – Cardiac ECHO was to be arranged as an outpatients appointment, as a heart murmur had been picked up on examination during the admission. She was discharged home on the 10th March. 4.2.1.3 Admission 12th to 15th March Child N was admitted once again on the evening of the 12th of March. Her parents had called 999, reporting that Child N was unresponsive, had vacant eyes, would not stop crying and was limp and floppy. The ambulance service reports that Child N had a high pitched scream throughout the emergency services call, and they felt she was very distressed at this point. By the time the ambulance crew arrived at her home, Child N was floppy and less responsive than normal. Her condition seems to have been much the same on arrival to hospital. Child N was immediately recognised as being significantly unwell and the immediate management, focused on identifying immediately treatable causes such as infection, was appropriate. Child N was cared for in the Paediatric Department’s High Dependency Unit, until 14th March when her condition had clearly stabilised. A chest X-Ray was obtained soon after admission, with the request form indicating that infectious causes for Child N’s illness were being sought. It has emerged subsequently that two rib fractures - most likely due to non-accidental injury, were not identified from the X-Rays taken at that time; from the X-Rays, her lungs were described as being “patchy”; this was assumed to be an indication of infection of the lungs and antibiotics were prescribed. The possibility of an intra-cranial haemorrhage was mentioned but not followed through as an indicator of possible non-accidental injury and the Consultant did not apparently think there was need for an ultrasound scan Although a Doctor and a Nurse noticed that Child N was briefly staring to the left and her eyes flickered during feeding – possible indicators of neurological trauma - these issues were not addressed or discussed with her parents prior to her discharge. Father reported during this admission that Child N “went black in the face” and that her oxygen saturation dipped, this does not seem to have been questioned or followed up either. It is important to note that these observations by Father were not seen by hospital staff. When Child N was discharged with antibiotics prescribed for her presumed chest infection, her parents were recommended to seek more support from the Health Visitor. By the time of Child N’s discharge, no clear evidence of infection to account for her initial presentation had been found and the working diagnosis was once again apparently apnoea secondary to reflux; the evidence to support that view is not clear. Child N had been quite unwell and more consideration should have been given to possible alternative causes. If the rib fractures had been identified in the X-Ray film, this would have triggered a safeguarding response and most likely Child N would not have remained in the care of her parents, and not suffered her subsequent catastrophic injuries. Child N’s X-Ray films during her admission were reviewed and reported by members of the Radiology Department who were general Radiologists, rather than Radiologists with specialist paediatric expertise or a paediatric interest. 12 | P a g e Final 19.12.2016 Previously, there had been a Radiologist with paediatric special interest at the hospital but he had retired and no-one with equivalent expertise could be recruited, despite repeated attempts to obtain this expertise. This position is not apparently unusual in smaller general hospitals, and there is a recognised shortage of Paediatric Radiologists nationally. There was a missed opportunity during this admission to identify non-accidental injury. If the rib fractures had been identified at that point, it is likely that the subsequent serious injuries to Child N could have been prevented by removing her from her parents’ care. 4.2.1.4 Admission on 20th March At her last admission, Child N’s condition deteriorated very quickly, she became critically ill and required life support intervention and transfer to Hospital B from the local hospital. On this last hospital admission, a previous fracture of the tibia and of her wrist were identified following further scans at Hospital B. Subsequent skeletal scans at the end of March 2014 showed that she had suffered several fractures of various ages. 4.2.2 Was a differential diagnosis considered? Why was a referral not made to Children’s Social Care at that time? 4.2.2.1 Initially at Child N’s first admission in March, non-accidental injury as a differential diagnosis was considered but not fully explored; the out of hours GP considered non-accidental injury and this was also initially looked at on admission to the Emergency Department. Thereafter, in subsequent admissions the differential diagnosis of non-accidental injury was not considered. Thereafter, referral to Children’s Social Care would not have been considered as part of the planning since evidence of non-accidental injury had not been identified. Was information shared appropriately and acted upon? 4.2.2.2 When Child N was being admitted to hospital during March 2014 with various symptoms, the hospital staff did not look at her mother’s antenatal notes; there is no system in the hospital for automatically linking the antenatal notes for Mother to the post-natal notes for the child. Her parents were regarded as behaving appropriately. The hospital Midwife had information about the parents’ mental health problems from their self-report but she was not aware of the admissions which occurred after she was no longer involved with the family. The Health Visitor also had information about their mental health problems but, although on most occasions, she was kept informed of Child N’s admissions to hospital, she was not notified of the 12th March one; although a letter was prepared to inform her of the admission, it was not sent as a result of an “oversight”. There is a post of Paediatric Liaison Nurse which is responsible for linking between the hospital and the Community Nursing Services to ensure there is effective sharing of information when children are in the hospital. In this case, the Paediatric Liaison Nurse does not seem to have been notified of Child N’s admissions and her role seems to have been unclear. 4.2.2.3 During the second admission from March 12th 2014 to hospital, a Doctor and a Nurse both observed that Child N seemed to have a period of staring to the left and eye flickering whilst she was feeding. They were both concerned and thought this should have been considered as significant but this information does not appear to have been referred on or considered more fully in the clinical assessment before Child N was discharged home. Were effective services provided? 4.2.2.4 In the hospital, there was liaison between the Emergency Department, Paediatrics and Orthopaedics and the symptoms which Child N had were responded to without delay. 13 | P a g e Final 19.12.2016 Appropriate tests were ordered and the possibility of infection was explored. At the first admission in March 2014 on the 6th March , it appears that non-accidental injury was briefly considered but this was discounted in favour of considering various possible medical diagnoses related particularly to mother’s congenital hip problems but also to a possible heart problem on 9th March. The parents appeared to be appropriately concerned and did not arouse any suspicion. 4.2.2.5 During the third admission to hospital from March 12th, Father reported to the nursing staff that the baby had an episode of “going black in the face”; he said that the “monitor showed heart rate greater than 200 and oxygen saturation at 70%”. No staff saw this and this was not questioned even though only Child N’s parents had observed any evidence of apnoea then or prior to her admission to hospital. This should have been considered and explored more fully with both parents. During these admissions, Child N’s parents showed some knowledge of “medical” matters, both of them referred significantly to their own illnesses. When provided with information about resuscitation, they both said they already knew all about that. 4.2.2.6 There is no indication that the need to consider abuse as a differential diagnosis was sufficiently considered. Doctors are required to consider familial / inheritable and medical causation for symptoms but this should not exclude keeping the possibility of abuse in mind. 4.2.3 Child N had six admissions to hospital over a period of 5 weeks from the time of her birth until she was admitted to hospital with life threatening injuries. Was a chronology made of these admissions and were health professionals alert to the safeguarding concerns presented? What was the process for paediatric review of the case and was it consultant led? Was information shared appropriately and acted upon? 4.2.3.1 As stated above, there were gaps and missed opportunities for the sharing of information. There was no system in the hospital for ensuring that the information and outcome from each admission was collated in a single record or chronology of episodes of care, and as a result, it was not possible to see any possible pattern. At each admission, the medical team were in effect “starting again”. On each occasion the search began anew to seek medical or congenital reasons for Child N’s condition. There was no one consultant with overall accountability as may be the system when a child is admitted with a longer term condition which requires follow up. In Child N’s case, each episode was treated as a new single incident; the hospital needed to consider and define at what point an accountable consultant with clinical overview should be appointed for children with repeated admissions but this did not occur in this case. 4.2.3.2 The hospital service operates around the clock and inevitably several different clinicians and practitioners will be involved with the care of any child. Child N’s case was reviewed on each admission and a senior doctor was responsible for assessing the situation and overseeing the decision to discharge. However, it is not clear who was case accountable or whether one of the clinicians retained an overview of her case to ensure that the original concerns from previous or current admissions had been fully resolved. This was particularly significant from the fourth admission when the out of hours GP referred Child N with a suggested safeguarding concern. Although this was considered initially on that admission, it was not fully resolved then and was never mentioned again in subsequent admissions until the final one when she was admitted in a critical state. 14 | P a g e Final 19.12.2016 Were effective services provided? 4.2.3.3 Several different doctors oversaw Child N’s care and both Paediatric and Orthopaedic specialists were involved. Some information such as the fact that only parents observed the apnoea episodes and that medical staff observed Child N’s eye flickering were not fully considered when decisions on diagnosis and to discharge were being made. The possibility of an intra-cranial haemorrhage was mentioned on 13th March but not followed up as a possible indicator of non-accidental injury. Hip dislocation was seen as a high possibility for Child N’s pain and floppy limbs but pain is not a marker of this condition and this should have been considered as a counter-indicator of medical cause as the explanation. Child N’s Mother’s suggestion that her own childhood DDH was a possible explanation was too readily accepted and not fully researched. 4.2.3.4 The information gathered was in relation to a possible medical cause. There is no evidence that any attempt was made to gather information to assess and question the behaviour of her parents – in relation to Father, in particular, as being the one who saw the apnoea which no one else apparently observed throughout a three day hospital admission. 4.2.3.5 The mind-set that there was a medical cause for Child N’s symptoms was a major obstacle to consideration of other differential diagnosis; it also meant that medical and nursing staff were not sufficiently attuned to querying what the parents said; it was accepted at face value that only they observed the apnoea episodes. Research has shown that previous “sentinel injuries”: “…are common in infants with subsequently identified severe physical abuse and rare in infants evaluated for abuse and found to not be abused.” Nugent et al 2013. This refers to visible precursors or events which precede children receiving severe injuries; in Child N’s case the unidentified cause of her painful leg and the two apnoea presentations in rapid succession, particularly when there was additional evidence of a neurological issue (eye flickering observed), are likely to have been sentinel events / injuries which, if they had been identified, may have resulted in earlier intervention to prevent further injury to her. “Failure to recognize and take action when relatively minor, suspicious injuries occur may have devastating consequences for the infant and family.” Paediatrics Nugent et al 2013 4.2.3.6 There is some evidence that the parents were demonstrating they had some knowledge of the symptoms which they described and perhaps this might have been seen as unusual; this was the first child either of them had cared for and, although Mother had had some education in Biology, Father had not. When they were shown how to give life support to Child N if apnoea should recur, no one questioned how or when they had previously had this training – as they stated was the case. This significant level of medical “awareness” was not questioned or considered in relation to the high number of hospital admissions for Child N and these may have been indicative of the parents “fabricating” symptoms. However, it is not possible from the information available, and without a specific specialist assessment of the parents, to conclude that this was the case. 5. Child N’s Experience 5.1 The indications are that for the first two weeks or so, Child N’s parents were coping well with her care. Her Mother was initially breast-feeding her but this does not seem to have continued and by the end of March there is no further reference to this. The Midwives who visited were appropriately supportive and checked on the baby as well the parents’ well-being and mental health. Child N’s experience seemed to be good with loving parents who were connecting well with her and providing good physical care. 15 | P a g e Final 19.12.2016 5.2 However from early March 2014, it appears that Child N’s Mother’s mental health had deteriorated and she was reporting feelings of depression. Evidence has emerged from the Police investigation following Child N sustaining the serious injuries, that her Father’s handling of her became very rough and inappropriate; this was seen on a video made by her parents. By 6th March, it is now clear that injury had been caused to Child N and that she was in pain. Child N’s experience from then until the hospital admission on 20th March seems to have been more concerning, though even on 18th March, when seen by the health visitor for a developmental check, Child N seemed to be alright in her Mother’s care. 5.3 The expert clinical specialist who reviewed all the X-Rays and scans is of the opinion that the head imaging pictures were “consistent with a recent forceful acceleration/deceleration injury (shaking) around the time of (Child N’s) clinical deterioration” on 20th March. There were also older rib fractures identified which were “consistent with forceful circumferential squeezing to the chest that occurred several weeks before the acute change.” It was also stated that “the wrist injury is recent no more that than 10 days old at the time the skeletal survey was taken 8 days after presentation and is due to a forceful over extension injury. The tibial metaphyseal fracture is due to a forceful grab and yank type injury. The patterns of injury is that of non-accidental injury on several occasions by different mechanisms all involving force well beyond normal handling”. It was the expert’s opinion also that he would expect the perpetrator(s) to recognise that they had applied excessive force and that their actions had hurt (Child N) even if they did not realise they had fractured a bone. 5.4 It appears therefore that Child N would have been in considerable pain but also frightened and intimidated by this rough and inappropriate handling. 5.5 Child N has settled well with Foster Carers and she is making some progress. Her parents are still having regular contact with her; they allege that her injuries were caused by hospital staff. Police have been involved with a full investigation into these allegations, expert opinion has also been sought and it has been concluded that the injuries could not have been inflicted by hospital staff. 5.6 It appears that Child N has very limited sight as a result of her injuries and has overall developmental delay. Her sleep at night is erratic and she wakes most nights distressed, crying and screaming in the early hours of the morning. Child N does seem to gain some pleasure from touch and from food but it is clear that she will not now reach original potential. 6. THEMATIC ANALYSIS This section addresses and suggests possible reasons for actions taken or not taken at the time. 6.1 What factors contributed to practice decisions at the time? Pre Birth? 6.1.1 It is clear that none of the agencies directly involved held all the information which would have been relevant to considering whether Child N’s Mother and Father would have difficulties in parenting. However, neither the Midwife nor the Health Visitor sought to check out what the Mental Health Services knew about the parents; even though their mental health was seen as a vulnerability, it was not believed to raise a serious enough concern about their ability to parent because they presented in a positive way. The SG2 (Safeguarding Form 2) form was completed to alert colleagues in Health to this vulnerability. The parents only presented part of their history and they gave a positive impression through their preparation and avowed commitment to the baby which they said resulted from a planned pregnancy. 16 | P a g e Final 19.12.2016 6.1.2 Although a plan to refer them to the Children’s Centre was made this was not carried through. This seemed to have been an oversight – likely because all seemed to be well – Mother said she was not depressed – and because the parents were not apparently keen to pursue this either. To the health professionals, this did not seem to be a high priority case with major concerns and the parents sought to present this positive image. Indeed it seems likely that they were genuinely happy and looking forward to having the baby to care for. 6.2 What factors contributed to practice decisions at the time? Post Birth? 6.2.1 For the most part, Child N appeared to be having good and positive care from her parents during the first few weeks. They were proactive in seeking support, saw the Health Visitor and Child N had her first developmental check. All seemed well though Mother told the GP she was feeling down and she was prescribed antidepressants. 6.2.2 The possible opportunities to see beneath this arose when Child N was admitted to hospital – particularly the admissions in March. The first one prompted by the out of hours GP who referred Child N to hospital when she had a painful, floppy limb; he clearly made a good decision to make this referral; he wondered about a fracture and also included in his notes Mother’s suggestion that the symptoms could be related to her congenital hip dislocation. At the hospital, both possibilities were considered but the medical causation was seen as more likely and was pursued. This rested on the fact that there was no clear sign of injury and the X-Rays were not seen to show fractures. 6.2.3 On the next admission it appears that non-accidental injury was not considered. The outcome of the previous admission led there to be a fixed mind-set that Child N’s problems had a physical cause. 6.2.4 It is likely that a number of case specific and systemic factors contributed to a failure to consider non-accidental injury at this admission and with this presentation: Once again, Child N had no bruising or and other physical signs of injury. There were no obvious concerns in relation to the behaviour and responses of her parents, who seemed to be appropriately concerned and involved. As already discussed, information about the possible additional vulnerabilities for Mother and Father was not available to the Paediatric Team. Hospital systems – medical rota arrangements, paper and electronic records - did not facilitate the development of a clear picture of Child N’s multiple admissions. Previous possible non-accidental injury concerns (in relation to the painful leg) had been forgotten and lost. 6.2.5 The parents’ positive and concerned behaviour and presentation led the medical staff to believe there must be a physical cause and to adopt that optimistic view. There was insufficient critical analysis or challenge to ensure that the differential diagnosis of abuse was maintained as a possible element of, if not the main explanation, for Child N’s symptoms and pain. 6.2.6 The professionals who were involved with Child N and her family had all received relevant safeguarding training; they should have had the knowledge to avoid ruling out completely the idea of a differential diagnosis of non-accidental injury. Within the hospital, additional specialist safeguarding advice could have been sought but there is no evidence that it was. The lack of clarity about and availability of the Paediatric Liaison Nurse was another missing opportunity for Child N’s case to be reviewed and considered holistically. 17 | P a g e Final 19.12.2016 6.2.7 During the review, there was some concern about the behaviour of Child N’s parents in particularly in relation to their contact with health services. We considered whether there may be an element of fabricated illness activity driving the parents’ behaviour. Child N had several admissions to hospital during her first few weeks. Both her parents seem to have had an unusually high knowledge of some health issues and appeared to observe symptoms such as apnoea which were not seen by others. Child N was physically abused but it is not possible to understand fully her parents’ behaviours or whether her “illness” provided them with inappropriate “gratification”. Although this issue was considered, no conclusions have been reached as this would require a psychological assessment of the parents to identify their concerns and behaviours. 6.2.8 It is likely that after Child N was born, her parents coped with caring for her. However, particularly for Father, it was stressful to care for such a highly dependent infant; his own experience as a child of being neglected and physically abused for many years, is likely to have impaired his own capacity to respond appropriately to such a young infant with tender, sensitive care and handling. 7. Findings 7.1 There should have been greater consideration of safeguarding as an alternative explanation for the symptoms the baby had during her hospital admissions. There is a need to manage a balanced judgement between purely (or mainly) medical causes and other social and parental factors particularly in young babies who are immobile and entirely dependent on their parents. 7.2 This case demonstrated that non-accidental injury can be difficult to recognise. All practitioners working in this field need to be aware that significant injuries such as fractures can occur without bruising or other visible signs, and that fractures may even be “missed” on X-Rays. There are particular difficulties if the right level of experienced Paediatric Radiologist is not available. 7.3 The first requirement for recognition of non-accidental injury is a high level of awareness of the possibility. In this case there were two occasions where a very vulnerable young and immobile infant presented with symptoms that were not adequately explained at the time. In retrospect, it is very likely that both these presentations were directly linked to abuse, but any suspicion of non-accidental injury was lost at an early stage. “Many children who have suffered some form of abuse present to the accident and emergency department or clinic; however, none of the screening markers currently used to identify children who should be assessed further for possible abuse or neglect (e.g., repeated presentation, age, injury type) have been found to be sufficiently accurate. Therefore, clinicians should maintain a high level of suspicion for abuse in injured children who present to the A&E department or clinic with or without these specific characteristics of abuse.” BMJ Best Practice. http://bestpractice.bmj.com/best-practice/monograph/846/diagnosis/step-by-step.html 7.4 The working hypothesis should be that abuse should be actively investigated with consideration given to additional investigation or further opinions, proportionate to the circumstances of the case. In this case, Child N was a completely dependent immobile infant with an unexplained injury. Abuse should not be seen as something additional to consider and to identify after all possible medical causation has been explored. In this case, a lack of physical injuries, initial normal X-Ray reports, and no apparent concerns about parental interaction, may have allowed a judgement (not made or recorded explicitly) that abuse had been excluded. 18 | P a g e Final 19.12.2016 Practice guidance indicates that safeguarding concerns must be resolved before a child is discharged from hospital. Keeping an open mind and putting additional safeguarding measures in place are essential. In Child N’s case, non-accidental injury had not been excluded as an explanation for her presentations to hospital. 7.5 The parents’ apparently appropriate and concerned behaviour was insufficiently tested when Child N presented with unexplained symptoms. The parents sought to provide explanations from their own medical history; these were pursued without sufficient focus being kept on the possibility of non-accidental injury or abuse being present. This was partly understandable given the lack of identified clear visible physical evidence of abuse. However, the physical evidence which existed at her penultimate admission was not identified until her admission to Hospital B when Specialist Imaging was possible. 7.6 There were indications of possible neurological trauma. Inflicted brain injury such as a shaking episode can present with apnoea. Child N’s presentation, with irritability followed by reduced responsiveness, should have suggested a possible neurological cause, including a shaking injury. In addition, a possible brief seizure (staring to the left with eye flickering) was noted soon after admission, but this does not seem to have been taken in to account when causes for Child N’s illness were considered. 7.7 The absence of a Paediatric Radiologist in the hospital may have contributed to the failure to identify rib fractures on X-Rays taken at an earlier hospital admission. However, as safeguarding concerns were not identified or seen to be justified by the clinicians, the need for such detailed and specialist examination was not identified. If these fractures had been discerned from the X-Rays, it is possible that the subsequent serious injuries which occurred could have been prevented. 7.8 The X-Ray films were also available to view by the clinicians caring for Child N on the ward. As discussed above, possible signs of a fracture during Child N’s admission with a painful leg were very subtle and likely to be missed by non-specialists. There is no evidence that any Paediatrician reviewed the Chest X-Ray during Child N’s penultimate admission. This was a failure of usual expected practice, where there was the potential that the severe consequences for Child N might have been avoided. This has been recognised and acknowledged by the paediatric staff. 7.9 The Paediatricians would normally expect to review all films available on the ward. They consider that on this occasion, they relied on the fact that this film had already been reported by a Radiologist, whom they saw as having more expertise in this area. Having looked again at the chest X-Ray from Child N’s final admission, they consider that all of the Consultants would most likely have identified the rib fractures on this film. This opinion is of course with the knowledge of Child N’s actual injuries; rib fractures may be hard to recognise and “missed” fractures are an occasional occurrence in most hospitals. 7.10 Systemic factors made it harder to recognise possible risk in this case, hospital systems did not allow, through staffing or records, a single clear overview of the case particularly as it evolved rapidly over a short period of 10-12 days before Child N’s final admission. Current approaches in Universal Services do not build a full picture of possible vulnerabilities for parents, and in this case even the limited information already available was not shared with the Paediatric Team. Better coordination and collation of information about each hospital visit could have ensured a better overview of events and the baby’s experience which included unexplained severe pain. 19 | P a g e Final 19.12.2016 7.11 Better read across of records and exchange of information about Mother’s and Father’s mental health problems between the Midwife, the Health Visitor, the GP team and the hospital would have provided a much more comprehensive and accurate assessment of the parents. The GP record also contained information about Father’s childhood abuse. Consultation outside the immediate health professionals “team” with Mental Health Services and Children’s Social Care would have provided a broader perspective to consider causes and explanation. The MASH was not contacted at any point to see whether there was any helpful information which could have been provided. Parents with mental health difficulties are more likely to need additional support to parent as various research studies have identified including Brandon’s biennial studies of SCRs. In this case, however, the parents were cooperative, apparently strongly committed to the baby, and sought out advice and help. 7.12 Although there is access for clinicians to safeguarding advice within the hospital, there is no routine arrangement in place for the hospital teams to access multi-agency discussion of cases of concern. This is available and effective in some areas nationally through linking a Social Worker to local hospital services; this provision ensures that cases of concerns are considered more widely and that, in particular, the local Authority’s records are checked. 8. CONCLUSIONS 8.1 Child N was a very vulnerable young child who was totally dependent on her parents for her care and safety. Both parents had troubled childhoods especially Father who was abused and neglected but who remained in the care of his parents. Both her parents have mental health problems and have sought treatment for these. Babies are almost entirely dependent on their immediate caregivers. A parent’s capacity to respond appropriately to the motions and needs of their babies has a profound impact. Becoming a new parent is a major transition; there are times when every parent feels under pressure and may struggle to cope with the stresses and responsibilities of their role. But, for very young parents, or parents facing additional challenges in their lives such as mental illness and domestic abuse, this can be a particularly difficult time. NSPCC 2011 All Babies Count 8.2 It seems that the stress of parenting led to difficulties for them in caring safely for Child N. Unfortunately, in many respects and for several weeks they presented as appropriately caring and concerned parents who were managing. However, from early March, Child N was brought to hospital on two occasions with unexplained symptoms. On the last admission, she was in a critical condition having sustained significant injuries at home. Her life was saved but she still has been left with major disabilities and developmental difficulties from which she will never fully recover. 8.3 At the time of writing, the parents have declined the opportunity to contribute to this review. Their perspective would be a very important factor in helping us understand what occurred and it is to be hoped that they will reconsider whether they would like to contribute. 8.4 There was much positive practice in this case. The Midwife rightly identified the potential vulnerability of Child N’s parents. She provided advice to them and informed other health professionals of the possible need for additional support when the baby was born. The Health Visitor and GPs responded appropriately when the parents sought advice about Child N’s care. 20 | P a g e Final 19.12.2016 8.5 It is possible that the difficulties which Child N’s parents experienced in caring safely for her could have been predicted if the full information about them and their histories had been known. However, there were several positive indicators pre-and post-birth that they were managing and devoted to their baby. The parents themselves, particularly Father, withheld some key information which would have raised the level of concern and may have led to further information being sought from Mental Health Services and Children’s Social Care. 8.6 Unfortunately in the last two to three weeks before the non-accidental injury which almost led to Child N’s death, the likely “sentinel” presentations such as her painful leg and apnoea episodes were missed. The parents explanations were accepted and insufficient consideration of differential diagnosis on non-accidental injury in such a young baby was not kept in mind; the fact that only Child N’s parents had seen the apnoea episodes even though medical staff saw nothing during her two admissions to hospital lasting several days was not questioned; the observations of unusual eye flickering seen by two staff was not fully explored. 9. Recommendations for LSCB to consider and action 9.1 NSCB to ask the Designated Doctor to ensure processes are in place within the Acute Hospital Trusts for specific clinician case accountability, clinical overview and follow up for individual children when non-accidental injury is a possible diagnosis. 9.2 NSCB to support the CCG and Designated Doctor to review and develop an audit process to test the effectiveness of clinical practice in the identification of non-accidental injury including consideration of differential diagnosis and to ensure that there is clarity about how concerns should be shared and referred. 9.3 NSCB to review how joint working can be improved between Health (the acute hospitals) the multi-professional MASH and Children’s Social Care when non-accidental injury is suspected particularly in relation to children under 4 months old. Consideration should be given to whether there should be a direct regular multi-disciplinary contribution to the work of the Emergency and Paediatric Departments at Northamptonshire Hospitals. There is a particular need to consider the arrangements for consultation out of hours. 9.4 NSCB to ensure that the importance of all practitioners seeking, collecting and sharing all available information about family and parental history is fully appreciated – through its learning and development and case auditing activity. 9.5 NSCB to ensure - through its learning and development activities - that all practitioners are required to ensure Fathers, and their history, are fully included in their work with families. 10. Next steps - Progress Report / Learning Since this review was established a number of measures have been put in place to respond to the learning from the case: Health Professionals no longer complete SG2 Safeguarding Forms and are expected to complete a Common Assessment (CAF) if they believe parents are vulnerable and require additional support to parent effectively. A pilot project with Northamptonshire GPs is trialling a process to ensure that information about fathers is shared with professionals even when the father is registered with a different GP from the mother. 21 | P a g e Final 19.12.2016 Lack of identification of non-accidental injury – an external safeguarding review has been undertaken at the hospital and additional training and support provided to clinicians by an independent clinician. Lack of paediatric radiology access - The hospital has now obtained a limited amount of specialist paediatric radiology expertise, through a contractual arrangement with a larger paediatric centre. This is in the context of the continuing national shortage of paediatric radiologists. The role of the paediatric liaison service has been reviewed and changes implemented to ensure it reports on emergency admissions. Access to inter-agency consultation about cases of concern has been improved through the advice line at the MASH which has been in place since April/May 2014. If any professional wants to make a referral or speak to a senior practitioner; the number has been published in several newsletters from the Children’s Services Improvement Board and the LSCB. In addition to the advice line, there is also a helpline if there is a question about a CAF. Further discussions supported by the Designated Doctor are continuing between the local authority and the acute hospital to consider how further improvements can be made to increase access to consultation including out of hours. There is a new Northamptonshire Safeguarding Children’s Board protocol about (unexplained) bruising in young babies – the “Bruising/Marks in Non-Mobile Infants Policy and Toolkit”. The NSCB undertook in 2014 a scoping exercise of six cases where pre-mobile babies had sustained non-accidental injuries – the findings of this review have identified some similar issues and there is an action plan in place to take forward the learning. Workshops for practitioners and managers and locally have been held to discuss the findings and to share the learning locally. The LSCB will continue to share the learning from this review in its regular workshops about the findings from all recent SCRs and in its interagency training. 22 | P a g e Appendix A - Family and Significant others and Genogram Maternal Grandfather Maternal Grandmother Mother Paternal Grandfather Paternal Grandmother Father Step – Paternal Grand-mother Previous partner Sibling Previous partner Previous partner Child N 23 | P a g e Appendix B - Scope and Full Terms of Reference 1. Introduction 1.1 Child N sustained a serious injury on 20th March 2014 which is thought to have resulted from physical abuse. She survived but it is likely that her development and physical health will be permanently impaired – though the degree of this impairment is not yet clear. 1.2 The Serious Case Review Panel made the recommendation to the Chair of the LSCB that, with reference to the requirements as set out in Chapter 4 of Working Together to Safeguard Children (2013)1, the threshold was met to commission a Serious Case Review in respect of Child N. 1.3 The decision to undertake a serious case review was taken on (insert date). 2. Purpose and principles for the Review (SCR) 2.1 The purpose of the review is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations are expected to translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children. 2.2 The following principles – as set out in Working Together 2013 - should be applied by the LSCB and its partner organisations to all reviews: There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice; The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined; Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed; Professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith; Families, including surviving children, should be invited to contribute to reviews2. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring the child is at the centre of the process23 Final reports of SCRs must be published, including the LSCB’s response to the review findings, in order to achieve transparency. The impact of SCRs and other reviews on improving services to children and families and on reducing the incidence of deaths or serious harm to children must be described in LSCB annual reports and will inform inspections; and Improvement must be sustained through regular monitoring and follow up so that the findings from these reviews make a real impact on improving outcomes for children. 1 Working Together 2013 – Dept. for Education. 2British Association for the Study and Prevention of Child Abuse and Neglect in Family involvement in case reviews, BASPCAN, further information on involving families in reviews. 24 | P a g e Final 19.12.16 2.3 SCRs and other case reviews should be conducted in a way which: Recognises the complex circumstances in which professionals work together to safeguard children; Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; Is transparent about the way data is collected and analysed; and Makes use of relevant research and case evidence to inform the findings. 3. Scope and methodology for this review 3.1 The following principles will govern the review and the role and responsibility of the Lead Reviewer: Fairness Impartiality Thoroughness Accountability Transparency Focus on the Child’s experience 3.2 The SCR will be carried out within a Root Cause Analysis Framework. The focus of this systems based approach is on what happened to Child N’s interaction with the systems around her. A key part of the approach is to understand how things were perceived and the rationale for decisions, actions or inactions at the time. It will be carried out by and experienced, independent Lead Reviewer who has a good understanding of interagency safeguarding including health and children’s social care. 3.3 The process will include: Requests to each agency for information and briefing of IMR authors SCR Panel for completion of scoping and Terms of Reference for the review Initial briefing for managers and practitioners on the case Focused interviews with staff involved by IMR authors SCR Panel to receive IMRs and discuss initial findings Feedback workshop for managers and practitioners on the findings thus far First draft of Overview report by Lead Reviewer and mapping of findings within the Learning Summary SCR Panel to receive draft SCR report and to discuss Lead Reviewer to deliver final SCR for publication – December 2014 Presentation to LSCB and discussion of action required on findings and areas for consideration, recommendations – January 2015 Follow up learning workshop for managers and practitioners 3.4 The IMR interviews with managers and practitioners will explore: critical points in the case possible reasons for actions taken at the time the significance of these insights for current practice. 25 | P a g e Final 19.12.16 3.5 The critical points in the case that will be considered are: 1 What information, prior to and following Child N’s birth, was known about the mental health of both her parents? Was this information effectively shared between agencies? 2 What early intervention services were provided to support the parents and protect the unborn child? Please give consideration to whether the Pre-Birth Assessment was timely and robust, and whether a Pre-Discharge Plan was required? Were issues of domestic violence appropriately explored during Mother’s antenatal care? 3 A Safeguarding 2 (SG2) form was completed by the Midwife, was this document shared with other agencies? Why was a CAF not considered or completed and would this have alerted agencies of the need for early intervention provision? 4 In early March 2014 Child N was brought to the Emergency Department of Hospital A and was admitted with a painful right leg. No obvious fracture was identified and she was discharged two days later. Were the X-Rays taken at that time reviewed by a Paediatric Radiologist? Was a differential diagnosis considered? Why was a referral not made to Children’s Social Care at that time? 5 Child N had six admissions to hospital over a period of 5 weeks from the time of her birth until she was admitted to hospital with life threatening injuries. Was there a delay/lack of completion of Paediatric Liaison Forms? Was the Health Visiting Service informed of Child N’s admissions and if so what actions resulted? Was a chronology made of these admissions and were health professionals alert to the safeguarding concerns presented? What was the process for paediatric review of the case and was it consultant led? 6 The possible reasons for actions taken / not taken at the time 7 What factors might have contributed to practice decisions at the time? 8 What could have been improved? 9 Was there any consideration given to differential diagnosis and the possibility that Child N may have been subject to non-accidental injury or “Fabricated or Induced Illness”? 10 It is known that in the past Father had been subject to Child Protection plans and that he had fathered a child with a mother who was 15 years old when she gave birth. What information was known to agencies about Father’s history and his parenting capabilities? 11 What level of safeguarding children training had professionals involved with Child N and her parents undertaken, and how did that training inform decisions taken at the time? 12 The significance of these insights for current practice. 13 If the same event occurred now – what factors would influence the response? 14 What is working well now and what still needs to be improved? 26 | P a g e Final 19.12.16 IMR authors should consider and research whether there has been any change initiated following the events which occurred in this case and / or whether further change or improvements are required. 3.6 Focus on the Child’s Experience All those involved in undertaking these enquiries will take full cognizance of the child’s experience: Child N’s experience as a baby living with her parents, her numerous hospital admissions and the consequences of the injuries she sustained. 4. Analysis and interpretation of the Information gathered. The methodology agreed for this review will include conducting conversations with the practitioners and clinicians involved, and holding a multi-agency briefing at the start and near the end of the process, in order to identify learning and encourage reflection on their involvement; to examine the actions and decisions taken; and to understand the context. An adapted version of the “fishbone” diagram – a tool used within root cause analysis - will provide the framework for taking a whole system approach. The aim of using this framework is to gain an understanding of how the interaction between the various factors influenced the way practitioners responded to Child N and her family. It seeks to look at cause and effect and to extract the lessons from considering why and how things occurred. The appended diagram sets out the model framework for analysis which will be applied by the lead reviewer. 5. Scope of the Review and Timescale 5.1 The period under consideration for this Review will be from May 1st 2013 to 31st May 2014. Agencies will need to consider the period from 1 May 2013, when it is believed Mother became pregnant with Child N and up to and including 31 May 2014 when Child N began to recover from her injuries. 5.2 Where there is additional historical information relevant to the review going back beyond these dates (e.g. within the parents’ own childhoods) agencies should provide a summary of their previous involvement within the Individual Management Review in the section Background. This should include a summary of early contact with the family relevant to the learning and the approach to multi-agency working. 27 | P a g e Final 19.12.16 Appendix C - Membership of the Northamptonshire LSCB Serious Case Review Panel Independent Panel Chair Independent Lead Reviewer (in attendance) East Midlands Ambulance Service, Head of Safeguarding Integrated Business Office, Safeguarding Project Officer Kettering General Hospital Trust, Director of Nursing & Quality Legal – Northamptonshire County Council, Principal Lawyer Nene & Corby Clinical Commissioning Groups, Designated Doctor for Safeguarding Nene & Corby Clinical Commissioning Groups, Head of Nursing Northamptonshire Foundation Health Trust , Patient Safety Manager Northamptonshire Police, Head of the Protecting Vulnerable Persons Department Safeguarding and Quality Assurance Service - Northamptonshire County Council, Head of Safeguarding Serious Case Review Sub Group Representative 28 | P a g e Final 19.12.16 Appendix D - List of References Brandon M, Pippa Belderson, Catherine Warren, David Howe, Ruth Gardner, Jane Dodsworth and Jane Black - Analysing Child Deaths and Serious Injury Through Abuse and Neglect: What can we Learn? A Biennial Analysis of Serious Case Reviews 2003-2005 Brandon M, Sue Bailey and Pippa Belderson - Building on the Learning from Serious Case Reviews: A Two-Year Analysis of Child Protection Database Notifications 2007-2009; DfE 2010 Brandon M, Peter Sidebotham, Sue Bailey, Pippa Belderson, Carol Hawley, Catherine Ellis & Matthew Megson - University of East Anglia & University of Warwick – July 12: New Learning from Serious Case Reviews: a Two Year Report for 2009-2011 Department for Education – Working Together to Safeguard Children: A Guide to Inter-Agency Working to Safeguard and Promote the Welfare of Children – 2013 Department for Education - Safeguarding Children in Whom Illness is Fabricated or Induced - 2008 DH 2011 Health Visitor Implementation Plan: A Call to Action DH Healthy Child Programme 2009 Protecting Children and Young People - The Responsibilities of all Doctors GMC 2013 All Babies Count – NSPCC 2011 Sentinel Injuries in Infants Evaluated for Child Physical Abuse; originally published online March 11, 2013; 131;701 Paediatrics Nugent and Pippa Simpson Lynn K. Sheets, Matthew E. Leach, Ian J. Koszewski, Ashley M. Lessmeier, Melodee |
NC50685 | Fractured skull to a 13-month-old boy in March 2017. Parents sought medical advice because of a swelling to John's head but were not able to explain how the injury had occurred; they advised the paediatrician that he was a very active child with a habit of head banging. Some weeks later, following a change of manager at Children's Social Care (CSC), a child protection conference was arranged, John was placed on a child protection plan and care proceedings commenced. In August 2016, John bruised his face whilst trying to crawl, but the GP did not refer the episode to CSC; a couple of months later mother took him to GP with a torn frenulum after which the GP did send a referral to CSC who decided no further action was required. Lessons learned: the role of the father was largely absent in practitioner records; professional curiosity is especially important for unexplained injuries; the case mapping exercise undertaken by the social worker and team manager used the Signs of Safety model but focused too much on the present and did not take into account historical concerns. Recommendations include: ensure that practitioners are reminded about the effect of their intervention on families and importance of involving them in the formulation and delivery of plans; ensure that multi-agency safeguarding hub (MASH) workers are clear about whether parental consent has been given and for what purpose; advise MASH workers that formal feedback should be given to GPs who make a referral regarding a possible non-accidental injury.
| Title: Serious case review on John: born February 2016, date of serious incident March 2017. LSCB: Bexley Safeguarding Children Board Author: Felicity Schofield Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page 1 of 22 Bexley Safeguarding Children Board Serious Case Review on John Born February 2016, date of serious incident March 2017 Independent reviewer: Felicity Schofield Date of publication – September 2018 Page 2 of 22 Contents 1. Introduction pg. 3 2. The process pg. 3 3. The involvement of the parents pg. 4 4. Background to the period covered by the Review (prior February 2016) pg. 4 5. Practice during the period covered by the Review (January 2016 to June 2017) pg. 5 6. John’s lived experience pg. 12 7. Organisational context pg. 12 8. Lessons learned/findings pg. 13 9. Action taken already pg. 16 10. Recommendations pg. 17 Appendix – Terms of Reference pg. 18 Page 3 of 22 1. Introduction 1.1 The subject of this Serious Case Review (SCR) is a young boy, John. John is a pseudonym, chosen in consultation with his family. 1.2 John suffered a fractured skull in March 2017 when he was 13 months old. His parents had sought medical advice because he had a swelling to his head but were not able to explain how the injury had occurred. John has an older half-brother, born in 2010, about whom there have been no concerns and who is not the subject of this SCR. 1.3 This SCR was commissioned because some weeks after John’s injury a new manager within Children’s Social Care Services (CSC) reviewed the way the case had been managed and expressed serious misgivings about the safeguarding actions that had taken place following John’s injury. As a result of these concerns, a child protection conference was arranged, John was placed on a child protection plan and care proceedings were commenced. 1.4 This Review covers the time period from John’s birth in February 2016 through to a child protection case conference in June 2017. Three key practice episodes within this 17 month period are described and analysed in detail. The Review has sought to understand what can be learned from the safeguarding activity that took place during this period and in particular to identify ways in which professionals might respond more effectively to unwitnessed or unexplained serious injuries in the future. 1.5 If these circumstances were repeated it is quite possible that, without change, the outcome for any child would be potentially life-threatening and a number of areas have been identified where practice could be improved. The recommendations from this Review are listed in the final section of the report. 1.6 John has subsequently made a full recovery. He has continued to live with his birth parents and the care proceedings were discontinued. Following a further period of social work support, the case was closed to CSC in January 2018. 2. The process 2.1 In July 2017, The Chair of the LSCB decided that this case met the criteria for a SCR as described in Working Together to Safeguard Children 2015. The reasons for this decision were that John had been seriously harmed and that there were concerns about how organisations had worked together to safeguard him following the serious injury and before he had been made safe. 2.2 The detailed terms of reference are attached as an Appendix. The purpose, framework, agency reports to be commissioned and the particular areas for consideration are all described there. Six agencies contributed reports to this Review. 2.3 Not all of the areas for consideration included in the Terms of Reference feature in this report because as the SCR progressed it became evident that some were not, in fact, relevant to the key practice episodes that are central to this Review. 2.4 Working Together to Safeguard Children 2015 states that SCRs should: Page 4 of 22 • understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • understand practice from the viewpoint of the individuals and organisations involved at the time, rather than using hindsight; • provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence; • be written in plain English and in a way that can be easily understood by professionals and the public alike HM Government (2015:74) 2.5 A practitioner event was held in December 2017 and was attended by practitioners from the key agencies who were working with John and his family, together with the authors of the single agency reports. 2.6 The lead reviewer, Felicity Schofield, is independent of all professional agencies in the London Borough of Bexley, has had no previous direct involvement with or knowledge of the family who were subject to the review and has had no previous involvement in a professional capacity with safeguarding practice in Bexley. She is a social worker by profession. 3. The involvement of the parents 3.1 The lead reviewer and an officer from the LSCB met with the parents in November 2017 and again in March 2018. The parents already understood the reason for the SCR and were happy to contribute. By the time of the first meeting, John was no longer the subject of either a child protection plan or care proceedings. 3.2 The parents understood that unexplained injuries, especially in very young children, are a cause for concern and that non-accidental injury would normally be considered as a possibility in such circumstances. They also knew that a torn frenulum could be regarded as an indicator of abuse but said that they had only learnt this since the care proceedings had commenced. 3.3 The parents’ views are included as relevant throughout this review. It must be acknowledged, however, that their greatest concerns arose from finding themselves the subject of care proceedings weeks after John had been discharged from hospital, when they believed that they were working well with CSC and that no new concerns had been identified, which was in fact the case. The decision to commence proceedings falls outside of the scope of this SCR and is therefore not commented on in this report. 3.4 John’s mother has some difficulties with literacy, both reading and writing, and on occasion finds it difficult to understand complex information and to express herself clearly. Both parents came from supportive families who live nearby. 4. Background to the period covered by the Review (prior February 2016) 4.1 The mother’s first child was born in 2010. Between March 2011 and April 2015 there were three anonymous referrals to CSC alleging that the mother was neglecting her son, was intoxicated and smoking cannabis and that her son was ‘always bruised’. These reports were investigated by CSC and not substantiated and, therefore, the service did not remain involved with the family. Page 5 of 22 4.2 In the period leading up to her pregnancy with John, the mother received some help from Thriving Families, which was the local early help service. She was given advice about managing her older son’s behaviour which she found helpful. This service had ended before John was born. 4.3 John’s mother was identified as vulnerable during her pregnancy with him. The mother told her midwife that she had a history of depression and that her partner had a son who suffered with an inherited syndrome which had resulted in a physical impairment. This child did not live with them but visited regularly. The mother agreed to a referral for additional support from the Best Beginning team of midwives and thereafter she met with them every two weeks. 4.4 The mother’s depression was categorised by her GP as mild in that whilst on occasion being prescribed anti-depressant medication, she was never referred to psychiatric services. The mother was able to recognise when her mental health was beginning to deteriorate and would seek help accordingly from her GP. 5. Practice during the period covered by the Review (January 2016 to June 2017) 5.1 John’s birth was straightforward and no safeguarding concerns were identified by hospital staff or by the community midwife around the time of his birth. 5.2 The mother had significant contact with both the health visitor and the GP during the first few months of John’s life first because he had vomiting and feeding difficulties and then because of an erratic sleep pattern. On two occasions his parents took him to the local Emergency Department (ED) with feeding related problems and in July 2016, John was referred to a dietician for a possible milk allergy. 5.3 Neither of these difficulties affected John’s development, which was within normal limits, with his weight gain being described as ‘steady’. He was also very active and by the age of 6 months was beginning to crawl. 5.4 In August John bruised his face when lying on the carpet trying to crawl. The mother took him to the GP who accepted the mechanism of injury. With hindsight, the GP thinks that a referral to CSC should have been considered at that time because facial bruising to babies under the age of 12 months can be an indicator of physical abuse. 5.5 Throughout this period the mother sought advice on a very regular basis from both her health visitor and her GP, neither of whom were concerned about her care of John. Key Practice Episode 1 (October 2016) 5.6 Towards the end of October 2016, the mother took John to the GP because a few days earlier he had injured his mouth whilst pushing himself up on a washing basket. In fact he had torn his frenulum, which is the fold of tissue inside the mouth that joins the upper lip to the gums. 5.7 A torn frenulum is a rare injury which can be a sign of abuse and the GP, following a discussion with the practice safeguarding lead, decided that given the nature of the Page 6 of 22 injury, together with the mother’s other vulnerabilities, she should make a referral to CSC. The GP discussed this proposal with the mother, who gave her consent. 5.8 The GP’s written referral to CSC described the mother’s anxiety and depression which had been made worse by John’s sleep problems. The GP advised CSC that the mother had sought her advice on a number of occasions. She also stated that, in her opinion, the mother’s explanation could explain the torn frenulum. The GP did not refer to the incident of facial bruising in August in her referral letter. 5.9 The family were also discussed at the practice safeguarding meeting, where it was noted that the health visitor knew them well and that she had referred them to Family Lives, a befriending service for families with preschool children. 5.10 The team manager and assessing social worker in CSC decided that no further action was required because ‘safeguarding concerns had not been identified’. This decision was reached without making any contact with the GP, the mother or the health visitor. The GP was informed of and accepted CSC’s decision. 5.11 Family Lives responded promptly to the health visitor’s referral, arranging for a volunteer to visit the mother some three weeks later. Analysis 5.12 A torn frenulum can be indicative of physical abuse because it is an unusual injury to occur accidentally. Typically it can be caused by rough feeding where a bottle is pushed too hard into a baby’s mouth. Whilst there is not enough evidence in the literature to support the view that a torn frenulum in isolation is diagnostic of child abuse, any injury of this type must be assessed in the context of the explanation given, the child’s developmental stage and a full examination (NSPCC, 2012). 5.13 In this case, it was known that John had a history of feeding problems and that the mother had a history of anxiety and depression. There had also been anonymous referrals in 2013 and 2015 of neglect and physical abuse/rough handling in respect of the older half-sibling, albeit unsubstantiated when investigated by CSC. There had been an earlier incident of facial bruising to John, although this information was not included in the referral from the GP. 5.14 It would have been helpful to consult the health visitor before deciding whether or not an assessment was needed. The reason the health visitor was not contacted by CSC was because the social worker had concerns about whether or not the mother had given her consent to contact partner agencies. There was, of course, no reason why the social worker could not have sought the mother’s agreement to contact her health visitor. 5.15 In these circumstances, an assessment, in consultation with partner agencies, would have been the most appropriate course of action to take. It would have provided CSC with a fuller picture of the family and enabled them to determine whether or not the family would benefit from some extra support. CSC could also have considered consulting a paediatrician about the injury. GPs do not undertake child protection medicals and are, necessarily therefore, less experienced in diagnosing possible non-accidental injuries. As part of this SCR CSC have concluded that their response to this referral did not give sufficient weight to the mother’s history and the previous referrals. Page 7 of 22 Key Practice Episode 2 (March 2017) 5.16 On an evening in March 2017, John’s parents took him to an Urgent Care Centre on the advice of NHS Direct because he had a lump on his head. They did not know how he had got the injury. In view of the fact that this was an unwitnessed injury, the doctor who saw John referred him to the Paediatric Emergency Department, in line with the agency’s safeguarding policy. The parents were equally keen for John to be seen by a specialist. 5.17 In the early hours of the following day, further tests showed that John had a skull fracture and he was admitted to hospital. The hospital staff were concerned because this was a serious injury for which the parents could offer no explanation despite the fact that John would have been expected to be distressed following the injury. The parents advised the paediatrician that John was very active and had a habit of head-banging. They also thought that he might have hurt himself whilst being bathed by a relative, but the relative denied this when questioned by the mother. A full skeletal survey was arranged and a body map was completed. There were no other external signs of injury. 5.18 The paediatrician, a registrar in the ED, contacted the CSC out-of-hours team and faxed them an inter-agency referral form, with the parents’ consent. He recorded that CSC had implied that there was other information about this family but did not share it with him. On interview the paediatrician stated that he questioned the social worker’s refusal to provide background information but again, the social worker refused to do so. 5.19 It was hospital policy to check that the referral had been received by CSC but this was not done on this occasion, possibly because the ED was very busy that night. 5.20 There is no record within CSC of either the telephone conversation to the Out-of-hours team or that the faxed referral was received. Consequently it has not been possible to establish why the social worker did not share any background information about the family. 5.21 The hospital safeguarding adviser was notified of John’s admission later the same day. He contacted John’s health visitor and CSC who provided him with relevant background information. He also updated the inter-agency referral form to include details of the other children in the home and faxed it to the multi-agency safeguarding hub (MASH). 5.22 On the same day, in response to the referral, a MASH worker contacted the ward for further information but none was available at that time. Later that day the outcome of the full skeletal survey was that not only were there no other injuries but there was also no evidence of the skull fracture which had been found by the earlier CT scan. All the test results were sent to Birmingham Children’s Hospital for expert opinion from a paediatric radiologist. It was not unusual for there to be a discrepancy between test results which is why it was standard practice to seek the expert opinion of a paediatric radiologist (there was no such an expert in the local hospital). 5.23 The hospital safeguarding adviser advised the Consultant and recorded on the electronic case file that John should remain on the ward until the results of the skeletal Page 8 of 22 survey had come back from Birmingham and then that CSC should be contacted to discuss a plan of care. However, the ward staff did not read the electronic case file where the safeguarding adviser had recorded the background information and his advice about not letting John go home, reading only the paper records which were in operation alongside the electronic records. 5.24 Neither the MASH health professional nor the health visitor advised either their line manager or the provider trust safeguarding team when John was admitted to hospital, which would have been expected practice. Therefore, there was a missed opportunity for the safeguarding team to have oversight of and challenge decisions made in respect of the risk analysis and management plan put in place prior to John’s discharge from hospital. 5.25 Despite the fact that non-accidental injury was being seriously considered at this time, CSC made no enquiries about John’s sibling’s welfare and no plan was discussed with the hospital staff regarding the parents’ contact with and care of John in hospital pending the outcome of the opinion from the paediatric radiologist. A strategy meeting at this point does not appear to have been considered by any agency. 5.26 Over the weekend the parents received ‘mixed messages’ from hospital staff regarding their care of John. On the one hand they were required to keep the door open of the room where John was being cared for in hospital, yet they were allowed to take John home and bring him back to the hospital on two consecutive days over the weekend. They were then not allowed to take him home on a third occasion. 5.27 The decision to allow John to go home over the weekend was made by the consultant in discussion with the nurse in charge of the ward. They noted that the parents’ care of John on the ward was appropriate and decided that the injury was accidental and that there were no safeguarding concerns. This decision was taken against the advice of the hospital safeguarding adviser and without consulting CSC, the GP or the health visitor, which was contrary to the hospital’s safeguarding guidelines. 5.28 After the weekend, John’s care transferred to a second consultant whose approach was more cautious. In his opinion John should not be allowed to return home again until more information was available. CSC advised the ward that they had taken no further action since the original referral but the case had been allocated for an assessment that day. It was agreed that John should remain in hospital until the expert opinion from Birmingham had been received. The parents struggled to settle John and wanted to take him home as they had over the weekend but this time their request was refused. 5.29 The following day, the hospital confirmed that John had a skull fracture which remained unexplained but no other injuries had been identified. The paediatrician confirmed that in the absence of an explanation, it was not possible to know whether or not the injury was accidental. CSC made a referral to the police. 5.30 A number of meetings took place on March 22. First a professionals meeting, also referred to as a discharge planning meeting, took place at the hospital. The police were not invited. The consultant was not able to attend. A junior doctor advised attendees that John’s head banging was unlikely to be the cause of the injury which was more likely to have been caused by a fall. The social worker is recorded as saying that this Page 9 of 22 information made her ‘more worried’. Ward staff noted that John was very active. It was agreed that: • John would remain in hospital until CSC had completed their assessment • The social worker would assess the safety of the sibling • The health visitor would visit every 2 weeks • The volunteer from Family Lives would visit weekly Whilst the meeting was formally minuted, the minutes were not circulated to the attendees. 5.31 Later that same day the Police and CSC held a telephone strategy discussion where it was agreed that there should be a joint child protection investigation. The police promptly began their enquiries. They consulted a junior doctor who provided them with an update and interviewed both the parents and John’s older brother. None could offer any explanation for John’s injury. However, John was reported to be very active and particularly to like climbing. The parents also advised the police about John’s head banging. 5.32 There was also a case mapping meeting that day involving the CSC team manager and the allocated social worker, where a safety plan was developed to enable John to return home. An initial child protection case conference and a legal planning meeting were highlighted as needing consideration. 5.33 On 23 March in the absence of any medical evidence suggesting non-accidental injury, the police closed their criminal investigation. The police informed CSC of their decision, suggesting that the injury was likely to have been an accident, possibly as a result of lack of supervision. 5.34 The social worker discussed the case with her team manager and the decision was made that John should return home with a safety plan (a safety plan is an interim plan pending a longer term child-in-need or child protection plan). The plan included the grandmother staying with the family for a period of two weeks to provide additional support, although the specifics of the grandmother’s supervisory role were not detailed. 5.35 On 24 March, John was discharged from hospital following a meeting with a number of members of his extended family who together drew up a support plan which a relative sent to the social worker. The support plan included details of children’s centre activities and was subsequently updated by the relative over the course of the next few weeks. Whilst this meeting was minuted, the minutes were not distributed to the attendees. The social worker rang the health visitor to inform her of John’s discharge. 5.36 The CSC team manager left the department on 24 March, with the Assistant Team Manager being given responsibility for overseeing her work pending the arrival of a new Team Manager. On interview the Team Manager said that she was expecting there to be an initial child protection conference (ICPC). However, that was not the social worker’s understanding and she recorded that ‘the case will not be progressing to ICPC as the police have not been able to substantiate that the injury to John was non-accidental it is their view that the injury was caused due to neglectful parenting and they will be taking no further action.’ This course of action was signed off by the Assistant Team Manager who accepted the social worker’s analysis, based she believed on an earlier discussion with the team manager. Page 10 of 22 Analysis 5.37 The use of faxes within the hospital has ceased since this SCR was commenced and has been replaced by secure email. It is of concern that there is no record of either the phone call made by the ED registrar or of the first faxed referral, which appears not to have been received. 5.38 There is no reason why a social worker should not have shared relevant information with the hospital registrar given the circumstances of the referral which were clearly related to a child protection matter. It is fortunate that the safeguarding adviser sent an updated version of the referral the following day. 5.39 On receipt of the referral, CSC took no further action waiting instead for updated information from health colleagues. No interim safeguarding action was identified as being necessary and as a result, for a period of five days, no agreements were reached about the parents’ continued care of John whilst in hospital and no enquiries were made about his sibling’s safety. 5.40 John’s unexplained head injury was identified as potentially non-accidental on a Thursday evening and yet a strategy discussion between police and CSC did not take place until the following Wednesday. Despite the fact that John was in hospital, that discussion did not include a health professional. In the intervening period, whilst CSC regarded John as being safe in hospital, he had in fact been allowed to return home on two separate occasions for lengthy periods of time. 5.41 Working Together 2015 states that ‘Whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm there should be a strategy discussion involving children’s social care, the police, health and other bodies such as the referring agency. This might take the form of a multi-agency meeting or phone calls and more than one discussion may be necessary.’ (p.36) 5.42 If a strategy discussion had taken place before the weekend, an interim plan could have been agreed between the relevant agencies which could have been explained to both hospital staff and the parents. Instead individual professionals drew their own conclusions which differed over time despite the available evidence having remained unchanged. 5.43 When the strategy discussion did take place, it should have included the hospital consultant, not only because it was the hospital who had referred John in the first place but also because the degree of potential risk was particularly difficult to assess and therefore a medical opinion was especially important. 5.44 The social worker did not visit John, the family home or interview the parents before deciding, with her team manager, that it was safe to discharge him, relying instead on her police colleagues’ assessment. Whilst the decision to discharge John was taken by the social worker and team manager together, given the degree of uncertainty, a multi-agency forum would have been more appropriate. 5.45 Whilst the decision to discharge John may well have been the right one to take given the information available at the time, it was vital that the hypothesis (that the injury was accidental) was tested out through the ongoing social work assessment and review of Page 11 of 22 the safety plan. For this reason, the discharge planning meeting should have agreed a review date and all the relevant parties should have been provided with copies of the safety plan. Key Practice Episode 3 (After John’s discharge from Hospital, March to June 2017) 5.46 At the beginning of May, a new team manager discussed John in supervision with the social worker for the first time and was concerned about the safeguarding action that had taken place following his head injury in March. The social worker had still to complete her assessment. As a result of the team manager’s concerns, a more senior manager was consulted and she stated that there needed to be an Initial Child Protection Conference (ICPC), which took place at the beginning of June. There was also a legal planning meeting in May. 5.47 In the 6 weeks since he had been discharged from hospital there had been no multi-agency review of the safety plan, although both the social worker and the health visitor had visited the family home and had not identified any significant concerns. The social worker does not appear to have discussed either with her manager or with the health visitor whether or not it was appropriate for the grandmother to leave the family home following her 2 week stay or to have recorded whether in fact the grandmother did stay for the full 2 weeks. There was no liaison between the social worker and the health visitor, the GP or the Family Lives volunteer, who had been identified in the safety plan as being required to visit weekly. 5.48 In April the health visitor recorded a bruise to John’s cheek and a graze on his forehead. The mother explained that the graze had occurred whilst John had been at a children’s centre and an accident report had been completed and sent to the social worker. She could not explain the bruise. The health visitor did not share this information with the social worker. 5.49 In May the mother showed the health visitor a bruise to John’s forehead which she said he had sustained falling against the settee. The health visitor did not share this information with the social worker or refer to it in her report to the ICPC, held at the beginning of June. 5.50 Overall, despite the fact that the cause of John’s head injury remained unknown, once he had returned home there seemed to be an acceptance that it had been accidental and the general level of concern decreased. There was a lack of professional curiosity from the health visitor regarding other facial bruises which was concerning in the context of the unexplained head injury. There is no reference in the CSC records to the safety plan or to the actions that had been identified in it, for example, assessing the sibling’s safety. There had been no review of the safety plan in the weeks since John had been discharged from hospital. Analysis 5.51 The first few weeks after John’s discharge from hospital were an opportunity to assess the family situation and to test out the hypothesis that his serious head injury had been accidental. Page 12 of 22 5.52 The Government guidance on timescales for assessments is that they should take no longer than 45 working days from the point of referral, but in this case there was a strong argument for the assessment to be completed more quickly. Similarly, the pan-London Child-in-Need procedures, which Bexley follows, state that Child-in-Need cases should be reviewed every 3 months as a minimum. Again, an earlier review was called for in this case given the level of concern following John’s head injury. 5.53 Immediately prior to John’s discharge from hospital a number of additional measures of support had been identified and put into place. These measures needed to be monitored and reviewed, but such actions were not evident in the weeks between his discharge and a reconvened strategy meeting which took place on 4 June. 5.54 Relevant practitioners, together with the parents, should have been provided with copies of the meeting minutes and of the safety plan. Additional efforts should have been made to ensure that the mother, given her literacy and comprehension difficulties, understood what had been agreed and what was expected of her. 5.55 Given the length of time that had passed since John’s discharge from hospital, a robust assessment and review of the family situation could have informed the strategy meeting in June and potentially avoided the need for either a case conference or care proceedings. 5.56 Whilst the initial response to John’s injury may have been flawed, he had been at home for a further 11 weeks, the parents had met the requirements of both the safety plan and the support plan, and the social worker had been undertaking an assessment. There had been no further injuries or new concerns identified. 6. John’s lived experience 6.1 John was 13 months old when he suffered a fractured skull. He is a white child, with normal levels of development, born in the Borough with a large extended family, many of whom live nearby. 6.2 The most commonly mentioned feature of John is his level of activity. He learnt to crawl and walk at an early age and was seen to be ‘into everything’ whilst staying in hospital. In fact he was so determined to try and climb everything within his sight that his father had to dismantle the bunk beds in the family flat to prevent him from climbing on them. 6.3 John’s parents reported that he had a high pain threshold, rarely crying out when he fell over or hurt himself. 7. Organisational context 7.1 In September 2016, the Paediatric Liaison service in the hospital ceased and was subsequently incorporated into the Lewisham and Greenwich Trust (LGT) safeguarding children team, with the loss of two dedicated posts. From that date health visitors were only notified of ED attendances which were RAG rated Red and Amber and not those which were rag rated Green. John was brought to the ED on six separate occasions with minor ailments prior to the serious incident in March 2017. As a result of this change in policy, John’s Health Visitor did not receive notification of his last three ED attendances, Page 13 of 22 although the mother advised her after each visit and the GP would still have been notified. 7.2 Between January and June 2017 the health visiting service had to hold all vacancies and could neither recruit nor remodel the service while in a period of transfer to a new provider. 7.3 At the time John’s case was allocated to the CSC referral and assessment service, the receiving team was holding two social work vacancies and the manager and assistant team manager were concerned about the impact on caseloads of the remaining team members. 8. Lessons learned/findings Referrals and Parental Consent 8.1 When the GP referred John to CSC in October 2016, she did so with the mother’s consent. However, enquiries were not made of other agencies following that referral, for example the health visitor, before making a decision to take no further action. One of the reasons for this decision was because the social worker did not think they had the mother’s consent to approach other agencies. 8.2 It is vital that workers within the MASH are clear about consent, whether it has been given and for what purpose. The social worker could have asked the parents for their consent to approach other agencies. 8.3 The role of the father was largely absent in practitioner records despite the fact that he attended and stayed in the hospital with the mother and was present at all subsequent meetings. 8.4 The MASH worker left a message for the GP regarding her referral. A conversation might have helped both parties gain a clearer picture of the situation. Recommendations: MASH workers should be advised to give formal feedback to GPs who make a referral regarding a possible non-accidental injury. The Safeguarding Partnership ensures that MASH workers are clear about whether or not parental consent has been given and for what purpose. The Safeguarding Partnership should seek assurance that practitioners are routinely considering the role of and including fathers in their work with families Unexplained/Unwitnessed Injuries 8.5 Unexplained injuries are the most difficult for practitioners to investigate and respond to appropriately. Contributions from all the key agencies are necessary in order to agree a way forward. For these reasons, it is vital that health, police and social work perspectives are taken into account. In the absence of a crime and with an injury that may or may not have been accidental, the social work perspective can be the deciding factor in those early decisions. In this case CSC were guided by their colleagues from Page 14 of 22 health and the police without contributing their own early social work assessment of the family situation. 8.6 Professional curiosity is especially important for unexplained injuries and must be maintained not just at the beginning of an investigation but throughout any subsequent monitoring period. 8.7 In the absence of an explanation any initial conclusion regarding an injury can only be made ‘on balance’ and in the weeks that follow practitioners must continue to be alert to the possibility that their initial conclusion was incorrect. Recommendation: The Safeguarding Partnership should consider whether practice guidance is required in relation to unwitnessed/unexplained injuries, including the importance of practitioners maintaining a professional curiosity throughout the duration of their involvement with a family. Involving parents & sharing plans 8.8 John’s parents had a history of seeking advice appropriately when they were anxious or concerned about their children’s health. However, the unclear and inconsistent messages they were given following John’s head injury potentially jeopardised their relationship with practitioners. 8.9 An unexplained injury is a difficult scenario for practitioners to deal with, having to balance the possibility that the parents may be being entirely truthful with the possibility that they may be deliberately misleading professionals. In such situations it is essential that plans and decisions are shared with relevant parties, not just verbally but in writing. 8.10 The failure to agree a plan across agencies whilst John was in hospital potentially put both John and his sibling at further risk and resulted in the parents questioning the hospital’s refusal to take him home when it had been agreed on the previous two days. Later on, the failure to share the safety plan with either family members or other relevant professionals potentially compromised practitioners’ abilities to monitor the plan and also led to the family not being clear about the parameters of the grandmother’s supervisory role. 8.11 The minutes of meetings and any plans which stem from them must be shared with those who have an ongoing role to implement and monitor those plans. Recommendations: The Safeguarding Partnership should seek assurance that the minutes of meetings and plans are routinely shared with families and practitioners. The Safeguarding Partnership should ensure that practitioners are reminded about the effect of their intervention on families and of the importance of involving families, as appropriate, in the formulation and delivery of plans. Strategy meetings Page 15 of 22 8.12 Working Together 2015 is clear that health colleagues should participate in strategy discussions and meetings. An audit by CSC of 30 cases held within the Referral & Assessment Team between the period 17/3/17 to 25/4/17 found that 86% of the strategy discussions had no health representative present. This practice must change. 8.13 In this case an early strategy meeting was needed to ensure the child’s safety whilst further enquiries were made. Simply being admitted to hospital is not a sufficiently robust plan for a child who may have suffered a serious non-accidental injury. Action needed to be agreed with regard to the parents’ contact with him whilst in hospital and with regard to his siblings. Without such guidance, hospital staff were left in a very difficult position and neither child was adequately safeguarded. 8.14 On 22 March there were three separate meetings about John. A single strategy meeting including both the police and the hospital consultant would have been a more appropriate way forward. Recommendation: The Safeguarding Partnership is assured that the ‘Multi Agency Strategy Meetings Joint Health, Police and Children’s Social Care Practice Guidance’ has changed practice and that health colleagues are now routinely included in strategy meetings and discussions. Use of the Signs of Safety (SOS) Model 8.15 Bexley uses the SOS framework as a practice model across agencies as a means of helping practitioners to develop a common language to assess risk of harm in families. Signs of Safety has become one of the most widely adopted research-based programmes in child protection services in England, having been developed in Western Australia in the 1990s. It is a strengths-based approach which stresses the importance of working alongside families. It is, however, just a model and it cannot be assumed that its introduction will necessarily improve the quality of decision-making. 8.16 The authors of a comprehensive evaluation of SOS, published in July 2017, concluded that ‘while Signs of Safety is not a ‘magic bullet’ for the challenges that face CSC, it has the potential to help improve services for children and young people’, and that ‘the Signs of Safety framework was workable where authorities made the necessary commitment of trust in their staff at all levels, backed up by resources and time.’ 8.17 In John’s case, the case mapping exercise undertaken by the social worker and team manager using the model focused too much on the ‘here and now’ and did not take into account historical concerns. The case mapping was also not informed by any social work assessment. Initial danger statements and safety goals were not created in line with expected practice standards. The safety plan was essentially a timetable of activities that mother was expected to participate and engage in. Recommendation: The Safeguarding Partnership should ensure that the Signs of Safety approach is consistent with the requirements of Working Together and the Child Protection Procedures and complements the Statutory Guidance. Discharge planning & continued monitoring Page 16 of 22 8.18 The practitioners involved in the child protection investigation decided that ‘on balance’ John’s injury was accidental. Given the uncertainty regarding this conclusion, the early weeks following John’s discharge required a robust multi-agency plan which could test out this hypothesis and contribute to a fuller assessment of the family. The parents, the members of the wider family who had been asked to support them and practitioners needed to understand their respective roles, why there was an ongoing concern and what needed to happen in order to offer assurance (or otherwise) that John and his sibling were safe. These processes were insufficiently robust. At the very least there should have been a review of the safety plan at the point that the grandmother was no longer staying with the family. The use of the Child Protection procedures & Case Conferences 8.19 There is no doubt that a fracture in a young baby is a potentially serious incident. The forum for sharing information to determine what risks are posed to children is well set out in Working Together 2015 as a child protection conference. If John had been discharged pending a child protection conference it is likely that the assessment of risk would have been more robust. 8.20 A child-in-need plan could have served the same function but only if it was given a similar priority to a ‘child protection case’ which did not happen with John. 9. Action taken already Partners have reported that the following action has been taken: 9.1 Regarding the faxed referral since this SCR an email address has been supplied to the hospital to use and in addition the hospital safeguarding team have requested that no referrals are to be faxed. 9.2 With regard to the failure of hospital staff to read the electronic case records, a stamp has been obtained so that the safeguarding team can put an alert into the hospital notes indicating that there is information in the electronic records of relevance. 9.3 To improve and promote collaborative working relationships between agencies Children’s Social Care, Health and Police have created a ‘Multi Agency Strategy Meetings Joint Health, Police and Children’s Social Care Practice Guidance’ which details expectations of all agencies in relation to Strategy Discussions. 9.4 Since June 2017 all contacts within CSC that relate to an injured child under the age of five years are shared with the service manager and head of service. 9.5 The Multi Agency Safeguarding Hub has been re-designed to increase management oversight and capacity. 9.6 A review of caseloads within CSC was commenced in August 2017. Caseloads have now significantly reduced and are for the most part at expected caseload standards for frontline social workers. The issues attributed to not closing work down are being closely monitored by service managers and heads of service. Page 17 of 22 9.7 The team for referral and assessment now has a permanently appointed team manager who can offer stability and continuity to the team. 10. Recommendations The Safeguarding Partnership should: (1) Ensure that the recommendations identified to improve practice within the single agencies’ reports are implemented (2) Share the findings from this SCR with practitioners across the partnership, ensuring that the findings regarding the following areas are highlighted; • The timeliness of strategy discussions and meetings, assessments and the review of child-in-need plans • The importance of sharing plans and minutes of meetings with families and practitioners • The importance of ensuring that parents are given clear, consistent and timely messages regarding safeguarding concerns (3) Seek assurance that practitioners are routinely considering the role of and including fathers in their work with families (4) Ensure that practitioners are reminded about the effect of their intervention on families and of the importance of involving families, as appropriate, in the formulation and delivery of plans. (5) Ensure that MASH workers are clear about whether or not parental consent has been given and for what purpose. (6) Advise MASH workers that formal feedback should be given to GPs who make a referral regarding a possible non-accidental injury (7) Consider whether practice guidance is required in relation to unwitnessed/unexplained injuries, including the importance of practitioners maintaining a professional curiosity throughout the duration of their involvement with a family. (8) Seek assurance that the ‘Multi Agency Strategy Meetings Joint Health, Police and Children’s Social Care Practice Guidance’ has changed practice and that health colleagues are now routinely included in strategy meetings and discussions. (9) Ensure that the Signs of Safety approach is consistent with the requirements of Working Together and the Child Protection Procedures and complements the Statutory Guidance. Page 18 of 22 Terms of Reference November 2017 a. Purpose of the review The Serious Case Review of John is seeking to learn more about the following: • Use of family history and sharing information between agencies • Early intervention • Ensuring compliance with child protection procedures • Use of the Signs of Safety approach • Management oversight, decision making and escalation • The culture within and between agencies b. Time period being considered John’s date of birth to date Interim Supervision Order obtained. NB: Any relevant information from outside this time period to be included in ‘2. Context’ section of single agency reports. c. Key questions The Serious Case Review will focus on the following key questions which will be considered in single agency reports. Use of family history and sharing information between agencies • What did each agency know about John’s previous injuries? • Was information shared between agencies? Early intervention • What involvement did agencies have with the family prior to the significant event? • Were there any opportunities for early intervention and support? Ensuring compliance with child protection procedure • Was Working Together guidance followed in this case and if not what were the barriers? • Are the London Child Protection Procedures understood and do these inform multi-agency working? • How are child protection procedures used and referred to in day to day practice? • Do staff know where to go to get professional support including how to access good practice guidance and research? • Are there any specific procedures on working with young babies who are non-verbal and non- mobile and/or identifying abuse in babies and young children? • What training had staff involved with John had on basic child protection procedures, on child development and on signs and symptoms of abuse in Page 19 of 22 babies and young children? Did the training give them the skills and confidence to put their learning into practice? Use of the Signs of Safety approach • Is the Bexley practice model – Signs of Safety - well understood and applied in cases of non - accidental injury? • How does the Bexley practice model - Signs of Safety - impact on practitioner’s understanding of and management of risk? Management oversight, decision making and escalation • Who was responsible for decision making on this case and how were decisions made? • What do policies and procedures say about management oversight and decisions. Were these followed in this case? • How does the Bexley practice model - Signs of Safety- impact on decision making? • What is the policy for escalation within agencies? Were staff and managers aware of their agency’s escalation policy and the BSCB escalation policy? and does training cover what to do if there are disagreements within and between agencies and how to escalate concerns? • Is there specific training for managers/supervisors in overseeing cases of non-accidental or unexplained injuries in babies and young children? • Was legal advice sought at the time of the referral? The culture within and between agencies • Does the culture within and between agencies promote collaborative working and encourage debate, challenge and professional curiosity? • What is the professional culture around unexplained injuries? d. Principles underpinning the Serious Case Review • To always remember that the main purpose for undertaking a Serious Case Review is to learn and improve. • A recognition that safeguarding children is complex. • It is important to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did. • The review will seek to understand practice from the viewpoint of the individuals and organisation involved at the time rather than using hindsight. • Relevant research and case evidence will inform findings and recommendations. e. Timescale and key milestones for the SCR Date Milestone 15.09.17 Single-agency report template, chronolator template and meeting note to be sent to members. Letter notifying of review to be sent to the Chief Executive of each agency. To be confirmed BSCB Chair and allocated social worker to meet with the family to discuss the SCR process. Page 20 of 22 27.10.17 Members to return completed single-agency reports and chronologies. All reports and chronologies to then be circulated to members to review. 07.11.17 SCR Team Meeting, 11.30am-1.30pm, G21, Civic Offices. REVISED SCHEDULE 17.11.17 SCR Team Members to share their own agency’s report with the practitioners and line managers involved in the case. SCR Team Members to also share the Practitioner’s Event invitation. SCR Team Members to email [email protected] the name, role and email address of the practitioners and line managers to be invited to the Practitioner’s event. 24.11.17 Factual corrections in single-agency reports to be highlighted and file saved as ‘…v2’. Addendum reports to be sent to [email protected] 04.12.17 Practitioner’s Event – led by Independent Reviewer. *multi-agency chronology to be available on the day. Independent Reviewer to meet with family after Practitioner’s Event. 22.12.17 First draft SCR overview report circulated to members. 08.01.18 SCR Team Meeting, 1-4pm, G05, Civic Offices. Review report | Feedback on Practitioner’s Event | Feedback on meeting with family 22.01.18? Final draft report circulated to members. ? SCR Team Meeting (if required) 12.03.18 SCR Report to Quality and Effectiveness Board. To be confirmed Feedback to family. To be confirmed Feedback to staff. To be confirmed Copy of SCR overview report to be sent to Ofsted, DfE and the National Panel. To be confirmed SCR overview report published. To be confirmed Learning event. f. Involvement of family • BSCB Chair will meet with the family. • A meeting with the reviewer will be offered. • A meeting with the family once the review is completed and before publication. g. Roles and responsibilities A single agency report template and a chronology template have been sent to the SCR Team Members. SCR Team Members to identify a report writer within their agency. A letter to the agency Chief Officer has been sent notifying of the review (cc SCR Team Members). Agency SCR Team Member Report Author Chief Officer Bromley Healthcare Lorraine Thomas, Named Nurse Safeguarding Children Lorraine Thomas, Named Nurse Safeguarding Children Jacqueline Scott Page 21 of 22 Lakeside Medical Centre Karen Upton, Named GP for Safeguarding Children Dr Laura Hindley Dr Prem Anand London Borough of Bexley Allison Parkinson, Head of Service, Family Support & Child Protection Nicki Shaw, Head of Professional Standards & Quality Assurance Gill Steward Metropolitan Police Service Caroline Jackson, Detective Inspector Russell Pearson , Specialist Crime Review Group Stuart Bell & Fiona Martin NHS Bexley CCG Jill May, Designated Nurse Safeguarding Children Sarah Ismail, Lead Consultant Community Paediatrician and Designated Doctor for Safeguarding Bexley N/A Dr Nikita Kanani Oxleas NHS Foundation Trust Jane Downing, Head of Safeguarding Children, Lead Named Nurse Rachel Lanlokun, Named Nurse Safeguarding Children Bexley Ben Travis Queen Elizabeth Hospital, Lewisham & Greenwich NHS Trust Clare Hunter, Named Nurse Safeguarding Children Dr Ildiko Schuller Tim Higginson h. Publishing the report The final report will be published on the BSCBs website for a minimum of 12 months and will include information on actions which have already been taken in response to the review findings, the impact these actions have had on improving services, and what more will be done. i. Governance arrangements for the review • There is an SCR Team (see 7. above) chaired by the BSCB Independent Chair. • The team will oversee and contribute to the review by adding their professional and local knowledge and support the reviewer through debate and discussion. • The team is responsible for quality assuring the review and ensuring that lessons are learned. • The team will meet periodically throughout the review process (see 5. above). • The BSCB Quality & Effectiveness Board will sign off the SCR report. j. Communication plan • As areas of learning are identified throughout the review process, anonymised information will be shared. • One of the key themes already identified by the SCR Team was professional’s understanding of, and safeguarding response to physical injuries in pre-mobile babies. A Learning Hub event is being organised to review single-agency and multi-agency policies and procedures used in Bexley around physical injuries in pre-mobile babies, consider relevant research, and identify best practice. Plans Page 22 of 22 will then be made for sharing learning and improvement actions will be recommended to the Q&E Board in January 2018. • In addition to learning being shared and action being taken through the review process, the BSCB will also host a Learning Event upon completion of the review to share all the findings, recommendations and wider programme of action. k. Media plan Lead responsibility for external communications rests with the BSCB Independent Chair in consultation with relevant service providers. Publication of any external messages will be facilitated by the London Borough of Bexley’s Head of Communications and its communications team supported by the BSCB Business Team. |
NC52480 | Death of 4-month-old boy in July 2018 from injuries attributed to non-accidental shaking. Baby X was taken to hospital acutely unwell after having been in the care of a family relative. Findings include: professionals should communicate with parents about the impact of caring for children with complex health needs on their health and mental wellbeing; there should be opportunities for discussions between services about the meaning behind families not attending health appointments, and the impact on children of frequent non-attendance; agencies should consider how best to coordinate support in the form of an early help or a common assessment framework (CAF) plan; issues with children's emergency department attendances being seen in isolation rather than in the wider family context; recognition that a CAF plan can allow different agencies to consider the risks and vulnerabilities for a family and identify their support needs; and that professionals need to consider children's lived experience, considering how parental issues impact on children as well as children's home conditions.
| Title: Serious case review Baby X. LSCB: Coventry Safeguarding Children Partnership Author: Daryl Agnew Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. SCR Report: Child X Final November 2020 Page 1 Coventry Safeguarding Children Partnership Serious Case Review Baby X Date of serious incident: 29 June 2018 Date of report: October 2020 Agreed by Coventry Safeguarding Children Partnership: 4.11.20 Independent author: Daryl Agnew Chair of Coventry Safeguarding Children Partnership: Derek Benson SCR Report: Child X Final November 2020 Page 2 Contents Page no. 1. Summary of the case 3 2. Terms of Reference 3 3. The process 4 4. Involvement with other agencies 4 5. Analysis of professional involvement with the family 10 6. Findings and recommendations 11 SCR Report: Child X Final November 2020 Page 3 1. Summary of the case 1.1 The subject of this serious case review (SCR) is Baby X. The baby was born at 33 weeks gestation. He was intubated and ventilated shortly after birth and was initially very unstable. He was treated for suspected sepsis. A cranial ultrasound scan prior to discharge revealed in retrospect a stroke. However, subsequent health checks at 11 weeks old indicated he was well, gaining weight and meeting his development milestones. The health visitor and GP had no concerns about him or his care. 1.2 Baby X was 4 months old when in late June 2018 he was left at home in the care of a family relative while his mother took his siblings to school. He was reported to be well when his mother left him. On her return he was acutely unwell, and an ambulance was called. 1.3 The ambulance crew found him in cardiac arrest and resuscitation attempts were prolonged. He was admitted as an emergency to University Hospitals Coventry & Warwickshire (UHCW) NHS Trust and later transferred to the paediatric intensive care unit at Birmingham Children’s Hospital. His CT scan showed significant brain damage and chronic subdural haemorrhage. He remained unstable and further tests revealed brain stem death and bilateral retinal haemorrhages. After discussions with his parents, his care was withdrawn, and he died in early July 2018. 1.4 A forensic post-mortem attributed the injuries to non-accidental shaking as the primary cause of death. A criminal investigation was conducted and the sole member of the family present at the time was charged with the murder of Baby X. Subsequent criminal proceedings were concluded at Warwick Crown Court in December 2021 whereby the family member was found guilty of man slaughter and sentenced to 9 years 2. Terms of Reference 2.1 The following detailed terms of reference for the serious case review were agreed by the SCR Panel Meeting on 30 April 2019. 2.2 For individual agencies to review any statutory assessment carried out by their agencies, attendances at A&E and medical contacts specifically to consider:- • the quality and appropriateness of any assessments undertaken, whether there were any indicators of neglect, significant harm, or other concerns that should have been actioned; • whether there were any missed opportunities to intervene in the family, either with a view to providing support to the parents and / or children, or due to a need to escalate any concerns held about the family; and SCR Report: Child X Final November 2020 Page 4 • the extent to which professionals challenged or simply accepted the medical diagnoses reported by the parents in respect of the children. 2.3 The original focus of this review is Baby X and the non-accidental injuries sustained by him. However, it was agreed that the scope of the review would be a period of nine years beginning with the birth of Baby X’s older siblings and the family’s involvement with a range of agencies during that time, in particular health. 3. The Process 3.1 The Coventry Safeguarding Children Board (CSCB) Serious Case Review sub group undertook a rapid case review in August 2018 and a decision was made in September 2018 to undertake a serious case review as outlined in Chapter 4 of Working Together to Safeguard Children (2015). 3.2 Individual agency reports (IARs) and chronologies were sought from the agencies for this case. 3.3 This overview report is a brief summary and analysis of the evidence considered by the review panel. 4. Involvement with other agencies Genogram Broth Uncle Aunt Grandmother (Maternal) Grandmother (Paternal Step Grandfather Mother Family friend Uncle Father Brother Brother Sister Baby X SCR Report: Child X Final November 2020 Page 5 Health agencies 4.1 From the time of the birth of Baby X’s siblings who were twins born in 2009, the family had considerable involvement with various health agencies. During 2009 and 2010 there were numerous attendances at A&E and at the Children’s Emergency Department (CED). During this period the family were accessing health services via emergency care rather than through the more appropriate route of a family GP. 4.2 The reasons for these hospital visits were various ranging from gastro-enteritis, respiratory infections, attendances for ‘funny turns’, a possible epileptic seizure, an accidental injury sustained when one of the twins fell from a sofa on to a carpeted floor and a reported concern that one of the twins had spina bifida. A picture emerges of anxious parents who were struggling to cope and did not know how to access the most appropriate health services. 4.3 Throughout 2010, the children were brought to hospital increasingly by the parents with reported illnesses and problems, few of which were directly observed by health professionals. There is some evidence of the parents being signposted to other agencies and of information regarding the family being shared across the different health agencies. 4.4 However, a referral in 2010 to attend Consultant Paediatric sessions following the earlier hospital admission of one twin for a possible epileptic seizure indicated that the child was not brought to the appointment. Results of brain wave tests showing no abnormality had been sent to the parents and GP beforehand, so this may have been the reason for their failure to attend. Two days later, the twin was again presented at the Children’s Emergency Department as mother reported the child to be lethargic. However, following further examination and parental reassurance, the child was discharged home. 4.5 During 2011, there were numerous hospital attendances and involvement with health visiting services. Both twins were seen by the speech and language therapy service (SALT). Mother reported sleep and behaviour management difficulties for the twins and requested support which was provided. 4.6 A third sibling was born in the summer of that year and in the autumn, following a bump to the head, was brought promptly by his parents to the CED. It was reported that the baby had been sleeping on the sofa when an older sibling picked him up and dropped him onto a wooden floor. A head scan revealed a hairline fracture of the skull. Following overnight observation, the baby was discharged home the next day. 4.7 In summer 2013, the second twin was brought to CED after a reported fall the previous day from a chair on to wooden decking in the garden. At the time, the child continued playing so medical advice was not sought. The next day the child woke with a headache and was brought to CED. On examination the child was SCR Report: Child X Final November 2020 Page 6 documented as being alert and routine observations were normal. The child was discharged with head injury advice. 4.8 A diagnosis of Autistic Spectrum Disorder (ASD) was confirmed for one of the twins in November 2011. Health records at that time indicate that the parents were expressing their ‘lived experience’ to practitioners. It was recognised that the family needed support as they found the behaviour of their twin children increasingly challenging. In 2013, their third child was referred to the Community Paediatric team by his GP for a possible diagnosis of ASD and subsequently the diagnosis was confirmed in late 2015. In 2014, a Consultant Neuro-disability Paediatrician confirmed a diagnosis of ASD for the second twin. 4.9 During the course of the next three years or so, all three siblings were supported with developmental, behavioural and sensory issues relating to their ASD diagnoses such as speech and language difficulties, aggressive behaviour and sleep problems. In some instances, services such as SALT and Child and Adolescent Mental Health (CAMHS) recorded examples of the ‘voice of the child’ being heard and how the children presented on occasion. A SALT therapist recorded her observation of one of the twins interacting with his mother, showing affection and interest in his mother and seeming ‘at ease in his own home’. On another occasion, a health professional recorded using signs and expressions to communicate with the child. 4.10 The health visiting service1 was involved with all four children in this family between 2009 and 2018. A review of health visiting records indicates that the service had good engagement from the family with both parents contacting the service at different times when additional support was required. The service conducted all health assessments in line with the service specification, with visits taking place both within the home and in clinic locations. The service was notified on the occasions when children were seen at the CED and appropriate follow-up took place. However, there is no evidence that staff considered any wider safeguarding issues within the family. 4.11 During 2011, the parents requested additional support from the service on three occasions regarding the behaviour of the twins and the impact on their mental wellbeing. Appropriate support was signposted (i.e. to the GP and a referral to the Children’s Centre). It has been recognised however that there was a lack of professional curiosity at that time into any additional family stressors or a wider assessment of any impact on the children. 4.12 Following the birth of the third child, early identification of depressive symptoms in mother was made during the six week postnatal assessment. The health visitor put a plan in place and made four additional visits to support mother. However, there 1 Since September 2018, health visiting and school nursing services for Coventry have been provided by South Warwickshire Foundation Trust (SWFT) and before that by the Coventry and Warwickshire Partnership Trust (CWPT). SCR Report: Child X Final November 2020 Page 7 is no evidence of any liaison between maternity and health visiting services during the pregnancy or during the immediate postnatal period. 4.13 The health visiting service was made aware of the children’s numerous visits to CED during a four year period with differing symptoms (i.e. through the Paediatric Liaison notification process) and did contact the family to discuss the attendance and to offer additional support and advice. However, there is no documentation to suggest that these frequent attendances were explored further, or any patterns noted in the reasons for them. In isolation these attendances could have been dismissed as minor childhood illnesses nature of the attendances and their frequency seem to indicate a family struggling to cope. General Practice 4.14 Baby X and his family were registered at a health centre in the city. A key ‘procedural’ incident was identified as part of this review process. The incident occurred in January 2018 during mother’s pregnancy with Baby X when a social worker contacted a midwife at the health centre. The social worker had recently undertaken a Child and Family Assessment in response to concerns that the parents had allowed a ‘risky adult’ (known to social services) to live with them. An earlier request for information as part of the C&F assessment had been faxed to the practice. The midwife was informed that the assessment would soon be closed, and no further action required. A request was made that if any home visits were undertaken and there was a male adult and a twelve year old boy in the house, children’s social care should be informed. This information was shared subsequently at a Multi-Disciplinary Team meeting in the practice. 4.15 The SCR review process revealed that there were no entries in the medical records about the original fax from children’s social care or any request for information. However, there had been ‘four attempts’ recorded by children’s social care to gain information through a fax to the GP practice. After a telephone request, the information was eventually transferred back. 4.16 It is important to note here that practice in gathering information between social care and GP practices has since changed. Historically, social workers would fax a non- specific request for information to GPs. Early in 2019, communications improved with the development of a new pro-forma (‘V5’) which was agreed (via the Safeguarding Children Board) between Primary Care and Children’s Social Care. The new V5 pro-forma clarifies the purpose and context of the request, actions currently planned and the specific information that is being requested for any safeguarding matter. It has been reported to the review panel that the efficiency and quality of information sharing between social care and GPs have improved as a result of these changes. 4.17 A second ‘procedural’ incident was identified by the GP practice regarding 6-8 week baby checks. When questioned about this check by the practice nurse, mother reported three failed attempts to book this check for Baby X at the health SCR Report: Child X Final November 2020 Page 8 centre. A new procedure has been introduced when registering a new-born child whereby a recall is added to the computer system that triggers at 8 weeks of life. This recall prompts the surgery to audit whether the check has been completed or booked for completion. Failure to do so is proactively followed up by the surgery until the check has been completed. Children’s services 4.18 Coventry Children’s Services had limited involvement with the family prior to the death of Baby X. In early 2017, a referral was made by the older siblings’ primary school reporting that all three children were currently staying with the maternal grandmother due to concerns about a risky adult who was believed to be part of a gang ‘scamming’ people and who was staying in the family home. In order to protect her children, mother had sent them to stay with their grandmother to ensure they were safeguarded. Children’s services were satisfied that the mother had put enough measures in place to safeguard her children. A Multi-Agency Support Hub (MASH) assessment was completed and a referral made for the primary school to offer a level 2 CAF. The mother however declined the offer of CAF support from the school. 4.19 A second referral made by a social worker took place in late 2017 during the mother’s third pregnancy. The social worker was involved in the case of a father and son who were known to children’s social care. It was alleged that they were staying with the family and potentially presented a risk to the children in terms of alcohol misuse and inappropriate language in the family home. A Child and Family Assessment was completed in January 2018 with an outcome of no further action. It concluded that while Baby X’s parents were defensive about the allegation and/or potential risk, they denied having the two males living with them. The parents were assessed as being able to ensure their children were safeguarded. There were no concerns noted at that time with regards to the parents’ direct care of the three children or of the unborn child. 4.20 A written agreement was put in place in respect of mother ensuring that no unsupervised contact would take place between her children and this man and his son. The case was subsequently closed in early 2018. It is no longer the practice within children’s services to use ‘written agreements’ of this nature. Current practice would involve a safety plan for the children with clear expectations for the family. 4.21 As part of the serious case review, children’s services acknowledged that the CFA in January 2018 could have been more detailed and should have also referenced the referral of the family to the MASH in early 2017. The CFA could have also considered a more in-depth assessment of the historical non-attendance at autism awareness sessions by the parents. Children’s services reported that this would not have had any impact on the decision to close the case at that time. 4.22 Children’s services have identified that on both occasions when the case was closed either directly at the referral stage by the MASH or by the area team SCR Report: Child X Final November 2020 Page 9 following completion of the child and family assessment, there is no record of closure letters being sent to the family or other professionals working with them detailing the decisions. This was a weakness in information sharing. 4.23 A referral was made by paramedics to the MASH following Baby X’s admission to hospital in June 2018. It was appropriately identified as a priority safeguarding concern and the potential for non-accidental injury was clearly recorded. Given the older siblings in the family, it would have been appropriate to have held that same day a strategy discussion, an S47 investigation initiated and a home visit undertaken to ensure timely safety arrangements were in place, pending further assessment. This would have enabled an important multi-agency discussion from the outset. In practice, the strategy discussion took place four days later; the home visit two days later. This delay has been acknowledged and the local authority has issued new guidance and provided training on strategy discussions to address these weaknesses. 4.24 The family relative who was caring for Baby X at the time of the non-accidental injuries was not known to children’s social care or to the police. Education 4.25 All three siblings have diagnoses of Autistic Spectrum Disorder and their needs are managed within their primary school through a range of in-school strategies. None of the children have individualised education plans or Education Health Care (EHC) plans. At the outset of this review, it was reported that no external agencies were involved with the children as their primary school can access support from the Coventry Autism Support service if required. During their time at primary school, the children’s medical concerns have had an impact on their school attendance. 4.26 The review process by the school revealed one incident with implications for future practice. In late 2017, the school was contacted by children’s services as they were undertaking a Child and Family Assessment on the family (see paragraph 4.16 above). Following this initial contact by children’s services, there was no further contact. The school made enquiries but received no further information regarding this CFA assessment or the outcomes. The school reported that it was only after the death of Baby X that the concerns of health agencies about missed health appointments by the children became known to school staff. Police 4.27 West Midlands Police (WMP) had no involvement with the family until 2017 when there were two referrals through the MASH (see above paragraphs 4.18 and 4.19). Both events relate to MASH processes and the sharing of information between agencies. 4.28 The first incident in early February 2017 was reported by the children’s school after they were informed that the three children were staying with grandmother due to SCR Report: Child X Final November 2020 Page 10 concerns about a risky adult staying in the family home. The matter was appropriately recorded on a Child Abuse Non-Crime report and evaluated as an Amber MASH referral. During strategy discussions at the MASH, information was shared, and the poor school attendance of the children was noted. There was no information shared to suggest the children were at risk of serious significant harm, and in light of this, it was recommended that the school offer a CAF to the family to explore and improve the attendance. As noted above (see paragraph 4.18), this offer was subsequently declined by the mother. 4.29 In late 2017, a second Child Abuse Non-Crime report was generated following a further Amber MASH referral made by a social worker regarding a child not related to the family who was residing within the family home along with his father. The father and son considered themselves to be homeless and were housed on an informal basis by the family (see paragraph 4.19). Following the strategy discussion within the MASH, a Child and Family Assessment was recommended with a specific focus on the parents’ understanding and management of risk for their family. 5. Analysis of professional involvement with the family 5.1 It is clear that all three children had complex health needs and mother expressed her ‘struggles’ during home visits by health visitors. Professionals liaised with parents to encourage attendance at appointments and numerous telephone calls were made to remind parents of planned home visits and appointments. However, there is no evidence of any conversations with the parents about the impact of caring for three children with complex health needs on their own health and mental wellbeing, nor of the practical difficulties faced by them in taking the children to numerous different appointments. 5.2 Records indicate that there were occasions during 2011-2012 when children were not brought to health appointments. Records also indicate that mother rang to cancel some appointments for reasons such as child unwell, childcare issues or other medical appointments. There was no pattern identified of individual children not being brought for appointments and no indicators of neglect identified. The Trust’s ‘Did Not Attend’ (DNA) policy was followed appropriately with phone calls and letters to parents but opportunities for further discussion between the services about the meaning behind the non-attendance or the impact on the children of frequent non-attendance do not appear to have been taken. 5.3 The escalating needs of the family between 2009 and 2013 were recognised by the health visiting service and additional support put in place. However, despite the involvement of numerous agencies there appears to have been little consideration at the time of how best to coordinate this involvement in the form of an Early Help or a Common Assessment Framework (CAF) plan. 5.4 Records of follow-up visits by health visitors following the falls of the twin in 2010 (see paragraph 4.2 ) and the third sibling in 2011 (see paragraph 4.6) do not include SCR Report: Child X Final November 2020 Page 11 any further discussion with parents regarding the falls or consideration of any wider safeguarding issues. In retrospect it is not clear why this discussion did not take place. It may have been due to professional over optimism given that the parents engaged well with the service or an assumption at that time that hospital staff would have considered the wider safeguarding issues. 5.5 During the period of time the health visiting service was involved with the family, the children attended the CED on numerous occasions with differing symptoms. The service was informed of these visits through the official notification process however not all of these attendances were recorded in the main health visiting record. This inconsistency could have resulted in attendances being seen in isolation rather than in the wider family context. At the time of the third sibling sustaining a hairline fracture (see paragraph 4.6) the family context included a mother being treated for depressive illness caring for three children under the age of 3, two of whom had challenging behaviour that was being investigated further. 5.6 As part of this review process, health professionals recognised that a Common Assessment Framework (CAF) could have been undertaken to provide an opportunity for different agencies to consider the risks and vulnerabilities for the family and to identify their support needs. There were numerous contacts with the family, but it appears that practitioners were reactive, and incident led, responding to each health need and missing the opportunity to consider the needs of the family as a whole, to ‘Think Family’, as would be the practice today. There was a lack of professional curiosity into any additional family stressors. Use of an early help model would have offered a co-ordinated approach and a means of assessing how well the parents were coping with the differing demands of their three children. 5.7 The voice of the children and their lived experience are not evident in the children’s health visiting records considered for this review. There is little description given as to how the children presented when seen. Parental issues have been identified and managed but there is no indication of how these issues impacted on the children or information of the home conditions. In addition, the CFA assessment undertaken by children’s services in late 2017 did not include any recorded evidence of the ‘voice of the children’ despite concerns about risky adults in the family home. 6. Findings and recommendations 6.1 The judge for the Findings of Fact hearing at the Family Division of the High Court of Justice in spring 2020 found that ‘neither the mother nor the father caused any harm to or inflicted any injuries’ upon their baby. He also found that ‘there was no question of them failing to protect their baby’ from the family relative involved in this case or any other person. SCR Report: Child X Final November 2020 Page 12 6.2 There is no evidence from this review to indicate that the injuries sustained by Baby X could have been predicted or prevented by agencies working with the family. 6.3 It is clear however from the review that this family met the threshold on two occasions for a CAF and effective information sharing across the agencies, as happens now with the ‘Acting Early’ model, would have identified the needs of the family prior to the birth of Baby X. However, early help is a voluntary process and at the time the mother declined these offers. 6.4 Coventry Safeguarding Children’s Partnership policy and guidance ‘Right Help, Right Time’ (2018) is comprehensive and clearly sets out the shared responsibilities professionals from all agencies have to ensure that children receive help early and at a level according to their needs. Through ongoing training and supervision, staff from across the multi-agency partnership are encouraged to adopt a ‘Think Family’ model to assess the needs of all the children in a family and to access appropriate help. 6.5 The nine year scope of this serious case review focused mainly on the older siblings and the way in which different agencies worked with the family. This review has identified shortcomings in the practice of some services at that time and action has been taken within the past two years to address these issues. 6.6 The findings of this review show the changes in processes introduced in recent years include the following improvements: a. Information gathering between social care and GP practices has been improved by the introduction of a new pro-forma (‘V5’) which clarifies the purpose and context of a social care information request, the actions currently planned and the specific information that is required for any safeguarding matter. Historically, social workers would fax a non- specific request for information to GPs which sometimes resulted in delayed and/or inadequate responses. b. A new procedure has been introduced in GP practices when registering a new-born child whereby a recall is added to the computer system that triggers at 8 weeks of life. This recall prompts the GP surgery to audit whether the baby’s check has been completed or booked for completion. Failure to do so is proactively followed up by the surgery until the check has been completed. c. Children’s social care no longer use written agreements with parents as identified in paragraph 4.20. Current practice now would involve the development of a robust safety plan for the children with clear expectations for the family. SCR Report: Child X Final November 2020 Page 13 d. The delay in holding a strategy discussion following Baby X’s admission to hospital (see paragraph 4.23) has been acknowledged and the local authority has issued new guidance and provided training on strategy discussions to address these weaknesses. |
NC52226 | Potentially life-threatening non-accidental head injuries to a 6-week-old girl in August 2019. A criminal investigation into the injuries was ongoing at the time of this review. Emily lived with her mother and her five siblings and half-siblings. Her mother and father separated in April 2019. Throughout the period covered by this review, there were several referrals to children's social care expressing concerns about the care the mother was providing. There were also a number of domestic abuse incidents between Emily's mother and father. The children in this family were the subjects of child in need plans from June 2018 for 12 months and child protection plans from June 2019. Between July and August 2019, when Emily sustained her injuries, there were regular visits from social workers and health visitors, who reported that children appeared happy and settled. Ethnicity/nationality of family not stated. Learning includes: inconsistencies around attendance at meetings meant that there was never a clear, shared understanding of the children's lived experiences; key people were missing from child in need meetings, child protection conferences and core group meetings; and possible indications of neglect were missed. Makes recommendations including: child in need plans should clearly describe areas of concern, actions to be taken and measures of success; changes in the composition of a household where there is a child in need or child protection plan should lead to an updated social work assessment; and schools should put arrangements in place so they can contribute to conferences and meetings during school holidays.
| Title: Child safeguarding practice review concerning Emily: overview report. LSCB: Bradford Safeguarding Children Board Author: Peter Ward Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Bradford Safeguarding Children Board Child Safeguarding Practice Review concerning Emily Overview Report 1st February 2021 Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 2 of 43 Table of Contents Page 1. The child and the circumstances leading to decision to carry out a Child Safeguarding Practice Review 3 2. The Review Process 3 3. Family Circumstances 5 4. The Facts - Summary of Agency Involvement 5 5. Analysis 11 6. Previous Serious Case Reviews 26 7. Learning from the Review 27 8. Recommendations 29 Appendix 1 - Actions Taken by Agencies related to the findings of this review Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 3 of 43 1. The child and the circumstances leading to the decision to carry out a Child Safeguarding Practice Review 1.1 The decision to undertake a Serious Case Review was agreed following a Rapid Review conducted on 12 September 2019 into Emily. The Rapid Review was undertaken after Emily was taken to hospital, aged 6 weeks, with swelling to her head. Medical investigations indicated that she had sustained serious head injuries which potentially were life threatening or which may have long term consequences for development. The injuries were assessed as non accidental in nature. 1.2 The cause of the injuries has not been established and a criminal investigation is ongoing. 2. The Review Process 2.1 This review followed the process outlined in Chapter 4 of Working Together to Safeguard Children 2018. 2.2 A Review Panel with the following membership was established to oversee the review: • Peter Ward, Independent Lead Reviewer & Overview Report Author; • Child Safeguarding Practice Review Lead, Bradford Safeguarding Partnership; • Deputy Designated Nurse, Bradford and Craven Clinical Commissioning Group; • Named Nurse, Bradford Teaching Hospitals Foundation Trust; • Chief Inspector, Safeguarding Partnerships, West Yorkshire Police; • Head of Service, Early Help, Bradford Council; • Access to Housing Strategic Policy Officer, Housing Services, Bradford Council; • Head of Safeguarding, Bradford District Care NHS Foundation Trust; • Education Safeguarding Officer, Education Safeguarding Team, Children’s Services, Bradford Council; • Service Manager, Safeguarding and Reviewing Unit, Children’s Services, Bradford Council. Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 4 of 43 2.3 The Review Panel decided that the review should consider a period from 24 February 2018 when an anonymous contact was made to Children’s Social Care that the mother and father were in the pub and the children may have been left at home on their own, until 23 August 2019 when Emily was taken to hospital with the aforementioned head injury. Agencies which had been involved with the family between these dates were asked to provide chronologies and brief reports of their involvement including relevant background information which pre-dated this time period. The key learning from these reports has been used to inform this Overview Report. 2.4 Reports were provided by the following agencies: • Bradford District Care NHS Foundation Trust • Bradford Metropolitan District Council, Access to Housing • Bradford Metropolitan District Council, Children’s Social Care • Bradford Metropolitan District Council, Education Safeguarding • Bradford Teaching Hospitals NHS Foundation Trust • Bradford and Craven Clinical Commissioning Group – regarding General Practice • West Yorkshire Police 2.5 Chapter 4 of Working Together to Safeguard Children 2018 states that the safeguarding partners should seek to ensure that: • “practitioners are fully involved in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith • “families, including surviving children, are invited to contribute to reviews. This is important for ensuring that the child is at the centre of the process. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively” 2.6 In order to comply with the first of these principles, in carrying out this review the Lead Reviewer held a ‘Learning Event’ to which front line staff and their managers were invited. This helped the Lead Reviewer to gain a greater understanding of the context in which practitioners worked with the family and the reasons for the decisions they made and the actions they took. This in turn has assisted with drawing out relevant learning and recommendations for action and as such has been an important part of the systems approach that has been used. Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 5 of 43 2.7 The Lead Reviewer wanted to speak with both parents as part of the review. Unfortunately, this has not yet happened due to the ongoing criminal investigation. 3. Family Circumstances 3.1 Following her birth and until she sustained the injuries, Emily lived with her mother and five siblings and half-siblings aged from 10 years to one year. These children are referred to throughout this report as Sibs 1, 2, 3, 4 and 5. Emily has the same father as Sib 5. Sibs 1 and 2 have the same father as each other whilst Sibs 3 and 4 each have different fathers. Agencies involved with the family did not have any contact with the fathers of Sibs 1, 2, 3 and 4 during the period covered by this review and it is believed that none of these fathers had any contact with the children during this time period. 3.2 The mother and father of Emily had an ‘on off’ relationship with each other during the period considered by the review. They each contacted the police on a number of occasions to report incidents of domestic abuse against the other. They are believed to have separated around April 2019 and not to have reconciled by the time Emily was injured. However, reports alleging domestic abuse between them did continue. 3.3 Records seen by this review make reference to some support being provided to the mother by the maternal grandmother and a maternal uncle. 3.4 The children were the subjects of a Child in Need Plan for 12 months from June 2018 and a Child Protection Plan from June 2019. This Child Protection Plan remained in place when Emily was injured. 4. The Facts - Summary of Agency Involvement 4.1 Introduction 4.1.1 This section of the report provides a factual summary of key areas of agency involvement with the family. It is not a comprehensive record of all contacts with the family but focuses on those episodes that are considered to be significant to the way the case developed. 4.2 Historical Information; Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 6 of 43 4.2.1 Bradford Children’s Social Care (CSC) first had knowledge of the family in February 2013 when concerns were raised about the mother being intoxicated and attending the hospital emergency department claiming her drink was spiked. At this time the mother had three children aged from 3½ years to two months. The children were in the care of their maternal grandmother at the time and no further action was taken. Four contacts were made to CSC during 2014 in which concerns were raised about the family. None of these resulted in ongoing involvement from CSC. 4.2.2 In July 2015, a referral was received stating that the mother was intoxicated in a pub and Sib 3, who was 18 months old was locked in a toilet. The referrer expressed concerns about the mother’s use of alcohol. This referral resulted in an assessment which identified that the children’s health and educational needs were being met and that there was emotional warmth between the mother and the children. Support was provided to address the mother’s alcohol use, previous domestic violence incidents and boundary setting for the children. This was provided via a Family Centre and the case was stepped down to Early Help in April 2016. 4.2.3 Between May 2016 and February 2018 there were a further twelve contacts regarding the family, none of which resulted in further assessment or intervention by Childrens Social Care. The contacts came from a variety of sources and many expressed concerns about the care the mother was providing to the children. During this period, Sibs 4 and 5 were born. Early Help remained involved throughout this time. 4.2.4 West Yorkshire Police have had extensive engagement with both the mother and the father of Emily individually from one another over several years. In January 2018, the month before the start of the period being covered by this review, the mother contacted the police three times making allegations of assault and abusive and threatening messages from the father, whom she described as her ex-partner. On 25 January 2018, the Court issued a non-molestation order forbidding the father from contacting the mother. 4.3 Key Practice Episode 1 – Social Work Assessment and subsequent Child in Need status Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 7 of 43 4.3.1 On 24 February 2018, an anonymous contact was made to CSC that the mother and father were in the pub and the children may have been left at home on their own. This contact progressed to referral and enquiries with partner agencies and mother ensued. It was believed that the anonymous contact may be malicious but the enquiries raised concerns and the referral progressed to assessment. This included concern that the parents had not sought appropriate medical support when Sib 3 injured her leg or when Sib 4 had blood in his stools, parental hostility at school and domestic abuse between the parents. The assessment was completed in June 2018; records attribute the delay to “worker availability”. 4.3.2 The social work assessment identified concerns relating to domestic abuse between the parents. The manager’s comments stated that the mother appeared to minimise the extent of the abuse but also that both parents demonstrated some understanding of the impact of domestic abuse on the children and wished to engage with the MAZE domestic abuse agency. Concerns were also identified about parental boundary setting, school attendance and Sib 2’s behaviour at school. It was suggested that Sib 2 might have Attention Deficit Hyperactivity Disorder (ADHD). 4.3.3 The assessment resulted in a decision that a Child in Need plan was necessary and this remained in place from June 2018 to June 2019. Records suggest that during this time period six Child in Need meetings were held, in July 2018, August 2018, November 2018, January 2019, February 2019 and April 2019. Child in Need meetings scheduled for October 2018 and May 2019 were cancelled; the first because the social worker did not arrive and the second because no-one was at home when professionals arrived for the meeting. CSC, however, only has records of four of these meetings taking place and only has minutes from the one that was held in February 2019. 4.3.4 Following the Child in Need meeting in April 2019, CSC reallocated the family to a different social worker whose role was to implement the ‘step down’ to Early Help. 4.4 Key Practice Episode 2 – Progression to Initial Child Protection Conference and Child Protection Plan 4.4.1 In May 2019, before the family had been stepped down from Child in Need to Early Help, a strategy discussion was held as a result of an incident of domestic abuse when the mother reported that the father was Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 8 of 43 at her property threatening to ‘kick the door down’ and take Sibling 5. The result of the strategy meeting was that an Initial Child Protection Conference should take place. 4.4.2 The outcome of the Initial Child Protection Conference was that the children were made subject to Child Protection Plans due to emotional harm with neglect highlighted. The resulting Child Protection Plan contained three main areas of concern each of which was sub-divided. The first of these relates to domestic abuse between the parents, the second concerns specific issues about the father’s wellbeing and lifestyle and the third concerns the mother’s parenting and how she responded to the children’s behaviour. This third area made specific reference to the mother not taking Sib 2 to appointments with Child and Adolescent Mental Health Services (CAMHS) and little change to how she responded to the children’s behaviour. 4.4.3 Core Group meetings were held in both June and July 2019 but minutes were only written of the first of these. The allocated social worker and allocated health visitor undertook a joint home visit to the mother and children in August 2019 which the health visitor recorded as being a Core Group meeting. 4.4.4 A Review Conference was due to be held in August 2019 but was inquorate because only the chair, social worker and health visitor were in attendance. This was during the school holiday and no-one from school 2 attended. A report from the school nurse was circulated prior to the meeting. It was the day after the inquorate Review Conference that Emily sustained the injuries that led to this Child Safeguarding Practice Review. 4.5 Key Practice Episode 3 – Response to Reports of Domestic Abuse 4.5.1 In January 2018, the mother secured a non-molestation order against the father following incidents of domestic abuse. During the social work assessment the mother said that she had taken this out in haste and had been back to Court on 16 May 2018 when it had been revoked. 4.5.2 West Yorkshire Police was called to four reported domestic abuse incidents between the parents over a five week period in March and April 2018. West Yorkshire Police was also called to one incident in September 2018, one in October 2018 and three on one day in January 2019. Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 9 of 43 4.5.3 In mid April 2019, the mother told practitioners who were working with her that she and the father had separated. West Yorkshire Police was called to three reported domestic abuse incidents between the parents over the next two days and six more between 6 May 2019 and 8 June 2019. 4.5.4 The mother secured another non-molestation order against the father on 14 June 2019. Five days later this was amended to allow father to have contact with his children. Four more domestic abuse incidents were reported after this. 4.6 Key Practice Episode 4 - Response to concerns about Sib 2’s behaviour 4.6.1 In March 2018 school 1 raised concerns about Sib 2’s behaviour and wondered if he may have ADHD. Sib 2’s behaviour continued to cause concern, particularly at school, throughout the period considered by this review and formed part of the Child in Need Plan and the subsequent Child Protection Plan. 4.6.2 A referral was made to CAMHS whose view, based on the information in the referral, was that Sib 2 did not have ADHD. Nevertheless, a joint appointment was offered to Sib 2 and his mother with CAMHS and the school nurse. Three appointments were offered but the mother and Sib 2 did not attend any of these. The school nurse was told by CAMHS that a new referral was required before another appointment would be offered. 4.6.3 At the Initial Child Protection Conference, the school expressed concerns about Sib 2’s behaviour at school and the mother said that it was also a problem at home. Problems escalated in June and July 2019; staff at school 2 were struggling to manage Sib 2’s behaviour despite considerable extra support, he was excluded from school 2 for individual days on several occasions and by the end of the summer term in mid July 2019, was at significant risk of a permanent exclusion. At the Core Group meeting in July 2019, the Deputy Designated Safeguarding Lead (DSL) from the school stressed that they were extremely worried about Sib 2's behaviour in school and in the home towards his younger siblings. Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 10 of 43 4.6.4 In June 2019 the mother contacted the police on one occasion and reported that Sib 2 was damaging property in the house. Officers were despatched and were told by the mother that he had damaged his own television. During a home visit, the mother told the health visitor that she was struggling with Sib 2’s behaviour and that CSC was considering a temporary foster placement for him. There is no evidence of this in CSC records. 4.6.5 The end point of the period covered by this review was 17 months after concerns had first been raised about Sib 2 and it was suggested that he may have ADHD. However, he had still not had an appointment with CAMHS. 4.7 Key Practice Episode 5 – Agency Involvement with the family from the Birth of Emily until she was injured at six weeks of age 4.7.1 Emily was born in hospital on 9 July 2019 and discharged home with her mother the following day. The following week a Core Group meeting was held in the family home with the social work and the deputy DSL from school 2 present and at the end of that week, school 2 broke up for the summer holiday. 4.7.2 During this period the social worker visited four times with the last visit taking place two days before Emily was injured. All the children were seen on each visit, most were seen on their own and the older children were spoken to. They reported being happy and appeared to be settled with evidence of a good attachment to the mother. They were playing appropriately and when necessary the mother was observed to manage them in a calm manner, using appropriate strategies. The home was clean if a little disorganised and it was noted that decorating was taking place. The mother appeared calm and did not come across as stressed; she reported that her family were supporting her. Emily was observed to look well and was making appropriate sounds. The third of these visits was a joint visit with the health visitor that incorporated a Core Group meeting. 4.7.3 The health visitor also visited the family home on four occasions during this period with the final visit being on the morning of the day that Emily was injured. 4.7.4 The health visitor observed that Sib 4 had a chesty cough and was crying throughout the first visit and at the second visit, Emily was Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 11 of 43 coughing and appeared to have nasal congestion. The mother told the health visitor that she had phoned NHS111 the previous evening and been given a late evening appointment for Emily but had been unable to attend because the maternal grandmother could not look after the other children at that time of the evening. Also at this second visit, the health visitor noted that Emily’s weight had been at the 25th centile at birth, the 2nd centile at day 15 and was now below the 2nd centile. 4.7.5 At the third visit the health visitor also observed that the home was tidy and there were lots of appropriate toys. This was a joint home visit with the social worker and included a Core Group meeting. Emily was heard coughing a few times but was much improved from the previous week. The mother had taken her to A&E and said that she was recovering from bronchiolitis. She was still below the 2nd centile for weight having gained 4-5 ounces in seven days. At times during the visit, the mother seemed distracted by the demands of the older children. 4.7.6 The final visit from the health visitor was on the morning of the day Emily was injured. During this visit the mother said she felt tired but she did not report any low mood or anxiety and maintained good eye contact. Emily presented as clean and suitably dressed and the mother was observed to handle her gently, with warmth and affection observed. Emily’s weight was just below the 2nd centile and the health visitor described this as excellent weight gain and documented that she planned to visit again in six to eight weeks time. The health visitor did not see the other children during this visit and the mother stated that they were in bed upstairs. 4.7.7 Five days before this visit, the mother had phoned 999 and reported that the father had been at the home trying to see his children. The police had visited and completed a DASH risk assessment which identified a number of risks, including that the mother was feeling depressed. The health visitor was not aware of this incident when she visited. 5. Analysis 5.1 Introduction 5.1.1 This section contains an analysis of aspects of this case by considering the key themes to emerge. Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 12 of 43 5.2 Theme 1 - Multi-Agency Working, Focusing on the Needs of the Children 5.2.1 During the majority of the period considered by this review the children were subject either to Child in Need or Child Protection Plans. Therefore, there was a framework in place for organisations to work together in addressing the needs of the family. Child in Need meetings 5.2.2 The core membership for the Child in Need meetings was the allocated social worker, the allocated health visitor, the deputy DSL from the older children’s school and the parents. School nurses in Bradford do not usually attend Child in Need meetings and do not have the capacity to do so. However, the health visitor should have consulted with the school nurse before meetings and fed back afterwards. It is not documented in the record whether such consultation and feedback took place. The mother was pregnant at the time of the first Child in Need meeting and pregnant again when the last two were held. It would have been appropriate to have involved the community midwife in these meetings but there is no indication that this was considered. 5.2.3 Due to there being no records of two of the Child in Need meetings that reportedly took place it is not known who was in attendance. Of the other four Child in Need meetings, the deputy DSL was unable to attend one because it was held during the school summer holiday. The health visitor was unable to attend one held in February 2019. She has recorded that this was because the meeting was rearranged at short notice and also that none of her colleagues could attend in her place. It is not clear whether updates were provided by any other professionals involved with the family such as the health visitor, the school nurse or the midwife. Initial Child Protection Conference & Child Protection Plan 5.2.4 In addition to the chair, the Initial Child Protection Conference was attended by a social worker, the allocated health visitor (who had only recently started to work with the family), the designated safeguarding lead from school 2 and a police officer. Neither the recently allocated social worker, the previous social worker nor the team manager was present and it is unclear whether the social worker who did attend had had any previous involvement with the family. The recently allocated Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 13 of 43 social worker did write a report that was shared at the meeting. Apologies were received from both parents; the school nurse, who sent a report and the GP. 5.2.5 No-one from maternity services attended this Conference despite the mother being pregnant at the time. Following a Care Quality Commission (CQC) recommendation, the expectation is that all Child Protection Conferences are attended by the named midwife or a deputy if the mother is pregnant at the time of the Conference. Bradford Teaching Hospitals NHS Foundation Trust has worked to improve attendance at Conferences and has received funding for an additional whole time equivalent post for vulnerable women to support this. Where the named midwife is unavailable, the safeguarding midwifery team will try to attend on their behalf. 5.2.6 As with the Child In Need Plan, the Core Group consisted of both parents, the allocated social worker, allocated health visitor and designated safeguarding lead from the school. Neither the school nurse nor the community midwife was part of the Core Group and as with the Child in Need Plan, there is no evidence that relevant communication took place with these professionals before or after Core Group meetings. 5.2.7 The health visitor did not attend the Core Group meetings in June or July 2019 so the only professionals present were a social worker and the deputy DSL from school 2. Records suggest that the health visitor arrived at the office where the first meeting had been scheduled to take place but it had been moved to the mother’s home because she was unable to get to the venue for the time arranged due to being heavily pregnant, having three children to get to school and two pre-school children. The health visitor was not invited to the second Core Group meeting and only found out that it had taken place when she phoned the social worker a few days later. No-one from school 2 attended the Core Group meeting in August 2019 because this was during the school holiday. 5.2.8 The limited attendance of agencies at the Review Conference in August 2019 meant that it could not fully consider the children’s safety or what progress had been made with the Child Protection Plan. Addressing concerns about Sib 2’s behaviour Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 14 of 43 5.2.9 Sib 2’s behaviour at home and school was an issue of concern throughout the time considered by this review and was included within the Child in Need and Child Protection Plans. The focus of addressing this was on trying to get an appointment with CAMHS. There is evidence of considerable communication between professionals about this but there appears to have been a lack of overall co-ordination. School nurses took the lead on this and spent a great deal of time trying to facilitate the appointment. Because the school nurses were not involved in Child in Need meetings, child protection conferences or core group meetings there was a lack of direct communication between this two processes. Both schools were actively involved in trying to ensure that Sib 2 had an appointment with CAMHS and deputy DSLs from the schools attended the majority of Child in Need and Core Group meetings. However, there was very little evidence of direct communication between the schools and CAMHS. 5.2.10 The process used to refer Sib 2 to CAMHS was that the school nurse provided the school with SNAP (Swanson Nolan and Pelham tool for ages 6-18 years) forms to complete. These are forms which CAMHS use to see if ADHD is indicated. The school and the mother then completed these forms together and returned them to the school nurse who sent them to CAMHS. On both occasions that the schools were asked to complete SNAP forms with the mother there was a considerable delay before these were returned to the school nurse. The first time was when Sib 2 was attending school 1 and the second was when he was attending school 2. It is not clear why these delays occurred but they resulted in significant delay before referrals were considered by CAMHS and consequently a significant delay before an appointment was offered. 5.2.11 A letter with the date of the first CAMHS appointment for Sib 2 was sent to the mother in October 2018 but this was sent to an address that the family had left two months earlier. This review has been told that the reason the first appointment letter was sent to the incorrect address is that this was the address on SystmOne. The family had moved home approximately two months before the letter was sent and staff from the 0-19 service of Bradford District Care Foundation Trust were aware of the change of address. However, Bradford District Care Foundation Trust 0-19 staff do not have authority to change addresses on SystmOne as this is the responsibility of the GP. Therefore, staff from the 0-19 service advise parents to contact the GP and inform them of the change of address. The letter was returned, unopened, to the service before the Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 15 of 43 date of the CAMHS appointment but there is no indication that anyone took any action to address this. 5.2.12 After the second missed appointment, the school and the school nurse both liaised with CAMHS and a third appointment was offered for Sib 2 to meet a CAMHS practitioner with his mother and the school nurse on 7 February 2019. The mother did know about this appointment but phoned she school on the day it was due to take place and said she could not attend because Sib 4 was unwell that day. 5.2.13 Given that the first appointment was sent to the wrong address, the mother’s actions on the day of the February 2019 appointment and Sib 2 being subject to a Child in Need plan, consideration of another appointment, without the need for a new SNAP form and new referral may have been appropriate. 5.2.14 CAMHS staff have told this review that they were not aware that Sib 2 was subject to a Child in Need Plan when the appointments were offered. There is evidence that the school nursing service had knowledge of the Child in Need and Child Protection Plans but it is not clear that every school nurse was aware of this when speaking with CAMHS practitioners. SystmOne has a facility whereby children can be flagged as being subject to a Child Protection Plan but it does not provide a similar facility for children who are subject to a Child in Need plan. 5.2.15 In 2018 Bradford and District Local Health Economy issued best practice guidance for the management of children not brought to medical appointments. This includes guidance that the secondary care response if a child is not brought to an appointment should include the “Existence of multi-agency plans (Child Protection Plan, Child Looked After, Child In Need) when relevant professionals should be notified of the child not being brought.” Ideally secondary care should be made aware at the time of referral if a child is subject to any multi-agency plans. However, on occasion the referrer may be unaware or the multi-agency plan will be instigated between the date of the referral and the date of the appointment. It would therefore be beneficial if the existence of a Child in Need Plan could be identified on SystmOne. Domestic abuse Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 16 of 43 5.2.16 The Police responded to 20 reported domestic abuse incidents between the parents during the period covered by this review and three involving one parent and someone else. CSC was notified about the majority of these incidents, as required, but on five occasions this was not done. The reasons for each of these incidents not being referred to CSC have been identified by West Yorkshire Police and appropriate action has been taken to minimise the likelihood of a recurrence. Details of these reasons and the action taken are explained in detail in the West Yorkshire Police report to this review. 5.2.17 The incidents comprised a mixture of physical assaults, threats made over the phone from the father to take their child and/or to physically harm the mother, a threat from the mother to physically harm the father, occasions when the father was outside the house kicking the door and shouting abuse and one reported theft of the mother’s bank card. In some cases the mother was recorded as the victim of abuse from the father and in others it was the other way round. The physical assaults involved slight or no injury and as such were dealt with by different patrol staff rather than specialist officers. With the exception of attendance at the strategy discussion and the Initial Child Protection Conference there was no ongoing interaction between the Police and other agencies working with the family. Maternity Care 5.2.18 The mother gave birth to two babies during the period covered by this review, the first whilst the children were subject to Child in Need Plans and the second whilst they were subject to Child Protection Plans. The social worker did consult with the named midwife when she was undertaking the Social Work Assessment but the midwife was not involved in any Child in Need meetings, did not contribute to the Initial Child Protection Conference and was not a member of the Core Group. 5.2.19 When the mother attended her maternity booking appointment for her pregnancy with Emily she disclosed CSC involvement with the family. The midwife made several attempts to contact the named social worker during February and March 2019 to but they never managed to have a meaningful discussion about the case. 5.3 Theme 2 – Recognising and responding to physical and emotional neglect Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 17 of 43 5.3.1 The Bradford Safeguarding Children Board Continuum of Need and Risk Identification Tool (April 2019) describes neglect as “The failure to meet a child’s basic needs.” It states “Neglect can happen over a period of time, but can also be a one off event” and that “it is the cumulative effect that is the most impactful.” It identifies five types of neglect: physical, emotional, educational, medical/dental and emotional abuse. 5.3.2 The initial referral that led to this episode of CSC involvement was a clear allegation of neglect but was deemed to be a malicious referral. Enquiries made following receipt of the referral identified concern that the parents had, on occasion, delayed seeking medical help for the children. 5.3.3 The injury to Sib 3’s leg was a spiral fracture of the right tibia sustained when she was 5 years of age. The presenting history is that it was sustained when she was play fighting with her brother. The mother did not take Sib 3 to hospital until 10 days later despite advice to do so from NHS 111. There was minimal swelling, Sib 3 was able to weight bear and A&E staff had no concern about the cause of the injury. The hospital safeguarding team was notified of the delayed presentation and made enquiries with CSC who confirmed that the case was not open to them. No referral was made to CSC but School Nursing was notified of the injury. A check found the case was not open to CSC and because there was no concern about the cause of the injury, no further referral made to CSC. 5.3.4 Neither the A&E discharge summary nor the orthopaedic clinic letters made any mention of the delay in presentation as a potential safeguarding red flag for neglect, nor made any mention of an assessment of parenting ability. 5.3.5 It is not uncommon for people to delay attendance at A&E with injuries to themselves or their children. These are usually minor injuries where parents monitor the child at home and when no improvement is noted after a couple of days then they often seek advice at this time. If all delayed presentations of children were reported to CSC this could result in several notifications every week. Therefore it is appropriate for safeguarding specialist nurse to consider the circumstances of individual cases, including what is known about the family. Given the circumstances of this injury and the information available to the safeguarding specialist nurse, it is considered that the decision not to refer to CSC was correct. Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 18 of 43 5.3.6 The concerns about the mother not accessing medical care more quickly for Sib 3 were addressed in the Social Work Assessment and the social worker was reassured by the mother explanation. However, the explanation is not consistent with the information in the health records. This suggests that the mother’s explanation was accepted at face value and may have provided false reassurance. 5.3.7 The multi-agency best practice guidance ‘Management of Children not brought to medical appointments’ (referred to in paragraph 5.2.15) notes that the terminology ‘Did Not Attend’ of ‘Failure to Attend’ when children miss healthcare appointments “does not put any emphasis on the parenting requirement to bring the child.” It further notes that “in a small number of cases (the) failure to attend may be detrimental to the child and may also be a missed opportunity for identification of underlying medical or safeguarding concerns.” For these reasons, the guidance suggests that the terminology should be changed to ‘Was Not Brought’ which “puts the emphasis on the issue that the parent did not bring the child.” 5.3.8 Section 4.6 of this report describes the response to concerns about Sib 2’s behaviour and identifies that he was not taken to appointments that were offered by CAMHS. Similarly, in March 2018, , Sib 3 was not taken to an appointment with Speech and Language Therapy (SaLT) that had been offered as a result of concerns raised by the school. 5.3.9 Notwithstanding the multi-agency ‘Management of Children not brought to medical appointments’ best practice guidance, neither CAMHS nor SaLT have a written ‘Was Not Brought’ policy in place at the present time. Bradford District Care Foundation Trust has a Trust wide ‘Failure to Attend Appointments’ policy which was issued on 30 May 2018 and includes CAMHS service specific guidance. This includes guidance for CAMHS staff about considering the circumstances of the case and the potential risk to the child when deciding what action to taken in connection with the missed appointment. However, it does not emphasise children’s dependence on others to bring them to their appointment. 5.3.10 The most recent discharge policy for SaLT is dated 2016 but the service reports that it is common practice in the service that if a child does not attend an appointment, it is recorded on SystmOne as “was not brought Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 19 of 43 to appointment” and if the child is subject to a Child Protection Plan SaLT contacts the services that are involved with the child. 5.3.11 The Bradford Safeguarding Children Board Continuum of Need and Risk Identification Tool (April 2019) describes Medical/Dental Neglect as: “Failing to provide appropriate health care, including dental care and refusal of care where a child/young person has been diagnosed with a health condition e.g. Asthma, or ignoring medical recommendations and/or persistent not attending key appointments.” 5.3.12 This review shows that although there were occasions when the children were taken for medical appointments, there were other occasions they were not. It suggests that services did not always consider whether the non-attendance might indicate neglect. It further suggests that ‘Failure to Attend’ policies do not encourage staff to consider neglect. 5.3.13 The Social Work Assessment addressed possible areas of neglect and provided a balanced view of the children’s lived experiences. The assessment rightly identified the risk of the children experiencing emotional harm as a result of their exposure to the parents’ domestic abuse. The assessment did not identify physical neglect of the children and this review has not found evidence that signs of physical neglect were overlooked. Considering the assessment alongside the Continuum of Needs, the outcome of a Child in Need Plan appears to have been appropriate. 5.3.14 It is well established practice for police officers to record their observations regarding child welfare on DASH assessments. The observations were generally positive about the children’s presentation and officers never identified a need to remove the children from their mother’s care. The emotional impact, on the children, of domestic abuse incidents between the mother and the father were identified but police did not express any concerns that any of the children were otherwise subject to neglect or abuse or at risk of harm from their mother. 5.3.15 The decision to hold an Initial Child Protection Conference in June 2019 was due to an incident of domestic abuse, not because of increasing concerns about the care of the children. Indeed, prior to this incident of domestic abuse, CSC was working to step the case down to ‘Early Help’. Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 20 of 43 5.3.16 When the children were made subject to Child Protection Plans this was recorded as being due to emotional harm with neglect highlighted. The Child Protection Plan shows that the social worker recommended this category of plan whilst the other attendees at the Initial Child Protection Conference recommended the category of emotional harm. It appears that the concern about emotional harm was due to the domestic abuse between the parents. Areas of neglect are not spelt out but concerns identified in the Child Protection Plan included outstanding health appointments for some of the children, Sib 4 still drinking milk from a bottle which might affect his teeth and the mother not responding appropriately to the children’s behaviour at home. In addition, the Signs of Safety summary from the meeting noted problems with school attendance and punctuality and Sib 1 sometimes being dishevelled in school. All of these factors are potential indicators of neglect. It was however, also recorded that there were no concerns about the mother’s day to day care of the children, that their basic needs were being met and the home conditions were good. 5.3.17 Records show that over the next few weeks Sib 2’s behaviour deteriorated at home and school. At the second core group meeting the children were playing with a hammer at home which raises concern about the level of supervision and potential risk. The health visitor’s records of the four home visits she undertook during the school holidays suggest a chaotic home environment where the mother was struggling to meet the varied needs of her six children. 5.3.18 The inquorate Review Conference was held 11½ weeks after the Initial Child Protection Conference and the day before Emily was injured. At that meeting it was recorded that the home was chaotic due to the number of children and that the mother had a limited support network and was struggling to prioritise Emily’s needs over the other children’s competing demands. The minutes note that the mother was a single parent to 6 children, 3 of whom were under 3 and that whilst she was trying hard, it was a struggle for her to care for so many children. This suggests that concerns about neglect had increased during the period since the Initial Child Protection Conference when it was recorded that there were no concerns about the mother’s day to day care of the children and that the home conditions were good. 5.4 Theme 3 - The Response from Children’s Social Care to Other Concerns Raised Regarding the Family Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 21 of 43 5.4.1 The referral that led to the social work assessment was an anonymous contact. Subsequent enquiries suggested that this referral might have been malicious. The enquiries, however, revealed other potential areas of concern that had not been referred to CSC (see Sections 4.3 and 5.3). 5.4.2 During the period covered by this Child Safeguarding Practice Review, West Yorkshire Police notified CSC of 16 domestic abuse incidents that had taken place between the parents. Three of these were received before the social work assessment was completed and were considered within the assessment. Three incidents occurred during the period when the couple were in a relationship and the Child in Need plan was in place and the remainder took place after the couple separated in April 2019, including the one in May 2019 that resulted in the strategy discussion and Initial Child Protection Conference. 5.4.3 The incident in September 2018 is worthy of particular consideration. The police reported to CSC that the father had alleged that the mother had hit him and had also told Sib 2 to punch and kick him. Furthermore, that the father had said that approximately two weeks before this, the mother had said that she felt like slapping Sib 5 when he was crying and not sleeping. Sib 5 was just a few weeks old at the time. The referral from the police noted that the children were highly distressed at the time of police attendance and seemed to be heavily involved in, or witnessing the domestic incidents between their parents. The police assessed this incident as high risk and report that the only reason it was not referred into MARAC was because of the level of agency engagement already being undertaken. A social worker spoke to the parents about this referral and it is recorded that the parents minimised what had happened. There is no evidence of further follow up. Unlike the majority of domestic abuse notifications in this case, this referral included first hand observations of the children being ‘highly distressed’, and specific allegations linking the children to possible physical abuse. These allegations warranted robust challenge of the parents and consideration of holding a strategy meeting. The record suggests that CSC may have been too ready to accept the parents’ minimisation of concerns. 5.4.4 On 18 August 2019, police officers visited the mother after she called and reported that the father had been at her address breaking his non-molestation order. He had left but had been shouting and swearing when she asked him to leave. A DASH risk assessment was completed which identified a number of risks, including that the mother was feeling depressed. A multi-agency referral form was submitted by the police but Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 22 of 43 CSC has no record of this referral and the health visitor did not know about it. This incident occurred five days before Emily was injured. The health visitor undertook home visits around this time and consistently recorded that the mother did not report any low mood or anxiety. 5.5 Theme 4 - The quality and application of care and support plans and their effectiveness in protecting and supporting Emily and her siblings 5.5.1 The principal care and support plans put in place with the family were a Child in Need Plan that was in place from June 2018 to June 2019 and a Child Protection Plan that was in place from 3 June 2019 and was still in place when Emily was injured on 23 August 2019. 5.5.2 The Child in Need Plans do not provide a clear record of the concerns, what action needs to be taken to address them and what will represent success. This is partly due to the way the pro-forma is set out and partly due to how it has been completed. Many of the outcomes are generalised statements of what should be expected for all children. For example, “children to live in a stable home free from violence” and “children will grow and thrive with appropriate routines and boundaries at home”. There is almost no record of what is to be done to achieve the required outcomes and in almost every case the service provision is simply stated as ‘mother’ or ‘mother and father’. 5.5.3 The Child in Need Pans were updated in July 2018, November 2018 and February 2019 and these show little change from one to the next. This reflects the lack of clarity in the plans and means that one cannot gain an understanding of whether any progress was being made. This problem is exacerbated by the absence of minutes from most of these meetings. 5.5.4 The minutes of the meeting held on 28 February 2019, are brief and built around the signs of safety headings of ‘what is going well’, ‘what are we worried about’ and ‘what needs to happen’. Specific reference is made to both parents and to Sibs 1, 2 and 3 but there is no reference to Sibs 4 or 5 or to the mother being pregnant. There is some overlap between the list of ‘what needs to happen’ and the ‘outcomes’ in the Child in Need Plan but several of the required actions are not carried across to the plan. Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 23 of 43 5.5.5 It is recorded in the minutes of the Child in Need meeting that the family would be “stepped down to early help once all tasks are completed”. The list of what needs to happen does not include any reference to the parents addressing the domestic abuse. Whilst it is the case that no significant incidents of domestic abuse had been reported since the previous Child in Need meeting, there was a long standing history of domestic abuse and the parents separating and reconciling. Domestic abuse was a key reason the children had been made subjects of Child in Need Plans and the agreed action to address this, which was for the parents to engage with MAZE, had not been implemented. 5.5.6 The Child Protection Plan following the Initial Child Protection Conference in June 2019 is more robust than the Child in Need Plans in the sense that for each danger statement there is a clear record of what needs to happen, who is responsible, the timescale and the safety goals/desired outcomes. Where the plan referred to concerns about Sib 2’s behaviour, the focus was on the mother having not taken him for CAMHS appointments and needing to do so. There could have been more focus on agencies ensuring that the child received the assessments and services that he required. There is no indication that professionals considered whether family factors were impacting on Sib 2’s behaviour even though he was living in a household where there was numerous domestic abuse incidents involving the parents and concern about boundary setting. 5.5.7 Although meetings were held in June, July and August that have been termed as Core Group meetings, there is no indication in the records or from any other source that the Child Protection Plan was referred to during the meetings, that progress with the Child Protection Plan was ever formally reviewed or that the plan was updated as it should have been. In effect the first two of these meetings appear to have been joint home visits by the deputy DSL and the social worker and the third was a joint home visit by the health visitor and the social worker. 5.5.8 At the Initial Child Protection Conference in June 2019 it was reported that the parents had separated. This was viewed as being positive, due to the concerns about domestic abuse between them. However, a worry was identified that when the baby was born the mother would be a single parent with three children under the age of three. This was not explicitly carried over to the Child Protection Plan and no support plan was put in place to help the mother to care for all the children. Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 24 of 43 5.5.9 The concern that the mother would be a single parent with three children under the age of three did not recognise that within seven weeks of the Initial Child Protection Conference the school summer holiday would begin and that all six children would be at home for six weeks. There is no indication that any consideration was given to how the mother would manage this situation. 5.5.10 One of the actions was for the social worker to explore support networks and family tree with the mother and the children within the next two weeks. It seems likely that this action had been completed by the time of the Review Conference as the record from that meeting refers to the maternal grandmother, a maternal uncle and a friend of the mother, all of whom could provide some support. There is, however, no indication of the amount of support these people were actually providing or the impact this was having. It is of note that the social work assessment undertaken more than 12 months earlier had not considered wider family support. 5.5.11 The Core Group meeting in July 2019 was held at the family home and School 2’s record of the meeting makes reference to the children playing with a hammer. Within the meeting the deputy DSL stressed that they were extremely worried about Sib 2's behaviour in and out of school and in the home towards his younger siblings. The mother of Emily was aware that school were looking into possible permanent exclusion for Sib 2. This meeting took place within the first week after Emily was born and just a few days before the school broke up for the summer holiday. It was recorded that the mother was to be referred to a parenting course and the Freedom domestic abuse programme but as before, there is no indication that any consideration was given to how she was going to manage with the children during this period, the risks were not assessed and no support plan was in place. 5.5.12 There was a high level of input from the social worker and health visitor during the school holidays with them visiting the family home three and four times respectively. This included a joint visit during which a Core Group meeting took place. The case recordings suggest there was some difference between their views as to how well the family was functioning over this period with the health visitor noting a chaotic environment where the mother was struggling to meet the needs of all the children. However, there is no indication that the health visitor had significant concerns over the short-term welfare of the children or raised concerns with the social worker. Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 25 of 43 5.5.13 Concerns about the care of the children increased during the period between the Initial Child Protection Conference and the Review Conference 11½ weeks later. Core Group meetings with the social worker, school, health visitor, midwife and school nurse in attendance and with consideration of the Child Protection Plan may have enabled changes to be made to the Child Protection Plan to address these concerns. By the time of the Review Conference, the mother had agreed for the social worker to make a referral to the Intensive Family Support Team to carry out work on routines and boundaries in the home. The parents’ ability to set clear routines and boundaries had been identified as a concern in the original Child in Need Plan more than a year earlier and it is unclear why this had not already been addressed. Furthermore, this was not going to be a quick solution and at the time the problem was the mother was struggling, as a single parent, to cope with six children, including a new born baby. 5.6 Theme 5 – The extent to which the views of the children were appropriately sought and understood 5.6.1 There is evidence throughout the social work assessment of the social worker seeking the views of Sibs 1, 2 and 3 as part of the assessment. This was undertaken when Sib 4 was just over one year old and before Sib 5 and Emily were born. 5.6.2 Following completion of the assessment, social workers saw the children on their own at home and at school as well as observing them within the family. They completed direct work sheets with the children, so there was an element of play within some of the sessions. The record of the Initial Child Protection Conference suggests that since the parents had separated, Sibs 1, 2 and 3 had started to open up to the social worker and at school regarding domestic abuse that they had witnessed. 5.6.3 Sibs 1 to 5 were all present when the first Core Group Meeting was held; Emily had not yet been born. The minutes make reference to how each of the children presented during the meeting and brief comments about their view of school. 5.6.4 Sibs 1, 2 and 3 all attended School 1 and School 2 and were seen regularly by staff within the school settings. There is evidence from both schools of occasions when staff spoke to the children to ascertain their views and, where appropriate raised these with the mother and, on Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 26 of 43 occasion with CSC. Both schools ensure that the class teacher or another trusted adult is present when a member of the safeguarding team talks to a child. They use Signs of Safety tools, such as ‘three houses’ to ascertain children’s wishes and feelings in a child friendly manner. 5.6.5 The named health visitors consistently made observations of the younger children during home visits. During the school summer holiday of 2019, health visitor 1 undertook four home visits when six children were at home. She recorded her observations of the children and their interactions with one another. There is some evidence of her engaging with the older children to ascertain their views at that time. 6. Previous Serious Case Reviews 6.1 In carrying out this review, the Lead Reviewer has read previous serious case reviews concerning Alice, completed in 2016 and Kieran, completed in 2019. The Lead Reviewer has also read the Bradford Safeguarding Children Board Challenge Panel Outcome Report concerning Non Accidental Injuries and Head Injuries from 2016. 6.2 Three significant findings in the review concerning Alice also apply to this review: 1. Key information was not recorded by Children’s Social Care; 2. Key agencies were not represented at the initial child protection conference. 3. The risk to the child was increasing, but professionals were holding on their original decision despite clear evidence that the protection plan was not working effectively. 6.3 Two recommendations from that review also apply to the review of Emily 1. It is crucially important that all key professionals and agencies attend the Initial Child Protection Case Conference. Attendance at this meeting is pivotal in terms of sharing information and knowledge of the child and their family. It is an opportunity for professionals to weigh up all the relevant information, and to make a decision about risk with the full knowledge and understanding that is collectively shared and owned. 2. There needs to be continued awareness raising through professional training and development that highlight the risks associated with Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 27 of 43 fixed thinking and the need for professional inquisitiveness and challenge. 6.4 The review concerning Kieran found that agencies sometimes had difficulty contacting Children’s Social Care staff. It was told that Children’s Social Care has made changes to address the issue of people having difficulty making contact with individual social workers. This includes systems that allow managers to override voicemails and access email accounts if staff are absent from work. In addition, a duty system is now in place in each social work team so that practitioners can contact the duty worker if the allocated staff member cannot be contacted. However, practitioners from other agencies are not confident that these changes have resulted in significant improvements. It is suggested that Children’s Social Care should ensure that partner agencies are informed that there is now a duty system in each locality team and that the duty officer can be contacted if there are difficulties contacting the named worker. 6.5 The review recommended that: 1. Children’s Social Care should ensure that partner agencies are aware of the changes made to contact arrangements for social work staff and the action that should be taken if someone is unable to make contact with the allocated worker within a reasonable timescale. 6.6 This review was told that these same problems sometimes still apply when attempting to contact Children’s Social Care staff. The issue has been exacerbated by rapid staff turnover and high numbers of agency staff within the service. Staff should set specific voicemail messages and out of office email replies when they are away from work but this does not always happen. The message to practitioners from all agencies should be to escalate their concerns if they are having difficulty contacting a colleague. 7. Learning from the Review 7.1 As a result of inconsistencies around attendance at meetings and the way meetings were conducted, there was never a clear, shared understanding of the quality of the parenting and the children’s lived experiences, including the risk of cumulative neglect 7.2 There were no suggestions within the review period of the children being hit by their mother and no clear indications that any of the children were Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 28 of 43 at risk of a non accidental injury whilst in their mother’s care. However, there was one occasion when Sib 5 was very young and the father told the police that the mother had said she felt like hitting Sib 5. This was not fully explored or risk assessed. 7.3 The parents’ separation was viewed as positive because the main concern had been about the domestic abuse in their relationship. However, no assessment was made of the mother’s ability to care for her children as a single parent. 7.4 There was no assessment of the likely impact of a new born baby in the household. 7.5 It should have been anticipated that the mother might find it difficult to provide suitable care for all six children during the school summer holidays and a support plan should have been put in place before the holiday. 7.6 Key people were missing from Child in Need meetings, Child Protection conferences and Core Group meetings. Some were not invited and others did not attend. In some instances the non-attendance was due to late changes of meeting date or venue not being communicated. 7.7 All members of a Core Group have responsibility to ensure they are aware of the date and venue for the next meeting. If an individual misses one meeting they should take responsibility for ensuring that they find out the outcome and the arrangements for the next meeting. 7.8 CSC must take responsibility for ensuring that minutes are written of Child in Need and Core Group meetings and that these are distributed to all members of the group whether or not they were in attendance at the meeting. 7.9 Notwithstanding a Child in Need Plan for 12 months followed by a Child Protection Plan for two months there is little evidence of any change being affected. The Child in Need Plans are difficult to follow and do not provide a clear account of what needs to be change and how this is to be achieved. There is no measurement of what has changed. This is due to the pro-forma that is used and how it was filled in. 7.10 The Child Protection Plan is more explicit than the Child in Need Plans in respect of concerns and how these will be addressed. 7.11 Child in Need and Core Group meetings must be used to review the support and protection plans that are in place. There is no indication that this happened in this case. 7.12 Sib 2’s behaviour was reported as being difficult throughout the review period but this was never addressed. Possible reasons other than Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 29 of 43 ADHD were not considered. There was no consideration of whether issues such as parenting and domestic abuse were impacting on his behaviour. 7.13 The referral process to CAMHS was not pursued suitably quickly. 7.14 The process for changing patients’ addresses on SystmOne is too reliant on the patient informing their GP that they have moved home. 7.15 ‘Did Not Attend’/’Failure To Attend’ policies are not appropriate for children who are dependent on an adult to take them to an appointment. 7.16 Neither CAMHS nor SaLT had ‘Was Not Brought’ policies in place which emphasise children’s dependence on others to bring them to their appointment. 7.17 Possible indications of neglect were missed when there were delays seeking medical attention and when health appointments were missed. 7.18 The mother’s explanation for the delayed presentation of Sib 3 with a broken leg was accepted at face value by the social worker and this may have provided false reassurance. 7.19 CSC did not challenge the parents sufficiently strongly over the incident of domestic abuse in September 2018. Consideration should have been given to holding a strategy meeting in respect of this incident. 7.20 The decision in April 2019 to step the case down to Early Help was not appropriate because the agreed action relating to domestic abuse had not been implemented. 8. Recommendations 8.1. Individual agencies have already made changes to practice which address some of the learning from this review and single agency recommendations within their individual reports. Summaries of the action taken by agencies are included in Appendix 1. 8.2. The Lead Reviewer suggests that Bradford Safeguarding Partnership seeks to assure itself that partner agencies have taken action to address gaps identified in this review. The following areas have been identified. In implementing these recommendations, it is important that agencies focus on practice issues such as observation, analysis, professional curiosity and information sharing; not just on process. Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 30 of 43 1. All key professionals and agencies attend Child Protection Conferences. 2. Child in Need Plans clearly describe areas of concern, action that needs to be taken, who is responsible, when this will be achieved and the measurement of success. 3. Child in Need Plans are reviewed at all Child in Need meetings and Child Protection Plans are reviewed at all Core Group meetings. 4. Key professionals are members of Core Groups and attend Core Group meetings. 5. Changes in the composition of a household where there is a Child in Need or Child Protection Plan in place lead to an updated social work assessment. 6. Schools seek to put arrangements in place to contribute to Child Protection Conferences and Core Groups during school holidays. 7. ‘Was not brought’ policies are written and implemented for all health services offering appointments and home visits to children, in line with Multi Agency Best Practice Guidance (2018) ‘Management of Children not brought to medical appointments’. 8. Consideration is given to how Child in Need status can be noted on SystmOne. 9. Health professionals who become aware that a family has moved home ensure that relevant professionals are informed of the change of address as soon as possible. Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 31 of 43 Appendix 1 - Actions Taken by Agencies related to the findings of this review Bradford and Craven Clinical Commissioning Group CCG GP actions relating to the findings from the CSPR for Emily. Actions already taken. Safeguarding Children training for GPs includes • CCG GP Safeguarding Children training covers documentation in the child safeguarding node. The training specifically advises making corresponding entries in family members’ records as well as making an entry when an adult with parenting responsibilities suffers a significant episode of mental illness/mental distress. • All GP practices have a Did Not attend Policy and this policy is reinforced within training. In March 2018, the CCG safeguarding team provided all GP practices in Bradford and Craven with model ‘Was Not Brought’ policies. This policy is promoted in Level 3 child safeguarding training for GPs and at the GP Lead networks. There is also an over-arching multi-agency Was Not Brought policy in Bradford. • GP safeguarding children training also includes the use of the Multi Agency professional Disagreement Policy and information on the use of this policy. Use of SystmOne safeguarding children’s node. • Multi-agency SystmOne Safeguarding guidance document has been drafted by a working group from the SystmOne Safeguarding meeting attendees and is currently being edited. This will be completed by February 2021 ready for dissemination to staff. This document supports GPs understanding and use of the safeguarding children node. This includes recording of significant mental illness or severe acute mental distress in adults who have parenting responsibilities. Contribution of all key professionals and agencies attending Child protection Conferences. • The CCG have representatives supporting the Multi Agency working group reviewing the contributions and capacity of the School Nurse service ability to attend /contribute to Child Protection meetings and the impact of this on health and CSC. Actions to take forward: 10. CCG to lead on understanding the mechanisms for address changes on SystmOne 11. To include key learning points from the review for Emily in safeguarding children’s training for GP’s. Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 32 of 43 Bradford District Care NHS Foundation Trust 1. Actions Already Taken by Agency and submitted in Agency Report BDCFT Safeguarding Team have developed and communicated information for staff in the format of 7-minute briefings. These have included Think Family which includes Silo working Disguised compliance Using chronologies to inform safeguarding practice’ Cumulative Harm / Neglect The briefings have been disseminated to staff as a key message during safeguarding supervision sessions and staff have been signposted to the Safeguarding Intranet page on CONNECT where the briefing can be located. Think Family and chronologies have been disseminated in Safeguarding Level 3 Children’s training. Specialist safeguarding practitioners have also disseminated information regarding the Neglect Strategy and Neglect Toolkit to staff during safeguarding supervision sessions. A PowerPoint presentation was produced and disseminated to the 0-19 service from November 2019 regarding the Continuum of Need following its launch, delivered to 178 attendees. The Bradford Continuum of Need document (this is the local threshold document) was made available as a resource for attendees to familiarise themselves with and Staff were signposted to the document. The document as available to assist professionals to accurately identify any concerns whilst working with children and has significant guidance around the identification of neglect. BDCFT Safeguarding Team have also disseminated to staff as a key message during Safeguarding supervision sessions the importance of routine enquiry of domestic abuse. Routine enquiry of domestic abuse is also covered in the coercive control total regime domestic abuse training package which has been delivered by the Safeguarding team since July 2019. This training has been delivered to 373 attendees since this date. Between July-August 2019 the training was delivered to 87 attendees. BDCFT Safeguarding Team have ensured that the Clinical Records Management Guidance 2020 has been sent to BDCFT Team Leaders to cascade to Staff within the Trust. 2. Areas of Further Action taken in 2020 2.1 Implications of Record Keeping on Safeguarding Practice During 2020 a guidance document was produced to support staff regarding the implications of their documentation on Safeguarding practice and is relevant to this review. Has been agreed at BDCFT Safeguarding Forum, circulated across BDCFT Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 33 of 43 Care Groups, communication in Quality and Operational Meetings (QUOPs). Embedded into QUOPS templates. Is also included in the appendix of the Safeguarding Adult Policy and Safeguarding Children Policy to guide staff in their safeguarding practice. Shared as a training resource and as a Key Message in Safeguarding Supervision. 2.2 Review of Safeguarding Supervision Model The supervision model for registered staff that are caseload holders for children is currently being reviewed. This will align the safeguarding supervision model for case load holders for children to 4 times a year minimum across BDCFT, promoting intra agency groups being ‘mixed’ i.e., Health Visitors, School Nurse and CAMHS to promote BDCFT information sharing and communication across the staff who may be working with same families. 2.2.1 Plan The BDCFT Safeguarding Children Supervision Policy is due for update in early 2021 and these changes will be included in BDCFT policy. 2.3 Groups & Relationships/Household Composition The BDCFT safeguarding team undertook a clinical audit of 0-19 records (2020-21 0734) regarding household composition and the documentation of groups & relationships on the clinical health record (following a SCR Kieran 2018), further audit was completed by 0-19 services and based on data between April – June 2020 the findings indicate there was an improvement in compliance (84%). 2.3.1 Plan BDCFT 0-19 Children Services intend to Review SystmOne Guidance to reflect routine enquiry of Domestic Abuse & where & how to record in the health record. Develop updated staff guidance to support the documentation of Routine Enquiry of domestic abuse & Groups and Relationships. 2.4 Was Not Brought Approach The Was Not Brought Approach has been re visited at BDCFT. An Info graphic (poster) was reproduced in 2020 with the permission of Leeds Safeguarding Children Partnership, Safer Leeds, and Leeds Safeguarding Adult Board. This has been disseminated throughout the Care Trust, via Care Group QUOPs, Safeguarding Forum, Staff eUpdate Communications and the Safeguarding Intranet Page. 2.4.1 Plan • Further work is planned in January 2020, to revisit the BDCFT Failure to Attend Appointments Policy to align to The Was Not Brought, Multi Agency Best Practice (2018) Guidance and be formulated as a Trust wide Policy to include failed home visits. 2.5 Training The Level 3 safeguarding children training product is currently being updated and the participative training product will include the importance of Information sharing and communication within BDCFT services, to include Child in Need, Child Protection, Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 34 of 43 Was Not Brought Approach, change of address and implications of record keeping on safeguarding practice. 2.6 Safeguarding Children Policy & Procedures Was routinely updated during 2020, Was Not Brought principles, Info graphic and The Implications Record Keeping on Safeguarding Practice included in this policy. 2.7 Child Protection pathway and School Nurses A report to the BSCP from the Children’s and Young People’s System Board in September 2020 described the Impact of Child Protection Work on the BDCFT 5-19 School Nursing Service in July 2020. This provided an overview from BDCFT 0 -19 Service Assistant General Manager and Public Health of the current pressures on the School Nursing Service for Bradford District, why this has occurred and a proposed solution to allow the service to develop its statutory child protection and universal elements. Currently being overseen by BSCP and the Designated Nurse for Safeguarding Children CCG. 2.8 Child in Need Flags BDCFT Clinical Systems Specialist Children’s Services Lead has requested in Nov 2020 A SystmOne TPP request: • Request 1 – Development of an alert within the system (like Child Looked After and Child Protection Plan) for children subject to a Child in Need Plan – Request number e5f20000 • Request 2 – To have the option to record child ‘was not brought’ when saving a record Request Number 71130000 This may improve information sharing and communication if documented within the SystemOne Clinical Health Record. 2.9 Change of address It is acknowledged that the historical agreement that the General practitioner is the only practitioner that can change a child’s address on SystmOne requires review. This will be led by the Deputy Designated Nurse for Safeguarding Children in CCG as appears to be a Bradford district wide challenge for all health providers BDCFT 0-19 staff currently update the ‘correspondence address’ for the child. 2.10 Learning Event October 2020 The report should note that there was good representation of BDCFT staff at the Learning Event from this case. Attended by Health Visitor, School Nurses, Speech & Language Therapist and CAMHS. Each staff member has fed back to their own BDCFT service. Given work has progressed during 2020 during the COVID:19 pandemic it is difficult at present to provide evidence of the impact on changes. The CSPR recommendations will be monitored via BDCFT Safeguarding Forum and included in the BDCFT Safeguarding Team annual audit plan. Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 35 of 43 Bradford Teaching Hospitals NHS Foundation Trust 1. All key professionals and agencies attend Child Protection Conferences and key professionals are members of Core Groups and attend Core Group meetings. There has been a positive change in practice in relation to attendance at Initial Child Protection Conferences since the time of this incident. Following a Care Quality Commission (CQC) Inspection in February 2019 a recommendation was made to ensure that midwives are regularly contributing to the safeguarding process by consistently attending child protection conferences and submitted good quality reports to facilitate decision making and robust safety planning. Process Ideally most unborn babies are considered at Initial Child Protection Conference between 29 and 34 weeks gestation following a pre-birth assessment but this can be much later in the pregnancy depending when and why the referral was made. Invitations to all Initial Child Protection Conferences where an unborn baby is being considered are sent to the safeguarding midwifery team. The named safeguarding midwife will notify the named community midwife to facilitate attendance at these conferences. The Local Authority safeguarding administration team has details of all the community midwifery team’s. Anything up to 15 working days’ notice of the meetings is provided. Attendance is dependent on a number of factors such as clinical commitments, leave or being absent from work due to being out on call the night before a meeting. The actions below detail how the Trust supports the midwives to attend. Actions • Changes implemented in maternity (continuity / case loading) mean that the midwives caring for the most vulnerable women have a smaller caseload, which will support attendance at child protection conferences, core groups and reviews. • In early 2020 the formation of a new team to support vulnerable women was implemented. • In October 2020 an additional full time midwife was added to this vulnerabilities team to assist in meeting the conference requirement. Safeguarding training • All trust safeguarding level 3 training includes the themes which have been identified within this review. Trust training is reviewed each month to ensure that it is current and following up to date guidance and best practice. • The Trust has delivered specialist training around ACE’s Safeguarding checks using CP-IS (Child Protection Information Service) The Child Protection - Information System (CP-IS) is a system that connects Children’s Social Care (CSC) IT systems with those used by the NHS in England. CP-IS gives health professionals the ability to see whether a child is subject to a Child Protection Plan (CPP) , a pre- birth CPP or is a Child Looked After (CLA) Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 36 of 43 regardless of which local authority the child resides in. In turn, Local Authorities can see where, when and how often a child in their care has made an unscheduled visit to the NHS through emergency departments, minor injury units and other unscheduled paediatric and maternity settings. This allows staff to trace the patient via the National Spine which will display the child care alert tab if: • The child is on a Child Protection Plan (CPP) • The Mother is pregnant and the unborn child is subject to a Child Protection Plan (CPP) • The Child is Looked After (CLA) The information shared by CSC will be: • Type of plan (CPP or CLA) • Start date and end date of plan • Local Authority (CSC) name and code • CSC Emergency Duty telephone number • CSC office hours telephone number Each time the Summary Care Record is accessed and there is an active alert the Local Authority will receive information that the pregnant woman/child has accessed an unscheduled care setting. It is therefore expected that the health practitioner shares any child protection concerns direct with children’s social care (CSC) using the contact numbers that are detailed on CP-IS at the point of contact and prior to discharge. Actions- • In December 2018 the Trust signed up with NHS Digital to implement CP-IS into the all unscheduled care settings within the Trust. • CP-IS checks are completed in the Accident and Emergency Department, Children’s Clinical Decisions Unit and Maternity services. Every child or pregnant mother attending any of these departments for unscheduled care will have a CP-IS check to alert staff caring for them that they are either on a CPP, CLA, unborn is on a CPP or that within the past 12 months they have been subjected to one of the following orders. • Note this does not replace any safeguarding actions or checks with CSC at the time of attendance. Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 37 of 43 Bradford Metropolitan District Council, Children’s Social Care There have been changes made within the LCS system for ensuring things like CIN reviews and plans and assessments are more useable documents and direct the social worker to explore the issues raised within the learning (Section 7). Additionally, there has been the production of practice standards and practice guidance on all aspects of CIN/CP planning, when to update assessments etc How to write an assessments and this is all being embedded across the authority. Additionally we have undertaken an audit of partner agencies attending CP conferences (not CiN meetings) to look at what attendance is like and there is a training programme planned for partner agencies to highlight the importance of attending such meetings. There has also been an updated supervision policy and a new template for supervision built within LCS to target recommendations and follow up of actions for cases. There is a new re-structure coming into place in January – streamlining the assessment and long term teams created too much pressure because of the high volumes of cases that come through Bradford’s front door and the impact this had on being able to balance assessment and long-term work as a single team – so it is being split again. There is nothing in the learning / recommendations made that CSC isn’t aware of already and the focus on practice guidance / assessments / Section 47’s is there – so there is a bridge – but there are competing demands of high staff turnover, high level of referrals and caseloads that make it very difficult to embed. 1. Practice Standards for all aspects of social work have been written and are being embedded within the organisation. 2. There is an LCS (IT) review which is streamlining and developing forms/processes which promotes better recording this includes core group meetings and the conferences. The change in Conference reports is in place, core groups are at the testing stage. 3. There is on-going work between Safeguarding and Reviewing Unit and the Safeguarding Board about representation at meetings; there has been a review. 4. There is a comprehensive auditing process which routinely audits cases and feeds back required changes to practice directly to the social worker and team manager to improve standards. Including targeted audit areas. 5. There is greater emphasis for challenge from the CP chairs – improved by the appointment of a designated CP Team Manager 6. The screening for ICPC’s has been streamlined; with greater emphasis on the CP Chair having oversight 7. There is an overview of training taking place which will target specific training areas for social workers / team managers (this includes Section 47 training). Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 38 of 43 The senior management team are also in constant dialogue with CAMHs in regard to services on offer and waiting lists for the children we serve. In respect of the recommendations 1. All key professionals and agencies attend Child Protection Conferences. This is a collective responsibility – but from CSC perspective there has been an audit undertaken in regard to the contribution of partner agencies within the CPC process, following this training is being reviewed to build upon partner agencies understanding – due to be presented at the board in February. Alongside this, CSC are adapting their LCS process to have clearer recording of which partner agencies attend to enable greater overview and improved communication with the Board. 2. Child in Need plans clearly describe areas of concern, action that needs to be taken, who is responsible, when this will be achieved and the measurement of success. There has been an LCS overhaul of all the plans for children open to CSC, to make them more user friendly and clearer in terms of actions and outcomes. It is too early to fully tell what the impact is as we are in the ‘go live’ phase and this means that we are looking at any snagging that occurs when new IT process go live. However all plans are audited under the thematic approach undertaken by the auditing team. 3. Child in Need plans are reviewed at all Child in Need meetings and Child Protection Plans are reviewed at all Core Group meetings. As above – there has been an LCS overhaul of CIN and CP reviews, as well as a plan to ensure that core groups are signed off by a team manager to improve the quality of what is written within the meetings. CIN meetings already have a team manager sign off. There has also been a complete production of Practice Standards, the Practice Standards are being embedded across CSC within individual areas as Practice Standards are the basis for all work provided by CSC as well as the benchmark for all auditing work of cases. The auditing team does thematic audits and reports on the quality of work to the strategic management group in regard to files and work undertaken on cases. Thus it is another measure of quality and compliance. 4. Key professionals are members of Core Groups and attend Core Group meetings. The key members for core groups are identified at the CPC, and always have been so there is no change to this. Attendance at core groups is a collective responsibility, but from CSC perspective the format for reporting on LCS has improved and feeds into the response for Q1. 5. Changes in the composition of a household where there is a Child in Need or Child Protection Plan in place lead to an updated social work assessment. Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 39 of 43 The single assessment has also been updated within the LCS project, the whole assessment is now updated for each review or every 6 months (or when needed) as cited within Practice Standards. Again the changes within LCS are in its infancy and we cannot report of the success or not. However as cited above, assessments are a key area for the auditing team and there is a drive to improve practice. Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 40 of 43 Bradford Metropolitan District Council, Education Safeguarding School 1 and School both provided full CPOMs (safeguarding) records for the children whilst they attend their respective schools, these included the concerns and the actions carried out by staff. They have engaged well with the process of the safeguarding review and provided staff members to be available for meetings and discussions as part of this. Since the children attended School 1, they have now employed a school based social worker who works with children and their families in addressing safeguarding concerns. School 2 have been proactive in ensuring that when they break up for holidays, the contact details of the DSL are shared with all social workers involved with their children, to ensure that they have a point of contact if any significant safeguarding concerns arise outside of term time. The Safeguarding team’s out of office email reply also provides contact details for the DSL who s contactable via phone outside of school hours. Both schools are accepting of providing a written update for the purposes of CIN and CP reviews, where these occur outside of term time. Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 41 of 43 West Yorkshire Police Two areas of learning are suggested: i. In order to ensure that information about attendance at domestic incidents is shared with partners in all cases Bradford District Senior Leadership Team (SLT) will communicate to supervisors the need to confirm that the domestic abuse Niche template has been completed and if not to ensure that this is done and appropriate referrals made when finalising domestic abuse occurrences; This action was completed by BD SLT September 2020. An Acting Superintendent requested for a reminder to be sent out to all supervisory staff and the new domestic abuse template was to be used when finalising domestic abuse (DA) occurrences to show that additional considerations had been made. ii. That DAU staff are advised that where a notification is received from another District that a domestic abuse incident has occurred in that other District and there are children in the family resident in the Bradford District the reviewing staff member confirms that notification to social care has taken place and if not undertakes that task; This has been taken as a Force issues, it has been recognised from the learning in this case and following an additional dip sample conducted in September which identified that there was areas for improvement around cases where cross districts were involved @ action 3 below. that this may occur in other district areas and therefore the Central Safeguarding Governance (CSGU) Team are working on implementing the following process and updating the Force policy in relation to this area and endeavouring to future proof this for when the new PPN (public protection notices come into force). From our CSGU specialist; We are about to add a dedicated section into the DA policy to make it clearer around referrals to Children’s Social Care. Basically we propose to reinforce in the policy that districts will ensure that Children’s Social Care (CSC) are notified (in line with local multi-agency processes) of all children present at or living in a household where DA has been reported, regardless of DASH (Domestic abuse stalking and harassment) risk grading. This is already happening, as I have been advised by each district, although slightly different mechanisms and processes for doing so. The policy already covers the need to make a formal referral to CSC where there are certain criteria, for example, a child is injured, a child is used as a shield, the victim is pregnant etc. It also asks for attending officers to consider police protection where it is believed that the child will suffer immediate significant harm. Whilst this is already captured, we wanted to add it to a dedicated section within the policy and also remind officers of the need to document children on the DASH, speak to them and accurately record their demeanour, school, GP etc.. Public Protection Notices (PPN) is a Niche functionality which works alongside Pronto to ensure that officers and staff can submit timely concerns to Social Care via Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 42 of 43 their handheld devices and/or Niche. This process ensures a consistent approach across the force but is also a simpler and more effective process for officers and staff. The current PPN module on Niche has the ability to share concerns with Social Care for several areas of safeguarding, for example Adult at Risk, Child Concerns, Domestic Abuse, Stalking and Harassment and Honour Based Abuse. When using PPN, an occurrence is created on Niche which documents the notification, ensuring a consistent and auditable mechanism for sharing concerns with social care. However, at the moment, we have only gone live with Adult at Risk and Child concerns in Calderdale District – not DA. We are currently evaluating the pilot and hope to produce the findings in early February, once we have 3 months of data (at the end of January.) Once the report is finalised we will be sharing with Districts to discuss opportunities to consult with partners. When we expand this to domestic abuse, the DASH risk assessment is completed via PPN where there are children present, this would then allow officers to submit the notification of the domestic incident to children’s social care whilst at the scene. Again, this would all be recorded on Niche. The challenge with PPN is that we need to have the buy in from partners, which may take some time. The feedback we have received in Calderdale, which will feature in the report, has been really positive, particularly around the quality of the notifications they receive and the standardisation of the process. A 3rd area of learning was also identified and can be detailed as below; iii. That the Safeguarding Central Governance Unit repeat the dip sample process in September and confirm that reports are being properly referred. A dip sample of 20 occurrences was carried out 15/09/20 and 24/09/20. It found that 13 were endorsed with the template and showed a notification to CSC. Of the remaining seven the following circumstances were found: Summary: 1. Two supervisors have agreed that individual omissions were oversights on their part. Both are acting sergeants with around four years’ experience at the time of reviewing the occurrences (one joining June 16 and one November 16). A third supervisor who was tasked but did not create a template who has not been contacted yet has similar experience, having joined in March 16. This appears to be an issue of new and relatively inexperienced supervisors learning procedures while in acting roles and a product of the Force’s current demographic; 2. One report was as the original circumstances – created Calderdale District and re-allocated to Bradford District where dealt with by DAU who assumed referrals would have been made by the attending response officers; 3. In one report a supervisor made an active decision not to notify. This does not appear to be contrary to policy; Child Safeguarding Practice Review concerning Emily; Overview Report 1st February 2021 Page 43 of 43 4. Two occurrences were not tasked by the attending officer to their supervisor although they were tasked to Bradford District Safeguarding partnerships (attending officers similarly experienced as above). |
NC52468 | Death of an adolescent boy by suicide in September 2018. Learning and recommendations are combined and include: ensure that all agencies work with children and young people in a way that considers the consequences of attachment difficulties; the need for agencies involved to explore issues around risk assessment; risk formulation; and risk management; ensure that agencies are working with children and young people in a way that places the responsibility for engaging children and young people and their families with professionals and that professionals use appropriate language in records which reflects this responsibility; ensure that agencies review procedures for informing staff about the death of a patient or service user and what procedures are in place to offer appropriate support to affected professionals; review safeguarding policies and training to ensure that staff don't discount safeguarding disclosures when they are made by children and young people with mental health presentations; ensure that professionals take appropriate forensic and psychosexual histories to inform assessment of risk and needs and to manage the safety of others.
| Title: Serious case review: Child W. LSCB: Wigan Safeguarding Children Board Author: Kenny Ross Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Independent Reviewer: Dr Kenny Ross - Consultant Adolescent Forensic Psychiatrist 1 CONTENTS Paragraphs Page 1-9 Section 1: Background 2-3 10-18 Section 2: Parallel Proceedings: Coronial, NHS and Criminal 4 19 Section 3: Terms of Reference 5 20-21 Section 4: Sources of Information 6 22-24 Section 5: Serious Case Review Panel Members 7 25-267 Section 6: Key Lines of Enquiry (KLOE) 8-47 25-31 • KLOE 1 8-9 32-92 • KLOE 2 10-19 93-128 • KLOE 3 20-25 129-143 • KLOE 4 26-28 144-224 • KLOE 5 29-40 225-267 • KLOE 6 41-47 - Overview of Independent Reviewer Recommendations 48-49 - Appendix 1 Glossary of Terms Used 50 - Appendix 2 Anonymisation Used 51 - Appendix 3 CARSO 52-53 - Appendix 4: Independent Reviewer Information 54 2 SECTION 1: BACKGROUND 1. Child W was found deceased by a member of the public on 19 September 2018 and his death was thought to have been caused by suspension by a ligature around his neck. A Rapid Review took place within fifteen days. The decision was made to progress to Serious Case Review and an Independent Reviewer was commissioned. 2. His brother described Child W as being “cynical” and as having “a dark sense of humour”. He also described him as being “very loving” but as being “very, very blunt”. Child W had been “more of a best friend than a brother to me”. However, his brother also described Child W “used to just switch from looking normal to going glazed with his head down and looking like he was going to go for my throat”. There was no obvious trigger described for this. 3. Child W’s mother and stepfather described him as being “a joker” and “very happy” but also as being “very stubborn”. They stated that he was looking forward to becoming 18 and having a pint in the pub. His mother described him as being “happy go lucky” and a character although sometimes he would become “stressed”. 4. Practitioners attending the Practitioner Event were asked to describe Child W in a few words. He was described by them as follows: • “Child W was slim-built, quiet, but engaged with his peers at times”. • “He was bright articulate, driven and well-read, quick witted with a dark/dry/good sense of humour”. • “He was suspicious and wary but engaged when he wanted to”. • “He knew what he wanted and could be stubborn”. • “Child W was determined to get out of the system and could not wait to turn 18”. • “He occasionally gave hope to staff but then could change quickly and shut down again”. • “Child W was described as an anxious little boy at the age of 5 who seemed to be the same aged 17”. • “He had low self-esteem and thought of himself as a fat little boy, he was anxious, impulsive and struggled to cope in large groups”. 5. Information provided states that school reported that Child W had no established relationships within schools and was described as being anxiety-driven and sensitive to rejection. 6. In his Pathway Plan Child W is described as being “a very articulate young person who is good company with his good sense of humour and observations. Child W can challenge others when required and can express his wishes and feelings in the majority of situations however he can struggle when emotionally overloaded”. 3 7. A Record of Consultation dated 25.11.2009 by County Psychological Service states “Overall, Child W presents as a boy of high average general ability, with a particular strength in verbal reasoning and a noticeable weakness in auditory working memory”. 8. A chronology received states: • Between 2005 and 2006 Child W was placed with Local Authority foster carers, initially under Section 20 of The Children Act but this was replaced by an Interim Care Order. During this placement Child W was cared for on a temporary basis by other foster carers on three occasions due to holiday plans made by the foster carers. • Between 2006 and 2009 Child W was made subject of a Freeing Order and placed with potential adopters along with his two younger siblings. • Between 2009 and 2013 Child W was placed with foster carers following the breakdown of his adoptive placement although his siblings remained there. Child W was moved to out of borough foster carers in Carlisle through Family Foster Care. • During 2013 and 2014 Child W was placed in a residential placement, in the Carlisle area. • Child W was placed with foster carers in the Carlisle area from April to October 2014 • Between 2014 and 2016 Child W was placed at a Children’s Home in Wigan (an internal provision). • In early 2016 Child W was placed with Local Authority foster carers. • In mid-2016 Child W was placed at a residential children’s home in the Wigan area. • Between 2016 and 2017 Child W was placed in another residential children’s home in the Wigan area. • From August 2017 until March 2018 Child W was placed in a semi-independent accommodation in the Wigan area. • During 2018 Child W was placed within a residential children’s home in the Wigan area. • In mid-2018 Child W was placed in semi-independent accommodation in the Wigan area. • Autumn 2018 Child W was admitted to Ancora House, a Tier 4 Child and Adolescent Psychiatry inpatient unit. • Upon discharge from Ancora House Child W was placed in semi-independent accommodation in the Wigan area. 9. Child W had a total of ten Social Workers between July 2003 and September 2018. This works out as an average of just over 18 months per Social Worker. However, it should be noted that Child W had two long periods where the Social Worker remained consistent, these were: September 2012 to January 2015 and, January 2015 to July 2017. 4 SECTION 2: PARALLEL PROCEEDINGS: CORONIAL, NHS AND CRIMINAL Coronial 10. The coroner requested that the WSCB Serious Case Review took place before the Inquest. 11. The Independent Reviewer acknowledges that at the time of writing the Coronial process had not concluded and this may have inhibited the way in which the professionals felt they could contribute to this process. NHS 12. The case met the criteria for investigation under the NHS Serious Incident (SI) Framework. 13. Cheshire and Wirral Partnership NHS Trust (CWPT) added the incident to the NHS Strategic Executive Information System (StEIS). An SI investigation was then carried out by CWPT and submitted to NHS Wigan Borough Clinical Commissioning Group (WBCCG) for review and closure. 14. North West Boroughs Healthcare NHS Foundation Trust (NWBH) were also providing care to Child W therefore they conducted a 72-hour Concise Review under the NHS SI Framework. This Concise Review was considered by their Patient Safety Panel where it was agreed that a Comprehensive SI Investigation was not required. This decision was endorsed by WBCCG. 15. Wrightington, Wigan, and Leigh NHS Foundation Trust (WWL) and Bridgewater Community Healthcare NHS Foundation Trust (BWCH) reviewed the care and treatment provided and did not feel that a SI Investigation was required. 16. An SI Comprehensive Investigation Report was provided by CWPT and reviewed by WBCCG Serious Incident and Never Event (SINE) Panel. The Business Manager from Wigan Safeguarding Children Board was invited to take part in the SINE Panel. The SI Investigation Report; comments from the SINE Panel; and correspondence between WBCCG and CWPT in relation to the report has been shared with WSCB for consideration as part of the Serious Case Review process. Police 17. The Independent Office for Police Conduct (IOPC) conducted an investigation because Child W was Missing from Home. 18. There are no criminal or civil proceedings known to the Independent Reviewer. 5 SECTION 3: TERMS OF REFERENCE 19. The Serious Case Review Panel Members agreed six Key Lines of Enquiry (KLOE) as outlined below: KLOE 1 To develop an understanding of Child W’s developmental history of attachment and consider the impact of life events on him KLOE 2 To consider and review the various risk assessments undertaken by all agencies involved with Child W KLOE 3 To review the content and chronology of interagency communication in Child W’s care and the multi-agency care planning in relation to his mental health and placement history. KLOE 4 Review the care planning afforded to Child W in the context of his being a child with Looked After status, including the potential impact of location on Child W’s access to services KLOE 5 Explore the interventions Child W experienced in the later part of his life. KLOE 6 Establish learning from critical episodes which are identified through the SCR process. 6 SECTION 4: SOURCES OF INFORMATION 20. This Serious Case Review report is based on the following sources of information: Date Meeting 16 July 2019 Initial Panel Meeting held 03 December 2019 Second Panel Meeting held 05 February 2020 Third Panel Meeting 03 April 2020 Fourth Panel Meeting held 03 September 2020 Meeting with CWP representatives 02 November 2020 Fifth Panel Meeting held 11 February 2020 Practitioner Learning Review Event held. This included a session solely for Practitioners in order to facilitate a full and frank discussion by Practitioners about how Child W’s death was communicated to them and about the support offered to them by their organisation thereafter without their managers being present. 28 February 2020 Meeting with Child W’s mother and stepfather and their legal representatives 06 March 2020 Attendance at Coroner’s Court 20 March 2020 Telephone interview with Child W’s brother 21. I have been provided with large amounts of information from involved agencies although some information remains missing (CAMHS records from Cumbria and Yorkshire; Mental Health records from Lancashire (Blackpool); and some General Practice (GP) records. 7 SECTION 5: SERIOUS CASE REVIEW PANEL MEMBERS 22. The Serious Case Review (SCR) Panel was comprised of: The Independent Reviewer Business Manager Wigan Safeguarding Children Board (WSCB) Learning and Improvement Officer WSCB Named Nurse for Safeguarding Children Cheshire and Wirral Partnership NHS Foundation Trust (CWPT) Named Nurse for Safeguarding Children and Children in Care Wrightington, Wigan, and Leigh NHS Foundation Trust (WWL) – Acute and Community Services Community Services were provided by Bridgewater Community Healthcare NHS Foundation Trust (BWCH) which transferred to WWL in April 2019 Specialist Nurse for Safeguarding Children WWL Named Nurse for Safeguarding Children North West Boroughs Healthcare NHS Foundation Trust (NWBH) Service Lead, Children’s Social Care Wigan Council Assistant Director/Designated Nurse for Safeguarding Children & Looked After Children NHS Wigan Borough Clinical Commissioning Group (WBCCG) Associate Named Nurse for Children in Care CWPT Advanced Nurse Practitioner for Safeguarding Children NWBH A Representative from Cheshire Police Cheshire Police Secure and Specialised Case Manager for Cheshire, Merseyside, and Lancashire NHS England - Cheshire, Merseyside, and Lancashire 23. The following people were subsequently added to the SCR Panel: Detective Sergeant Greater Manchester Police (GMP) Serious Case Review Team A representative from Pathways and Inspire Pathways and Inspire (Placement Providers) Lead for Children in Care Children’s Social Care, Wigan Council Virtual School Head Wigan Council Strategic Lead Practice and Quality and Assurance Team Children’s Social Care, Wigan Council. 24. The SCR Panel Members created a detailed multi-agency chronology that was compiled as part of the Serious Case Review Process. 8 SECTION 6: KEY LINES OF ENQUIRY (KLOE) KLOE 1: To develop an understanding of Child W’s developmental history of attachment and consider the impact of life events on him 25. Life events had a significant impact on Child W and there are several mentions of major changes adversely impacting on him (change of Social Worker; change of placement; moving to the Leaving Care Team etc.). However, throughout the documentation provided there seems relatively little in the way of understanding of his difficulties or indeed seeing his behaviour through the prism of attachment difficulties. Rather the responsibility for his not engaging with professionals is laid fully with him and this is reflected in the language used e.g., you failed to engage in… There seems little ownership by professionals i.e., it is their role to facilitate his engaging with them. 26. QQ described that Child W struggled with “the constant change” of both Social Worker and placement. 27. On two occasions documents contain reports and/or statements that strongly suggest that a professional did have more understanding: • In the Pathway Plan Part 1 – Assessment – completed December 2017 by his Social Worker states “Child W feels let down by professionals and adults throughout his childhood, alongside his attachment difficulties, which has had a detrimental effect on his ability to manage present working relationships which is a significant barrier to him accessing support to ensure his needs are met. Therefore, there is a risk of unmet needs”. • An Educational Psychology Service Report from June 2015 states that the hypotheses developed by the Educational Psychology Service which included Child W struggling to form relationships, replicating relationship patterns to those of his parents, the need to be in control, struggling to adapt his strategies and with routine and change. He also is reluctant to engage but can respond positively; and seems to do better in smaller settings with firm boundaries and behaviour management strategies. KLOE 1 - Independent Reviewer Concluding Comments: 28. It is very likely that given Child W’s early history of not being provided with safe and appropriate care; multiple placements, with many failing (compounded by his siblings being successfully adopted); changes of professionals allocated to his case; geographical moves; and changes of school that he had attachment difficulties or possibly an attachment disorder. 29. The diagnosis made in Ancora House of F92.9 – Mixed Disorder of Conduct and Emotions, Unspecified can be seen as being one of the end points of earlier attachment difficulties. 9 30. The overall feeling of the Independent Reviewer was that professionals did have an awareness that Child W had difficulties with attachment as a result of his life experiences but that this rarely seems to have translated into written documentation or impacted on their interactions with Child W. 31. Independent Reviewer Recommendation 1: WSCB should seek assurance that all agencies work with children and young people in a way that considers the consequences of attachment difficulties This includes the long-term effects on behaviours, relationships, and engagement with professionals. Language used in agency records should reflect that the responsibility for engaging children and young people sits with the professional. The ethos should be included in the following: • Workforce development and training • Agency assessment and planning documentation • Trauma-informed practice • The use of professional language • How professionals engage children and young people 10 KLOE 2: To consider and review the various risk assessments undertaken by all agencies involved with Child W Referral to Wigan CAMHS - 28/02/18 32. A referral to CAMHS was made by Child W’s Social Worker on 28/02/18. The referral included a detailed list of Child W’s risk factors, protective factors, unmet needs, and other issues such as him presenting as unkempt, not sleeping, damaging property, being missing from home and disengaging from the staff. 33. In this referral the Social Worker documented that Child W had said he would “hang himself” if he had to stay at his residential placement and there was concern that he may do this. Looked After Child (LAC) Review Health Assessment - 13/03/18 34. A statutory Review Health Assessment (RHA) was completed by a Specialist Nurse for Children in Care and Child W’s Support Worker. Child W gave his consent for this to occur with his Support Worker’s involvement but opted not to take part himself. 35. The RHA documentation outlined that Child W was not reported to be self-harming. He was described as accessing social media, but it is not known what sites he accesses. It states “It is thought he may be accessing inappropriate material on-line. He will not engage in meaningful discussions around Internet safety. It is not thought he is being exploited, however, this could not be discussed with him”. Strategy Discussion - 31/08/18 36. A document entitled ‘Record of Strategy Discussion’ from a telephone Strategy Discussion held on 31/08/18 states the professionals involved were from Children’s Social Care and the Police. Child W was reported missing from home on 30/08/18 and subsequently located in Blackpool. 37. Child W is described as having stated to a Police professional and the staff at the care home in Blackpool that he cannot return to Wigan “as his family are going to kill him”. There were concerns expressed by him about how a family argument. 38. Child W is described as being extremely anxious and professionals are described as being concerned he was experiencing psychosis. The Police Officer in Blackpool felt that Child W may try and run away should he be made to come back to Wigan. The Police Officer was advised that if there were concerns for Child W’s mental health he needed to be taken to hospital or Paramedics called to review him. Child W declined to go to A&E and was taken back to his placement and ran away on return. 39. Child W was placed in a staff car to return to Wigan and the Police followed this onto the motorway because of concerns he would jump out of the car. Child W later accused 11 staff of being liars and that he was going to be put into a Secure Unit. He also reiterated that he was “in danger” and was “a dead man”. He asked to go to A&E but stated he wanted to go to A&E in Blackpool. Staff believed that he would abscond if he was taken to hospital in Blackpool so offered to take him to Wigan A&E, but he refused. Shortly after returning to the unit Child W absconded again. 40. Information from the Police states that Child W has a Section 39 Assault, criminal damage, and threats to cause damage in 2018 that have not been pursued with the Police and have occurred in placement. Mother and stepfather are described as having a forensic history. 41. Child W was assessed by the Police as being medium risk missing but the Deputy Practice Manager from Children’s Social Care thought that he should be high risk. 42. Plans from the Strategy Discussion held on 31 August 2018 included that Police should inform Social Care and Child W’s brother when Child was located. Then assess his mental health and support access to mental health assessment if appropriate. If this was not required Child W would be returned to his placement. The grading of risk should then be collectively reassessed. The Police agreed to consider any risk in relation to where Child W was staying and his family and if concerns identified contact Social Care. Letter from Wigan RAID/CAMHS - 02/09/18 43. A letter from Rapid Assessment and Interface Discharge (RAID) Team/Child and Adolescent Mental Health Services (CAMHS) Wigan follows an assessment of Child W. This included a review of Child W’s: • Risk to Self within which he denied having any current thoughts of self-harm or suicide as he reported feeling safe in hospital. • Risk of Self-Neglect as it was reported that Child W had not been maintaining his personal care and restricting his dietary intake. • Risk to Others which included reports that Child W had assaulted staff. • Risk of Vulnerability, Child W was seen as vulnerable due to his mental state and risk of absconding. He was also reported to smoke cannabis daily to reduce auditory hallucinations. • Risk of Eating Disorder as he had been restricting his dietary intake as a means of self-harm. 44. The formulation from the RAID assessment was: “Child W is presenting with psychotic symptoms where the present auditory hallucinations are causing Child W distress”. 12 “Child W’s risk to self has increased due to his presentation where his delusional and paranoid beliefs are enhancing the auditory hallucinations which are increasing his vulnerability and risk factors”. 45. The plan was for a further assessment with the CAMHS psychiatrist with a request for a Tier 4 (a child and adolescent psychiatry inpatient) bed. Fairhaven (the local Child and Adolescent Psychiatry inpatient unit in Warrington) were aware of this. Street Triage from Knowsley Adult Mental Illness Services - 03/09/18 46. On the 03/09/18 the Street Triage from Knowsley Adult Mental Illness Services completed a comprehensive Risk Screening Tool. 47. This Risk Screening Tool completed by Street Triage does list the presence or absence of many potential risk factors but does not lead to any formal assessment of risk e.g., the risk of self-harm is currently high and related to the patient’s mental state. The use of alcohol and/or illicit substances that have a disinhibiting effect may be associated with an increased risk. Referral for Access Assessment into Inpatient Services for Children and Young People - 04/09/18 48. A Referral for Access Assessment into Inpatient Services for Children and Young People form dated 04/09/18 was completed by Clinical Lead at RAID services in Wigan contains the following information. 49. The risk factors section of the report is completed including his history of self-harm and suicidal ideation; he has absconded from the ward; his assault on care staff; the risk of self-neglect; risk of exploitation. The referral form does not ask for an assessment of risk as such but asks for one to be attached. Mental Health Act (MHA) Assessment Form - 06/09/18 50. A Mental Health Act (MHA) Assessment Form dated 06/09/18 follows Child W being assessed whilst he was under Section 136. Under risk to others, this assessment states that “Child W can present as agitated and aggressive to others especially when trying to act on his voices’ commands to get away”. Under risk to self, it states “Child W is at risk of self-harm and suicide. He has attempted to hang himself on two occasions in the last 48 hours. He continues to have suicidal ideology and is stressing he will act on this and the voices telling him to kill himself”. 51. Child W was detained under Section 2 of The MHA (1983) due to: • An evident mental disorder (hearing voices and persecutory thoughts) of a nature and degree that warrants hospital detention. 13 • Risk to own health and safety due to lack of insight into mental state, persecutory thoughts and inability to risk assess. • Lacks capacity regarding voluntary admission and consent to assessment. • DoLS not appropriate as admission only for assessment/treatment of mental disorder. 52. Community alternatives were deemed inappropriate given him being actively at risk of self-harm or suicide. AMP Outline Report – 06/09/18 53. This follows Child W undergoing a Mental Health Act Assessment. The reasons for this as stated on the form were: “actively suicidal, attempted hanging, hearing voices and numerous attempts to abscond. Absconded from the ward and detained by Police on Section 136 MHA 83”. 54. The assessment is summarised as “Child W is hearing voices, responding to outside stimuli which is telling him to commit suicide. He has attempted to hang himself on two occasions over the past 48 hours and continues to express suicidal thoughts. He used cannabis approximately 4 days ago. He continues to be a risk to himself if not admitted to hospital under the MHA. Child W has absconded from the general health ward at Wigan Hospital and returned on Section 136.” 55. He was felt to lack capacity to agree to informal admission and an alternative care plan was not deemed appropriate as his risks could not be managed in the community. Mental Health Act Assessment Form – 06/09/18 56. A MHA Assessment Form follows him being assessed whilst he was under Section 136. This states that Child W was unknown to CAMHS prior to these presenting concerns. It describes him hearing persecutory voices telling him to kill himself and states that he had attempted to ligature himself and had cut himself with plastic. A history of cutting his arms is noted. He is described as hearing voices encouraging him to kill himself and has been actively suicidal. 57. The history is noted. He was described as being happy to engage in the MHA assessment although he remained in bed and presented as tired and lethargic. He described hearing voices that were “always there” and told him to kill himself and called him “a nonce”. There were in internal space and intrusive to his thoughts. They had been present for a month. The voices were of his “dad”, QQ, his girlfriend, and a cousin. The voices said that his “dad” wanted to kill him, and he should kill himself. He had attempted to hang himself by tying his hospital gown to the roof. He explained that he absconded because the voices told him that his “dad” was coming to get him to kill him. The voices said “run” so he got on a train. The next stop was Preston 14 where he tried to self-harm in the station toilets. Child W stated he was unsure whether the voices were real or not. Clinical Assessment of Risk to Self and Others (CARSO) Summarised View of Risk - 06/09/18 58. The opening statement to this document states: What is the nature & degree of risk? Who is at risk? Can you state how likely it is to occur? Is risk escalating or decreasing? Under what circumstances might it occur? Relationship between risk and mental disorder, social circumstances, or their contextual factors? Factors increasing risk and protective factors which reduce risk. What benefits to the user may arise from taking considered risks? What would be in the best interests of the service user? Are there any gaps in the information or areas which require further assessment? 59. This risk assessment included ‘Risk to self’, ‘Risk to others’, Risk from others and a ‘Summarised view of risk ‘. 60. I think it is fair to say that this is not a risk assessment in that there is no view expressed about risk in terms of either severity or imminence. No mention is made of any potential risk factors that were not present. There is no attempt to formulate risk, or any plan developed to manage risk, in the short, middle, or longer terms. The CARSO process does not of itself lead to a weighted score for risk e.g., high or low risk. Baseline Summary by Mental Health Practitioner Ancora House - 06/09/18 61. A document entitled Baseline Summary (undated but appears likely to be 06/09/18) contains the recent history. The “Risks” heading is followed by: 62. Risk to Self: Risk to self through self-injurious behaviour, he cuts superficially and scratches as a method of coping with derogatory voices that he hears. Child W also reports voices telling him to harm himself and end his life. He believes that the only way to stop what he is experiencing is to end his life. Child W has been restricting his diet as he described the discomfort caused by hunger helps to distract him from the voices and focus his mind, this can cause a risk to his physical health. 63. Risk to Others: The document states: “There are reports of historical violence and aggression that has caused breakdown of foster placement and residential care placements. However, there are no clear details of these incidents and Child W denies any risk to others.” Child W does report paranoid beliefs about others wanting to hurt him and feeling that he is being watched/recorded and “bugged”, this may cause some increase in agitation and risk towards others. 64. Indirect Risk to Self: 15 Child W reports smoking large amounts of cannabis. He states that he does this to reduce the voices and distressing thoughts that he has, this may cause an indirect risk towards his physical health and may alter his sense of perception and awareness of danger plus allowing him to place himself in vulnerable situations. 65. From Others: Child W reports being at risk from others as he believes people are trying to kill him. There is no evidence he has been targeted by others; however, he presents as a vulnerable young man who may be easily influenced by others, particularly due to the large amount of cannabis he consumes on a daily basis. 66. There is some attempt here to link risk factors with actual assessment of risk. There is recognition of the need for further information to inform the assessment of risk e.g., in relation to the reported history of assaultive behaviour towards residential staff “there are no clear details of these incidents and Child W denies any risk to others”. 67. There is a heading stating Forensic followed by “none identified”. It is not clear how much detail was pursued in this area. 68. In the formulation Child W’s presentation was described as being “consistent with an expected presentation where a young person has experienced significant trauma and neglect”. It goes on to describe Child W reporting auditory hallucinations and paranoid beliefs; hears voices telling him to end his life and harm himself and he believes that people are trying to harm him as they believe he is a paedophile. Child W reports that these symptoms have begun in the past few months and a full assessment of his mental state is required to ascertain the nature of these thoughts. 69. Under the heading of “Likely impact of hospital admission” the following is mentioned: 1. Positive – admission will allow a full assessment of mental state and allow risk to be assessed in a safe environment. A psychological formulation can be completed to allow an understanding of Child W’s difficulties and inform future CAMHS work. 2. Negative – Child W may become dependent on the inpatient unit due to the provision of a structured and safe environment that meets his needs. Minutes Care Planning Meeting - 07/09/18 70. Minutes from a Children’s Social Care Care Planning Meeting state that Child W had been detained under Section 2 of The Mental Health Act (MHA) and is in Ancora House. Professionals involved will be led by Mental Health in addressing care planning for his future. It makes note of “numerous missing from home episodes, suicide attempts” since the last meeting. 16 71. The plan describes that a package of support around Child W once discharged from hospital would be put into place and Wigan CAMHS would become involved with him ASAP. 72. I note that this plan is incomplete with remaining areas not completed. Under ‘Risks identified and mitigation’ it states “currently Child W is presenting with paranoia, psychosis (possibly drug-induced). He has made several attempts to commit suicide. Child W is described as being “a very poorly young man”. CARSO Summarised View of Risk – 11/09/18 73. CARSO Summarised View of Risk was completed by a Staff Nurse. It has been explained to the Independent Reviewer that after an initial CARSO document is completed that information contained in it is automatically prepopulated in subsequent CARSOs. This did lead the Independent Reviewer to incorrectly believe that this had been the result of cutting and pasting information. It is important to note this in the final version of the report. 74. This second CARSO contains no additional information under the headings “Risk to Self” and “Risk from Others.” 75. However, under the heading “Risk to Others” three new items which included verbal and physical aggression against staff and patients. 76. The additional information has been added into the prepopulated subsequent CARSO. Again, this summarised view of risk does not contain any assessment of risk. It also does not mention any missing factors. Again, there is no statement about degree or imminence of risk. There is no formulation of risk or any plan to reduce risk. CARSO Summarised View of Risk - 14/09/18 77. CARSO Summarised View of Risk was completed by Staff Nurse. This CARSO also has additional information under the heading “Risk to Others” which includes verbal and physical aggression and assault. Child W is reported to have “Exposed himself to female staff on a number of occasions” and set off the fire alarms off causing Fire Service to attend the ward. The ‘Risk from Others’ section was updated to acknowledge that Child W “Could be a target due to disinhibited and provocative behaviour”. 78. Again, there is no statement about degree or imminence of risk. There is no formulation of risk or any plan to reduce risk. 17 Risk Review prior to discharge – 18/09/18 79. The following sentences are included within this section: “No thoughts to harm others or self-expressed and no reports of any voices. No evidence of any psychotic symptoms.” 80. What this entry does not make clear is whether or not Child W was asked questions in order to elucidate any symptoms of psychosis or thoughts of self-harm or suicide. The statement that he did not express thoughts of self-harm or thoughts to harm others could be seen as meaning that he was not asked. The fact he did not express these thoughts is not evidence that he did not have them. There is a need to ensure that case note entries are very clear i.e., Child W denied having thoughts of self-harm or suicide. This makes it clear that the question was asked of him (the veracity of the answer is of course never certain). Electronic Discharge Summary - 18/09/18 81. The Electronic Discharge Summary includes the following information: • Child W was “reluctant to state where he obtains his cannabis but stated that he gets it for free”. • He stated that he has a history of superficial self-harm by cutting and scratching himself as a coping strategy as the pain caused by self-harm results in “the voices stopping”. He also stated that he sometimes harms himself because the voices tell him to. • Child W appears preoccupied at times by thoughts that he is evil and a paedophile, he is unable to state why he believes this is the case, but he expresses thoughts that he believes people, particularly his father, will try and kill him as they know he is a paedophile. 82. The electronic discharge summary includes reference to the CARSO. 83. Language is used to incorrectly describe this young man, i.e., he never exposed himself. He was wearing ill-fitting hospital pyjamas resulting in his genitals being visible. This is not the same as indecent exposure. Again, he is described as “does not engage” with professionals but this puts all the responsibility on him. 84. The Risk Assessment contained here really is risk factors rather than a risk assessment although to be fair it is called Risk Identified. Section 136 Assessment at Arrowe Park A&E - 18/09/18 85. The Risk Assessment states: “Risk to Self – Child W would not elaborate fully when exploring suicidal thoughts, however, he is asking for help, he said that he would want an inpatient admission and 18 therefore, strong indicators of future planning and help seeking. He has self-harmed in the past and also on the ward. He can contact staff at his accommodation should he have thoughts of harming himself or contact RAID Team. Risk to Others: the ward Discharge Summary stated that he can be verbally aggressive to staff and peers and has a low tolerance of peers. Risk of self-neglect – he was unkempt today. This will be monitored by supported accommodation.” 86. There is consideration here of factors that could impact on risk – both increasing and decreasing risk. However, there is no formulation of risks and no risk management plan. KLOE 2 - Independent Reviewer Concluding Comments 87. There are very few actual assessments of risk documented. The majority of documents are simply lists of risk factors that are present in Child W’s case (and rarely the risk factors that are absent). In general, there seems to be no attempt to describe any risk, certainly in terms of imminence or degree (low, medium, or high). Generally, there are no formal risk management plans, albeit that his being detained under The Mental Health Act and admitted to a Tier 4 CAMHS inpatient unit and his being placed on Level 3 (‘enhanced’ i.e. line of sight observations) and then Level 2 (at a frequency between 5 and 15 minutes i.e. the frequency required to maintain safety) observations could be seen as contributing to a plan to manage risk. I understand that there is a daily risk review process whereby the observation levels are reviewed and can be raised or lowered as appropriate. Risk levels, and therefore observations levels, are reviewed at the weekly Case Planning Meeting. 88. The three CARSOs provided are incomplete. The opening statement to this document states: What is the nature & degree of risk? Who is at risk? Can you state how likely it is to occur? Is risk escalating or decreasing? Under what circumstances might it occur? Relationship between risk and mental disorder, social circumstances or their contextual factors? Factors increasing risk and protective factors which reduce risk. What benefits to the user may arise from taking considered risks? What would be in the best interests of the service user? Are there any gaps in the information or areas which require further assessment? The next section is entitled “Summarised view of risk” and contains the following prompts: Can you identify previously helpful interventions; are there any lessons to learn about what to do and what not to do in the future? There is a text box to “Detail any reasons for inability to consider or collect information on any of the above.” 89. None of the three CARSOs have any statements in relation to the above three paragraphs. 90. It is difficult to state whether or not better-quality risk assessments; risk formulations; and risk management plans would have led to a different outcome. It is likely that better risk assessments would lead to better risk management plans. 19 91. A further factor that impeded risk assessment was that information was not always shared between agencies. Information concerning Child W’s statements about being in a pornographic video with someone underage was not shared with Ancora House. Information about his being “the victim of childhood sexual abuse” seems not to have been shared with a number of agencies. 92. Independent Reviewer Recommendation 2: Agencies involved should explore the issues raised in this report regarding Risk Assessment; Risk Formulation; and Risk Management. They should consider the need for further workforce development and strengthening of existing policies and processes. 20 KLOE 3: To review the content and chronology of interagency communication in Child W’s care and the multi-agency care planning in relation to his mental health and placement history Language used to describe Child W and his difficulties with engagement with professionals 93. Across documentation from agencies involved in Child W’s care there is a pattern of language use that places the responsibility for his engaging with professionals with him as opposed to the professionals. Phrases such as “refused to engage;” “chose not to engage;” “has not engaged with any appointments;” and “has always refused to attend any appointments;” are used. 94. The language used places all of the responsibility for any failure to form a therapeutic alliance on Child W and absolves professionals of any responsibility. Engagement skills should be a core facet of any professional who works with children and young people and it should be seen as the responsibility of professionals to facilitate the engagement of children and young people. Children and young people have often had adverse experiences with adults who have let them down, abused and/or abandoned them and it should not be surprising that many children and young people who come into contact with services find it extremely difficult to form trusting relationships or engage with professionals. Professionals need to work in a flexible manner, including not expecting children and young people to necessarily attend a clinic in order that they can be seen. 95. There is a distinct issue about the use of language used both to describe Child W and to communicate with him. There is minimal acknowledgement that he may have found it difficult to trust people. In the Pathway Plan Part 1 – Assessment – completed 5 December 2017 the Analysis section states “Child W’s significant difficulties with adults and his lack of engagement has resulted in a number of his needs being unmet as this barrier prevents Child W assessing support available to him”. It also states however, “Child W feels let down by professionals and adults throughout his childhood, alongside his attachment difficulties, which has had a detrimental effect on his ability to manage present working relationships which is a significant barrier to him accessing support to ensure his needs are met. Therefore, there is a risk of unmet needs”. This shows insight into Child W’s likely difficulties. 96. Child W is described as being “a very articulate young person who is good company with his good sense of humour and observations. Child W can challenge others when required and can express his wishes and feelings in the majority of situations however he can struggle when emotionally overloaded”. 97. Independent Reviewer Recommendation 3: WSCB should seek assurance that agencies are working with children and young people in a way that places the responsibility for engaging children and young people and their families with professionals and that professionals use appropriate language in records which reflects this responsibility. 21 Communication with and to Child W 98. It appears that when Child W moved placement that professionals involved in his care changed: not only those providing care but Looked After Children Nurse professionals; and CAMHS professionals and this must have had an adverse impact on their ability to engage him and his ability to trust in them. Child W was described as having a good relationship with his Social Worker who was consistently in his life from the ages of 12 to 16 but then he had to change to the Leaving Care Team and was allocated a new Social Worker. The Independent Reviewer understands that this no longer is the case. 99. The appointment letter from Wigan CAMHS sent out on 03/04/18 enclosed questionnaires to be completed by the child/parent. It must be borne in mind that Child W was a Looked After Child and this potentially could be seen as being insensitive or inappropriate. He did not attend the appointment and was discharged following contact with Social Care. 100. A Pathway Plan Review held on 20/06/18 states that the review report was completed on 21 May 2018. Again, language is again emotionally laden such as “Child W refused to engage in his health assessment”. The Young Person’s Review of Pathway Plans – dated 24 June 2018 uses language such as “Child W was present in placement but refused to give his views”. Statements such as “I chaired your CLA Review today, although you was present in your placement you refused to attend your review or give your views”. 101. The language used in communications to Child W is often ‘professional’ and emotionally laden such as “refused to give his views”; “refused to attend” as opposed to “chose not to attend” or “you decided not to attend”. There are some positive statements but others are quite negative such as “unfortunately you are not motivated to explore further educational opportunities”. Later on, it states “Child W we heard how you refused to attend to your health needs”. This type of language was unlikely to have made it any easier for Child W to engage and, indeed, may have made it even more difficult. Ancora House and Child W “exposing” himself 102. The Electronic Discharge Summary dated 18/09/18 includes the following information “Exposed himself to female staff on a number of occasions”. A Discharge Planning CPA Review took place on 18/09/18 Child W was described as demonstrating some disinhibited behaviour on the ward towards female staff at times and this is explained as “has been known to expose himself to female staff”. 103. Child W had inappropriate and inadequate clothing. He had hospital pyjama trousers that were too big for him and he had no underwear on as he did not have any. His genitals were then visible at times. The issues here are: 22 • Child W did not have appropriate clothing in Ancora House. This does not seem to have been provided for him, at least for a period of time. • The impact of language used – “exposing oneself” has certain connotations of a criminal/deviant nature and this seems to have led to a change in the discharge placement. • There was a request for additional support following the Discharge Meeting which may not have been related to discussion about Child W “exposing himself”. 104. It is apparent that this issue was a clear misunderstanding of the term ‘indecent exposure’ and that there was absolutely no intent to cause difficulty for Child W or to be malicious towards him. The use of this phrase led to Child W’s community placement changing but it does not seem that there was any questioning of Ancora House staff as to exactly what had transpired. Professionals could have sought clarity and this would probably have meant that the original placement plan could have progressed. Meetings at Ancora House 105. The CPA Meetings and the Discharge Planning Meetings at Ancora House were integral to Child W’s care, both as an inpatient and after he was discharged. There was confusion, in particular when inpatient staff stated that the plan was to discharge Child W the following day. However, after concerns were raised the discharge was deferred and two further meetings took place. This was seen as Ancora House adopting a pragmatic approach to the situation and allowed for local services to put plans and services in place. 106. The Wigan CAMHS Care Co-Ordinator reported having little knowledge or notice of the Discharge Planning Meeting. He met Child W on that day and arranged to meet him again on the Thursday (the day Child W died). Wigan CAMHS were aware that Child W was an inpatient for the whole of his admission. 107. There was an issue as to whether a junior member of staff from one service would feel able to challenge a manager of another service in a meeting. 108. When NWBH were concerned about Child W’s potential discharge from Ancora House being unsafe this was escalated through the Business Manager at WSCB but not to the Designated Nurse for Safeguarding Children and Looked After Children in WBCCG. The concerns were subsequently escalated to the Designated Nurse by a Senior Manager from Wigan Children’s Social Care. The Senior Manager was not aware of the exact time, date, or venue for the planned Discharge Meeting and the Designated Nurse for Safeguarding Children and Looked After Children in WBCCG tried unsuccessfully to find out these details. Following the meeting the Designated Nurse for Safeguarding Children and Looked After Children in WBCCG was informed that Child W had not been discharged and that an agreed discharge plan was put in place and therefore there was no further need for her to be involved. 23 109. If the Designated Nurse for Safeguarding Children and Looked After Children in WBCCG had been aware from the outset of the concerns about a possible unsafe discharge, then she could have been involved i.e., attended the Discharge Meetings. 110. Independent Reviewer Recommendation 4: Wigan Safeguarding Children Board should ensure that escalations made regarding unsafe discharge are shared with the Designated Nurse at WBCCG in line with the agreed escalation policy. 111. Did the CAMHS Duty Practitioner (a Tier 2 practitioner) from Wigan CAMHS have enough knowledge of the case to challenge the decision to discharge? Should a more experienced Practitioner have attended? 112. A Children’s Social Care note dated 17/09/18 relates to Child W’s discharge from Ancora House. It states “It is not within our remit to challenge the discharge decision” but surely as he is subject to a Care Order and, therefore, the Local Authority is his corporate parent then it is within their remit to do this. 113. It appears that Ancora House staff were not aware of some of the statements that Child W had made prior to admission e.g., that his family were going to kill him because he was “a nonce.” 114. The SI Concise Investigation by North West Boroughs NHS Foundation Trust report includes in the conclusions “It is evident that the agreed multi-agency discharge plan was not fully implemented and that there were a lack of clear lines and timely communications between agencies. There is poor evidence of collaborative decision making and cohesive working across agencies and no formal agreement/procedure with external safeguarding teams/providers as to timeframes and communication pathways.” 115. The author of the SI Concise Investigation found little evidence of the voice of the child in Child W’s discharge planning and through the limited involvement of NWBH. 116. The Recommendations/Lesson Learned for NWBH included lack of clear lines and timely communication between agencies and escalation processes. 117. The Independent Reviewer concurs with these recommendations. Communication between agencies could have been clearer and there is evidence that significant information was not shared e.g., regarding Child W’s statements that he was at risk from his family. Clear processes for the escalation of concerns between different agencies involved in complex cases, including those young people admitted to hospitals or placed in residential and/or educational settings out of borough, must be in place. This should include expectations as to the timescale for a response. 118. There is a piece of work that is required to help professionals working with young people who are admitted to mental health units, either detained or informally, to help them understand what The Mental Health Act does, and indeed does not, allow. Professionals must feel confident to challenge decisions to admit and indeed to discharge young people from a mental health unit, in particular those who are Children 24 Looked After/subject to Care Orders as the Local Authority is acting in loco parentis and who they have Parental Responsibility for. Safeguarding Communication 119. In Ancora House a Clinical Support Worker made a Safeguarding Children note in the electronic case notes detailing the conversation and emailed CWP Safeguarding with the details requesting advice. A response was sent the same day but the Clinical Support Worker did not see this prior to them taking a period of leave. The advice was to contact Child W’s Social Worker and make them aware of the information. It does not appear that this was actioned. 120. In Ancora House a Nurse made a Safeguarding Children note in the electronic case notes detailing the conversation and emailed CWP Safeguarding team. A response to the email was sent on 10/09/18 with the advice being told make Child W’s Social Worker aware of the information and “If factual, may indicate child sexual exploitation in relation to the older women.” It also asked if the names of the sexual partners were known. The Nurse did not note the response until they were back on shift, but this was after Child W’s death. It does not appear that this information was passed on the Child W’s Social Worker. The CARSO was not updated. 121. Both professionals at Ancora House took the expected actions when informed of information that raised safeguarding children concerns. Notes were entered in the electronic case record as soon as was possible (in the same shift) and CWP Safeguarding Team was informed (again in a timely manner). CWP Safeguarding Team responded in a timely manner. 122. The issues were that neither staff member received/accessed the email response prior to a period of them not being in work. This meant that the advice from CWP Safeguarding Team was not acted on. 123. The Comprehensive SI Investigation performed by CWP makes recommendations about developing specific advice and reiterating staff members’ responsibilities regarding safeguarding. 124. Recommendations/Lesson Learned for NWBH from their internal review included that there should be clearer guidance in relation to the Trust communication channels with agreed time responses with external providers for safeguarding children. 125. It is essential that communication pathways and protocols between professionals and designated Safeguarding Leads are robust, and this clearly was not the case whilst Child W was an inpatient at Ancora House. CWP and NWB drew up action plans to address the issues raised. 25 126. Independent Reviewer Recommendation 5: Wigan Safeguarding Children Board should seek assurance that the actions from the NHS SI Investigations have been completed. 127. It is apparent that Child W made a number of statements that relate to his potentially being at risk from others and a risk to others. Interagency communication and communication with the relevant Safeguarding Children Teams are addressed in Paragraph 163 onwards. Other Issues Communication 128. There seems to be a great deal of confusion about Child W’s biological parents. His biological mother is known, and his father’s name is not known to the Reviewer. His stepfather is not Child W’s biological father although he does appear to have been his “Dad”. 26 KLOE 4: Review the care planning afforded to Child W in the context of his being a child with Looked After status, including the potential impact of location on Child W’s access to services Pathway Plan Part 1: Assessment – Completed 05/12/17 129. This is a comprehensive Needs Assessment. The Analysis section states “Child W’s significant difficulties with adults and his lack of engagement has resulted in a number of his needs being unmet as this barrier prevents Child W assessing support available to him”. It also states however, “Child W feels let down by professionals and adults throughout his childhood, alongside his attachment difficulties, which has had a detrimental effect on his ability to manage present working relationships which is a significant barrier to him accessing support to ensure his needs are met. Therefore, there is a risk of unmet needs”. 130. There is acknowledgement here that Child W’s difficulties accessing support are not merely his being difficult or awkward but are related to his previous life experiences. This should lead to Child W being seen as not solely responsible for these difficulties. It is the role of professionals to engage with young people and sometimes this can be difficult and different professionals (with different approaches) can and will have different levels of success in forging therapeutic/working relationships with a particular young person. Statutory Review Health Assessment - 13/03/18 131. The statutory Review Health Assessment documentation dated 13/03/18 states plans/actions are required in the areas of dental health; vision; diet; sleep routine; immunisations; cannabis use; generalised anxiety/High SDQ score; and independence skills. All issues were to be reviewed by his Social Worker and IRO/Reviewing Officer at Looked After Young Person Reviews. 132. The Care Plan (Part 2) dated 21/05/18. This covers the following areas of need: Physical Health; Education, Training, and Employment; Emotional and Behavioural Development; Identity; Family and Friends; Independent Living; Accommodation; and additional needs - personal care and navigating his way around the local area. 133. The document includes details on how his needs in these areas would be supported, monitored, and reviewed. Under the heading of Support Child W’s view was that he did not need support from staff, but the Worker’s view was for staff in placement to continue to engage Child W and continue to support him in regards to his independence, education and health appointments. 134. Actions identified as follows: • Child W to have his basic needs met. • Child W needs age-appropriate stimulation so he can meet his full potential. 27 135. This was to have a detailed support plan which the Social Worker would monitor. This was to be delivered by the carers and Social Worker. 136. The plan is incomplete (in particular around “How will we know if things have worked or not worked?”) and also contradictory in that it states in some places that Child W does not wish contact with his mother and stepfather and other that he is having this. It is however a comprehensive assessment of needs. It uses a comprehensive structure and allows the whole range of needs to be assessed and then addressed if needs be. However, the assessment is incomplete as stated above. This assessment does not seem to have been shared with other agencies e.g., mental health and this may have been helpful. Minutes Care Planning Meeting - 07/09/18 137. Minutes from a Children’s Social Care Care Planning Meeting that took place on 7 September 2018 state that Child W had been detained under Section 2 of The Mental Health Act (MHA) and is in Ancora House. Professionals involved will be led by Mental Health in addressing care planning for his future. It makes note of “numerous missing from home episodes, suicide attempts” since the last meeting. Of course, the assessment could be that Child W’s mental health difficulties were not of a degree that would mean that it was appropriate for mental health services to adopt the lead role. 138. The plan describes that a package of support around Child W once discharged from hospital would be put into place and Wigan CAMHS would become involved with him ASAP. 139. I note that this Care Plan is incomplete with remaining areas not completed. Under ‘Risks identified and mitigation’ it states “currently Child W is presenting with paranoia, psychosis (possibly drug-induced). He has made several attempts to commit suicide”. Child W is described as being “a very poorly young man”. 140. The care plan is a comprehensive document that should have had information in the ‘How will we know if things have worked or not worked?’ sections. 141. Child W appears to have potentially had access to services. However, services did not have access to all the information held in various agencies about Child W, including incomplete records in General Practice and, importantly, CAMHS. It appears that when Child W moved across geographical boundaries that the relevant information did not necessarily follow him. 142. The lack of complete records must be seen as potentially compromising Child W’s care; the assessment of his needs; and the assessment of his risks. Gaps in information may have meant that he had unidentified needs or that interventions that had been unsuccessful in the past were tried again. It is essential that information about a patient/service user is complete and accurate. Otherwise, care is compromised. 28 143. When a person is subject to a Care Order and the Local Authority has Parental Responsibility then it should be a core part of corporate parenting that the information held about that person is complete and accurate as well as being shared appropriately with other agencies/services in order to meet needs and manage risks. 29 KLOE 5: Explore the interventions Child W experienced in the later part of his life Educational Psychology Service Report - June 2015 144. An Educational Psychology Service Report from June 2015 states that Child W had been referred to CAMHS for intervention and he “engaged well but his difficulties continued”. An overview of the hypotheses developed by the Educational Psychology Service are outlined in paragraph 27. 145. These seem to be eminently sensible and helpful suggestions and would have been helpful to the professionals working with Child W both in terms of enhancing their understanding of Child W and his behaviour and making management plans to meet his needs. However, the Independent Reviewer is not certain if these were shared with the professional network or not. Letter from NWBGM Control Room Triage to GP record – 01/09/18 146. In the chronology from WBCCG dated 1 September 2018 there is mention of a letter from NWBGM Control Room Triage to GP record. It states that Child W was in A&E awaiting treatment and assessment awaiting outcome of meeting from MASH Team. A history of deliberate self-harm noted, and the Police reported history of criminal damage, minor assault and anger related issues and then states, “this in response to CSA as the victim”. 147. This does not appear anywhere else. What happened to this information? There does not seem to have been a referral made to Safeguarding. Mental Health 148. Information in the chronology from Children’s Social Care 2001 – 2005 suggests that Child W’s behaviour was “extreme” and that CAMHS could have been involved. CAMHS involvement in Leeds and Carlisle during 2013 information is missing. In 2014 when Child W moved back to Wigan there does not seem to have been a transfer of care to Wigan CAMHS. 149. Child W was assessed in both Blackburn and Blackpool in August 2018 because of concerns about his mental health. The Independent Reviewer has not had sight of the assessment report from Blackpool, and it seems that the assessment report from Blackburn was not shared with all of the professionals involved in Child W’s care in that the letter following the assessment was sent to Child W’s GP but not copied to his Social Worker or to local Mental Health Services in Wigan. 150. QQ stated that Child W never got an appointment; that a referral never went through; and that local services did not know that Child W had been in contact with mental health services in East Lancashire. 30 151. A document from WBCCG dated 28/02/19 entitled SCR Information Request Report states that not all GP records were available at that time and that those available dated from 11 September 2016 to 19 September 2018. 152. A report entitled Timeline of Agency Involvement for WBCCG GP services provided to the SCR suggests that there may have been missing GP records that have not been shared possibly as a result of Child W being registered at a number of different GPs throughout his life. 153. What appears clear is that the detail was not available, merely the GP coding for the contacts. 154. In 2012 there were mentions of low mood (on two occasions) and Separation Anxiety Disorder of Childhood. Again, these are coding entries and may relate to information being received elsewhere. 155. Similarly, in 2014 there is GP coding for "anger management counselling". 156. Information in chronologies and in documentation often describes that Child W did not attend appointments but that the whole DNA area has been re-thought and current practice would deem a child to be Was Not Brought rather than Did Not Attend. I am assured that this is reflected in current policies and procedures. 157. A note on the chronology dated 31/12/14 (covering that calendar year) states that Wigan CAMHS reported that Child W was not in a stable enough placement for CAMHS involvement. Whilst this may be the case for some interventions e.g., psychodynamic psychotherapy there would have been interventions that were possible, despite the placement not being stable including: • CAMHS being part of the professional network in order to provide advice to the non-CAMHS professionals involved. • “Here-and-now” interventions – such as anger management or medication (if indicated) • Risk and/or Needs Assessment. • Advice on the type of placement that may have benefited Child W if the current placement was not stable. 158. There seems to be significant amounts of information that is not present in Child W’s records as a result of his repeated moves. Significant information could be contained within these records e.g., what types of therapeutic input had been offered previously; what approaches had worked or not worked; what Child W’s experience of therapeutic input had been like (including were there any specific reasons why he found it so hard to trust adults); had he felt that his trust been breached leading to issues with trust; what the context for his previous referrals and difficulties has been etc. 31 159. Child W does not seem to have been offered non-verbal therapy. Professionals found it difficult to engage him in verbal therapies and this could have been tried. The Independent Reviewer is not aware however if such therapy is available in Wigan. 160. There does not seem to be a single document and/or agency that has all the information about Child W. This must have an impact on the ability of agencies involved in his care to effectively plan for his care and to assess his risks and needs. 161. There clearly is a need for further knowledge for professionals about other professionals’ roles and responsibilities and the frameworks need work within. This should include when to consider Secure Accommodation and when to seek legal advice. 162. According to Child W’s brother QQ there was a lack of communication between Blackburn and Wigan Mental Health Services. Sexual Behaviour and concerns regarding threats to life 163. This next section will explore agencies responses to Child W’s statements that he was a paedophile; that he had been involved in inappropriate sexual behaviour; that his family/his father were going to kill him; and that he had been filmed engaging in sexual activity. 17/08/18 A disclosure is made by Child W about appearing in a pornographic video but this does not appear to have followed-up or actioned in any way whatsoever. 29/08/18 Entry in chronology from CSC that Child W had returned to his placement extremely upset as there was “a price on his head”. He “would not” disclose any further information. 31/08/18 Entry in the chronology by CSC stating that Child W had disclosed to the Police that he had been in a sexual video with somebody underage and that this had been shared with his family. He stated that he was “a dead man”. When missing in Blackpool he had also told another adult about the video. 31/08/18 Entry in chronology by CSC states that there was a Strategy Discussion held in part as a result of Child W’s disclosure. Information was shared that “his family had found out that he was gay and had seen a pornographic video of him and that his family were going to kill him”. 164. Child W’s Social Worker was not aware of any pornographic video. They were aware that Child W had a couple of girlfriends, but they were deemed age appropriate. There does not seem to have been a Strategy Meeting or a referral to Safeguarding. 165. A document entitled Record of Strategy Discussion from a Strategy Discussion held on 31/08/18 states that this was held by telephone. Child W was reported missing from home on 30/08/18 and subsequently located in Blackpool. Child W is described as having stated to a Police professional and the staff at the care home in Blackpool that he cannot return to Wigan “as his family are going to kill him”. When asked why he stated, “they have found out that he is gay as they have seen him in a porn video”. 166. Child W is described as being extremely anxious and professionals are described as being concerned he was experiencing psychosis. The Police Officer in Blackpool felt 32 that Child W may try and run away should he be made to come back to Wigan. The Police Officer was advised that if there were concerns for Child W’s mental health he needed to be taken to hospital or Paramedics called to review him. Child W declined to go to A&E and was taken back to his placement and ran away on return. 167. Child W was placed in a staff car to return to Wigan and the Police followed this onto the motorway because of concerns he would jump out of the car. Child W later accused staff of being liars and that he was going to be put into a Secure Unit. He also reiterated that he was “in danger” and was “a dead man”. He asked to go to A&E but stated he wanted to go to A&E in Blackpool. Staff believed that he would abscond if he was taken to hospital in Blackpool so offered to take him to Wigan A&E but he refused. 168. In the chronology from WBCCG dated 01/09/18 there is mention of a letter from NWBGM Control Room Triage to GP record. It states that Child W was in A&E awaiting treatment and assessment awaiting outcome of meeting from MASH Team. A history of deliberate self-harm noted and the Police reported history of criminal damage, minor assault and anger related issues and then states “this in response to CSA as the victim”. The Independent Reviewer has not been able to find out more information about this. 169. In the letter from RAID/CAMHS Wigan dated 02/09/18 it states that Child W had a Mental State Examination. In this he reported low mood and he made reference throughout the assessment to “others being aware that he was a nonce and a paedophile”. He did not make eye contact, rarely lifting his head other than when he was distressed by the auditory hallucinations where he was observed to sit up and cover his ears in a distressed state. 170. Child W presented as paranoid, reporting that his father was trying to kill him. He was paranoid about care staff at the first residential setting he was residing in that he reported them being able to intercept his text messages that were sent to his phone. He had smashed up his phone as a result. 171. Child W spoke about staff on the ward and stated that he was aware that when staff look at him that he is aware they are not believing him and telling the doctor that he is not telling the truth so they can discharge him to be killed. 172. In NWBH note dated 02/09/18 Initial Assessment by Rapid Assessment & Interface Discharge Team (RAID) it states that Child W stated that he was not feeling safe at his then placement as he “has a fear that his family are looking for him and are attempting to kill him”. 173. Child W stated that he does not feel safe in the community as he will take his own life as he has been followed by his family who want to kill him. He reported that he felt safe in the hospital as he had thrown all his clothes away so could not be traced. The boots and all of his clothing were in the ward sluice where he had asked for them to be incinerated. 33 174. A Referral for Access Assessment into Inpatient Services for Children and Young People form dated 04/09/18 was completed by Clinical Lead at RAID services in Wigan states: “A full history is given including his fears that "he is going to be killed by his father or he needs to kill himself as he is a nonce". Child W reported that people are now aware that he is a paedophile although he was unable to explain why others think of him in this way.” 175. A Mental Health Act Assessment Form dated 06/09/18 follows him being assessed whilst he was under Section 136. This states that Child W was unknown to CAMHS prior to these presenting concerns (which is not correct as he had been seen by a number of CAMHS services in other areas and had been referred to and discussed with Wigan CAMHS). It describes him hearing persecutory voices telling him to kill himself and states that he had attempted to ligature himself and had cut himself with plastic. A history of cutting his arms is noted. He is described as hearing voices encouraging him to kill himself and has been actively suicidal. 176. The history is noted. He was described as being happy to engage in the MHA assessment although he remained in bed and presented as tired and lethargic. He described hearing voices that were “always there” and told him to kill himself and called him “a nonce”. There were in internal space and intrusive to his thoughts. They had been present for a month. The voices were of his “dad”, QQ, his girlfriend, and a cousin. The voices said that his “dad” wanted to kill him and he should kill himself. He had attempted to hang himself by tying his hospital gown to the roof. He explained that he absconded because the voices told him that his “dad” was coming to get him to kill him. The voices said “run” so he got on a train. The next stop was Preston where he tried to self-harm in the station toilets. 177. Child W stated he was unsure whether the voices were real or not. 178. A document entitled Baseline Summary (undated but appears likely to be 06/09/18) written by a Mental Health Practitioner from Ancora House contains the recent history. This document states that Child W reports that he gets his cannabis “for free” and there does not seem to be any effort to understand why this might be. This should have been explored further and Child W should have been seen as potentially vulnerable as a result of this. 179. This document states “Child W appears preoccupied at times with thoughts that he is evil and a paedophile, he is unable to state why he believes this is the case but expresses thoughts that he believes people, particularly his father will try and kill him as they know he is a paedophile”. 180. The Mental State Examination on admission states that Child W was dressed in hospital pyjama bottoms and a t-shirt and states that he does not have clothes or toiletries yet. He was disinhibited on occasions and was not aware of it (no detail). 181. He was responding to unseen stimuli and stating that he could hear me say he is evil. He was distracted at times. He sat with his head down with his hair covering his face. 34 He reported that this was due to his thoughts that people think his eyes showed he was evil. 182. In the formulation Child W’s presentation was described as being “consistent with an expected presentation where a young person has experienced significant trauma and neglect”. It goes on to described Child W reporting auditory hallucinations and paranoid beliefs; hears voices telling him to end his life and harm himself and he believes that people are trying to harm him as they believe he is a paedophile. Child W reports that these symptoms have begun in the past view months and a full assessment of his mental state is required to ascertain the nature of these thoughts. Ancora House Case Notes 183. 06/09/18: Child W tells admitting doctor that he hears voices telling him that “his father is going to kill him”. He also tells the admitting doctor that he had been told that he had been abused as a child but that he did not have memories of that himself. 184. 06/09/18: The admitting doctor’s case note entry includes a risk assessment which considers Risk to self; Risk to others; and Risk from others. Child W was worried that “his father wants to kill him but couldn’t say why, otherwise wasn’t concerned about any specific individuals”. 185. 06/09/18: Child W was seen by his Responsible Clinician. He described voices telling him that he is “evil” and “a nonce” and that he needed to be dead. The voices commanded him to harm himself by either hanging or slitting his wrists. He reported that he had tried to hang himself as a result. He admitted to suicidal ideation. 186. 07/09/18: case note entry – Child W stated that he did not want to return to the Wigan area because “his dad wants to kill him”. 187. 07/09/18: Child W spoke to a Clinical Support Worker about his belief that he was “a nonce”. He stated that he had told people this for over a year but could not remember why he thought this. He believed that it may be something to do with his 13-year-old sister but was unsure. Child W stated that he told his brother that while he was at his care home that a staff member looked through his mobile phone and found a video on there. Child W would not state what this depicted. 188. The Clinical Support Worker made a Safeguarding Children note in the electronic case notes detailing the conversation and emailed the CWP Safeguarding Team with the details requesting advice. A response was sent the same day, but the Clinical Support Worker did not see this prior to them taking a period of leave. The advice was to contact Child W’s Social Worker and make them aware of the information. It does not appear that this was actioned. 189. 07/09/18: Child W spoke to a nurse and indicated that at the age of 15 he had sex with a 25-year-old woman and again when he was 16. He added that he had had sex with ten females most of whom were older than him (and implied as being significantly older 35 in the context of the conversation). Child W also stated that when he was aged 14 that he had sex with a 13-year-old girl. He showed the nurse his back which had “numerous stretch/growth marks” and stated “she put all these scratches on my back and scarred me.” 190. The Nurse made a Safeguarding Children note in the electronic case notes detailing the conversation and emailed the CWP Safeguarding Team. A response to the email was sent on 10/09/18 with the advice being told make Child W’s Social Worker aware of the information and “If factual, may indicate child sexual exploitation in relation to the older women.” It also asked if the names of the sexual partners were known. The Nurse did not note the response until they were back on shift, but this was after Child W’s death. It does not appear that this information was passed on the Child W’s Social Worker. The CARSO was not updated. 191. A Datix (an electronic incident form) was completed but the CARSO was not updated. There does not seem to have been any liaison with Safeguarding about his statement about just finding out that he had been abused as a child. This was a missed opportunity to further explore this with Child W, at least to ascertain where he had learned this and what form the abuse had taken. Potentially the opportunity to have therapeutic input was missed. The Initial Care Programme Approach (CPA) Review - 12/09/18 192. The Initial CPA Review took place. Apologies were received from Child W’s Social Worker; the Manager of Wigan CAMHS; and staff from the care home. The Duty Social Worker Wigan attended as did a member of staff from Wigan CAMHS. Apologies were also received from Fairhaven bed management team who indicated that they were not aware of the meeting. 193. Minutes initially state that since admission there has been no evidence of psychosis in Child W’s presentation. However, it goes on to state “on admission he was guarded at times, over-familiar at times, some disinhibition, excessive showering; preoccupied with thoughts that he is evil and a paedophile and preoccupied with thought he had been rejected by his family”. Yesterday Child W reported that voices have diminished, showed no remorse about assault to peer and threats to assault staff. Some preoccupation about being evil/not of a delusional intensity; some over-familiarity (with his Responsible Clinician) at times. There does not seem to have been any challenge or comment from other professionals about Child W’s presentation. Electronic Discharge Summary - 18/09/18 194. The Electronic Discharge Summary includes the following information: “Child W appears to experience intrusive thoughts about being evil; other people believing he is evil and being a paedophile. It is unclear how long he has been experiencing these 36 difficulties but Child W states that this has been gradually getting worse over the past few months.” KLOE 5 - Independent Reviewer Concluding Comments 195. In the information provided Child W is reported to make a number of statements that raise concern – that he is a “nonce” or a paedophile; that he is “evil”; that his family or his ‘father’ are going to kill him; that there is a video in circulation of him being involved in sexual activity with someone underage; that he is gay; and that he had been involved in sexual activity with older females (at least one of whom is 26). Additionally, there is a statement about his being the victim of Childhood Sexual Abuse. 196. These statements are generally not acted on. On two occasions in Ancora House members of staff (a Clinical Support Worker and a Staff Nurse) sent emails to the Safeguarding Team seeking advice. The advice was sent by email but both clinicians were either on leave or rostered off duty when the replies came through and did not access these emails until after Child W had died. 197. These disclosures were made to a range of agencies – Children’s Social Care; the Police; Wigan CAMHS/RAID; and CWP inpatient staff. 198. It appears that professionals in general made assumptions that these statements were part of Child W’s mental health difficulties and not based in reality. No professional other than those mentioned above in Paragraph 7.217 referred this information on to Safeguarding. No professional seems to have undertaken (or at least attempted to undertake) a psychosexual history with Child W. This was not a part of any assessment documentation provided, including the inpatient clerking. This should have included information about his sexuality, thus possibly clarifying the statements about his being gay, and about his being a paedophile. 199. If Child W was sexually attracted to children this potentially placed other residents in his placements as well as other inpatients at Ancora House at risk. This does not appear in any risk assessment documents provided to the Independent Reviewer. 200. Likewise, Child W reported that he had been sexually active with older females. This was reported to the CWP Safeguarding Team but the advice received was only accessed after his death. 201. The statements that his family/his father were going to kill him do not appear to have been explored. 202. The Independent Reviewer has no way of ascertaining whether Child W’s statements were based in reality or were part of his symptomatology. However, what is clear is that he made these statements between 17/08/18 and 12/09/18 and they are mentioned in the Discharge Letter of 18/09/18. 37 203. There were potentially missed opportunities to understand Child W’s presentation and to keep him safe by the lack of professional curiosity about the range of statements that Child W made. He could have been involved in sexual activity with underage children and/or adult females; he could have been struggling with his sexuality; he could have been the victim of exploitation (pornographic video; free cannabis; sexual exploitation etc); and there may have been a risk from his extended family. These were not explored by the professionals involved. 204. When QQ was asked about Child W’s statement of being “a nonce” QQ described he had an inkling what this was about. He described that their mother had a girl called MM living there who was aged 13 and that she had tried to set Child W up with her. 205. QQ was not sure whether anything had happened with MM or not. However, he described MM as being “very upset” when Child W died and described that she has his name tattooed on her body. When asked about the statements about under-age sex and being gay QQ stated that he had only heard these at the Inquest. QQ stated that he asked Child W’s friends who did not believe that Child W had been gay. QQ described him as being more of a “ladies’ man”. 206. When asked about whether Child W had expressed any concerns about his sexuality Child W’s mother and stepfather reported that they were not aware of any issues around his sexuality and that he talked about girls. They were clear that if Child W had not been heterosexual that they would not have had a problem with this. 207. There appears to be no formal psychosexual history or any detailed forensic history in any of the records provided. It is unclear how his forensic history was explored i.e., was Child W asked about previous convictions/Cautions etc or was he asked about involvement in criminal behaviours such as fighting aggression, stealing, fire setting etc. Making assumptions that a young person who has no convictions or Cautions has not been involved in high-risk behaviours such as interpersonal violence or fire setting can lead to significantly impaired assessments of risk and needs. Similarly, not taking an appropriate psychosexual history can lead to important information not being gained e.g., worries about sexuality, being the victim of sexual abuse etc. 208. Issues about communication and safeguarding are included elsewhere in this report. Standard of Care Ancora House 209. The CWP SI Comprehensive Investigation Report states: “With regards to the overall quality of care provided this was deemed "good". The Psychiatrist on the Panel concurred with the initial impression of First Episode Psychosis and the change to Acute Intoxication of Cannabinoids and Mixed Disorder of Conduct & Emotions.” 210. The treatment offered to Child W was in general within expected standards. The medication regime (PRN) was as expected. He has regular contact with his Responsible Clinician. His wishes about not having contact with his family were respected. 38 211. The CWP Investigation Report highlights some issues about Child W’s care: • Ancora House staff to be provided with additional support in the identification and response to challenging behaviour. • Ancora House Management to ensure compliance with the process and documentation of Section 17 leave. • Further development of the psychology team (an increase in the numbers in post) was discussed. Internal standards for psychology input were to be explored with the CAMHS Clinical Director. Wigan CAMHS/RAID 212. Child W seems to have engaged with the CAMHS/RAID Worker well. The assessment is thorough and appropriate advice was sought and acted upon. Communication between professionals (both within agencies and between agencies) was good. The risk assessment did contain a formulation of risk although there were areas that could have been included. It did not seem that a formal risk assessment tool was used. 213. Independent Reviewer Recommendation 6: Agencies should review their risk assessment procedures and develop urgent action plans to improve practice. Consideration could be given to using a formal tool e.g., STAR to aid in the assessment of risk. WWL Inpatient Stay 214. During his admission to WWL in Wigan Child W attempted to hang himself. From the information provided it is unclear how he did this. If he managed to attach a ligature to part of the fixtures and fittings of his hospital accommodation, then it is essential that a Ligature Point survey be undertaken to ascertain if there is a need for modifications to prevent other patients from doing the same thing. 215. Independent Reviewer Recommendation 7: WSCB should seek assurance from WWL that Ligature Point surveys have been completed and that patients are safe. Good Practice 216. There were areas of good practice noted as follows: • The CWP Safeguarding Practitioner received an email from the Named Nurse in NWB Healthcare on 14 September 2018 to thank her for her input into the meeting. • Two members of staff from Ancora House made referrals to the CWP Safeguarding Team when Child W discussed issues that raised safeguarding concerns. One of 39 these concerned Child W stating that he had engaged in sexual activity with adult females. • Multiple staff from the unit were noted to have offered support to both Child W and the Support Worker following his discharge on 18 September 2018, including two Clinical Support Workers; his Responsible Clinician; and the Unit Manager. • There is evidence of good practice by the Police in terms of Operation Madison on 17 July 2015 – this took the form of monthly meetings between the Police and residential staff following concerns about the vulnerability of the residents • QQ stated that some professionals had been supportive to him naming “JJ, KK, and LL”. He was asked if he wanted his brother’s possessions and asked about funeral arrangements. However, he stated that nobody had checked if he wanted support and stated “they hid from Mum” i.e., professionals. Support Provided After Child W’s Death Family 217. QQ stated that some professionals had been supportive to him naming professionals “JJ, KK, and LL”. He was asked if he wanted his brother’s possessions and asked about funeral arrangements. However, he stated that nobody had checked if he wanted support and stated “they hid from Mum” i.e., professionals. QQ stated that he asked if the person who had found Child W after he had died had received support. The Independent Reviewer was assured that this person was offered support from agencies involved but declined this. QQ described that he saw his own GP and was referred to ‘Minds Matter’ but this was not helpful. He felt that he would benefit from more longer-term input in terms of therapy. 218. Child W’s mother described that they were told about Child W’s death by the Police who had been “really nice” and explained more than Social Services had. His mother stated, “Social Services didn’t want to tell us anything”. Child W’s mother did acknowledge that support was offered to the family. 219. RR (younger sister) had six months of support from Rainbow at school in terms of bereavement work, but Child W’s mother stated that she had had to ask for this. Professionals 220. As part of the Practitioner Learning Event frontline staff were asked about the provision of support in light of Child W’s death from their agencies to them. A number of professionals from a number of agencies reported that they were either informed of Child W’s death by email or heard by chance from other professionals. Details of funeral arrangements etc. were not circulated. In contrast other agencies very clearly offered their staff support, either in-house or by signposting them to appropriate agencies. 40 221. Of note, professionals who had previously been involved with Child W (including those with significant amounts of involvement with him) were not necessarily informed as at the time of Child W’s death they were not actively involved in his care/case. 222. It was not felt by practitioners that it would have been difficult to find out who had worked or was working with Child W and consideration must be given to how staff are informed and supported through difficult situations, including the death of a person who they have worked with professionally. 223. The Independent Reviewer has concerns about both how the sad news of Child W’s death was communicated (or not) in some agencies and the lack of support offered to some professionals. 224. Independent Reviewer Recommendation 8: Wigan Safeguarding Children Board should seek assurance that agencies have reviewed their procedures for both informing staff about the death of a patient/service user that they are/did work with and what procedures are in place to offer appropriate support to affected professionals. 41 KLOE 6: Establish learning from critical episodes which are identified through the SCR process. 225. The Independent Reviewer is of the view that the following represent areas where lessons need to be learned and Wigan Safeguarding Children Board should wish to be assured that agencies have put Action Plans in place to do so. Risk Assessment 226. The vast majority of documents that are denoted “Risk Assessment” that the Independent Reviewer has seen have been lists of risk factors. There is rarely any attempt to formulate or describe risk (including factors that will potentially increase or decrease risk) or to generate a risk management plan. 227. This is true across all health and social care agencies involved. Therefore, these agencies should review their risk assessment procedures and develop urgent action plans to improve practice. 228. For example, if the risk of self-harm is related to a diagnosis of depression and more likely when the patient uses alcohol and seems related to a history of childhood sexual abuse then the risk assessment should include factors in the formulation such as: a) The risk is increased when the patient’s mood is low b) The risk is reduced when the patient’s mood is normal or good c) The risk is increased when the patient is non-compliant with their medication d) The risk is increased when alcohol has been taken e) Input to help the patient overcome the adverse effects of being the victim of childhood sexual abuse may reduce the risk of self-harm in the longer-term but may actually increase the risk in the short-term. 229. The risk assessment will lead to a statement about the imminence and/or severity of the risk (e.g. the risk is high when the patient does not take her medication and does consume alcohol). 230. The risk management plan could include elements such as: a) The prescription of an antidepressant that is both effective but safer if taken in overdose. b) Providing verbal therapy sessions on a regular basis. c) Regular monitoring of mood, including for thoughts, plans, and acts of self-harm/suicide. d) Increased support around the start of therapy sessions. e) A plan on how to manage distress and thoughts of self-harm. 42 Safeguarding 231. There are several issues that are seen as crucial in this area. It appears that although Child W made a number of statements to a range of professionals that fall under the safeguarding umbrella that his voice was not truly heard. 232. In general, there was a lack of professional curiosity about several statements made by Child W relating to his sexuality, sexual activity with underage people and an older female, pornographic material, threats to his life, obtaining cannabis for free and that he was a victim of childhood sexual abuse. 233. The Independent Reviewer does not know if any of these statements were factually correct or if they represent his mental illness. Child W certainly stated them over a period of several weeks to a range of professionals. 234. Only two referrals were made to designated Safeguarding Leads/Teams (both to the CWP Safeguarding Team whilst Child W was an inpatient in Ancora House) but the advice provided was not accessed due to the professional being either on leave or not rostered for duty. 235. It appears that assumptions were made that these statements were made by Child W as part of his mental illness. There were few efforts made to discuss any of these in more depth. It is possible that had this happened that professionals’ understanding of Child W and his presentation may have been more accurate and care plans and risk assessments more accurate and relevant. 236. Independent Reviewer Recommendation 9: Agencies should review safeguarding policies and training to ensure that staff don’t discount safeguarding disclosures when they are made by children and young people with mental health presentations. Staff should seek support and advice from their Safeguarding Team. Responsibility for engagement 237. Another recurring theme throughout the documents provided is the language used to describe Child W and his difficulties accessing the support offered. The responsibility for him engaging with professionals is almost always placed with him. Statements such as “you failed to engage” occur liberally throughout the documents received. 238. The Independent Reviewer’s view is that the responsibility for engaging children and young people lies with the professionals. The language used about Child W was highly unlikely to promote his engaging with professionals. Additionally, the gaps in information, particularly about input from CAMHS Services in a range of geographical locations, may mean that professionals are not aware of a particular issue that arose leading to Child W struggling to trust professionals thus increasing their difficulty engaging him. 43 239. The Independent Reviewer Recommendation in response to this has been outlined in KLOE 1. Action Plans 240. Independent Reviewer Recommendation 4 (outlined in paragraph 110) suggests that Wigan Safeguarding Children Board should seek assurance the Action Plans related to the NHS Serious Incident Investigations submitted by both CWP and NWB have been completed. Support after the death of a child or young person 241. It was clear that Child W’s family had been offered some support, but it seemed as though they were still struggling to come to terms with their sad loss. 242. Professionals described a range of experiences in relation to how they found out about his death and what support was available to them afterwards. 243. Independent Reviewer Recommendation 7 (outlined in paragraph 217) suggests that Wigan Safeguarding Children Board should seek assurance that agencies have reviewed their procedures for both informing staff about the death of a patient/service user that they are/did work with and what procedures are in place to offer appropriate support to affected professionals. This should ensure that staff are told such sad news in a personal as opposed to an impersonal manner and that appropriate support is offered (and this may include referral to external agencies). Assessment 244. There appears to be no formal psychosexual history and no detailed forensic history in the records of any agency. It is unclear how his forensic history was explored i.e., was Child W asked about previous convictions/Cautions etc or was he asked about involvement in criminal behaviours such as fighting, aggression, stealing, fire setting etc. Making assumptions that a young person who has no convictions or Cautions has not been involved in high-risk behaviours such as interpersonal violence or fire setting can lead to significantly impaired assessments of risk and needs. Similarly, not taking an appropriate psychosexual history can lead to important information not being gained e.g., worries about sexuality, being the victim of sexual abuse etc. 245. Independent Reviewer Recommendation 10: The Independent Reviewer recommends that agencies should review their training and ensure that professionals take appropriate forensic and psychosexual histories to inform assessment of risk and needs and to manage the safety of others. The level of detail required will depend on the age of the patient/service user along with their history. 44 Accurate recording in case records 246. It is crucial that records contain information that is accurate, clear, and easily understood. This is especially important when it relates to risk (to both self and others). Entries must make it clear whether or not a person has been asked e.g., about thoughts of self-harm or not. An entry that states “He denied any thoughts of self-harm” makes it clear that the person was asked and denied having such thoughts. A statement such as “No thoughts of self-harm were reported” is much less clear – were they asked? Did they merely not say anything to the professional about this issue? Similarly issues around experiencing symptoms of mental illness or thoughts to harm others need to be written in a manner that is only open to one interpretation and makes it clear that the person was asked and denied having (or reported having) the symptom/thought. 247. The Independent Reviewer has a longstanding issue with how important issues such as the presence of thoughts of suicide/self-harm or the presence/absence of psychotic symptoms are recorded. It is crucial that records contain information that is accurate, clear, and easily understood. This is especially important when it relates to risk (to both self and others). Entries must make it clear whether or not a person has been asked e.g., about thoughts of self-harm or not. 248. Of course, it must be borne in mind that even if a patient/service user denies the presence of a symptom that this may not be the truth. CAMHS Procedures 249. A note dated 31 December 2014 states that Wigan CAMHS reported that Child W was not in a stable enough placement for CAMHS involvement. Whilst this may be the case for some interventions e.g., psychodynamic psychotherapy there would have been interventions that were possible, despite the placement not being stable including: • CAMHS being part of the professional network in order to provide advice to the non-CAMHS professionals involved. • “Here-and-now” interventions – such as anger management or medication (if indicated) • Risk and/or Needs Assessment. • Advice on the type of placement that may have benefited Child W if the current placement was not stable. 250. Independent Reviewer Recommendation 11: Wigan Safeguarding Children Board will wish to seek assurance that CAMHS can and do provide appropriate input to young people, even when their placement is not stable. 251. Information in chronologies and in documentation often describes that Child W did not attend appointments. More recently health services have reflected on the use of the term “Did Not Attend” when children miss appointments. The term “Was Not Brought” 45 is now accepted as more appropriate as this reflects that children are brought to appointments by adults. This change in terminology ensures that there is a safeguarding focus when a child “Was Not Brought” to an appointment. I am assured that this is reflected in current policies and procedures and have been provided with the relevant algorithm. Corporate Parenting 252. The Independent Reviewer feels that there are a number of issues for the Corporate Parenting Board to review/assess/address as follows: • Automatic change of Social Worker at 16 with the move to the Leaving Care Team (the Independent Reviewer understands that this no longer happens). • Issues of challenging discharge decisions. • Understanding of the roles of other agencies and professions. • Managing the needs of a young person who is an inpatient. There needs to be a clear procedure for what happens when a young person/child who is subject to a Care Order or whom Social Care have Parental Responsibility for is admitted to any hospital e.g. who will visit; what will be provided in terms of basic necessities and when; who will be the lead contact in Children’s Social Care for the professionals to liaise with; and how will the professionals know who to contact? • Risk and needs assessment. • Meeting basic needs. • Interagency working. • Secure Accommodation Orders – when and how to use them and what they permit professionals to do. • The other issues highlighted in this report for all agencies e.g., the language used to describe Child W and the impact of his experiences on his attachment abilities. 253. During his time at Ancora House Child W had insufficient attire and none was provided to him, certainly not in a timely manner. He was subject to a Care Order. If he was in the care of his biological parents and they failed to provide adequate clothing, then this would probably have raised safeguarding concerns, but this did not seem to happen in this case. 254. Independent Reviewer Recommendation 12: Wigan Safeguarding Children Board should seek assurance from Children’s Social Care that the issues identified (see paragraph 252) in relation consistency in Social Worker, challenging discharge decisions, risk and assessment, meeting basic needs of LAC in hospital, and trauma informed practice have been addressed. This recommendation from this review should also be shared with the Corporate Board and added to the workplan. 46 Interagency Working 255. Independent Reviewer Recommendation 13: Wigan Safeguarding Children Board and individual agencies should explore opportunities to enhance existing training to include information about the roles, responsibilities, and remits of agencies working with children and young people. This would enhance understanding of other professionals’ roles and lead to fewer misunderstandings and misperceptions. Information Sharing 256. Child W moved to at least three different regions of England during his life (Wigan to Leeds to Cumbria and back to Wigan. He had input from a range of services including universal services, Children’s Social Care, and CAMHS. 257. However, services did not have access to all the information held in various agencies about Child W, including incomplete records in GP and, importantly, CAMHS. It appears that when Child W moved across geographical boundaries that the relevant information did not necessarily follow him. Additionally, information was not shared between agencies e.g., Ancora House reported that they were not aware of some issues relevant to risk. 258. There seems to be gaps in Child W’s records as a result of his repeated moves. Significant information could be contained within these records e.g., what types of therapeutic input had been offered previously; what approaches had worked or not worked; what Child W’s experience of therapeutic input had been like (including were there any specific reasons why he found it so hard to trust adults); had he felt that his trust been breached leading to issues with trust; what the context for his previous referrals and difficulties has been etc. 259. Although universal services’ (School Nurse, Health Visitor, and GP) records follow a child/young person other records seem not to (such as CAMHS, Health). This can lead to vital information not being shared with or even known about by those professionals charged with caring for and/or providing therapeutic input to that child/young person. Information that could inform risk assessments; needs assessments; therapeutic input; and choice of therapist amongst others is potentially missing. 260. Although WSCB may not be able to effect change on its own in relation to effective sharing of health records, this could be escalated centrally. 261. There does not seem to be a single document and/or agency that has all the information about Child W. This must have an impact on the ability of agencies involved in his care to effectively plan for his care and to assess his risks. 262. Independent Reviewer Recommendation 14: WSCB should seek assurance that agencies have reviewed their information sharing procedures and made amendments if necessary. 47 Secure Accommodation Orders 263. Was there consideration given to Child W being made subject to a Secure Accommodation Order given concerns about the risks he presented i.e. that he has a history of self-harm; history of absconding; and presents a risk to himself and others? If not why not? The Independent Reviewer has not seen any documentation to say that a Secure Accommodation Order was considered and discounted or even that it was considered. Would this have been the same if Child W were female? 264. Independent Reviewer Recommendation 15: Wigan Safeguarding Children Board should seek assurance that agencies make detailed notes when significant issues are considered, including an analysis of the potential positive and negative outcomes as well as what the alternative solutions could be. 265. Independent Reviewer Recommendation 16: Children’s Social Care need to ensure that Social Workers understand when to consider Secure Accommodation and when to seek legal advice. Training or guidance should include information about Secure Accommodation Orders, including how to apply for one; when their use is appropriate; and what a Secure Accommodation Order permits professionals to do (and what it does not permit them to do). Forensic Child and Adolescent Mental Health (FCAMHS) Assessments 266. In view of Child W’s history of potentially having contact with the criminal justice system as a result of his behaviours (Section 39 Assault, criminal damage, and threats to cause damage), in combination with his mental health needs was there consideration of Child W being referred to the Forensic CAMHS Service in Manchester for a consultation and/or assessment? 267. Independent Reviewer Recommendation 17: WSCB should seek assurance that agencies are aware of Forensic CAMHS North West and how to access their services (including which young people are appropriate to refer and what services FCAMHS North West offer) 48 OVERVIEW OF INDEPENDENT REVIEWER RECOMMENDATIONS KLOE and Number Recommendation Theme KLOE 1 Recommendation 1 WSCB should seek assurance that all agencies work with children and young people in a way that considers the consequences of attachment difficulties. This ethos should be included in the following: • Workforce development and training • Agency assessment and planning documentation • Trauma-informed practice • The use of professional language • How professionals engage children and young people. Trauma Informed Practice KLOE 2 Recommendation 2 Agencies involved should explore the issues raised in this report regarding Risk Assessment; Risk Formulation; and Risk Management. They should consider the need for further workforce development and strengthening of existing policies and processes. Risk Assessment KLOE 3 Recommendation 3 WSCB should seek assurance that agencies are working with children and young people in a way that places the responsibility for engaging children and young people and their families with professionals and that professionals use appropriate language in records which reflects this responsibility. Recommendation 4 WSCB should ensure that escalations made regarding unsafe discharge are shared with the Designated Nurse at WBCCG in line with the agreed escalation policy. Escalation Recommendation 5 WSCB should seek assurance that the actions from the NHS SI Investigations have been completed. Assurance RE: NHS SI Processes KLOE 5 Recommendation 6 Agencies should review their risk assessment procedures and develop urgent action plans to improve practice. Consideration could be given to using a formal tool e.g. STAR to aid in the assessment of risk. Risk Assessment Recommendation 7 WSCB should seek assurance from WWL that Ligature Point surveys have been completed and that patients are safe. Assurance RE: NHS SI Processes 49 Recommendation 8 WSCB should seek assurance that agencies have reviewed their procedures for both informing staff about the death of a patient/service user that they are/did work with and what procedures are in place to offer appropriate support to affected professionals. Policy/Procedure KLOE 6 Recommendation 9 Agencies should review safeguarding policies and training to ensure that staff don’t discount safeguarding disclosures when they are made by children and young people with mental health presentations. Staff should seek support and advice from their Safeguarding Team. Safeguarding Recommendation 10 Agencies should review their training and ensure that professionals take appropriate forensic and psychosexual histories to inform assessment of risk and needs and to manage the safety of others. The level of detail required will depend on the age of the patient/service user along with their history. Assessment Recommendation 11 WSCB should seek assurance that CAMHS can and do provide appropriate input to young people, even when their placement is not stable. Service Provision - CAMHS Recommendation 12 WSCB should seek assurance from Children’s Social Care that the issues identified (see paragraph 252) in relation consistency in Social Worker, challenging discharge decisions, risk and assessment, meeting basic needs of LAC in hospital, and trauma informed practice have been addressed. This recommendation from this review should also be shared with the Corporate Board and added to the workplan. Children’s Social Care and Corporate Parenting Recommendation 13 WSCB and individual agencies should explore opportunities to enhance existing training to include information about the roles, responsibilities, and remits of agencies working with children and young people. Workforce Development Recommendation 14 WSCB should seek assurance that agencies have reviewed their information sharing procedures and made amendments if necessary. Policy/Procedures Recommendation 15 WSCB should seek assurance that agencies make detailed notes when significant issues are considered, including an analysis of the potential positive and negative outcomes as well as what the alternative solutions could be. Record Keeping Recommendation 16 Children’s Social Care need to ensure that Social Workers understand when to consider Secure Accommodation and when to seek legal advice. Training or guidance should include information about Secure Accommodation Orders, including how to apply for one; when their use is appropriate; and what a Secure Accommodation Order permits professionals to do (and what it does not permit them to so). Workforce Development – CSC Recommendation 17 WSCB should seek assurance that agencies are aware of Forensic CAMHS North West and how to access their services (including which young people are appropriate to refer and what services FCAMHS North West offer). Awareness of Service Provision 50 APPENDIX 1: GLOSSARY OF TERMS USED 1. WSCB: Wigan Safeguarding Children Board (now Wigan Safeguarding Partnership (WSP)) 2. WBCCG: Wigan Borough NHS Clinical Commissioning Group 3. CWP/CWPT: Cheshire and Wirral Partnership NHS Trust 4. NWB/NWBH: North West Boroughs Healthcare NHS Trust 5. WWL: Wrightington, Wigan, and Leigh NHS Foundation Trust 6. BWCH: Bridgewater Community Healthcare NHS Foundation Trust 7. CAMHS: Child and Adolescent Mental Health Services 8 Tier 4: Child and Adolescent Mental Health Inpatient Services/Units 9. RAID: Rapid Assessment and Interface Discharge 10. Datix: an electronic incident recording system used in some NHS Trusts 11. CSC: Children’s Social Care 12. TAC Meeting: Team Around the Child Meeting 13. CiN: Child/ren in Need 14. IOPC: Independent Office for Police Conduct 15. SI: Serious Incident / SINE Panel: Serious Incident and Never Event Panel 16. RHA: Review Health Assessment 17. MHA: Mental Health Act 18. DoLS: Deprivation of Liberty Safeguards 19. CPA: Care Programme Approach 20. CLA Review: Child Looked After Review 21. CARSO: Clinical Assessment of Risk to Self and Others 22. CSA: Childhood Sexual Abuse 23. MASH Team: Multi-Agency Safeguarding Hub 24. PRN: pro re nata i.e. as required 51 APPENDIX 2: ANONYMISATION USED 1. Child W – the young person that this report is about 2. QQ – his older brother who was interviewed as part of the process 3. RR – one of Child W’s younger siblings 4. MM – a teenager living with Child W’s mother and stepfather 5. JJ – a professional mentioned by QQ 6. KK – A professional mentioned by QQ and in the admission records from Ancora House 7. LL - a professional mentioned by QQ 52 Appendix 3: CARSO: Harm to Others Factors 1. Concern has been expressed about others about risk of harm to others. 2. Current violent or threatening or impulsive or abusive behaviour. 3. Past violent or threatening or impulsive or abusive behaviour. 4. Violent or abusive thoughts or fantasies. 5. Misuse of drugs/alcohol 6. Possession of weapons with possible intent to use 7. Has access to potential or threatened victim 8. Being victimised/bullied/harassed 9. Has problems controlling temper 10. Witnessed or a victim of violence or sexual or emotional abuse in childhood 11. Living alone (or will do so after discharge) 12. Has symptoms which increase risk of this person harming others 13. Malnutrition (consider malnutrition risk screening tool) 14. Incontinence 15. Risk of accidents 16. Self or others 17. Driving risk 18. Is physical health affected by current mental state (has physical health check been completed) 19. Problem/compliance with prescribed/non-prescribed medication 20. Condition of skill/tissue viability (consider tissue viability screening tool) Harm to Self 1. Any previous suicide attempts, deliberate self-harm, and/or unintentional self-harm. 2. Family history of suicide 3. Major mental illness 4. Intent to end life 5. Social isolation 6. Feelings of hopelessness or lack of control 7. Disengagement from services or non-compliance 8. Loss or threat of loss 9. Physical illness or disability 10. Learning disability or intellectual disability 11. Concern expressed by significant others 12. Recent discharge from hospital 13. At risk of absconding or going missing 14. Threats to privacy and dignity 15. Disinhibited behaviour 16. Impulsivity 17. Is the main carer for a child(ren) – Child Protection issues. 18. Is the main carer for a (potentially) vulnerable adult 19. Problems with mobility ? risk of falling (consider falls assessment screening tool) Harm from Others (particular relevance for CAMHS) 1. Physical abuse 2. Sexual abuse 3. Emotional abuse 4. Neglect/Lack of supervision 53 5. Exposure to domestic violence (may or may not be directed at patient) 6. Parental mental illness 7. Bullying/victimisation – including on-line 8. Exposure to war or torture 9. Exposure to gang crime 10. Risk of sexual exploitation 11. Child in Need 12. Parental substance misuse 13. On Child Protection Register 54 Appendix 4: Independent Reviewer: Dr Kenny Ross, Consultant Adolescent Forensic Psychiatrist I am Dr Kenny Ross. I qualified in 1985 from the University of Dundee. I then completed General Practice Training before entering into Psychiatry in 1992. I completed Senior House Officer and Registrar Training in Psychiatry in Glasgow, gaining membership of the Royal College of Psychiatrists in 1996. I completed Higher Training in Child and Adolescent Psychiatry in 1999 and undertook a further year of training in Adult Forensic Psychiatry in order to be recognised to work in the field of Adolescent Forensic Psychiatry. I have been working in the Adolescent Forensic Service, Greater Manchester Mental Health NHS Foundation Trust since 1997 and took up a Consultant post in 2000. I have completed dual training in Forensic and Child and Adolescent Psychiatry. I am approved under Section 12(2) of the Mental Health Act 1983. I was the Named Doctor for Safeguarding Children for Greater Manchester Mental Health NHS Foundation Trust for many years until 2018 when I reduced my hours. Since October 2018 I have provided an in-reach session to Barton Moss Secure Children’s Centre weekly and continued my role as Guardian of Safe Working Hours for the Trust. As Named Doctor I was a member of both Bolton Safeguarding Children Board and the local Child Death Overview Panel. I have completed two previous Serious Case Reviews and one Serious Adult Review. Dr Kenny Ross, Consultant Adolescent Forensic Psychiatrist. 13 November 2020 |
NC52208 | Death of a 3-year-old boy in July 2016. Frankie was a hospital inpatient for life threatening asthma leading up to his death, and died within 24 hours of discharge. Parents were professionals and Frankie was cared for by a nanny; his older sibling was home educated. Frankie was seen at home twice post birth but was not immunised and did not attend the two-year developmental check. Frankie had twelve hospital admissions associated with severe asthma from the age of 20-months, until his death. Parents were reluctant to fully comply with medical advice and prescribed medication for Frankie; they feared steroids and declined or reduced numerous medications over various hospital admissions. Ethnicity or nationality not stated. Learning includes: medical neglect is less understood across all agencies and within the health system, which is a weakness in the multiagency children safeguarding system; impact of parents' social class upon the relationship with health professionals; parental challenge around medication is common but there is a lack of robust strategies to manage this in the hospital; absence of other categories of neglect appear to have reassured practitioners. Recommendations include: hospitals to explore how clinical teams manage parent consent for emergency treatment; hospitals must review how they manage severe illness in children when a parent favours alternative therapy; GPs and Health Visitors must have an agreed plan when following up issues of concern with families; all services must be able to evidence how their workforce participates in reflective safeguarding supervision which supports their learning and development.
| Title: Frankie: serious case review. LSCB: Wandsworth Safeguarding Children Board Author: Deborah Jeremiah and Nicola Brownjohn Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Official FRANKIE SERIOUS CASE REVIEW Independent Reviewer: Deborah Jeremiah 27 May 2019 Independent Reviewer: Nicola Brownjohn RN, SCPHN, MA June 2020Official 2 Official LIST OF CONTENTS 1 Introduction- the Circumstances leading to the Review 2 The Purpose of the Review and Methodology 3 The Circumstances of Frankie’s death 4 Chronology of Events 5 Contribution from Frankie’s family and friends 6 Analysis and Appraisal of Agencies’ Practice 7 Findings 8 RecommendationsOfficial 1 1. INTRODUCTION 1.1 The circumstances leading to this Review 1.2 This review was commissioned by Wandsworth Safeguarding Children Board (WSCB) following the death of a 3-year old, Frankie in July 2016. The child had been an inpatient in hospital for life threatening asthma in the days leading up to death and died within 24 hours of discharge. The London Ambulance Service was called to attend the child at the family home. Resuscitation attempts were made. Frankie was then transferred to hospital where despite ongoing resuscitation attempts, died. The cause of death is recorded as an “acute exacerbation of asthma.” The toxicology screen was negative. The child had a history of acute episodes of asthma with frequent admissions to hospital but also with some periods of stability. Frankie had required care on the Paediatric High Dependency Unit on several occasions and the asthma was considered by health professionals to be life threatening. 1.3 Frankie’s parents had been reluctant to fully comply with medical advice and prescribed medication for their child. They had a fear of steroids but declined or reduced numerous medications over the various admissions. This raised concerns with healthcare professionals. 1.4 Following the death, there was a Rapid Response meeting within the prescribed time where no safeguarding issues were identified. The family were not known to the Children's Social Services or the police and there were no apparent safeguarding concerns identified. The case was then reviewed by the Children’s Death Overview Panel (CDOP), but this was not until 10 months after the Rapid Response meeting. The death was brought to CDOP on 28th September 2016 but the case not ready for review (the full Postmortem was awaited). Then further delay occurred on 25th January 2017 when the CDOP review meeting cancelled as key members were unable to attend. On 22nd March 2017 Frankie’s death was reviewed and closed with a recommendation for the death to be raised at the Wandsworth Local Safeguarding Children Board Serious Case and Learning Sub-Committee. 1.5 At an extraordinary meeting of the Serious Case and Learning Sub-Committee on 2nd July 2017, it was agreed to recommend to the Independent Chair of the WSCB that a Learning and Improvement Review (LiR) be undertaken. This resulted in an Independent Chair and Report Author being commissioned and the learning review was formally commenced in February 2018 with an initial scoping meeting. 1.6 However after preliminary consideration of the case and in considering further information, the Independent Chair and report Author gave the view that the death merited a Serious Case Review (SCR). This view was raised formally to the WSCB on 4th May 2018. The matter was referred back to WSCB and after some deliberation a SCR was commissioned. The decision to proceed to a SCR was conveyed from WSCB to the Independent Chair and Author on 14th June 2018. A Serious Case review was then commenced.Official 2 Official 1.7 The WSCB concluded that the case meets the criteria for a Serious Case Review (SCR), as outlined in Working Together to Safeguard Children 20151, in that Frankie was a child at the time of death and there was information that: a) abuse or neglect of a child is known or suspected; and b) either – (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. This criterion is now contained in the updated Working Together to Safeguard Children published in 2018. 2. Purpose of the Review and Methodology 2.1 The key purpose in undertaking this SCR is to ensure that learning can be identified following the death of this individual child. Most importantly the purpose is to ensure the Review achieves the fullest understanding possible both of what happened but also why, in order to identify improvements and contribute to the prevention of future similar tragedies. The review report will be published. It will support local and national learning. 2.2 Case reviews should be conducted in a way which: • recognises the complex circumstances in which professionals work together to safeguard children; • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way data is collected and analysed; and • makes use of relevant research and case evidence to inform the findings. 2.3 A Review group was convened consisting of: Agency/Organisation Role Wandsworth CCG Chair Independent Report Author Wandsworth Borough Council Children’s Social Care Head of Safeguarding Standards Hospital A Named Nurse Wandsworth CCG Named GP for safeguarding Metropolitan Police Specialist SCR Review Unit Officer 1 Working Together: HM Govt March 2015Official 3 Central London Community Trust Named nurse for safeguarding Hospital A Named Doctor Hospital B Consultant in Respiratory Medicine Hospital B Named nurse for acute services Wandsworth Borough Council Head of Education. Inclusion and Performance Hospital B Head of Safeguarding 2.4 The WSCB Business Manager supported and contributed to Review Team meetings as well as to the overall process of the Review. 2.5 Consideration was given at the outset, to inviting others who might bring a specialist knowledge, particularly in relation to asthma. The Review and practitioner group included clinicians with a knowledge of paediatric asthma and a specialist children’s asthma nurse provided clinical expertise. 2.6 The Review Panel met on 6 occasions, and a practitioner meeting was also held to hear directly from frontline practitioners as to the interactions with this family and obtain more detailed information as to the issues which have emerged in looking at the care and management of this child across the agencies. 2.7 The Review began by gathering the necessary evidence which included the production of a multi-agency chronology involving all the services and agencies who had relevant contact with Frankie and family. All relevant voluntary sector and statutory agencies were contacted at the outset to check for any involvement with Frankie and family. As a result, full chronologies and individual management reviews (IMR’s) were provided by the following agencies: 1. Hospital A 2. University Hospital B NHS Foundation Trust 3. The family’s GP Practice 4. Wandsworth Children Social Care 5. Metropolitan Police 2.8 A report from Dr C a Consultant in Respiratory Medicine at Hospital 2 was also considered along with the Rapid response and CDOP records. 2.9 Equality and Diversity Both parents were professionals. They employed a nanny to care for their two children. There are no known health or disability concerns for either parent. There is also a paternal grandmother though it is unclear how involved she was with Frankie or the family more generally. The review adheres to the Equality Act 2010. All nine protected characteristics were considered by the Review group. The practices of agencies were carefully consideredOfficial 4 to ascertain if they were sensitive to the nine protected characteristics of the Equality Act 2010, i.e. age, disability, gender re- assignment, marriage and civil partnerships, pregnancy and maternity, race, religion and belief, sex or sexual orientation. The review panel considered all equality aspects and there is no information or inference in any records or other information to indicate that any incidents were motivated by ethnicity, faith, sexual orientation, gender, linguistic or other diversity factors. This should however be seen in the context that the family have declined to be part of this review, so it has not been possible to ask the family direct if there are any equality factors, they feel relevant. Although not one of the nine protected characteristics, the review panel did note that the social class of the parents was likely to have contributed to this situation. The approach that professionals adopted towards the parents in considering their opinions and position in relation to the treatment of their child’s condition was overly deferential and lacked robust challenge. It is the view of the panel that this is less likely to be seen when dealing with families without similar educational and employment backgrounds, where there is less likelihood of recourse to complaints systems and litigation. 2.10 The review examines the responses of all the relevant agencies that had contact with Frankie and family and considers whether there were gaps in services or wider learning about safeguarding children. The main timeframe for the review begins with the birth of Frankie in November 2012 and includes after death in July 2016 to consider the actions and decisions of the Rapid Response and CDOP process. 3. THE CIRCUMSTANCES OF FRANKIE’S DEATH 3.1 Frankie’s parents (Mr and Mrs F) moved to the UK in 2009. Frankie was born in November 2012 at 38 weeks gestation at a London hospital and the birth was uneventful. Frankie was low weight at birth but did not require any hospitalisation after birth. Frankie had one older sibling at the time of death. 3.2 The family were registered with a GP in 2010 and Frankie was seen for routine 8- week new-born check where a marked deformity of the left 4th toe was noticed. This was referred for a paediatric orthopaedic opinion aged 1. The rest of the physical examination was normal. Frankie was seen regularly by the GP throughout the first four months of infancy with viral illnesses of cough and coryza2 but these were all self-limiting and managed with advice and support. The first episode of this was at two months. 3.3 Frankie was next seen at 15 months of age when Mr and Mrs F presented to the GP with a further viral upper respiratory tract infection. At this consultation of note is that Mr F stated that both children had not had any immunisations as he had been warned about side effects and had read about the MMR and autism controversy. A discussion took place with the GP discussing the benefits of immunisation, explaining 2 Rhinitis, also known as coryza is irritation and inflammation of the mucous membrane inside the nose .Official 5 the falsified evidence around MMR and autism and discussing the risks of not protecting Frankie with immunisations. At that time Mr F agreed to discuss with his wife and come for review in two weeks. The parents did not attend as planned. The GP informed the Health Visitor and asked them to contact the family to encourage immunisation which they did but the parents would not engage. It should be noted that due to adverse research and publicity against MMR immunisations (which was later discredited) there was a backlash against immunisations due to the fear that there was possibly a link to autism. This proposition was widely profiled on social media platforms and despite evidence to the contrary some parents have remained to this day reluctant not to have their children immunised. 3.4 This was the first consultation of many where the GP’s at the practice tried to discuss immunisation with both parents. The children remained unimmunised. 3.5 Frankie continued to be taken to the GP with recurrent upper respiratory tract infections and wheeze. Frankie was brought to the GP aged 18 months in June 2014 by the nanny. This was the first discussion the GP had about wheeze and “distress in breathing” (DIB) The GP advised the nanny to attend the Emergency Department (ED) if Frankie’s breathing worsened. 3.6 On 24th August 2014, Frankie attended the ED with serious breathing difficulties and had been seen by the GP 6 days prior and antibiotics had been prescribed but the parents had not administered, it is not known why they did not administer. Frankie had a prolonged admission at this time at Hospital 1 (and required high dependency care. At this point was referred to the respiratory team led by Dr C; an experienced Respiratory Consultant based at the Hospital 2, but he was a visiting consultant at Hospital 1. Frankie was discharged home on inhaled steroids and oral Leukotriene antagonists (Montelukast) after a diagnosis of infantile asthma with severe wheezing was made. Frankie was subsequently seen by Dr C as an outpatient. It should be noted that neither Hospital 1 nor Hospital 2 are within Wandsworth Borough. 3.7 A letter from Dr C to the GP and copied to the Health Visitor in August 2014 communicated some of the difficulties with the parent’s compliance with Frankie’s asthma management. Dr C saw Frankie within a month after discharge and wrote to the GP stating the parents had reduced the fluticasone inhaler and that they were not giving Frankie Montelukast as they were concerned about its side effects, namely growth restriction. They had started Frankie on homeopathic alternatives. Dr C states clearly in his letter dated 14th August 2014 that he had a long conversation with Mr and Mrs F parents at this time about the importance of inhaled steroids and discussed the issue of side effects in detail. He was specific in guiding them that long term high/medium dose could possibly lead to a 1-2cm reduction in final height. He stated: ‘this must be countered however by the fact that inflammation that is unrestrained within the airways will reduce growth and some children die from asthma and it is usually those who are not receiving the inhaled steroid treatment they need.’ 3.8 Dr C was explicit to the parents that Frankie had a life-threatening asthma and optimal medical treatment was imperative. The plan was for Frankie to undergo some further investigations including a CT scan at Hospital 2 as clinical presentation wasOfficial 6 quite unusual for a child of this young age. Dr C explained that depending on the result it was likely Frankie would need other investigations. 3.9 A CT scan was performed but no further correspondence around any other investigations was received at this time. It is not documented whether these were declined by Mr and Mrs F. 3.10 At this time a flag was put on Frankie’s GP notes of suffering with severe asthma. 3.11 Frankie was also under the care of a Health Visitor for the first year of life but then moved to a health visiting “corporate caseload” (i.e. universal services) at the age of one as was not deemed to require any enhanced services. Frankie was seen twice at home by the health visitor. The first visit was a new birth visit In November 2012 (before the GP visit at 8 weeks when the toe deformity was discovered by the GP) and a follow up home visit in December 2012 which raised no concerns. 3.12 Frankie was not seen for the two-year developmental check milestone as the parents did not bring Frankie. This was not pursued and was not seen as obligatory nor necessitating any action under a “Did Not Attend” policy. This failure to attend was not seen as concerning by professionals. Frankie was not attending any early year’s provision so had no contact with professionals there. Therefore, it is not possible to say if Frankie was meeting the two-year developmental milestones. 3.13 Frankie had twelve hospital admissions to Hospital 1 from the age of 20 months until death -all associated with severe asthma. 3.14 On six of these admissions Frankie required admission to the Paediatric High Dependency Unit. Frankie required resuscitation on at least three occasions. Frankie had also previously stopped breathing at home, and last admission to hospital had been on 3 July 2016 when acutely unwell and was found limp and foaming at the mouth. Frankie had become unwell at around 2am and an ambulance was called some hours later and was treated at the hospital and then discharged on 7 July 2016 with a defined plan of medication. On discharge Mr F did not want the oral steroids prescribed despite medical staff explaining to the parents that Frankie’s had a life- threatening asthma. 3.15 There are numerous instances recorded where the parents declined or unilaterally reduced or stopped medication to Frankie for the asthma. There are periods when reported to be stable at home. The asthma was generally worse in the summer. The noncompliance of the parents to administer medication as advised did raise concerns but this was not referred for any safeguarding consideration. The parents had been advised that Frankie had a life-threatening condition and required medication. It is unclear what medication was being administered to Frankie at the time of death at home or whether alternative therapies were being administered. 3.16 When leaving the hospital on 7th July Mr F was clear that he would not accept steroids or other medication for Frankie based on possible side effects of which both parents were fearful. This was despite the concerns raised by the discharging doctor that Frankie had a life-threatening condition. No safeguarding concerns were raised at this point and Frankie was discharged back into the care of the parents. FrankieOfficial 7 returned the next day having had deteriorated at home overnight and could not be saved. 4. CHRONOLOGY OF KEY EVENTS 4.1 IMR’s were provided by all the agencies known to be involved with the family but agency contact was limited largely to the GP, health visitor and hospital. The most pertinent timeline is around hospital admissions and this gives the review the richest information around the management of Frankie’s asthma by practitioners and parents. This is a key aspect of this review. 4.2 The timeline is not an exhaustive list of contacts but centres around the main agency who by far had the most contact with Frankie and family- the hospital. For ease of reference the main exchanges with Frankie’s parents are in italics. The timeline commences when Frankie’s asthma starts to lead to hospital admissions as this reflects when risk to wellbeing appears to be increasing. It should be noted that two last entries in the medical records have been written retrospectively after the child’s death and are not contemporaneous. 5. CONTRIBUTION OF FRANKIE’S FAMILY AND FRIENDS 5.1 Frankie’s parents have declined to be part of this review which is their choice and one which must be respected. A face to face meeting was offered at the start of the review. The parents did initially agree to participate, and answer questions posed to them in writing. A letter was sent to the parents on this basis by the Chair of the SCR, but this has not elicited any response. Further contacts have been made to encourage involvement, but this has not been fruitful. 5.2 However, this means that our understanding of what was, or was not, happening within the family home is greatly limited and leaves many unanswered questions and a lack of wider family perspective other than is recorded in records. This also impedes understanding parental choices made; their rationale and what may have informed that including social class, cultural and faith aspects. It has not been possible through the parents to identify other family members who may have been able to contribute or the nanny who looked after Frankie for a period of time. 5.3 Understanding Frankie’s lived experience is also limited by the fact that no professional observed Frankie in the home setting following the Health Visitor visit in December 2012. Frankie had one older sibling but is too young to participate in this review. The sibling was home educated at the salient time. 5.4 The experience of Frankie who was very young and unable to understand the illness and the restrictions this will have placed at times should not be underestimated. Frankie’s condition would have been disruptive to routine and early learning as well as play. Frankie had repeated admissions to hospital as the condition was largely uncontrolled and had a high number of admissions where breathing was severely compromised. The potential negative psychological, physical and emotional impacts of hospitalisation upon a child is well researched and that play interventionsOfficial 8 is key to assisting a child. 3 It is not possible to ascertain Frankie’s quality of life at home or what medication was being administered to help but in the short life will have experienced the obvious stress a child will experience being admitted to a hospital which to even a young child is an alien environment. The review team and those clinical experts advising into the review are left wondering whether with better management of the condition such repeated admissions could have been avoided. 5.5 By 3 and a half years old a child should be able to verbally communicate and be understood by people outside the family. Three-year old’s meeting their developmental goals are mobile and active; playful and engaging. They enjoy books, music, storytelling, swimming, role play and learning about colours and numbers and exploring their world. However, the majority of time Frankie was in hospital was seriously ill, and the focus was on parental choice and we can only speculate whether Frankie sensed the contention and tension between the parents and those professionals seeking to care. Play workers did engage with Frankie but at times was simply too ill to play. Frankie required high dependency care on more than one occasion and must have been extremely stressful. 6. ANALYSIS AND APPRAISAL OF AGENCIES’ PRACTICE 6.1 The loss of a child is always a tragedy and the review panel do not underestimate what a great loss this will represent to Frankie’s parents and the wider family. This review however is tasked to capture any learning that can be gained by Frankie’s story and to that extent the review must approach the review from the child’s perspective and ascertain how agencies and practitioners worked around the child and the family to safeguard where necessary. 6.2 The crux of this review has been to what extent does parental responsibility and choice override the welfare and health of a child who has an identified life-threatening condition. Furthermore, when does noncompliance of a child’s parents to provide the child with optimal medical care become medical neglect? “Working Together to Safeguard Children A guide to inter-agency working to safeguard and promote the welfare of children (July 2018) defines neglect as: A persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to: 1. Provide adequate food, clothing and shelter (including exclusion from home or abandonment) 2. Protect a child from physical and emotional harm or danger 3. Ensure adequate supervision (including the use of inadequate care- givers) 3 Play interventions to reduce anxiety and negative emotions in hospitalized children • William H. C. L, Joyce Oi Kwan Chung, Ka Yan Ho and Blondi Ming Chau Kwok BMC PediatricsBMC series – open, inclusive and trusted 2016Official 9 4. Ensure access to appropriate medical care or treatment It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs. 6.3 Under the Children Act 1989 as amended, the term “parental responsibility” is defined as “all the rights, duties, powers, responsibilities and authority which by law a parent of a child has in relation to the child and his property”. This is a qualified right and in some instances the courts must intervene to protect a child where parental responsibility is not exercised in a way that meets the best interest of the child and puts them in harm’s way. There can be complex reasons why a parent may act in this way but the law is clear that if the child is suffering or likely to suffer significant or serious harm due to acts or omissions of a parent or indeed others all agencies and professionals have a duty to act to protect the child. This will inevitably require the expertise of safeguarding professionals to support professionals and families to work together to find an agreed way forward for an appropriate and safe care plan for the child. Some cases have attracted the attention of both High Court and Family Courts where medical care and attention has been impeded by parents and this has been to the detriment of the child and caused unnecessary suffering and /or harm. In some cases, children have required special guardianship or care orders. Asthma is not an uncommon condition amongst children and can be life threatening. There is a clear care pathway supported by National Institute of Clinical Excellence (NICE) and the British Thoracic Society 4 and the care pathway represents evidenced based practice. 6.4 What this review has clearly highlighted is that practitioners are much more comfortable in recognising the first three categories of neglect but consideration of the fourth pertaining to medical neglect presents a much greater challenge. When professional practice around Frankie was appraised it was found that there were several contributory factors for this. 6.5 The primary factor was that professionals felt unable to fully challenge parental responsibility and choice being exercised in the face of affluent, well educated, researched and assertive parents who willingly brought their child to medical attention but then sought to control what treatment the child was given. This was despite the parents having been advised of the real importance of asthma treatment judged to be safe and appropriate by numerous health professionals. This included a consultant expert in the field, Dr C. He was clear that those children who die of asthma are those that are not receiving treatment as prescribed and advised. Asthma is a condition that requires preventative and maintenance medications to stave off acute episodes and improve quality of life of the child. When the parents did comply as soon as there was improvement in Frankie’s condition they would unilaterally stop or reduce medication which will have increased the risk of serious and acute stages and caused the child more breathing difficulties than was necessary. The parents were open on their actions around stopping and reducing medication, but this did not trigger any safeguarding consideration. The child’s experience and wider impact of ill health appears to have been lost and yet there were other possible signs of failing to thrive such as weight loss and the child’s nanny describing Frankie as lethargic. 4 https://www.brit-thoracic.org.uk/.../guidelines/asthma/btssign-asthma-guideline-2014/Official 10 6.6 This review has found that the assertion from the parents around not giving medication was powerful even when the child was deteriorating. On numerous occasions professionals were held back by the parents from treating in the best interest of the child. The parents stated repeatedly said they had researched the suggested treatment regime and medications on the internet and posed their research and their findings as more authoritative than advice being given by experienced professionals. Clinical governance and sound medicine management mean that prescribed medicines should be administered to the child unless there is a clinically based rationale not to do so. 6.7 Without speaking to the parents direct and gaining their perspective it is impossible to fully understand their rationale for their approach or reasoning and whether the non-acceptance of conventional medicine and their preference for alternative therapies comes from fear/ cultural/religious/inherent lack of trust for professionals or any other factors. The information gained by the parents was used by them to counter treatment and over emphasise possible side effects despite reassurances from most senior health staff that such side effects were minimal if they materialised and that the child’s survival was the paramount issue. When the child had natural remissions from the acute nature of this condition and was not in hospital professionals were understandably reassured of a possibly stabilising condition. 6.8 Another factor is that practitioners managing Frankie lacked an understanding that parental responsibility does not extend to a degree that permits medical neglect. While it cannot be denied that the parents brought the child to medical attention the fact that they would then persistently fail to fully comply with the best evidenced treatment for Frankie and a well-recognised care pathway meant that they acted against their own child’s best interests. This relates to care in the acute phases of illness but in all probability also inconsistent maintenance treatment at home to prevent further acute and life-threatening episodes. Even during the last discharge, the day before the death, parental noncompliance was apparent. 6.9 Practitioners did not recognise the safeguarding significance of medical neglect in the form of a parent consistently and persistently withholding consent to medical treatment for a child who had a life-threatening condition. 6.10 Therefore the parents who are well educated, well informed and confident with strong beliefs around alternatives therapy felt they had superior knowledge. They were able to disrupt a well evidenced medical care pathway and at times coerce modifications away from optimal treatment. This happened even on occasions where Frankie was seriously unwell. This disempowered the medical professionals. Both parents presented as confident, well-educated and were challenging the wisdom of professional judgements with research they had sought from the internet focussing upon side effects of conventional medications not seemingly accepting that such medications have in themselves an evidence base as an established care pathway for asthma. Both Mr and Mrs F were persistent and strong in their held beliefs and their social class and demeanour in this regard led professionals away from the basic premise that the child’s welfare is paramount. The child being so young was unable to voice a viewOfficial 11 6.11 The admirable ethos of wishing to work in partnership with families which is embedded culturally appears to have been a barrier in this case to practitioners having a more challenging discussion with the parents around the safeguarding aspects of their decisions. The parents therefore drew practitioners away from their safeguarding duty to the child. 6.12 The child’s welfare is paramounti5 and the duty if care to the child became lost in the episodic exchanges with the parents permitting the parents to lead the medical care not medical professionals. 6.13 There was a professional over optimism around medical care being provided at home combined with no monitoring or support to the family in the community. 6.14 Parental challenge around medication is seen as a common problem and there may be desensitisation in that asthma is also a common condition though the severity of Frankie’s asthma was recognised. 6.15 Practitioners in the hospital also stated anecdotally that past experience meant that if practitioners had referred to children’s safeguarding this would not have met the requisite threshold or elicited action. The hospital works with numerous local authorities and this is their experience. However, Frankie was not discussed with any internal safeguarding professionals e.g. Designated and Named Professionals. These professionals could have usefully and if necessary, supported the health professionals speaking to the parents in safeguarding terms. The hospital concerned had /has clear safeguarding policy and designated professionals from whom advice could have been sought. 6.16 As it was the parents’ behaviours around their assertions on asthma treatment permitted them to keep to an approach that they knew best and put them central rather than Frankie. This was compounded by inconsistent clinical leadership and supervision to assess and oversee the accumulative impact upon Frankie of parental noncompliance. The lead consultant was based in another hospital. As the child had repeated admissions understandably, was seen by many different doctors and nurses of numerous grades, experience and expertise. The lead consultant had neither the detail of the challenges being faced by nurses on the wards in trying to administer care or the holistic oversight. 6.17 During the very many admissions, professionals who had contact with Frankie’s parents, strove to educate and impress upon them the importance of administering medication as prescribed and not to reduce or stop the treatment unless advised. It is impossible to ascertain without the parents participating in this review how much medication was being administered within the home or indeed what other substances were being given. The consultant did not see alternative therapies as a problem providing Frankie was also receiving inhalers and other prescribed medication. Dr C an experienced consultant wrote to the parents and their GP and this was copied to the Health Visitor. This letter set out the life-threatening risk to Frankie if the 5 The Children Act 1989 https://www.brit-thoracic.org.uk/.../guidelines/asthma/btssign-asthma-guideline-2014/Official 12 medication regime was not followed and monitored. The thread of this was then lost once expressed and so any opportunity to escalate to safeguarding was not utilised. 6.18 Frankie was also seen regularly by the GP. There were many opportunities for the GP’s involved with Frankie’s care to ask specifically about compliance with medication regimes communicated and prescribed by the respiratory team and lead consultant. On several occasions conversations around this were documented but there were many opportunities to explore and challenge some of the non-compliance further by GPs. Dr C’s letters to the GP each mention his explicit communication about the risk of non-compliance to Frankie. Dr C’s view expressed to the review into the review was that the death was avoidable with consistent and cooperative management. On balance he states that Frankie should possibly not have been discharged on 7th July 2016 but qualifies this by saying that view does include a hindsight bias. It was notable also that in the practitioner’ s event that professionals referred to other children with serious conditions with equally challenging parents so this would tend to indicate this is not an isolated case. This merits a safeguarding audit by Hospital A. There is a complex case meeting in the hospital but noncompliance by parents in this case was not seen as so worrying to merit the case being brought to that meeting. There are no formal terms of reference for the complex meetings and it would be helpful for these to be developed and medical neglect concerns around noncompliance be added as a factor that may bring a case to wider discussion. 6.19 The review was also able to have the benefit of a specialist asthma nurse to input into this review bringing her expertise and wealth of experience. She raises concerns around multiple documented occasions where Mr and Mrs F displayed obstructive behaviour and lack of engagement, even when their child was extremely unwell. 6.20 This extended to multiple reports of Mr and Mrs F’s fears around orthodox and evidence-based treatment and their resulting refusal to administer such treatment coupled with obstructive behaviour in hospital, even when their child was seriously unwell. This presented a paradox that though Mr and Mrs F reported they had done much research around asthma medication, homeopathic remedies employed by them lacked any robust evidence compared to orthodox medication for asthma. 6.21 Further Frankie would have benefitted from being considered by the “Difficult Asthma Team.” Usually if child is under care of Difficult Asthma Team, there would have been a more multi-disciplinary team involved and a home visit performed by an Asthma Specialist Nurse. Frankie was not “fully” under the care of the Hospital 2 and was just seen in the outreach clinic. “There is no universally agreed definition of difficult asthma in children or adults, and specifically at what level of treatment prescription or asthma attack frequency the term difficult asthma should apply” 6 6 BTS/SIGN Asthma Guideline 2016Official 13 6.22 However, generally children attending a designated Difficult Asthma Clinic have been prescribed high dose therapies, which was not the case with Frankie. In any event, the fact that: • the calibre of Frankie’s asthma was designated as life-threatening by a Respiratory Consultant very early on • this was explained to parents on more than once occasion • that if inhaled steroids not given risk increased of death • multiple episodes of hospitalisation for severe wheeze occurred likely due to “neglectful non-compliance” • parents persisted in not doing as recommended as they felt they knew better This should have triggered a local safeguarding team involvement and a referral to the local authority being made as the child’s best interests were not being met. 6.23 It may be that significant factor in a safeguarding discussion not being triggered was the range and volume of health professionals of health professionals involved in Frankie’s care with no single Consultant/team based at the hospital to take overall responsibility. Also, difficulties existed around the assertiveness of Mr and Mrs F. However, the safeguarding team could have been instrumental in helping to overcome such difficulties. 6.24 The GP IMR author suggests if Dr C and the hospital team had used the phrase neglectful non-compliance whether Frankie’s health journey may have been different. That IMR states that if members of the health agency who dealt with Frankie had perhaps met to have a Team around the Child (TAC) meeting with the family as a whole it might have helped the parents to reconcile some of the advice being given. 6.25 This IMR goes on to give a view that ultimately Frankie’s death may have been prevented by a more rigorous compliance to treatment, but it may also not have been as Frankie had an atypical presentation of early severe childhood asthma. There was potential for more rigorous review in primary care and it may have helped for the family to have always seen the same GP and to continue to build a rapport and trust around Frankie’s treatment. This is always an aim when caring for any child with a severe chronic illness and indeed the surgery did very well in ensuring as much continuity of care as possible and each member of the team being aware of his case. Unfortunately, due to the pressure on GPs within the NHS having to manage 10- minute appointments in often understaffed circumstances continuity of care is not always possible. 6.26 There were opportunities for a multi-agency approach to supporting Frankie and parents complying with the management and treatment regimes. These opportunities were not taken despite good written liaison between secondary and primary care. No attempt was made to have a Team around the Child (TAC) or Team around the Family (TAF) meeting. This should have been arranged. 6.27 A thorough review of Frankie’s GP notes and case has been discussed at practice level amongst the doctors who cared for Frankie. They have discussedOfficial 14 methods of monitoring compliance in addition to regular face to face review (e.g.; underfilling repeat prescriptions). 6.28 GP’s should be confident to challenge parents when thinking about the best interests of a child. This was noted to be very difficult in practice, particularly when parents are highly educated and are presenting well thought out (although not evidence-based) arguments about not agreeing to medications or immunisations. However, all GP’s are children safeguarding trained and so this should always be a consideration when they are seeing children and families. 6.29 There is helpful research which sets out the challenges for practitioners when working with affluent, resistant parents. It is set in a social work setting but has resonance for this review. 7 and emphasizes keeping the child central. “One of the most frequently discussed issues was that affluent parents’ confidence and sense of entitlement meant that they felt they could diagnose their own needs, expected children’s social care to accommodate them, and felt that they had a right to challenge those in authority. Practitioners reported that active engagement techniques, such as having a formal signed agreement and goal setting, often did not work with affluent parents” “the thinking was on the importance on holding the child as a central focus of the assessment, so that the parents’ interests did not outweigh consideration of what was in the child’s best interest” 6.30 The review explored what was available to protect Frankie and support the child in the community. Frankie was seen at home twice as per regime post birth but was never immunised and did not attend the two-year developmental check. Given children’s social care was not involved at any level and there was no social worker involved to drive forward a TAC although any agency can trigger that process. The health visiting service was more limited after the child past one year as the delivery model had been changed to accommodate resource issues by the commissioning body at the time. The same model of delivery dictated that unless a child was within safeguarding there would be no consideration of enhanced services or support. The health visiting service acknowledges that they would have received letters every time Frankie was admitted to hospital but states that health visitors now come from a wider pool of skills e.g. midwifery, mental health nursing. The IMR from the organisation that commissioned the service at the time states “new health visitors would not necessarily have a full working knowledge of the medical/ acute setting terminology used in a discharge summary”. 6.31 Asthma is stated to be a well-managed condition though the health visiting service did acknowledge that the condition could cause death. The issue of noncompliance was not appreciated by the health visiting service at the time because the direction from the GP was more around the child having not been immunised. It is unclear if the letter from Dr C to the GP explaining the concerns of noncompliance 7 An Exploration of How Social Workers Engage Neglectful Parents from Affluent Backgrounds in the Child Protection System 2017 Professor Claudia Bernard Goldsmiths, University of LondonOfficial 15 by the parents and the implications of that was ever actually seen by the health visitor. 6.32 The review was told that paediatric community services did not extend to an asthma nurse outreach into the community for children. It cannot be assumed of course that the parents would have engaged with the health visiting service under an enhanced service and there is evidence that the parents liked to keep professionals at arm’s length. 6.33. It is a difficult judgement now to make whether Frankie should have been discharged on 7th July and whether this constituted a safe discharge. Frankie’s deterioration appears to have been rapid that night and the fullest details are not known as to what the parents did to manage the condition at this point. It is also important to note that Frankie did have periods of stability and that in any circumstance given the severity of the asthma may have always presented some risk of death. However from a safeguarding perspective this meant that the stakes were higher in ensuring the best interests were met with medical care required and in a consistent manner that would have allowed the medical professionals to have accurate information and parameters on which to base their clinical decisions while the child was in and out of hospital. The parent’s suspicious approach toward the care and treatment and fixed belief that they knew best in terms of diagnosis and treatment was the biggest risk factor of all to Frankie. As a result of the matter not being referred to safeguarding Designated or Named professionals or referred to the Local Authority Children services the option of working with the family from that perspective was not used. That is not to say that this matter would have reached threshold8 to trigger a s47 child protection response but the important factor is one of a consideration in these circumstances. 6.34 The matter was referred to Rapid Response after Frankie died but those deliberating appear to have continued the lack of due consideration of the safeguarding aspects. This was largely informed by the medical history and lack of safeguarding response when Frankie was alive rather than a more independent consideration. This then took 10 months to reach CDOP for legitimate reasons stated in this report’s introduction. 6.35 On discussion with children’s social care in the context of some health professional’s perception that had they referred Frankie this would not have elicited a response, the review was advised that there have been previous cases where children’s social care have sought intervention in similar circumstances and that medical neglect is a recognised category of neglect in that service.9 It needs also to 8 Wandsworth Safeguarding Children Board Thresholds for Intervention March 2018 9 Wandsworth Safeguarding Children Board Neglect Strategy April 2017 Multi-Agency Neglect Strategy and Practice Guidance Wandsworth Safeguarding Children Board Multi-Agency Neglect Strategy and Practice Guidance 2017-2019Official 16 be acknowledged that this was a tertiary hospital that deals with multiple local authorities where there is potential for differing applications of thresholds. Further professionals in all agencies can resolve differing professional viewpoints and interpretations of risk by using the escalation policy10. There is a recognition that social workers can also be challenged by affluent, well-educated and well-informed parents who challenge professional judgements. Also, at the time of Frankie’s death the “front door” of children’s social care and the referral gateway had been strengthened to support professionals accessing a consultation with a manager. safeguarding. 6.36 There were no concerns raised around the older sibling though it is not clear if the sibling was ever seen by any agencies as was home educated. The responsibility for a child’s education rests with the parents, and while education is compulsory school is not. A parent’s right to educate their child/ren at home is upheld by Section 7(b) of the Education Act 1996. Once the decision to home educate has been notified, there is a lack of a strong, mandatory framework to monitor, assess or inspect the quality of home education provision. Moreover, there is no agreed route for the children involved to formally express their views as to where they wish to be educated, or to give feedback on their experiences of being educated at home. There is no statutory requirement for a local authority to maintain a register of pupils being educated at home, the authority cannot insist on regular contact with parents, and the latter are under no obligation to accept home visits. 7. Findings 7.1 This review has highlighted several findings: 1. That the parents, not the child became central to clinical decision making around the child. The child’s welfare is paramountii11 and the duty of care to the child became lost, as did authoritative practice. The child’s voice was not being heard. 2. As a form of neglect, medical neglect is less understood across all agencies and within the health system. This represents a serious weakness in the multi- agency children safeguarding system. 3. Professional practice around how a parent exercises their powers under parental responsibility and when this might cross into neglect was not 10 INTER-AGENCY ESCALATION POLICY The Resolution of Professional Inter-Agency Disagreements about Safeguarding Children Revised March 2018 11 The Children Act 1989 https://www.brit-thoracic.org.uk/.../guidelines/asthma/btssign-asthma-guideline-2014/Official 17 considered. Nor was the impact of social class upon the relationship with health professionals. There was an unconscious bias at play. 4. Persistent and wilful parental noncompliance of a potentially lifesaving care pathway to a child was not considered as a safeguarding matter nor appropriate expertise sought. 5. Consistent and reflective clinical leadership and supervision was missing. This is key to meet the medical duty of care to the child and avoid disruption of a care plan to treat a life-threatening illness. In this case professionals were successfully coerced away from a well evidenced medical care pathway which at times prevented optimal treatment being given to the child. 6. There was a professional over optimism around medical care being provided at home combined with no monitoring or support to the family in the community. 7. Parental challenge around medication is seen as a common problem but there does not appear to be a robust strategy to manage this in the hospital. 8. Some professionals were unfamiliar with the escalation process for safeguarding within Hospital A. 9. The internal forum for complex cases was not used in this case missing an opportunity for clinical oversight; safeguarding and information sharing around the child and family. 10. The absence of other categories of neglect appear to have reassured practitioners. 11. Currently there is no system to identify children who are regular attenders at the hospital with life threatening and acute illness rather than suspected non accidental injuries. 7.2 Previous SCRs nationally have included children who were the subject of serious case reviews involving possible medical neglect12. These highlight in the main undue professional optimism suggesting that medical professionals may be overly optimistic that families will be able to care for a child with a long-term illness even when there is evidence to the contrary. 7.3 Another theme has been around non-compliant parents, with some SCR’s suggesting professionals did not appropriately challenge parental behaviours in order to safeguard the child. There is however some ongoing learning to be achieved across agencies to identify, manage and act upon situations where this may be a factor. That is not to say that all cases of concern brought to safeguarding will conclude medical neglect is present but it is the objective and thorough consideration within the safeguarding system that is key to make those deliberations and work with families to enable them to understand that the impact of withholding care to a child (intentional or not) may amount to significant harm or even in some cases death. 12 Neglect and Serious Case Reviews A report from the University of East Anglia commissioned by NSPCC Marian Brandon, Sue Bailey, Pippa Belderson and Birgit Larsson University of East Anglia/NSPCC January 2013Official 18 8. RECOMMENDATIONS 8.1 The report made 8 recommendations which were challenged by the partnership in terms of their feasibility as they related to both health’s service contractual arrangements and national commissioning issues, both primary and specialist care. A new set of recommendations with action plans were drafted and progressed. However, given the concerns raised an independent critique of the report was also commissioned. The critique of the report was accepted fully by the partnership and key findings to ensure effective learning are: 1. All Lead Directors for providers submitting IMR’s must have oversight and sign off the reports to ensure that they are of good quality and to enable learning to be taken forward in a timely way. 2. Hospitals to explore how clinical teams manage parent consent for emergency treatment. 3. Hospitals must review how it manages severe illness in children when a parent favours alternative therapy. 4. Hospitals must review how ward staff act when there has been an incident of a parent administering medication, on the ward, to a child outside of the treatment plan. 5. The paediatricians at hospitals must undertake a reflective session to consider in what circumstances they would seek legal advice regarding parents who do not consent, and who would make the decision to escalate. 6. Acute Trust Boards must review how the clinical teams are supported in their decision-making regarding treatment when the parents do not agree with the treatment plan. 7. GPs and Health Visitors must have an agreed plan when following up issues of concern with families. 8. All services must be able to evidence how their workforce participates in reflective safeguarding supervision which supports their learning and development. 9. All children on the severe asthma pathway must have a management plan and names lead professional who has oversight of their care. Independent Critique Reviewer: Nicola Brownjohn RN(Adult), SCPHN (School Nurse), MA (Professional Practice Safeguarding Children) Further Research Since this death Health London Partnership have developed asthma standards as a key priority for improving the health of London Children and Young People. Healthy London Partnership Asthma is the most common long-term medical condition affecting children and young people. 1 in 10 children and young people are affected by the condition, meaning 240,000 have asthma in London. Many have badly managed asthma- to the extent that 4,000 are admitted to hospital with asthma every year and 170 have such a severe episode that they require admission to intensive care.Official 19 At the worst end of the spectrum around 12 children and young people die of this disease in the capital every year. Healthy London Partnership Asthma Standards In 2016 Healthy London Partnership (HLP) developed London asthma standards for children and young people. These standards support the identification of those who are high risk. This includes ‘children who have had more than one admission or admission to PHDU or two or more ED attendances in the last year. This would also target those with 80% or less uptake of repeat preventer prescriptions.’ The HLP have also developed a discharge standard to ‘ensure safe discharge and transfer between providers.’ This includes the need for discharge information to be sent to the GP and community teams electronically within 24 hours and for each hospital attendance to be followed up within 2 days of discharge.’ ‘Every child with asthma should have a Named professional and access to a named set of professionals working in a network who will ensure that they receive holistic integrated care which must include their physical, mental and social health needs.’ Reviewer Note 9 All CCGs/providers should now have established the HLP standards, for any children with severe asthma, to ensure that all have: • A clear management plan • Had follow up within 48 hours post admission /attendance at hospital • A named professional leading their care • A network of named professionals who meet to review the effectiveness of the management plan Healthy London Partnership (2016) London Asthma Standards for Children and Young People – https://www.healthylondon.org :accessed 30 March 2020 |
NC52755 | Mother of three children under 5-years-old convicted of father's murder. Murder was witnessed by one of the children. Learning includes: assumptions about domestic abuse can lead to plans for children that are not reflective of their experience and do not mitigate risk; fathers need to be considered and involved in assessments and plans for their children, even in cases of domestic abuse or where the father does not live with the children; professionals must have a full understanding of a parent's history and vulnerabilities and consider the impact of this when undertaking assessments and working with families; practice and systems need to be child centred and consider a child's lived experience so that work with a family is not dominated by adult issues; Covid-19 is likely to have had an impact on the family and support provided to them. Recommendations include: consideration of the findings of the Child Safeguarding Practice Review Panel's 'Multi-agency safeguarding and domestic abuse briefing paper' (2022); ensure that the requirement for timely assessments and the need to understand the nature of the abuse in each relationship is covered in domestic abuse training; ensure that partner agencies specifically request and record details of the GP for all children and adults in a household and that information is shared with all GPs; information about domestic abuse orders and plans should be shared with all professionals working with children in the family.
| Title: Child safeguarding practice review: learning identified from Family A. LSCB: South Gloucestershire Children’s Partnership Author: Nicki Pettitt Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Child Safeguarding Practice Review Learning identified from Family A Contents 1. Introduction page 1 2. Process page 2 3. Learning page 2 4. Recommendations page 12 1 Introduction 1.1 The South Gloucestershire Children’s Partnership (SGCP) agreed to undertake a Child Safeguarding Practice Review (CSPR) by considering the engagement of professionals with a family of three children to be referred to as Family A. 1.2 When the children were aged four, three and one, their father died and their mother has been convicted of his murder. At the time of their father’s death, the children were on child protection plans and a decision had been made to implement the Public Law Outline due to concerns about domestic abuse, the impact on the children of the parent’s poor mental health and substance misuse, and the emotional neglect of the children. 1.3 The rapid review that considered the case in the days following the father’s death, concluded that although the children in the family were not physically harmed themselves, there was evidence of emotional harm over time, culminating in one of the children witnessing his mother killing his father. It was decided that it met the criteria for a CSPR and that learning would be identified. 1.4 While there is potentially learning about the pre-birth assessment/s in the case, the review agreed to concentrate on more recent practice. 1.5 The learning is in the following areas: • Understanding what the domestic abuse involves in a specific relationship, to then consider how this will impact on the children • The need to consider other apparent risks alongside domestic abuse, in this case parental mental health, substance and alcohol abuse 2 • Information sharing of adult information and plans (such as MARAC plans) with those providing services to the children • The need to seek, share and consider information with and from the GPs of the adults living with children • Involving fathers in plans, even when there is domestic abuse and/or they do not live with the children • All professionals need to consider and understand the impact on a child when their parent is vulnerable with a history of adversity and trauma in their childhood and in their adult relationships • The need for preventative and early help services for perpetrators of domestic abuse • The importance of considering information from extended family 2 The Process 2.1 An independent lead reviewer1 was commissioned to work alongside local professionals to undertake the review. The detailed information provided to the rapid review meetings was considered and each agency involved was asked to provide further reflect on their agency involvement and consider whether any single agency recommendations were required. 2.2 A face-to-face multi-agency meeting with professionals involved at the time was held for discussions about the case and the wider systems in which they work. 2.3 A panel of local managers and safeguarding leads worked with the lead reviewer to identify the overall learning and recommendations included in this report. 3 The lead reviewer and a representative of the SGCP met with the children’s mother, maternal grandmother, maternal grandfather, and paternal grandfather with the aim of identifying any learning from their perspective2. Their views and this learning are included in this report. 4 The Learning 4.1 The learning identified for the safeguarding system and partnership is highlighted below, followed by detailed and case specific analysis. Assumptions about domestic abuse, without a clear assessment of what the abuse involves and who the victim/perpetrator is, can lead to plans for children that are not reflective of their experience and therefore do not mitigate risk 4.2 Domestic abuse and the impact on children are a major concern for professionals working in safeguarding roles. 80% of the CSPRs and Serious Case Reviews published in 2021 included concerns about children living in families where domestic abuse been an issue at some stage. Domestic abuse was identified in this case from 2016, prior to the first pregnancy. Both parents 1 Nicki Pettitt is an independent social work manager and safeguarding consultant. She is an experienced lead reviewer and entirely independent of the SGCP 2 Paternal Grandmother was approached but did not feel able to speak to the review 3 were teenagers at the time of the pregnancy. This review has concentrated on the most recent concerns. 4.3 Reports about domestic abuse increased from January 2021, with the police attending incidents between the mother and the father. There were also allegations of harassment at the time from both parents towards Father’s ex-partner who was the mother of another of his children, and similar allegations made by them about her. In 2020 Mother was issued with a two-year Protection against Harassment Order in respect of this3 as she had not attended a victim awareness course. Further allegations were made in 2021 and extensive investigations were undertaken by the police. The matter was complicated by Mother making counter allegations and the case was filed in February 2022 with no further action due to insufficient evidence. Children’s social care (CSC) in South Gloucestershire were not aware of the on-going harassment concerns until a strategy meeting was held in July 2021. Information was regularly shared by the police with CSC in another area regarding the child with the previous partner but not in respect of the children living with the child’s father. This was an oversight, as the children in South Gloucestershire may also have been impacted by the alleged behaviour of or to their parent’s. 4.4 Mother’s GP was aware of the police notifications4 about domestic abuse between mother and father. Mother and the children were registered at the same GP surgery. The GP also had an awareness of Mother’s alcohol consumption, so they made a referral to CSC that focused on concerns about the impact on the children of both matters, who were all under 5 years old at the time. This led to an assessment and from May 2021, the children were made subject to child in need (CiN) plans. The family agreed to work with professionals and to separate. Professionals had ongoing concerns in the months that followed, and the children were made subject to a child protection plan under the category of neglect in August 2021. The ICPC noted that there was a significant history of domestic abuse within the relationship, often witnessed by the children, accompanied by parental mental health concerns (largely depression) and drug (cocaine) and alcohol use, leading to neglect of the children. A lack of meaningful engagement with the CiN plan contributed to the decision for child protection planning. The review CP conference held three months later recorded the professional concerns that the couple were not separated, as they claimed, and were lying to those involved in the child protection planning. A decision to initiate the Public Law Outcome was made. 4.5 There is evidence that the parents were both potentially perpetrators and victims of both physical and verbal abuse in the relationship, and there was a pattern of them making counter claims and allegations. It is clear from the information shared by agencies that most services viewed the children’s mother as the victim and their father as the perpetrator however, and they both received 3 The order stated that Mother should not contact the ex-partner or her mother, or post anything about them on social media. 4 In South Gloucestershire Sirona (the service with responsibility for health visiting and school nursing) receive the report of an incident. If there are children under 5 in the household, it is then shared by them with the children’s GPs, but not with the GP for the adults. 4 services appropriate for this. Next Link5 had both parents listed as victims, but their services are for predominantly for women and children, and they worked with Mother. Father was referred to and engaged with Drive, a service that works with ‘high-harm, high-risk and serial perpetrators of domestic abuse to prevent their abusive behaviour and protect victims’.6 4.6 In this case it was not necessarily as simple as one victim and one perpetrator, and professionals need to recognise that domestic abuse is not always this straightforward and that a deeper understanding of relationship dynamics is required. While the abuse and violence superficially appear to have been two-way in this household, research shows that while there might be unhealthy behaviours from both partners in a relationship, there is almost always a primary perpetrator who tends to have the power and control, and this requires an assessment to ensure that professionals were clear about the situation. Having this knowledge was important, as it would have provided clarity to professionals about how they needed to work with the couple to safeguard the children. Truly mutual abuse is very rare, so specialist domestic abuse advice should be taken where this appears to be the case. Professionals working in children’s services need to have an open mind when mutual abuse is evident regarding where the power lies if they are to plan to protect children from the impact. 4.7 Conversations about the possibility of mutual or bi-directional abuse and their views on the power in the relationship were not held with either parent in this case. This was due to the limited time available to specialist agencies to engage with the parents in respect of this. Drive had seen Father on just three occasions before his death. For the work to be meaningful, a good relationship with trust is required. This takes time to build. Drive can undertake a bi-directional abuse assessment with perpetrators, known as ‘who does what to who’ to understand the complexities in an abusive relationship. They had not begun this work with Father. System’s learning is evident about delays in referring Father to Drive, which are linked to the issues with MARAC prior to 2021, that are considered below. This means however that professionals from children’s service were working with the family with a simplistic view of the domestic abuse, that did not include any specific assessment of how domestic abuse manifested in the parent’s relationship. In South Gloucestershire there is an awareness amongst domestic abuse professionals and those involved with the MARAC of the Respect Toolkit for work with male victims7, and plans to further promote and consider this. 4.8 In this case there needed to be an acknowledgement of the apparent bi-directional abuse and the resulting need to understand the detail and complexity of the domestic abuse in the parent’s relationship. Luke Martin on the Safe Lives blog explained in 2018 how challenging it can be for professionals when presented with counter-allegations. He adds that with ‘appropriate understanding and training, we can identify the power dynamic and our primary victim. By doing 5 Next Link is a local specialist domestic abuse service for women and children 6 Mother was not referred to Drive as she was not seen to be a repeat or serial high-risk perpetrator, and because Father had not been identified as a high harm victim to MARAC, which is part of the process for Drive involvement. 7 https://hubble-live-assets.s3.amazonaws.com/respect/file_asset/file/24/Respect-Toolkit-for-Work-with-Male-Victims-of-Domestic-Abuse-2019.pdf 5 this we can increase safety and manage risk. Always start from the point that the abuse is never equal and oppositional, even if that is how it is presented to you in the first instance.’8 Professionals also need to keep an open mind to whether the primary victim may be male. In this case it is not known what the power dynamic was, and whether Mother was a perpetrator or whether she was the primary victim who was responding to abuse. She was certainly the most obviously vulnerable due to her traumatic experiences as a child, her care experience and as a repeat young mother. It was pointed out during the review that she had been pregnant for 40% of her adult life by the time of the incident, and it is known that the risk of domestic abuse increases significantly during pregnancy. The father9 needs to be fully considered and involved in any assessments and plans in respect of their children, including when domestic abuse is apparent or when they do not live with the children. 4.9 It is not known where the power lay in the relationship between the parents in the case being considered, but because domestic abuse is largely seen as a crime that is perpetrated by men against women, this was accepted as the situation without a thorough assessment of what the abuse entailed. There were several indicators in this case that the parental relationship and the domestic abuse was not straightforward. One of the children told their childminder that his mother hit his father, there was information shared at a strategy meeting in 2019 that Mother had punched Father, and there were suspected instances of both verbal and physical abuse from her to him. There was no consideration at the time of whether the father was a victim or whether ‘violent resistance’10 from Mother was what was occurring. 4.10 During her pregnancies with her three children Mother did not disclose any domestic abuse to midwives who undertook routine questioning. Those who were aware of historic police reports from Mother that Father had been aggressive asked her about this during her 2020 pregnancy and were told by Mother that things were ‘good now’ and that she felt safe. It Is not unusual for the victims of domestic abuse to misrepresent what is happening from fear of what would happen if they disclosed, or an acceptance of abuse within a relationship. The 2021 national CSPR The Myth of Invisible Men11 asked valid questions about the effectiveness of routine questioning about domestic abuse when there is ‘limited capacity to develop trusting relationships with parents’ and ‘when women frequently may not recognise their relationship as coercive or controlling’. The review report also states that neither the midwives nor health visitors that they spoke to were able to ‘provide many examples of these questions being responded to positively or leading them to different service responses.’ In this case Mother told this review that she was afraid of telling the truth about the relationship as she feared the children would be removed from her care. 8 https://safelives.org.uk/practice_blog/managing-counter-allegations 9 It is acknowledged that there may be a same sex partner or a man who is not the birth parent living with the children. 10 In this context violent resistance is a form of self-defense, when violence is perpetrated by victims against their partners who have been domestically abusive. 11https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1017944/The_myth_of_invisible_men_safeguarding_children_under_1_from_non-accidental_injury_caused_by_male_carers.pdf 6 4.11 Routine questioning remains expected good practice and it is largely in place in South Gloucestershire, where women are asked regularly, when having contact with health agencies, whether domestic abuse is an issue in their homes or relationships. The question needs to be worded to enable women to speak about being either a victim or a perpetrator of domestic abuse, although the above findings of the national review need to be considered. A study conducted by Bristol University states that men seldom get asked about their domestic relationships by health professionals, and very rarely about whether domestic abuse is a feature, including when there are children in the family. This is alongside a cultural norm where professionals less readily recognise male victims, and where initial professional qualification training for those in health and social care jobs may not cover the importance of practice that always includes fathers. There is good practice in A&E in the area however, where a domestic abuse IDVA is placed, and they report that male victims are regularly being supported. There is insufficient guidance at present nationally around perpetrator enquiry however, including how to respond in the case of a disclosure. 4.12 At the time of this review being completed there was still no clear picture of who had the power to abuse in the relationship, and whether the other parent was pre-empting, responding, or defending themselves. Mother told the review that she was a victim of physical domestic abuse throughout the relationship. She made specific allegations of physical domestic abuse from Father at the time, including of a sexual assault, while Father made no specific allegations. However, it is known that men are less likely to come forward and speak about their experience of being a victim of domestic abuse than women, however. This is likely due to societal pressure, a fear of stigma, and support services either being unavailable or not as well publicised as support for female victims. The Office for National Statistics estimates that 1.6 million women and 757,000 men reported abuse in 2020. While most domestic abuse is undoubtedly inflicted on women by men, men can also be victims in both same sex and mixed gender relationships. The charity Mankind point out that while one in four women will be a victim of domestic abuse in their lifetimes, one in seven men will be victims too. They also point out that less than 5% of survivors being supported by services are male12. Specialist emergency accommodation such as refuges are also extremely limited for male victims. 4.13 There were opportunities for professional curiosity about domestic abuse in respect of Father. In August 2019 he attended for medical attention with injuries to his hand, stating he punched the wall when drunk the previous night. In July 2020 he attended with a foot injury and in September 2020 with a knee injury. They were presented by him as work related, which was feasible. More significantly, with hindsight, around a week before the fatal incident, Father attended the minor injury unit with an injury to his elbow. He claimed it was a football injury received when tackled and the result of a boot stud. The injury was recorded as a ‘superficial grazing to left forearm, small healing/scabbed 1cm laceration.’ The injury was recorded as consistent with Father’s explanation. During the court case which resulted in Mother’s conviction, it was accepted that this had been a previous injury inflicted by Mother. This was not known at the time by any agency. Members of the 12 https://www.mankind.org.uk/statistics/research-male-victims-of-domestic-abuse/ 7 family are now thought to have been concerned about this injury at the time, but this was not then shared with professionals. 4.14 Father was not asked about domestic abuse as routine enquiry is not usual practice in all admissions and is less likely to be considered if it is a man who is presenting with injuries. Medical staff do not tend to ask about parenthood as part of their admission assessment for men. However, on the last attendance to the minor injuries unit it was recorded that a safeguarding checklist was completed, and that the account given was consistent with the injury. This is good standard practice. 4.15 As Father was registered with a different GP than Mother and the children, his GP was not aware that domestic abuse was an issue in the household or that the children were on a child protection plan. This is an issue that is regularly found in reviews of this type, and it has been identified as requiring further work nationally. GPs are in a unique position regarding safeguarding as they hold information about a person’s health history by way of their own health records and information shared with them from other health providers and agencies. They are potentially able to consider new information alongside this history, but only if they are asked. Work is being undertaken in South Gloucestershire to improve the information sharing in respect of the GPs of children. This review shows that domestic abuse notifications and information from MARAC13s needs to be shared with all relevant GPs, including those for the adults living with children, and that the GPs for the children and both parents (or other adults living in the home) are consulted when social work assessments are completed, that they are all are invited to child protection conferences, and so on. There needs to be a review of documentation to ensure that the GPs for each family members are recorded and contacted. A recommendation has been made in respect of this. 4.16 A Multi-Agency Risk Assessment Conference (MARAC) is a meeting where representatives from statutory and voluntary agencies share information about high-risk victims of domestic abuse, with a co-ordinated action plan being produced to increase victim safety. Domestic abuse had been known about in the couple’s relationship for some years before the case was subject to a MARAC in November 2021. At the time there were limited numbers being referred to MARAC due to the criteria being clear high-risk cases only. It was also identified that practitioners across different agencies did not know how to complete a DASH risk assessment and the benefits of MARAC. At the time there were staffing issues in coordination of the MARAC, and this led to the process not being actively promoted across agencies as it was in other areas. This review was told that it is likely that this case would have come to MARAC and thus DRIVE earlier now. 4.17 The mother had engaged with Next Link for rehousing and a DVPO had been issued in this case before it came to MARAC. The referral of the father to DRIVE was not completed until after the MARAC however, as the system must ensure that the cases with most risk receive this limited and valuable service. He was said to be engaging well at the time of his death in March 2022 but had only received three sessions. Had the case been referred for a MARAC prior to this there could 13 Multi- Agency Risk Assessment Conference 8 have been earlier involvement with the father and a consideration of what exactly the domestic abuse entailed in the case. This work would have been beneficial for the children and the team around them. 4.18 A Domestic Violence Protection Order (DVPO) was issued by the police and was in place in July/August 2021, prior to consideration at the MARAC meeting. DVPOs can be positive as they remove the pressure on the victim to act, as a magistrate issues them following the police issuing a Domestic Violence Protection Notice (DVPN). They are also timely as a DVPN can be put in place with immediate effect. Other domestic abuse orders require the victim to feel ready to act, which is notoriously difficult. The police ownership of the orders also means that there can be checks by neighbourhood police teams to monitor compliance. They are most likely to be effective when the professionals working with the children are aware of the DVPO and when this is included as part of any child in need or child protection planning, however. They were very new at the time, and there is no evidence that the family health visitor knew that a DVPO was in place. The children’s social worker informed the police of a breach known to them, which shows that they were aware. There was no reference to the DVPO in the records for any of the multi-agency meetings in respect of the children. A recommendation has been made. 4.19 A Joint Agency Thematic Inspection (JATi) that considered the multi-agency response to children living with domestic abuse, ‘Prevent, Protect and Repair’ was published in 2017 and found a pattern of agency focus on the ‘victim’ with them having the responsibility to protect the children, with limited or no focus on the perpetrator. In this case there was evidence of meetings with Father and social workers informing him of their plans, such as to hold an ICPC and to seek legal advice and implement the PLO. The child protection conference chair also spoke to him prior to both conferences. There is a record of a new social worker ringing him in November 2021 but there followed a period of both parents effectively avoiding CSC, including not attending the initial PLO meeting. In supervision the social worker and their manager agreed that there were continued significant concerns about the parent’s relationship, them not engaging in services to add safety and them not prioritising the children needs, so legal advice was sought. 4.20 From July 2021 Mother had been receiving support from a Next Link IDVA.14 The support was largely in respect of her need to be rehoused and not for wider safety planning or support. There had been occasions during 2019, 2020, and earlier in 2021 that Next Link had offered support to Mother, but she had not engaged. When she was being supported during 2021 she was clear she was not having any contact with Father and that the children were only seeing him at their paternal grandparent’s home. This support with rehousing was offered without any consideration of the dynamics of the relationship between Mother and Father, and without any expectation that Mother would engage with support in respect of domestic abuse, such as the Freedom Programme15, as it 14 The Next Link IDVA (Independent Domestic Violence Advisor) service is a commissioned short term intervention service. The average support time is 6 weeks. 15 A 12 week programme for women (although it can also be used with men) who want to learn about the dynamics of domestic abuse in relationships 9 is recognised that safer housing is an essential part of a victim accepting further support. Mother was clear when speaking to the social workers involved at the time that she would not attend any groups, and the model available through Next Link did not include individual interventions. Considering this, CSC planned to work with both parents on healthy relationships as part of the child protection plan, and a Social Work Assistant had started this with Mother. A Family Support Worker (FSW) based at the children’s centre began a programme of parenting work with the mother in February 2022 and was undertaking one-to-one sessions in the family home. The programme is bespoke to each case but is based on the Solihull Approach ‘understanding your child’. The FSW was aware of the case history and the current child protection and legal processes and attended a core group. This was difficult work as the children’s mother was dismissive of the programme and insisted she did not require parenting work. 4.21 The parents’ lives were described as ‘intertwined’ and the proximity of the homes of all family members and the school in a relatively small community made it difficult for assertive traditional safety planning that focused on the children and achieved the aim of no contact between the parents. This remained the case after Mother and the children had been rehoused with support due to the domestic abuse. The new home was just minutes away from where Father was living with the paternal grandmother. The review was told that the new property had the benefit of being just in Mother’s name, which is important for women who wish to escape an abusive relationship. However the family are clear that the previous property had also just been in Mother’s name. There is a growing general concern about how domestic abuse is responded to, as the expectation to ‘separate and isolate’ does not tend to work when there are children in a family and there is co-parenting. There is also a need to recognise that domestic abuse often continues beyond separation, and that the risk can be exacerbated rather than decrease at this time. For many families, contact provides a context for domestic abuse to continue, and this needs to be considered when undertaking assessments and making plans for children. In this case the core group needed to consider how they could support the parents to make a realistic and achievable plan for child contact without parents needing to be in contact. 4.22 The National CSPR published in 2022 into the deaths of Arthur Labinjo-Hughes and Star Hobson ‘Child Protection in England’ found that there is a need for ‘sharper specialist child protection skills and expertise’, especially in relation to; ‘complex risk assessment and decision making; engaging reluctant parents; understanding the daily life of children; and domestic abuse’. The report also reminds professionals that ‘how things appear may not be the reality of a child’s experience.’ The learning identified in this case reflects this to some extent. The national CSPR panel has recently published a thematic review of multi-agency child safeguarding and domestic abuse16. It makes suggested recommendations that need to be considered by the SGCP alongside this review, to align any changes required, and a recommendation has been made in respect of this. 16https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1107448/14.149_DFE_Child_safeguarding_Domestic_PB2_v4a.pdf 10 4.23 Maternal grandmother told the review that she had shared her escalating concerns with CSC during February and March about the children a number of times including by email, which the review later had access to. She did not feel listened to however. The maternal grandfather also shared his concern that he did not receive a response to concerns that he shared with CSC. The grandmother stressed to the review the important role that grandparents can play in safeguarding children, but that there needs to be good communication to enable this to happen. She stated that the particular insight that wider family members bring needs to be taken seriously. The review agrees. There is evidence that concerns were largely responded to, however the parent’s lack of consent for information sharing was a hindrance in providing feedback to the grandparents, leaving them frustrated and concerned. A process which involves the relevant extended family in safety planning where children are on a child protection plan due to domestic abuse and where there is wider family involvement, would be beneficial. It would need to take into consideration, the family complexities, the impact on the children of domestic abuse and a pragmatic plan that the whole family can own to assist in safeguarding the children. 4.24 When they were seen individually by the social worker, both parents denied the concerns shared by their families. This included ongoing domestic abuse, unregulated behaviour, posting inappropriate and concerning content on social media and using cocaine. They also underplayed concerns that they were not able to manage the children’s behaviour, that Mother physically chastised the children, and that the children were sometimes dirty and hungry. The 2022 national review that is referred to above said, in regard to Star Hobson, that ‘the growing weight of concerned voices speaking on behalf of Star should have prompted professionals to reconsider the escalating risks to her.’ The emails sent by Maternal Grandmother in respect of the children in family A also warranted the same consideration. They were to a degree, as the case had recently been escalated to the PLO. However Mother’s avoidance of CSC over the next month (she was not available for five visits in March 2021, two of which were unannounced) means that there was no opportunity taken to discuss the concerns shared in detail. 4.25 The avoidance by Mother of the social work visits was accompanied by a complaint about the social worker having discussions with wider family members about the children. There had been a new social worker allocated in January 2021, who had to understand the history, build a relationship with the children and parents, and work to move the plan forward. There is no doubt that a new allocation at such a crucial time will have had an impact on the plan, and they told the review that they were concerned about damaging the relationship with Mother if she felt they were going behind her back to speak to her family. 4.26 There were a significant number of new professionals involved with the family at the time of the serious incident. New people had been introduced as well as a relatively new social worker for the children, including legal advisors as part of the PLO process, a family support worker and a social work assistant. The family support worker told the review that there was little time for them to build a relationship with Mother, which limited the opportunities to challenge her about the children 11 without her becoming defensive and avoidant. She also reflected on the perceived requirement for the work she was undertaking to be used as evidence in court, rather than to meaningfully engage with a parent in respect of their parenting. 4.27 The case was referred to the MARAC in November 2021, with Father noted as the perpetrator and mother as the victim. The review was told that the professionals involved in the MARAC locally are increasingly aware of the potential complexity of the abuse where there are reports of domestic abuse from both adults. There have been increasing numbers of reports submitted to the MARAC with indicators of violence from both partners. This is a challenge for the MARAC and for services in place to support perpetrators and victims of domestic abuse. The MARAC protocol is being reviewed to reflect this, with a plan to ensure that this issue is noted as a specific risk and that actions must be agreed to address these. They may include whether a ‘who does what to who’ assessment is required and completion of the Respect Toolkit. A further issue is that services for victims need to avoid a conflict of interest so will only work with one of the couples, not both. So, if it is thought there are two victims, this can be an issue, again highlighting the need to ensure that a timely assessment of the way that domestic abuse manifests in a particular relationship is prioritised. 4.28 There is evidence that the MARAC in South Gloucestershire considers any children in a robust way, and that while this may not be referred to specifically in the child in need or child protection planning, there is an expectation that the professionals working with the children are aware of the MARAC plan and that they attend MARAC meetings, which are now held using Teams17 to enable improved attendance. It may not be realistic for all the professionals working with a child on a child protection plan to attend a MARAC meeting. This case included the involvement of a family support worker, leaving care PA, school, health visitor and others. Good practice would be that there is a plan in place to ensure that at least one representative from a core group attends and that feedback is given to the others. It is understandable that MARAC plans are not specifically referred to in a child’s plan, due to the need to ensure that both the MARAC process and any plan are confidential. It is important that a victim is not put at further risk due to the perpetrator being aware of the MARAC. However, if there has been a MARAC and a plan is in place, all of those working with the children need to be aware of this. 4.29 It is only the high-risk domestic abuse cases that are considered at MARAC. The number of referrals has increased and they do not come just from the police, however the quality of referrals means that a large percentage do not meet the threshold for consideration at the MARAC. The local model now uses the Safe Lives best practice guidance18. When a new MARAC coordinator is in post in September 2022 (there have been staffing issues) there is a plan to ensure that even the cases which are referred but do not meet the threshold receive some guidance and consultation. 17 Video meeting technology 18 https://safelives.org.uk/practice-support/resources-marac-meetings 12 4.30 When Mother met with the lead reviewers. She said that she knew that the only option available to her was to separate from the children’s father if she wanted to avoid the children being removed from her care. She reflected that this was not a realistic demand in their case, and that professional help in improving their relationship would have been a more effective way of engaging the couple and safeguarding the children. She felt that her contribution to this review should be the message that parents are likely to feel unable to ask for help and may not be honest with professionals about their relationship if they believe they will ‘lose’ their children. Professionals across agencies need to have a full understanding of the parent’s histories and vulnerabilities, and must consider the impact of this when they are undertaking assessments and working with families 4.31 Concerns about domestic abuse having an impact on the children were first identified when the oldest child was just three weeks old in 2017, when a third-party report was received by CSC stating that there was domestic abuse in the home. This was followed by two incidents where the police were called, including one where Mother threatened to kill herself. An Initial Child Protection Conference was held and a child in need plan was the outcome. The plan was closed three months later. Just two months later, Mother made an allegation of a physical assault from Father while she was pregnant with her second child. An assessment was completed but there was no further action from CSC. Occasional reports were received by CSC during 2019 and 2020, none of which resulted in further action, until the GP for Mother and the children made a referral to the MASH in April 2021 stating that they were concerned about the children’s safety due to domestic abuse and mother’s drinking. As well as domestic abuse within the relationship, there were concerns about both parents’ behaviour towards the mother of another of Father’s children. 4.32 There is a commitment in South Gloucestershire to all professionals being trauma aware when working with children and their families. The impact of childhood trauma and adversity when adults enter a relationship and have children of their own needs to be considered whenever there are safeguarding concerns for their child/ren. This is particularly an issue when the parents are young, as they were in Family A. Research into ACEs show that when experiencing abuse or neglect as a child, and the longer it is experienced for, the worse the physical, mental, and social outcomes are likely to be. This serious impact includes the possibility that their children will be known to safeguarding services, and that they will require support in the future with their longer-term mental health. 4.33 In this case the children’s mother is a care leaver who had a history of extensive abuse and trauma as a child. She had sporadic contact with the Transition to Independence Team19 over the timeframe of the period being considered by this review but made contact again requesting support when the children became the subjects of child protection plans in August 2021. The service has the flexibility to provide this support if a care leaver is under the age of 25, and this is good practice and responsible corporate parenting. The involvement of this team and including 19 The South Gloucestershire team that supports care leavers 13 their information in any assessment was important. In Mother’s case the worker who knew her well was still working in the Transitions to Independence Team and was able to support Mother but also to work together with those involved with the children, to provide background information on Mother’s history and support in engaging with her. The review was told that the Child Looked After nurse can also hold important information and that they are a resource that could be consulted when a young care leaver becomes pregnant. 4.34 Father was not known to CSC as a child, but there was a contact with his GP about anger management when he was around 15. 4.35 Both parents had mental health issues. Prior to her first pregnancy Mother had taken an overdose. This was known to her GP but not shared by them or by Mother with the midwives who were involved during any of her pregnancies. The Transitions to Independence Team were also not aware of this. Mother was prescribed antidepressants on several occasions over the years following this overdose. The context around these prescriptions and mother’s mental health more generally was not well known to all of the professionals working with the family in respect of the children. However, there is evidence in the health visiting records of discussions with Mother about her mental health and what support she had in place. There were also conversations recorded about the impact on the children. She told the review that she particularly suffered with anxiety after her second child was born, and that she required support. The Transitions Service provided part time nursery places for the two children at the time which she described as incredibly helpful. 4.36 During the pregnancy with her youngest child in 2020, which was during the first wave of the COVID pandemic, Mother reportedly attended the hospital maternity department 18 times reporting common pregnancy symptoms like abdominal pain and reduced fetal movements. This frequency of attendance could be considered unusual. Maternity services did not record if there had been any consideration of whether domestic abuse or her mental health were contributing factors to the numerous admissions. She was asked about domestic abuse on four of these admissions and responded that there was none. 4.37 Father also had some known vulnerabilities due to his mental health. In July 2021 paramedics are called to the home address following reports that Father had taken an overdose following an argument between the parents. The following day the police were called as there had been a domestic abuse incident and Father was arrested. There followed a strategy meeting and agreement that an ICPC was required. There was recognition that Father’s overdose was potentially a sign of him being emotionally abusive, and the impact on the children was recognised. 4.38 Both parents were known to use cocaine on occasion, but this was presented to professionals as social use and was not considered by either parent to be an issue that impacted on their lifestyle or children. It was recognised that this required further assessment however and as part of the PLO process that was in place when Father died, hair strand testing for substances had been commissioned. The wider family had shared concerns early in 2022 about the extent of the cocaine use by the mother. Parental alcohol abuse was also thought to be further risk in the family, with 14 several references to mother’s drinking. There was no evidence of any plan to assess or address this. Part of the reasons for this was that the parents were never seen to be intoxicated when visited by professionals. Mother also downplayed the issue, stating that she would only drink when she went out and used babysitters to care for the children. There had therefore been a degree of professional over optimism in respect of substance misuse and consumption of alcohol by the couple. This was largely due to domestic abuse being the main and most pressing concern throughout the period considered by this review, and the issue that was most likely to increase the risk of harm to the children. Practice and systems need to be child centred and must consider a child’s lived experience when there are dominating adult issues 4.39 As well as understanding the parent’s vulnerabilities, all professionals need to be aware of the impact of this on the children, with particular regard to their lived experience. The parents’ relationship included domestic abuse, substance/alcohol misuse and mental health issues, and the impact on the children needed to be considered in respect of the risks to them of these parental vulnerabilities. The importance of professionals having a child centred approach is well recognised in safeguarding work. Those who were involved in this review reflected that when working with a complex case like this, it is possible for professionals to get ‘caught up in the chaos’ and for the drama around the adult relationship/s to impact negatively on the required focus on the children. The rapid review meeting that considered the records for the family across agencies reflected that the information held in agency records was focused predominantly on the parents rather than the children. 4.40 Previous CSPRs and Serious Case Reviews have found that professionals can become overwhelmed by complex interactions with parents who can be avoidant, resistant, angry, and/or emotional during visits. This is particularly a risk when the children are younger and do not yet have a voice. This was the case on occasion here. The FSW who was asked to undertake parenting work with the family in February 2022, told the review that Mother was very difficult to engage with. Having missed several appointments, she came across as angry and guarded on the three occasions she met with the worker. There was a degree of understanding about this from the FSW, who recognised that her involvement came at the time of legal processes beginning, and that parenting work tends to be more successful and engagement more meaningful when they become involved earlier in the process, when concerns are emerging, and professional involvement is less pressured for the family. 4.41 The focus of the work with this family was on the adults, as it was their relationship that required assessing and a plan was made in respect of the parent’s relationship in the hope that this would ensure that the children were safeguarded. There was a clear view from the professionals consulted with during this review that the children in this family were victims of domestic abuse in their own right. Consideration was given to reports by neighbours to the police and to the NSPCC stating that they regularly heard shouting and the children crying, and these were responded to. 15 However the allegations and counter allegations made by the parents dominated the professional contacts with them, and the period of child in need planning earlier in 2021 was not successful in safeguarding the children. 4.42 The assessment undertaken in September 2021 states that the children were observed to be ‘calm and unperturbed’ during specific abusive incidents between their parents and the assessing social worker recognised that this was a safeguarding concern. The child protection plans, and then the legal response show the level of professional alarm, and that the situation was being taken seriously and that there was a focus on the children. There were occasions when the social workers involved saw the older children alone. They reported an occasion where the eldest child was crying and upset, and attempts were made to find out why. It was acknowledged that the child did not really know the social worker on this occasion however, and that they had met three different social workers since the assessment was started in September 2021. The Parent Link Officer at the child’s school knew the child well and attended core group meetings and was able to feedback on her regular ‘check-ins’ with the child. The worker remains involved and is providing support following the death Father and imprisonment of Mother. 4.43 While speaking directly to children is good practice and, in many cases, essential, it is also important to understand that children may not be able to express themselves or that they may feel conflicted and/or concerned about sharing too much about their lives or any concerns they have. After the death of the children’s father, their grandmother told professionals that the children had been told by their parents not to talk to social workers and not to tell anyone when their father was at home. This would have made the children cautious and guarded with professionals and the likelihood of this needs to be considered whenever there is any contact with a child. It is also necessary and important to consider a child’s behaviour and what they might be saying without words.20 Mother told the health visitor in June 2021 that the two eldest children would fight with each other a lot and that she struggled to manage this. At the time this led to parenting advice but understanding that this was also potentially learned behaviour needed to be considered. The FSW involved in the six weeks prior to the father’s death saw the children all together with mother on just one occasion. She noted that there was no physical warmth shown to the children, particularly the boys, from their mother. She also noted that they were spoken about negatively by their mother who struggled to consider their experience and needs. She felt they were children who had not been taught to manage their behaviour and who were blamed for this at home. Professionals need to ensure that they are alert to this as emotionally abusive and recognise and challenge child blaming language. 4.44 Information sharing about domestic abuse needs to be timely and detailed, particularly when there are children in the household. Information on an incident in the family home on 11 September 2021 was not received by the children’s social worker until 1 October 2021. This included information that indicated that the parents remained in a relationship. This was due to the officer who attended 20 The voice of the child: learning lessons from serious case reviews. Ofsted 2010 16 not tasking this on the police system as a safeguarding matter at the time, although they did so two weeks later. Avon and Somerset police have identified improvement action in respect of this specific incident, although it is acknowledged that there was timely information sharing on other occasions. 4.45 The review has found evidence of the parents not entirely cooperating with services both historically and more recently. During her pregnancies, Mother’s engagement with maternity services was inconsistent. In her second pregnancy she reportedly did not engage with midwives after 28 weeks. Mother did not attend the child protection conference or respond to attempts by the chair to speak to her before each meeting. It is acknowledged however that the use of video technology for important and serious meetings with families can be extremely difficult for them. At the time the conferences and core groups were all being held on Microsoft Teams as video meetings and there are many parents who struggle to attend due to access to the technology or the anxiety about such a difficult meeting being held in this way. Mother told the review that she had to access the meetings on her telephone and that she was not always aware of what was being discussed. She also stated that it was difficult to know what meetings were being held and whether she needed to attend. 4.46 The lack of engagement alongside a professional view that the couple remained in a relationship, evidenced up by calls to the police reporting shouting from the family home in November 2021, led to a decision to seek legal advice and engage with the parents via the public law outline as a pre-proceeding intervention. There was some delay around the legal process once the decision to follow this route had been taken, due to the parents not attending meetings. There has been single agency learning in respect of this and the need to ensure that timescales are met in a way that is child focused even when parents do not engage. 4.47 There is a national focus on the need to ensure that fathers are seen as equal parents by all professionals working with a family, and that ‘parent’ does not mean ‘mother’. In this case it was the father was more often took the children to health appointments and to nursery. However, when parental contact was attempted to talk about the children, this was almost always attempted with the mother, even by those who knew and had contact with the father. The 2022 National CSPR ‘The Myth of Invisible Men’ states that practice continues to reflect ‘deeply engrained roles, stereotypes and expectations about men, women, and parenthood in our society’ and that ‘notwithstanding major social changes, women continue to be regarded as the prime and sometimes only protective carer for their children.’ Research21 by the Family Rights Group shows that professionals tend to see men in a family as either ‘a risk or a resource’ rather than an as equal parent who needs to be assessed, supported, and challenged along with the mother. In 2015, a report from the US by Sandstrom et al22 made specific helpful recommendations about identifying fathers and male carers, including: ‘being explicit with mothers about the importance of 21 Family Rights Group, Fatherhood Institute, Daryl Dugdale (Bristol), Professor Brigid Featherstone (Open University) 2012 22 Approaches to Father Engagement in Home Visiting Programmes. 2015 17 speaking to the father and including him in the process, while also ensuring that she would not be put at risk; speaking separately to the father rather than gathering information solely through the mother; and arranging separate home visits if necessary to explain the relevance of his involvement with the child, communicating a willingness to include him in decisions.’ Those involved in the case recognised the importance of this and planned to ensure this was the case. 4.48 The nursery being attended by the middle child on a bursary place told the review that they were not made aware of the child protection plan until some weeks after the child started there. Apparently there are no systems in place for a nursery to check CSC involvement with a family if this is not disclosed by the parent, as it was not in this case. The CSC records show that the nursery was in fact contacted two weeks after the child started. The nursery are now doing face to face meetings with the parents of a new child in order to complete the form, in the hope they can gain more accurate information this way and gain consent to undertake checks with health visitors, which would be good practice. 4.49 It appears that core group meetings were held regularly at this time but there are no minutes or updated plans to show whether the parents attended, what was discussed and who was invited or informed. It is known that when individual professionals are under pressure it is often administrative tasks that are not completed, and this appears to be the case here. The review was told that there has been a recent focus on improving administration support for core groups and that meeting records are now being completed and shared. 4.50 Learning has been identified and disseminated23 by the hospital trust following a decision made in A&E to not make contact with children’s social care following the stabbing. The learning includes the importance of professional challenge to senior staff if advice is not felt to be appropriate. The review is assured that suitable actions have been taken regarding this learning. COVID-19 is likely to have had an impact on the family and on the support provided 4.51 The national Child Safeguarding Practice Review panel published a briefing paper in 2020 that considered serious safeguarding incidents reported to them during the initial COVID-19 outbreak (March – September 2020). Their analysis shows that COVID-19 exacerbated risk due to an increase in family stressors (including an increase in domestic abuse and mental health concerns alongside less wider family support), children not being seen as regularly, school closures, and difficulties with the requirement for ensuring safe professional practice. As much of the work with this family was undertaken during the pandemic, this review has considered the impact. 4.52 While the CSC teams undertaking assessments and working in child protection still undertook face to face visits to children at home, not all services were undertaking direct work at the time due to COVID-19. This included those working with care leavers, domestic abuse support and health visiting. Mother’s third pregnancy occurred during the first few months of the pandemic and all health services including Midwifery were impacted by restrictions and working within national 23 With individual practitioners and through the formal major trauma clinical case review forum 18 guidance for service provision that was rapidly and frequently changing. She had requested further support from the Transition to Independence service during this pregnancy, but at the time only emergency visits were permitted. The case was closed not long after allocation due to Mother’s lack of engagement. Staff reflected that they would usually go to the family home to try and engage with a young person who was not responding, but that this was not an option at the time. Mother was notoriously poor at answering or returning phone calls, and in the past visits had been more successful. There was no communication between the Transition to Independence service and the midwifery service at the time, which may have been helpful in planning how best to support Mother. Gaining consent for this could have been an issue. 4.53 The health visiting service was impacted locally during the first six months of the pandemic, with 70% of health visitors in the area redeployed into adult services. This was the local response to national guidance at the time. All contact with service users by the remaining health visitors needed to be by telephone, as they were in this case. Clinics were not held. The national panel’s briefing paper noted that ‘virtual visits are not always effective in assessing changing needs and risks.’ Those involved in this case agreed and noted that it is impossible to establish who is in the home where domestic abuse is an issue. They also reflected that where there are concerns about how open and honest a service user is being, this is more difficult to establish during a telephone appointment. 4.54 Next Link continued with face-to-face contacts in essential situations or if the client preferred this, but largely used virtual platforms for their work from March 2020. One of the impacts of national lockdowns was the shortage of places to meet outside of the home, which is what is often required in their work. They also reflected on the impact among their service users of the fear about Covid, largely fuelled by misinformation on social media. Home visits could also lead to difficulties. With communities being vigilant about visitors to their neighbours, service users sometimes stated that they did not want visits from professionals that may lead to questions or recriminations. 4.55 As well as the lockdowns having an impact on mental health, there was also a potential financial impact for Family A, as father was self-employed. Despite this, Mother told the review that the first national lockdown was a happy time for the family, as Father was not working, was not spending time and money drinking at the pub or using drugs with friends. She was also not drinking as she was pregnant with her third child. 4.56 It is known that around 30 minutes before the serious incident that led to this review, Mother had contacted the police from a local pub saying she had been assaulted by receiving a punch to the face by a man who was not father. The man was apparently no longer at the scene. Due to operational demands and the Threat, Harm, Risk assessment24, the police were not able to attend immediately. Mother said she did not want the police involved, would not give an address, and agreed to call back if she changed her mind. It is thought that the children were present. The 24 Police process for decision making 19 police told the review that expected practice was followed in responding to this call and no learning has been identified. It is not known if this information would have been shared with CSC had the more serious incident not followed, considering the children were on a child protection plan. 5 Conclusion and recommendations 5.1 This CSPR has considered and analysed what happened in this case to identify learning that will be helpful for the wider system. It shows the importance of consistent, skilled and timely engagement with a family from professionals that know the history and understand the complex nature of domestic abuse within the particular relationship. This case has highlighted the need for professionals working with children in a case where domestic abuse features to have access to consultation with domestic abuse specialists to discuss a case and to gain an understanding of the particular dynamics that may be significant when planning for safeguarding the children, and for services to provide support and assessment for lower risk perpetrators. It has also led to a wider discussion about the need for preventative work with the most vulnerable young people before they become parents, and for services to be proactive rather than reactive in respect of domestic abuse. The Transitions Team are currently providing Freedom Programme work with a group of care leavers who they consider to be at risk of domestic abuse in the future. This is a model of prevention that should be considered more widely with particularly vulnerable children and young people. 5.2 Single agency learning has been identified during the review and recommendations have been agreed to address these, including single agency SMART action plans. There has been excellent cooperation with this review from partner agencies, which was essential in establishing the learning from this case. 5.3 Having considered the learning, the following recommendations are made with the aim of ensuring that the required improvement actions are achieved: Recommendation 1 That the SGSCP considers the practice briefing on safeguarding children in families where there is domestic abuse that was commissioned following the National CSPR ‘Child Protection in England’. The learning from the Family A review should be considered alongside to align any changes in practice or systems that may be required. Recommendation 2 The SGSCP to consider the learning from this review in their current review of the domestic abuse training offer. This should include the requirement for timely assessments and understanding of the nature of the abuse in each specific relationship. Recommendation 3 That the SGSCP requests that all partner agencies review their forms and guidance to ensure that they specifically request and record the details of the GP for the children and all the adults in a household, and ensure that information is shared with all relevant GPs 20 Recommendation 4 The SGSCP to seek assurance from partner agencies regarding what they are doing to the promote the Domestic Abuse Act 2021 in respect of children as victims of domestic abuse Recommendation 5 The SGSCP to consider making ‘including fathers25 as equal parents’ a priority for 2023 onwards Recommendation 6 The SGSCP to discuss the learning from this review with the South Gloucestershire Safeguarding Adult Board and the South Gloucestershire Community Safeguarding Partnership, and consideration to be given to a combined request that the relevant partner agencies commission services to provide earlier interventions with low to medium risk perpetrators of domestic abuse Recommendation 7 That the SGSCP seeks assurance that information about orders or plans in respect of domestic abuse (e.g. MARAC and DVPOs) are shared with all professionals working with children in the family, and that the MARAC plan and any plan/s for the children reflect and compliment each other Recommendation 8 That the SGSCP considers how it can ensure that professionals in all partner agencies are aware of the responsibilities for and services available to care leavers 25 Or a non-birthing parent in a same sex relationship |
NC046830 | Death of a 3-year-old boy in March 2013. Mother carried Josh into the path of an oncoming train, killing them both. Mother had a history of severe anxiety disorder and had been receiving treatment from her GP and various mental health services in the months preceding Josh's death. During this time mother: took an overdose of prescribed medication; held a knife to her throat; and self-reported suicide ideation and fears of self-harming. None of the professionals working with mother, nor maternal grandmother, considered mother to be a direct risk to Josh. Issues identified include: procedural failure responding to a referral to children's social care made by mother's psychiatrist; a culture of overreliance on children's social care for actions regarding a child; and perceived inconsistent and misleading advice from mental health services leading mother and family to continue accessing private mental health providers as they lost trust in NHS providers. Makes various interagency and single agency recommendations covering children's social, British Transport Police, health, mental health and ambulance services. Review was undertaken using the Significant Incident Learning Process (SILP).
| Title: The overview report into a serious case review of the circumstances concerning Josh. LSCB: Croydon Safeguarding Children Board Author: John Fox Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Croydon Safeguarding Children Board The Overview Report into a Serious Case Review of the Circumstances Concerning Josh Independent Author Dr John Fox MSc, PhD. February 2015 CONFIDENTIAL Josh - Serious Case Review 1 CONTENTS PAGE Family Structure 2 1. Introduction 3 2. Process of the Review 4 3. The Facts - Summary of agency involvement 15 4. A Day in the Life of Josh and his Family 19 5. Analysis of Practice and the Lessons Learnt 19 6. Conclusions and Summary of what has been learnt 37 7. Recommendations for LSCB 40 8. Recommendations for individual agencies 41 Appendices Appendix A – Terms of Reference Appendix B – Written contribution by Maternal Grandmother 48 50 CONFIDENTIAL Josh - Serious Case Review 2 The Family Structure at the start of the review period Claire 04/12/1972 F Mother Josh 16/03/2010 M Subject 11/04/1955 F Maternal Grandmother 27/05/1943 M Partner of Maternal Grandmother 10/08/1985 M Father N/K F Aunt N/K F Aunt N/K M Maternal Grandfather CONFIDENTIAL Josh - Serious Case Review 3 1. Introduction 1.1 Who was Josh? 1.1.1 Josh was a bright happy 3 year old boy and he was the only child in his family home which he shared with his Mother Claire, his Maternal Grandmother and her partner. The family home is a semi-detached house in a suburban area which is spacious, clean and tidy. It is a good environment in which to bring up a child. 1.1.2 His father lives in Egypt and Josh rarely met him. It is not believed that his father contributed to his upbringing and it was noted by the childminder that Josh seldom spoke about his Father, other than mentioning him a handful of times after he had returned from a visit to Egypt. 1.1.3 Josh was generally a healthy child who was developing well. His immunisations were up to date and he attended all health related appointments. He appeared well cared for and when seen by professionals his interaction with his Mother and Grandmother seemed appropriate. 1.1.4 His childminder also noted that Josh appeared to be ‘well cared for, happy, sociable and chatty. He was in line with appropriate development bands in accordance with his age.’ All the available evidence suggests that he was brought up and nurtured in a loving way by his Mother and Grandmother and extended family, and there is no evidence of neglect or maltreatment. 1.1.5 This Serious Case Review has Josh at the centre and this moving passage, taken from the written contribution to this Review by his Grandmother, gives a perfect picture of Josh. ‘Our Grandson, I will never hear him say nana, hear his laughter and see that big mischievous grin. We used to dance to the radio or the TV whenever he heard music he would start dancing, he loved playing in the park he kissed trees and rolled down the hills he loved the garden going on his slide he wasn’t so keen on his swing, playing with his Fireman Sam ball he loved picking the flowers only the heads after he smelt them, he loved playing in his paddling pool. He loved his bubbles and soaking the floor, he loved bedtime stories and we always got a big kiss at bedtime. He loved to sit and watch his favourite TV programmes with you.’ 1.2 Brief Summary of Circumstances Leading to the Review CONFIDENTIAL Josh - Serious Case Review 4 1.2.1 The case in question was triggered by the death of Josh. On 22nd March 2013, Josh was taken by his Mother to a railway station near their home whereupon Josh was carried onto the tracks and held in the path of an oncoming train by his Mother, killing them both. 1.2.2 During the preceding months, Claire had a history of severe anxiety disorder with some panic attacks and some limited depressive symptoms. She had been receiving treatment from her GP as well as various other health professionals and agencies. 2. Process of the Review 2.0.1 On the 25th March 2013, the LSCB Serious Case Review Subgroup met to decide whether a Serious Case Review was required following the deaths of Josh and his Mother. The British Transport Police is currently investigating the double fatality of both Claire and Josh. Consequently, those present at the meeting agreed unanimously that a Serious Case Review was required under Section 4 of the Statutory Guidance Working Together to Safeguard Children (2013). 2.1 The Statutory Basis for Conducting a Serious Case Review 2.1.1 The role and function of a Local Safeguarding Children Board is set out in law by The Local Safeguarding Children Board Regulations 2006, Statutory Instrument 2006/90. Regulation 5 requires the LSCB to undertake a review in accordance with guidance set out in Section 4 of Working Together to Safeguard Children (2013). The mandatory criteria for carrying out a Serious Case Review include where – (a) abuse or neglect of a child is known or suspected; and (b) either – (i) the child has died; or (ii) a child is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child. 2.1.2 The product of the Review, known as the Overview Report, is sent to the Secretary of State for Children, and scrutinised by the Department for Education. All reviews of cases meeting the SCR criteria must result in a report which is published. 2.1.3 Revised Statutory Guidance on Learning and Improvement published by the Department for Education as a consultation draft in June 2012, prescribes that SCR reports should be written with publication in mind and should not contain personal information CONFIDENTIAL Josh - Serious Case Review 5 relating to surviving children, family members or others. This includes detailed chronologies, family histories, genograms, or information known to organisations about the child and family members. Where possible, this Overview Report has been prepared within the spirit suggested and, whilst ensuring any lessons are learnt, every effort has been made to minimise distress for the surviving family members. Personal information about life within this family has been kept to the minimum required to provide a thorough and meaningful report into this review, although my analysis of practice benefited from a great deal of more detailed information contained within the agency reports, which are listed below. 2.1.4 Serious Case Reviews should be conducted in a way in which Recognises the complex circumstances in which professionals work together to safeguard children; Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; Is transparent about the way data is collected and analysed; and Makes use of relevant research and case evidence to inform the findings 2.1.5 LSCBs may use any learning model which is consistent with these principles, including the systems methodology. Having decided to undertake a serious case review to look at how well agencies were working together to support Josh and his family it was decided to implement the systems methodology provided by the Significant Incident Learning Process (SILP). 2.1.6 The key principle of SILP is the engagement of frontline staff and first line managers in conjunction with members of LSCB Serious Case Review Panels or Subcommittees, Designated and Specialist Safeguarding staff, etc. The involvement of frontline staff and first line managers gives a much greater degree of ownership and therefore a much greater commitment to learning and dissemination. 2.1.7 The SILP is a collaborative and analytical process. The main focus is to extract learning from the detailed study of a set of circumstances. From a practitioner’s point of view it takes account of: CONFIDENTIAL Josh - Serious Case Review 6 their view of what was going on in and around this case how they understood your role or the part you were playing their thinking and your context at the time their perspective on what aspects of the whole system influenced them as a worker the tools they were using 2.1.8 By taking account of these things, the process focuses on understanding why someone acted in a certain way. It highlights what factors in the system contributed to their actions making sense to them at the time. This process is NOT about blame or any potential disciplinary action, but about an open and transparent learning from practice, in order to improve inter-agency working. Importantly, it also highlights what is working well and patterns of good practice. 2.2 Independence 2.2.1 Working Together to Safeguard Children (2013) also mandates that reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed. The LSCB should appoint one or more suitable individuals to lead the SCR who have demonstrated that they are qualified to conduct reviews using the approach set out in this guidance. To ensure transparency, and to enhance public and family confidence in the process, the LSCB Chair appointed two independent people to lead this Serious Case Review. 2.2.2 In his document Protection of Children in England: A Progress Report Lord Laming (2009) expressed the view that in carrying out a Serious Case Review, it is important that the chairing and writing arrangements offer adequate scrutiny and challenge to all the agencies in a local area. For this reason, the chair of an SCR panel must be independent of all of those local agencies that were, or potentially could have been, involved in the case. Ms Donna Ohdedar – SILP Lead Reviewer and Panel Chair 2.2.3 Ms Ohdedar was appointed to chair the SILP and oversee and manage the review process in this case. She was the lead person for ensuring that a robust and transparent review was carried out within each relevant agency, and for ensuring that the business management plan and timescales were strictly adhered to. 2.2.4 She has had no involvement directly or indirectly with the child or any members of the family concerned or the services delivered by any of the agencies. 2.2.5 Ms Ohdedar is a solicitor with 18 years local government experience, latterly as Head of Law in a metropolitan authority. With CONFIDENTIAL Josh - Serious Case Review 7 a grounding in child protection law and advocacy, she also practised in a variety of other areas of regulatory law and governance and held the statutory role of Monitoring Officer within her authority. She was involved in Area Child Protection Committee, was instrumental in the formation of a children’s trust in a pathfinder authority and was a member of the Local Safeguarding Children Board. 2.2.6 Upon leaving local government in 2010, Ms Ohdedar commenced a second career as a safeguarding adviser, investigator and trainer. Alongside her involvement in the conduct of serious case reviews she takes a keen interest in alternative forms of review and delivers the Significant Incident Learning Process (SILP). 2.2.7 She is a member of the British Association of Adoption and Fostering Legal Group Advisory Committee and is passionate about improving outcomes for children in the child protection system. Dr John Fox MSc, PhD – Independent Overview Report Author 2.2.8 Dr Fox was responsible for drawing together all elements of the individual agency reviews, and for obtaining as much relevant information as possible from family members and significant others who might provide useful learning. He was responsible for analysing the professional practice of professionals and organisations and making recommendations to the LSCB for further action to better safeguard children. 2.2.9 He has had no involvement directly or indirectly with the child or any members of the families concerned or the services delivered by any of the agencies. He has never worked for, or been affiliated with, any agency in Croydon. 2.2.10 Dr Fox is a Senior Lecturer at the University of Portsmouth and previously was a police officer for 31 years including 8 years as a Detective Superintendent and Head of Child Abuse Investigation in the Hampshire Police. He sat as a member of 4 LSCBs and was Vice Chair of Hampshire ACPC. 2.2.11 He represented the Association of Chief Police Officers on various Government working parties and committees, concerning child abuse and related issues, including the drafting of the Working Together to Safeguard Children documents (1999, 2006, and 2013) and Achieving Best Evidence in Criminal Proceedings, and had the ACPO lead portfolio role for Childhood Death and Forensic Pathology. He was appointed as the Police Service representative to Baroness Helena Kennedy’s Intercollegiate Working Group on childhood death and was Lord Laming’s police advisor and assessor, on the Victoria Climbie Inquiry. CONFIDENTIAL Josh - Serious Case Review 8 2.2.12 He has previously chaired Serious Case Review Panels, and is regularly commissioned as Overview Report Author by LSCBs. During the period when Ofsted were evaluating SCRs, all his reports were graded as outstanding or good. In 2009, he conducted secondary evaluations, and provided reports as Independent Author concerning 4 Serious Case Reviews that had earlier been considered inadequate by Ofsted and the Welsh Assembly Government. 2.3 SILP Agency Reports 2.3.1 Although Individual Management Reviews are no longer required under Government guidance, the SILP process includes individual agency reports. 2.3.2 The SILP process also requires that those conducting agency reviews of individual services should not have been directly concerned with the child or family, or given professional advice on the case, or be the immediate line manager of the practitioner(s) involved. 2.3.3 The people preparing the individual agency reports for this Review were all approved by the professionals engaged in the SILP process and the Independent Author, as being senior personnel within each agency who were completely independent of any involvement or line management responsibilities concerning the case. On 9th May 2013, the Individual Agency Report Authors were briefed as to their responsibilities by the Independent Lead Reviewers. They were particularly asked to focus on Josh, and what life was actually like in his household. 2.3.4 The Lead Reviewers decided that the following agencies and organisations would be asked to contribute to the learning of this Review. Individual agency report provided by: Croydon CCG (GP) Bromley Healthcare Acute Croydon Children’s Social Care British Transport Police (Also covering services provided by the Metropolitan Police and South Yorkshire Police) Croydon Health Services NHS Trust CONFIDENTIAL Josh - Serious Case Review 9 Rotherham, Doncaster & South Humber (RDaSH) NHS Foundation Trust South London Health Care Trust South London and Maudsley NHS Foundation Trust (covering services provided by Community Mental Health Teams) Factual Report provided by: London Ambulance Service Childcare Private Psychiatry LLP Private CBT Therapy 2.3.5 The LSCB provided each agency report author with a SILP template to assist in the writing of their reports, and this was successful in achieving standardisation and consistency, as well as ensuring that the reports focused on the areas required by the Terms of Reference. Each individual agency report author was invited to present their report to the SILP meeting where any clarification was provided, or additional work requested. In addition to this, where necessary, I had direct contact with members of the Agency Review Team in order to best inform my analysis in this Overview Report. 2.3.6 It was noted by Ofsted (2010) that the duties of the Overview Report Author include ‘challenging the quality and content of individual agency reviews and ensuring that the overview report compensates for any identified deficiencies.’ Collectively, the quality of the Agency Reports was sufficient for me to understand the case and provide an analysis of the significant issues. 2.3.7 In addition to the Agency Reports mentioned above, the SILP review was also informed by a report prepared by an investigation team appointed by the South London and Maudsley NHS Foundation Trust (SLaM) who carried out a separate single agency inquiry into the services provided by that organisation. The report, which was received in late November 2013, mirrors much of the material provided by the SLaM SILP Agency Report but in certain areas CONFIDENTIAL Josh - Serious Case Review 10 provides a little more detail and context and it helped with the analysis. 2.4 The Practitioner Events 2.4.1 An initial scoping meeting was held at the beginning of the review process and this was followed by a briefing day for those professionals selected to write agency reports. 2.4.2 A Learning Event with over 30 attendees comprising agency authors, Designated and Specialist staff, LSCB Serious Case Review Subgroup, front line practitioners and their first line managers took place on 25th June 2013, and on 18th July 2013, a Recall Half-Day was held for all those who attended the Learning Day to consider and debate the first draft of this Overview Report. 2.4.3 Agency attendance at these events was generally very good. It is a matter of regret that although invitations were sent to three of their senior staff, no representative from Children’s Social Care attended the main SILP Learning Event. This resulted in a number of gaps in the information available to the Reviewers. The independent practitioner commissioned by Social Care to write their agency report was present, but she was in a difficult position in that she was not there as a representative of the Local Authority and therefore, was unable to answer some questions about the services provided. Children’s Social Care were appropriately represented at the subsequent Recall Day. 2.4.4 The Independent Reviewer chairing these meetings was assisted by the LSCB Development Manager as well as an administrative support officer at most meetings. 2.4.5 Agency attendees included: Agency Name Independence Status & Experience Independent Lead Reviewer, (Chair) Donna Ohdedar Experienced in audit and Serious Case Reviews. No direct case involvement. CSCB Development Manager, Croydon Social Care Representative Experienced in audit and child death case reviews. No direct case involvement. Children’s Social Care Representative Experienced in audit and Serious Case CONFIDENTIAL Josh - Serious Case Review 11 Reviews. No direct case involvement. Croydon Health Services Representative Experienced in audit and Serious Case Reviews. No direct case involvement. Croydon Clinical Commissioning Group Representative x 2 Experienced in audit and Serious Case Reviews. No direct case involvement. British Transport Police Representative Experienced in audit and Serious Case Reviews. No direct case involvement. SLAM Representative Experienced in audit and Serious Case Reviews. No direct case involvement. 2.5 Scope and Terms of Reference 2.5.1 Time period: 1 June 2012 (date of first presentation to GP with anxiety related issues) to 22 March 2013 (date of incident). Agencies were also asked to provide relevant information relating to Claire’s pregnancy and antenatal period and to the 3 head injuries sustained by Josh even where these fall outside the scoping period. 2.5.2 The Terms of Reference were discussed and agreed at the first SCR Panel meeting on 26th April 2013. They were then ratified by the Independent Chair of the LSCB and thereafter became the instructions to the two independent people about the scope required for the Review. 2.5.3 The Terms of Reference specified the following 3 ‘Key Issues in this case’ together with a requirement that these questions need to be covered by Agency authors and covered within the Overview Report. 1. What was known and identified by professionals about Claire’s parenting capacities and possible risks to Josh? 2. Did assessment and/or care plans take account of the whole family and potential risks to Josh and how was information shared with relevant agencies? 3. What was the outcome of the referral to Children’s Social Care and the rationale behind the decision making process? CONFIDENTIAL Josh - Serious Case Review 12 2.5.4 The full Scope/Terms of Reference can be found at Appendix A. 2.6 The Voice of the Family and Significant Others 2.6.1 The Statutory Guidance requires that families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. A commitment to providing the fullest opportunity for individuals with a close connection to the family to be invited to participate in the review was agreed at the first scoping meeting. 2.6.2 In order to gain as much learning as possible from Josh’s family, the Lead Reviewers reached out to them in the following ways: A letter explaining the process went out on 2nd May 2013 to Josh’s Maternal Grandmother, as well as Claire’s two sisters and her Father. The letter was jargon-free and as non-businesslike in tone as possible. The British Transport Police also wrote to the Josh’s Father in Egypt offering him the opportunity to participate in the review using the translation service they had used to correspond with him on other issues. A Lead Reviewer met with Josh’s Grandmother on 9 May 2013. On this occasion, she expressed a wish to participate in the review. She also expressed some of her views about services. On 13th May 2013, a second letter was sent to the four people named above offering a second meeting with the Lead Reviewers on 24th June. This letter outlined the 3 areas for consideration, i.e. What did services do well? What did they not do so well? How can services be improved? On 20th June 2013 Josh’s Maternal Grandmother agreed to meet the Lead Reviewers, but indicated that her two daughters would not want to meet as ‘they haven’t got anything to say’ and ‘it would be more hurtful for them to be there’. In order to engage Josh’s father in the review the British Transport Police (BTP) kindly offered their assistance. Their officers, together with the Honorary Consul from the British Consulate, had met with him in Egypt as part of their investigation. However, since that point he has not responded to messages or phone calls made by the Honorary Consul attempting to deliver the letter inviting him to contribute to the Serious Case Review. A BTP detective also tried to contact CONFIDENTIAL Josh - Serious Case Review 13 Josh’s father via his mobile phone but this again has proved to be unsuccessful. Also on 20th June 2013 a Lead Reviewer contacted Claire’s father by telephone, and he stated ‘the services ain’t no good. It’s the doctors and the psychiatrists who gave her the stronger and stronger tablets so she took her own life.’ He felt that if they had helped her more she would be alive now and he would not have lost his grandson. He added ‘they don’t know what they’re doing. I hope to God it don’t happen again.’ Both independent Lead Reviewers met with Josh’s Maternal Grandmother and her partner at their home on Monday 24th June 2013, and they contributed very helpfully to the learning in this review. The views of both Josh’s Grandmother and her Partner were shared by the Lead Reviewers with all professionals attending the Learning Event. 2.6.3 In addition to the meeting on 24th June 2013 between the Lead Reviewers and Josh’s Grandmother, she was invited to attend for the latter part of the Learning Event on 25th June 2013. Josh’s Grandmother wanted to attend with a friend to be present to support her but the Safeguarding Children Board required that she must be accompanied by an ‘objective supporter’ rather than a friend or family member. Josh’s Grandmother was very upset by this condition and declined to attend. It is noted that attendees at the Learning Event acknowledged how hard it would be for family members to attend such a meeting with so many professionals, and the difficulties for them to engage dispassionately in discussion about events which affected them so deeply and personally. 2.6.4 Finally, a comprehensive written report prepared by Josh’s Grandmother was received on 16th August 2013. Although it would have been very helpful to have had this report earlier in the SCR process in order to better allow agencies and practitioners the opportunity to respond to the points made, the report was considered by the independent reviewers and it helped to inform the analysis in the Overview Report, and some Agency Reports were revised to take account of it. For completeness, and to ensure the voice of the family is heard to the fullest extent, the entire (anonymised) report is included as an appendix. 2.7 Individual Needs 2.7.1 The guidance in Working Together to Safeguard Children requires consideration to be given to individual needs - racial, cultural, linguistic and religious identity – of the child who is the subject of a Serious Case Review. CONFIDENTIAL Josh - Serious Case Review 14 2.7.2 Josh’s father is of Middle Eastern heritage and lives in Egypt. Josh was named in accordance with Islamic tradition and Claire and Josh travelled to Egypt for a 3 week period in June 2012, but as far as is known Josh was brought up in a middle class white British environment. There was no evidence in the material that any issues of race, religion, language or culture affected events in this case or should have been significant in influencing the practice or approach taken to the delivery of services. 2.7.3 Josh lived in a quiet neighbourhood in South Croydon. The family home is a very clean, well maintained semi-detached house with a large rear garden which backs onto woodland. 2.7.4 There is no evidence of poverty within the family and there is no evidence in health records to suggest that this family experienced social or any other form of exclusion. It is reasonable to conclude that Josh had no individual special needs. 2.8 Accountability for the Overview Report 2.8.1 I attended the scoping meeting, the authors’ briefing, the Learning Event and the Recall Day i.e. all meetings involved in the process. 2.8.2 Whereas I am accountable for the content and analysis within this Overview Report, the participants in the Learning Event and Recall Day have contributed to the process of the preparation and have offered helpful comments and suggestions during the drafting process. CONFIDENTIAL Josh - Serious Case Review 15 3. The Facts - Summary of agency involvement This section is designed to summarise the key relevant information that was known to the agencies and professionals involved about the parents, and the circumstances of the child. Since the Review is primarily concerned with Josh, only events which may have affected him, or the capacity for adults to look after him, have been included in this section. 3.1 Significant events in Josh’s early life 3.1.1 Josh was born on 16th March 2010. The Community midwives attended Josh and his mother at home and there were no concerns shared with the Health Visiting service at handover (when community midwives discharge to the Health Visitor). 3.1.2 On 13th May 2011, Josh was seen at Princess Royal Hospital Emergency Department with Claire. The reason for the attendance was a head injury. The mechanism of the injury was given as a fall, hitting the back of head on a TV table. A small red bruise was noted, consistent with the history of the injury. 3.1.3 Records at Croydon University Hospital show that Josh was brought to the Emergency Department by ambulance with his Mother Claire on 23rd July 2011 following a fall at home from a plastic chair and hitting his head on a marble fireplace. He sustained a 1cm bruise to the left side of his head. 3.1.4 Josh again attended the Princess Royal Hospital on 9th October 2011. He was accompanied by his Mother who reported that whilst playing he hid behind a sofa and hit his head on the wall causing a bruise to the scalp. 3.1.5 Claire and Josh travelled to Egypt for a 3 week period in June 2012. Claire had lost a lot of weight during this period having already exhibited signs of anxiety from May 2012. These symptoms consisted of sweating and shaky hands. 3.2 The Relevant Period of the Review 3.2.1 In July 2012, Claire self referred to the local IAPT Psychological Therapies and Well Being Service. She stated that she has not received previous care from mental health services, psychological therapies or counselling services and had no previous episodes of self harm or suicide attempts. 3.2.2 On 20th July 2012, Claire attended the Emergency Department by ambulance complaining of palpitations. It was recorded that Claire commenced Sertraline medication the Source CHS RPT. CHS RPT. SLHT RPT. CHS RPT. SLHT RPT. CHS RPT. SLaM RPT. LAS RPT. CHS RPT. CONFIDENTIAL Josh - Serious Case Review 16 previous day as prescribed by her GP. She was seen by a casualty Senior House Officer who recorded that Claire disclosed she had suffered severe anxiety for the last 2 months. 3.2.3 On 18 September 2012 Claire, attended Private Psychiatry outpatient clinic at Fitzroy Square Hospital in London, on referral from her GP. She was referred with a history of severe generalised anxiety with panic attacks, having had difficulty tolerating two antidepressants. In total Claire attended for five sessions following the initial assessment appointment. The last session she attended was on 2 November 2012. In her therapy sessions she constantly talked about how important her son was to her indicating that he was the only thing that she was really motivated and committed to. 3.2.4 Her family contacted the Private Psychiatry office between 23rd and 26th November indicating that she would not be attending any further appointments. 3.2.5 On 13th November 2012, Claire and her Mother self presented in crisis to the SLaM Community Health Team. She recounted the events of the previous 48 hours. On the evening of 11th November 2012, she took Citalopram 20mg as prescribed and went to bed. She reported getting up in the middle of the night, totally unaware of what she was doing, and held a knife to her throat, fighting off her Mother’s attempts to take the knife from her. 3.2.6 On 16th November 2012, a telephone and email referral from CT1 psychiatrist was made to Children’s Social Care suggesting that Josh may be living within an emotionally difficult environment. 3.2.7 On 19 November 2012, at 08.39am the referral from CT1 psychiatrist, in the form of an email, was forwarded from a Customer Service Advisor, Initial Contact Centre in the local authority to the Children’s Assessment Team. A decision was made to request further information and to have the referral resubmitted with extra information. 3.2.8 A Croydon Children’s Social Care referral form was received by Children’s Social Care from CT1 psychiatrist, via email on 27/11/2012 at 11.30am. No action was taken as a result of this referral. 3.2.9 On 4th December 2012, Claire called the local community mental health team and spoke with CT1 psychiatrist. Claire said she had been having sensations of panic all day and felt she was not looking after her Josh properly. PP RPT. PP RPT. SLaM RPT. SLaM RPT. CSC RPT. SLaM RPT. CSC RPT. SLaM RPT. CONFIDENTIAL Josh - Serious Case Review 17 3.2.10 On 7th December 2012, having been referred by her GP, Claire was seen by a Psychiatric Liaison Service 1 in Croydon University Hospital A&E. She was referred for mental state review due to her high level of anxiety. During this consultation with the psychiatric liaison practitioner, she denied any suicidal intent or plans and cited her son as a protective factor. She expressed a strong commitment to parenting her son. It was agreed that Claire would see her GP on Monday, and her stepfather and Mother to hold medication to ensure it is only used as required. 3.2.11 On 14th December 2012, Claire was staying with a friend in Rotherham. The friend, unable to rouse Claire, called the emergency services and both the ambulance service and officers from the local home office force attended the premises. Two officers found that Claire was unconscious. The paramedics arrived within a short time of the officer’s arrival and carried out a medical assessment. Following the examination, Claire was taken by ambulance to Rotherham District General Hospital Claire was admitted to Critical Care via A&E following an overdose of medication. 3.2.12 On 15th December 2012, she was assessed by a social worker in the Psychiatric Liaison Service 2 who noted that Claire presented with acute but severe anxiety. The outcome of the assessment was an urgent referral to SLaM proposing an Intensive Home Service in her home locality of Croydon. 3.2.13 Claire was subsequently discharged to the care of her Mother on the 16th December 2012 and advice given regarding mental health law and how a formal mental health assessment may be sought. Following Claire’s discharge from the hospital in Rotherham, the family expressed concerns about the lack of contact from the local mental health team and requested intensive psychological therapy at home. 3.2.14 On 17th December 2012, Claire’s GP made telephone contact with the duty worker at the SLaM Community Health Team requesting assessment for suitability for home treatment following the overdose in Rotherham. 3.2.15 On 31st December 2012, Claire and her Mother attended an out-patients appointment with SLaM Community Health Team CT1 psychiatrist. Claire was not thinking of harming herself but stated she wanted help. Claire also informed CT1 psychiatrist that she did not feel she was being a mother to her son as her own Mother was caring for him. The risk of harm to herself was documented as low. CSC RPT. CHS RPT SLaM RPT. Rotherham RPT. Police RPT. RDaSH RPT. SLaM RPT. GP RPT. SLaM RPT. SLaM RPT. CONFIDENTIAL Josh - Serious Case Review 18 3.2.16 On 17th January 2013, Claire was taken by Ambulance to Croydon University Hospital with her Mother. It is reported that Claire’s sister called an ambulance following a comment Claire made about not wanting to be around anymore and feeling suicidal. A triage nurse recorded that Claire suffered with extreme anxiety. Claire was seen and assessed by a Psychiatric Liaison Nurse. Claire stated that her main concern was her anxiety and the need for help and she denied any suicidal intent or plan. Claire was discharged home and referred to Community Mental Health Team. 3.2.17 On 18th January 2013, a referral was apparently made by CT1 psychiatrist to Children’s Social Care although that agency has no record of receiving such a referral. 3.2.18 Two outpatient appointments were offered to Claire as a result of the events on 17th January but she did not attend either appointment. 3.2.19 Between January 2013 and March 2013, Claire’s Mother arranged for private Cognitive Behaviour Therapy (CBT) sessions to be conducted with Claire at the family home. The practitioner would see the child come and interact with the mother after the session had finished. Eleven CBT sessions were conducted and at the initial session on 12th January 2013, Claire reported feelings of anxiety and loss of self esteem. The practitioner observed nice, positive and a loving interaction between the mother and the child. The therapist recorded that Claire progressed well in her treatments, reducing her level of anxiety to such an extent that she was able to interact more with her son in terms of reading stories, baking cakes, bathing him. Throughout the course of the therapy no safeguarding issues were raised in respect of Josh, either by the family or as a result of observation by the therapist. The last session was held on 9th March 2013 and Claire said she did not have any active suicidal ideation or risk of harm to herself. She expressed some optimism for the future and that she wanted to get better for the sake of Josh. 3.2.20 On Friday 22nd March 2013, Claire, holding Josh, stepped down onto a railway track and they were both killed by an oncoming train. CHS RPT. SLaM RPT. LAS RPT. Police RPT. SLAM RPT. CBT Report CONFIDENTIAL Josh - Serious Case Review 19 4. A Day in the life of Josh and his family 4.01 Until the day of his untimely death, Josh was described as a happy, bright child. For much of his life, his mother Claire worked full time and the daily routine was appeared to be shared by his Maternal Grandmother, her partner and Claire. It was reported that the maternal grandmother had a significant role in the care of this family as a whole. 4.02 Because Claire worked full time Josh attended a registered childminder each weekday until January 2013. On the 23rd January, Claire decided to spend more time with Josh, and his sessions with the childminder were reduced to 2 or 3 days a week. This coincided with Claire losing her job. 4.03 The childminder noted that during this period she would often see Claire and Josh out and about e.g. going to the park and shops and they seemed happy together. 4.04 Josh was undoubtedly loved and nurtured within his family although as Claire’s anxiety worsened it was reported by the GP that she stopped washing him and dressing him in the mornings, with this role being taken on by his Grandmother. In the latter part of his life therefore, Josh’s Grandmother was the main carer of this family and this was considered by the GP to be a protective factor. 4.05 In her written contribution to this SCR, Josh’s Grandmother confirmed that when Claire was at her worst, and couldn’t cope, she and her partner took over Josh’s care. She also pointed out however that Josh’s life did not change when Claire wasn’t well and that ‘he saw his mum on a daily basis’ and always gave her a kiss in the morning and at night. 5. Analysis of Key Episodes and the Lessons Learnt 5.01 The main period covered by the SILP Serious Case Review starts in June 2012. However, Josh was taken to hospital with minor head injuries on three occasions before that date and this pattern of events was included within the terms of reference and the relevant Agency Reviewers have carefully considered the circumstances of each presentation. 5.02 It should be noted that these accidents occurred when Josh was between 14 and 20 months of age when children are becoming more mobile. There was an explanation given each time that was consistent with the injury and there was no suggestion in any hospital records that the head injuries may have occurred as a result of maltreatment. CONFIDENTIAL Josh - Serious Case Review 20 5.03 Josh was provided with a universal health visiting service during the early months of his life and the health visiting team did not receive any information from any other agency that there were any safeguarding concerns for this child. The health visitors themselves expressed no concerns about Josh. In addition, Josh had attended the GP’s surgery on 17 occasions, accompanied by Claire, for general consultations appropriate to the time of year and his age. There were no concerns about his health among the doctors at the surgery. 5.04 Whereas it was important that this SILP Review considered all aspects of Josh’s care, there was no evidence found of any maltreatment related injuries and therefore no reason why any professional should have raised concerns about him as a result of these earlier hospital admissions. 5.05 The remainder of this analysis section is not arranged chronologically but covers four ‘key episodes’ and will examine whether there was any reasonable possibility that an agency or individual professional could or should have been able to predict the events which occurred on 22nd March 2013. The analysis will consider the case specific themes prescribed by the Terms of Reference What was known and identified by professionals about Claire’s parenting capacities and possible risks to Josh? Did assessment and/or care plans take account of the whole family and potential risks to Josh and how was information shared with relevant agencies? 5.1 Referrals to Children’s Social Care 5.1.1 Until a few months before Josh’s death, Children’s Social Care had no involvement with, or referrals about him or his family. 5.1.2 On 13th November 2012, Claire and her Mother sought help from the Community Health Team. This team is part of the range of services provided under the umbrella of South London and Maudsley NHS Trust (SLaM) and according to the website of this team, it 'provides advice on the best treatment and care options available to people who have moderate to severe mental illness, such as anxiety, depression or personality disorder'. Claire explained to the duty mental health professional that on the evening of 11th November 2012, she took Citalopram 20mg as prescribed and went to bed. She reported getting up in the middle of the night, totally unaware of what she was doing, and held a knife to her throat, fighting off her Mother’s attempts to take the knife from her. She believed that the behaviour was caused by anxiety, it was impulsive, she had not CONFIDENTIAL Josh - Serious Case Review 21 planned it, had no intention to end her life and the events had scared her very much. 5.1.3 The assessment found the risks to Claire to be low and her family was identified as a protective factor. The duty worker advised Claire to visit some online support sites and she was discharged back to her GP. There is no evidence that the safety of Josh was particularly considered or discussed during the interview with the SLaM Community Health Team, although it is recorded that ‘a child risk assessment was also completed, following this contact.’ The duty nurse documented in the referral letter to the GP that she had discussed her conclusions at the team meeting. This was explored by the SLaM Agency Reviewer with the nurse at interview who acknowledged that it in fact it was unlikely she had actually discussed the case at the team meeting, as the appointment was on Tuesday, the letter was uploaded on Thursday and the team meeting would not have taken place until the following Monday. 5.1.4 At the SILP Learning Event, the structure of the SLaM Community Health Team case meetings was discussed and it was noted that the gap in discussing Claire’s case was due to ‘no medic being present at the team meetings.’ A full exploration of this issue has taken place and it was explained that there was first of all an informal discussion within the team prior to the letter being written to the GP and that was followed a few days later by a formal team meeting with a medic present. Although as a result of the SLAM investigation there is a discrepancy that has arisen to suggest that recollection of events is now doubtful. 5.1.5 Claire was asked to return to the SLaM Community Health Team for a full appointment to review her medication. This visit took place at 14.30 hrs on Friday 16th November 2012 and Claire, accompanied by her Mother, met CT1 psychiatrist the team junior doctor. She was given a preliminary diagnosis of ‘generalised anxiety disorder secondary to life events.’ 5.1.6 CT1 psychiatrist also told Claire that he was going to make a referral to Child and Family Social Services, although it is not clear if he explained to them that he was concerned primarily about Josh. 5.1.7 At the SILP Learning event, CT1 psychiatrist explained that when he saw Claire he wondered if Josh had seen her holding a knife to her throat and he also asked about the atmosphere in the house. It is clear therefore that CT1 psychiatrist was considering Josh’s welfare and he explained at the Learning Event the difficulties in making a judgement in just a 30 minute clinical appointment, and that as he had not seen Claire in her home he felt that more information was needed and that Children’s Social Care should ‘step in here.’ CONFIDENTIAL Josh - Serious Case Review 22 5.1.8 Although CT1 psychiatrist had an awareness of safeguarding children, it appears that he lacked complete awareness of the safeguarding referral process and procedures, and it was noted in the CSC IMR Report that ‘there was some confusion whether the referrer initially thought they were making a CAF referral or safeguarding referral.’ The view of the SLaM internal investigation team (see paragraph 2.3.7 above) is that the wrong format (i.e. email) was used for this referral, which was unhelpful, but this should not have affected the action taken by Children's Social Care because the analysis in the SLaM Agency Report concludes that the purpose of the referral and the form used are consistent with a clear understanding that the referral was a child protection referral, which was simply misnamed by the doctor. 5.1.9 However, there is no implied criticism of CT1 psychiatrist, and it is considered good practice that as an adult mental health professional he recognised a potential safeguarding issue concerning Josh, and began the process of involving the relevant agency. As will shortly be discussed however, there were failings in the processing system within Children’s Social Care which resulted in the referral being misplaced and no action taken. Recommendation 1 5.1.10 It is believed that CT1 psychiatrist telephoned and emailed his referral to Children’s Social Care on Friday 16th November 2012, although it is not clear who he spoke to or what time of day the referral was made. At 0839 hours on Monday 19 November 2012, the referral, in the form of an email, was forwarded from the Initial Contact Centre in the Local Authority to the Children’s Assessment Team. The referral states that CT1 psychiatrist ‘wondered what the emotional atmosphere is like in the house, and how this might be affecting Josh.’ 5.1.11 On receipt of this referral, information was placed on the ICS contact record and it is evident that the information was ‘cut and pasted’ onto the contact record directly from the referral email. The contact record was reviewed on Tuesday 20th November 2012 by the screener on duty that day and it is a matter of concern that the referral was not screened on the day it was processed by the Initial Contact Centre as this resulted in a total of four days (which, it is recognised, included a weekend), when no action was taken or considered. Nevertheless, when the referral was screened this resulted in the following: The Duty Assessment Officer was asked to advise the referrer to complete a referral form, as more information was required concerning Claire’s mental health, timescales of the incidents, diagnosis, interventions by the Community Mental Health Team CONFIDENTIAL Josh - Serious Case Review 23 and whether there was a father or any other children involved in the case. The Team Manager noted that the child was being safeguarded as he was in the care of his Maternal Grandmother, but that consideration needed to be given to advising her to seek legal advice with a view to obtaining a Residence Order. The Duty Assessment Officer wrote to CT1 psychiatrist on 20th November 2012 requesting the further information indicated above, and explained that Croydon’s Children’s Services would not be taking any further action until the further information required was received. 5.1.12 Until that point, apart from an apparently sluggish journey through the system, the referral had been dealt with appropriately and it is accepted that Children’s Social Care needed more information on which to base their decision making. CT1 psychiatrist re-sent the referral via an email including some additional information, and that was received by Children’s Social Care on 27th November 2012 at 11.30am. There was a gap of a week between Children’s Social Care requesting further information and the referral form being re-submitted by CT1 psychiatrist. The reason provided to this Review was that ‘there was a delay while the request for further information was discussed in the community health team’, but by now 14 days had elapsed since Claire had attended the SLaM Community Health Team seeking help, during which time no assessment had been made of any concerns for Josh. Recommendation 2 5.1.13 For reasons which have not been fully established by this Review, even when the correct referral form was received by Children’s Social Care it was ‘filed away’ without any assessment being made of the additional information it contained. As no contact was made with CT1 psychiatrist to request further information, or to inform him of the outcome of his referral, it would appear that that the referral form was not even assessed by any member of the Duty Team, or indeed any qualified social worker. The referral appears to have been merely placed on the electronic database (ICS) and no further action was taken. The Children’s Social Care Agency Reviewer spoke with the ICS Manager and his assumption was that the referral was seen by a person known as a Screener who thought no additional information was provided and so the referral not assessed by the Duty Team Manager. 5.1.14 Further information concerning the procedure for processing contacts and referrals was provided to this Review by the ICS Manager. He explained that all Children’s Social Care contacts are recorded centrally by Croydon Call Centre staff. These are then CONFIDENTIAL Josh - Serious Case Review 24 passed electronically to the Duty Team where they are looked at by screeners, who are not qualified social workers. The screener then passes the contact onto a manager if further guidance is needed or if closure/no further action (NFA) is the recommended outcome. Where contacts/referrals are received by post, these go via a scanning team who then send the information electronically to the screeners. Emails are received by screeners directly via a joint Duty Email Box. The ICS Manager explained that since Josh’s death the system has changed to ensure that no referral can be closed with no further action without being assessed by the Duty Team Manager. 5.1.15 The lack of assessment of a referral has featured in a recent serious case review undertaken by Croydon LSCB. The current Review has been unable to establish why there was no follow up to CT1 psychiatrist’s referral of 27th November 2012. All that is known is that it was filed on ICS, with no further action. It was, however, the responsibility of Children’s Social Care to inform the referrer of the decision to take no further action, and this did not happen. 5.1.16 It was evident that when CT1 psychiatrist’s original verbal/email referral was made, the Duty Team Manager reviewing that referral considered there was a need for further information and was aware of the potential need for the Maternal Grandmother to obtain legal advice. A lesson learnt and accepted by Children’s Social Care is that there is an urgent need for a system to be in place whereby it is not possible to file a referral on ICS without it being seen, assessed and signed off by the Duty Team Manager. 5.1.17 It is correct to say that although the referral was not put in terms which suggested an immediate safeguarding or child protection concern, CT1 psychiatrist clearly stated that there were ongoing child in need concerns due to Claire becoming extremely anxious and that she was the primary carer of a 2 year old child. He pointed out that she had threatened to take her life by putting a knife to her throat and that he was concerned about the possibility of future self-harm. CT1 psychiatrist made a clear request, “I am hoping that this CAF referral will objectively assess the Mother and Grandmother’s ability to meet the child’s needs, and to suggest support to make up any shortfall’. 5.1.18 It is the view of those conducting this Review that the failure to properly manage this referral within Children’s Social Care was a missed opportunity for Josh. Once the extra information had been provided by CT1 psychiatrist in the correct manner the referral should have triggered an Initial Assessment by Children’s Social Care. The GP Agency Reviewer commented that there was no contact made with the GP by Children’s Social Care and that had this happened, there would have been an opportunity to share relevant information which may have influenced the decision making in this case. The CONFIDENTIAL Josh - Serious Case Review 25 instigation of an Initial Assessment would have created an opportunity for formal sharing of information between agencies, including the GP. 5.1.19 Furthermore, Children’s Social Care should have contacted CT1 psychiatrist, acknowledging receipt of the referral and explaining what action they were planning to take. Neither of these things took place, but it is also regrettable that having heard nothing as to the outcome of his referral, CT1 psychiatrist did not re-contact Children’s Social Care to seek an update because had he done so it is likely the error in the referral not being properly assessed may have been discovered. CT1 Psychiatrist maintains that as far as he was concerned he knew that Children’s Social Care had received his referral and ‘did not suspect the referral was not being actioned’ by that agency, however the SLaM Trust policy and advice is clear that if no acknowledgment is received from the agency receiving the referral it is the responsibility of staff to follow up referrals to clarify what is being done, rather than make assumptions about the outcome. Having said that, it is once again highlighted that those conducting this review consider it good practice for CT1 psychiatrist to have made the referral in the first place and the primary reason for a failure to action it was due to a procedural failure within Children’s Social Care. Recommendation 2 5.1.20 It is however important for this Overview Report to clearly acknowledge that none of the professionals working with Claire (including Psychiatrists in both the private and public sector, and her GP) considered her to be a direct risk to Josh. It is also important to note that in her written contribution to this Review, Josh’s Grandmother also commented that she ‘had no inkling of any danger to Josh because Claire was always a loving mum and at no time did she appear any sort of threat to her son, if anything, she always said she lived for Josh’. It is now known that in the weeks leading up to Josh’s death a private trained therapist was regularly meeting Claire at home, and her observations as well as conversations with the family, led her to believe that Josh was not at risk and that Claire had no active suicidal ideation. It is acknowledged that during early meetings with the therapist, Claire ‘expressed some suicidal ideation…but denied any current or active intent or immediate plan’. At their last appointment on 9th March 2013 the therapist reported that Claire ‘denied any active suicidal ideation’ and expressed some optimism for the future’. The therapist noted ‘ Throughout the course of therapy, no adult or child safeguarding issues were observed, elicited or reported.’ 1 1 "The family do not agree with the suggestion that Donna was optimistic and that there were no thoughts of suicide ideation". CONFIDENTIAL Josh - Serious Case Review 26 5.1.21 Therefore even if an Initial Assessment had been completed, and information shared by all relevant professionals, it is highly unlikely that the outcome would have triggered child protection enquiries or steps being taken to remove Josh from the care of his Mother. However, it is reasonable to suggest that if Children’s Social Care had carried out an Initial Assessment, a support package for Mother and Grandmother may have been an appropriate outcome. It is certainly the view of Josh’s Grandmother that Children’s Social Care should have visited the home and seen the interaction between mother and child, and that they should have been more ‘proactive’. 5.1.22 When looking for potential systems failures within this Key Episode, the following has been highlighted to this Review by practitioners at the SILP Learning Event. The difficulties with getting through to Croydon Children’s Social Care ‘frontdoor’ (referrals desk) were highlighted by various professionals, including trying to speak with someone about referrals and checking progress. It was noted that extra staff are needed in CSC as there is a general sense of a difficulty for professionals to get through to the front line service in CSC in Croydon (accessibility). The need to have one point to call up to and feedback to was highlighted. It is noted that a Multi-agency Safeguarding Hub (MASH) has recently been set up in Croydon which, it is hoped, will improve information sharing and pathways. It was noted that the screeners of referrals are not qualified social workers. In a previous SCR a referral was scanned and placed on ICS without any further action being taken. It was only after the police officer in that case who made the referral followed up with CSC and action was then taken. Those attending the SILP Learning Event felt that there is a need for a qualified social worker to screen referrals. During the relevant period of this review it was possible for a referral into Children's Social Care to be filed away without ever being seen or checked by a social work manager. (NOTE: The ICS Manager confirmed that the system has now been changed to ensure that no referral can be closed/NFA, without being assessed by the Duty Team Manager). Adult Mental Health Professionals within Croydon may be unaware of the correct referral system when they feel a child may be at risk, or the fact that there is a requirement for Children’s Social Care to acknowledge receipt of the referral and explain what action will be taken. Had this gap in knowledge not existed, the delay in Children’s Social Care receiving a correctly formatted referral would have been CONFIDENTIAL Josh - Serious Case Review 27 reduced by about a week and CT1 psychiatrist may have realised something had gone wrong, perhaps prompting a follow up call. 5.1.23 It was highlighted at the SILP Learning Event that there is a culture of overreliance on Children’s Social Care for actions regarding a child, and it is not acceptable for other professionals to adopt a ‘fire and forget’ stance in respect of their referrals. 5.1.24 It has been reported by the SLaM Agency Reviewer that CT1 psychiatrist made a second referral to Children’s Social Care on 17th January 2013, by resending the November referral form to Children’s Social Care on 18th January 2013. Details of how this referral was made are not explicit within the SLaM notes and the current review has not been able to satisfactorily establish exactly why, or to whom, this second referral was made. It is therefore not known exactly what triggered this referral but it could be speculated that it was because Claire failed to attend a pre arranged appointment with CT1 psychiatrist the day before. 5.1.25 It is of great concern that no-one seems to have any proper record of this referral or the outcome. The psychiatrist (CT1) could not recall what referral form was completed or how the referral to Children's Social Care was made and SLaM records hold no correspondence letter attached to the system, which links to the referral screen. For their part, Children’s Social Care has no record whatsoever of this apparent referral having been received, and consequently no action was taken by them. 5.1.26 The SLaM Agency Reviewer notes that there is limited evidence to account for decision making processes in relation to this second referral regarding Josh to Children’s Social Care. The referral was believed to be simply a repeat of the November referral but there is no documentation which accounts for why a new referral was made and what new information or concern this was based on. No follow up is recorded in the SLaM notes and since the previous (November) referral had also not been followed up with Children’s Social Care there is no evidence that Community Mental Health Team were aware of the outcome of either of their referrals. As discussed above, it is unacceptable that referrals are made in this way and then simply left with the referring agency, with no attempt to follow up or challenge an apparent lack of acknowledgement or action. Recommendation 3 5.1.27 It is acknowledged that this was the CT1 psychiatrist’s first community mental health post and his supervision by senior colleagues was not sufficiently robust to highlight deficiencies in his note keeping which were identified by the SLaM Agency Reviewer. It CONFIDENTIAL Josh - Serious Case Review 28 was however noted in the SLaM Report that following this incident, CT1 psychiatrist ‘was able to rectify this deficit in record keeping’. 5.1.28 Because of a complete lack of information about it, there is little that this Review can offer in terms of learning regarding this second referral. It is noteworthy however, that had it been correctly dealt with, any assessment of Claire’s parenting capacity could have taken into account the recent events when she was admitted to hospital in Rotherham having taken an overdose, and admitted to Croydon University Hospital due to her feeling suicidal. 5.1.29 When analysing why there was a failure to properly record or follow up the two referrals it is important to acknowledge the following contextual information provided by the SLaM Agency Report, ‘Caseload size and the ability to manage competing demands were highlighted as a contributing factor by staff interviewed within the Community Mental Health Team. This was compounded by covering duty at least I day per week, which could increase dependant on staff leave or sickness. The expectation of the service was that “walk ins” would also be assessed which added an extra pressure to this role. It was also noted at interview that approximately 500 clients were managed in outpatient clinics. Management of the team was also disrupted at the time of the incident as the team leader was removed from duties resulting in the Head of Pathways taking on management responsibility. Whist core management tasks were undertaken by the Head of Pathways the investigating team noted that management of the Community Mental Health Team was only an element of the portfolio of duties and demands.’ 5.2 The admission to Rotherham District General Hospital 5.2.1 In December 2012, Claire travelled to Rotherham to stay with a friend. Josh remained at home and was in the care of his Grandmother. 5.2.2 On the morning of 14th December 2012, Claire’s friend was unable to rouse her and she called an ambulance. Claire was taken to Rotherham District General Hospital having taken an overdose of her prescribed medication. At the time of admission she was unconscious and staff were unable to verify her identity. After life support measures and neurological monitoring, Claire was moved to the Intensive Care Unit. It was noted on transfer that staff had information that she suffered from anxiety and depression. 5.2.3 As well as the ambulance crew attending the house where Claire became ill, there were also two police officers from South Yorkshire Police. These were uniformed patrol officers who did not have a specialist child protection role. The policy of South Yorkshire CONFIDENTIAL Josh - Serious Case Review 29 Police regarding the management of children at risk is similar to other forces within the UK. South Yorkshire has a bespoke child referral form called GEN 117. This form should be completed when officers attend any incident and there is any concern or need for further investigation in relation to children. PC 1, one of the attending officers confirms that he was aware that Claire had a small child however he established that the child was in the care of Claire’s parents and as a result of this information did not feel a need to complete the form GEN 117. 5.2.4 The Police Agency Reviewer offers no criticism in his report of these officers and points out, ‘the officers were aware that Claire was to attend Rotherham General and be provided with psychiatric support from the relevant agency in South Yorkshire. It is also right to consider what additional support Claire or Josh would have been provided with if the form had been completed. It is anticipated that if the form had been generated no further action would have been required as Claire had already been referred to psychiatric support.’ 5.2.5 At the SILP Learning Event, The Police Agency Reviewer did express the view that the officer should have contacted Rotherham Children's Social Care who then would hopefully have contacted Croydon Children's Social Care. Had this happened, it is possible that the earlier referral from CT1 psychiatrist would have been accessed in their filing system, revisited and actioned properly. 5.2.6 Records within A&E and the Intensive Care Unit, fully document the care and clinical interventions at Rotherham Hospital. It is recorded that Claire’s mother was contacted and stated she would visit from Croydon in the morning. It was established that the Grandmother was looking after Josh, reportedly in a safe environment. The Intensive Care Department at Rotherham Hospital does not deal with children, therefore, staff do not deal with safeguarding issues very often. In this case the hospital Safeguarding Team were not contacted to offer appropriate guidance on whether further enquiries should be made concerning Josh. Whilst care plans were robust in terms of intensive care and life support, staff at Rotherham did not 'think family' and liaison to agencies in Croydon in terms of Josh’s welfare was not carried out. Given the gravity of the suicide attempt this would have been good practice. In particular, there is no evidence that Children's Social Care in Croydon were contacted in terms of Josh’s welfare and it would have been good practice to alert the Hospital Safeguarding Team or the Liaison Specialist Paediatric Nurse so that information could be disseminated to services in Croydon to assist in planning. 5.2.7 Certain assumptions were made by staff at Rotherham Hospital. For example, it was established that Claire’s parents were reported to be caring for Josh yet little was known about them or whether Claire CONFIDENTIAL Josh - Serious Case Review 30 alone had parental responsibility, and the legal status of the child was unknown. It is fully accepted that Claire’s poor condition on admission could mean that the full family circumstances would have been difficult to establish in the early stages but as time went on more could have been done to contact agencies in her home area. 5.2.8 This assumption that Josh’s family, and his Grandmother in particular, could be relied upon as a ‘protective factor’ was made on several occasions by different professionals, often without knowing anything about her. Although all information suggests that she was a ‘protective factor’, in cases involving other children this may be a dangerous assumption and professionals need to refrain from making such assumptions but rather carry out a proper assessment to ensure that those being relied on to care for a child are, in fact willing and capable of doing so. Recommendation 4 5.2.9 Had contact been made with other agencies in Croydon it may have been confirmed whether or not the family were in fact appropriate people to care for Josh. In general, Josh is not mentioned in any great detail in the care plans and there are no details of his name and date of birth in the hospital records. Whether Claire had a partner or not is also not documented in hospital notes. It is the view of the Rotherham NHS Agency Reviewer that there were lost opportunities for hospital staff to gain information from the Croydon area with which to contribute to holistic plans of care. Although A&E and Intensive Care Unit staff access Group 2 Safeguarding Training, the voice of Josh in this case was not heard in terms of short and long term planning. 5.2.10 This admission of Claire to Rotherham Hospital highlights the barriers of adult focussed workers, particularly in a high dependency area, considering the welfare of the patient’s child. In this particular case, communication was further complicated by the family originating in another area and no background information being easily sought. However, there were professionals at the hospital who could have been of assistance with this, including the Safeguarding Team and the Paediatric Liaison Specialist Nurse and these services should have been called upon. A view was expressed by the Rotherham representative at the SILP Learning event that it would also have been good practice for the Rotherham Hospital Trust and/or Mental Health Crisis Team also to have made a direct referral to Croydon Children's Social Care. 5.2.11 The day after her admission to Rotherham Hospital, Claire was referred to the Rotherham, Doncaster & South Humber (RDaSH) Crisis Team and a member of that team visited her for an initial interview on the evening of 15th December 2012. This assessment highlighted that Claire’s current mental state rendered her unable to provide adequate care for Josh. The Crisis Team worker met Josh’s CONFIDENTIAL Josh - Serious Case Review 31 Grandmother and her Partner and was given assurance that they were taking responsibility for his care needs. 5.2.12 The plan of care for Claire was that she would be discharged from Rotherham Hospital the next morning (16th December 2012) to the care of her Mother and would return to her home in Croydon. This duly happened. The RDaSH Crisis Team worker spoke to someone in the Croydon Mental Health Crisis Team, who advised him of appropriate contact details of the relevant professionals in that area and a referral, dated 16/12/2012, was sent to the team and also a referral letter to Claire’s GP. The referral contained details of the assessment carried out the previous evening and made reference to the information provided regarding Claire’s inability to care for her child and also detailed that all care for the child was being provided by the maternal Grandmother. 5.2.13 It is very concerning that neither the SLaM Community Health Team, or SLaM have any formal record of receiving this referral from the RDaSH Crisis Team. The Crisis Worker at Rotherham does indeed seem to have liaised with Croydon Mental Health Services as it is documented on the discharge letter that a visit from the Crisis Team in Croydon will take place the day following discharge. At the SILP Learning Event, CT1 psychiatrist did recall seeing a referral letter from Rotherham to SLaM but this Review has been unable to discover why the referral was not properly recorded by Croydon mental health services and acted upon. Recommendation 5 5.2.14 Fortunately, Claire’s GP was also copied in to the referral from the RDaSH Crisis Team in Rotherham and on the 17th December 2012 she made telephone contact with the duty worker at the SLaM Community Health Team requesting assessment for suitability for home treatment following Claire’s overdose in Rotherham. A duty appointment was subsequently arranged for later the same day which Claire attended with her Mother. Claire reported acute overwhelming anxiety, panic attacks and insomnia, feeling useless, helpless and depending on her Mother. 5.2.15 It is noteworthy that during her discussion with the Independent Reviewers, Josh’s Grandmother recalled that the family was promised three visits a day from a psychiatric nurse and that the RDaSH Crisis Team had been promised this service by Croydon. The SLaM Agency Report comments that at the appointment on 17th December 2012, the role of the Home Treatment Team was explored with the family but a referral to this service was declined. It now appears that the reason the service was declined is that there was a significant failure in terms of communicating to the family what the Home Treatment Team could actually offer. CONFIDENTIAL Josh - Serious Case Review 32 5.2.16 In her written contribution to this review, Josh's Grandmother suggests that she and Claire were given misleading information by a SLaM clinical professional regarding the availability of home care and treatment. Specifically, it is claimed that the duty mental health nurse informed the family that SLaM did not support any type of home treatment other than the supervision of taking of medication, but because Claire felt she didn't need any external supervision as regards her medication intake, the service was declined. The information given to Claire and her mother was inadequate, and in fact there is a wide range of possible interventions available from the Home Treatment Team. 5.2.17 When discussing SLaM in her written contribution (see Appendix B), Josh’s Grandmother used very strong terminology to describe her experience with staff at SLaM and how, in her words, they "...denied my daughter home care, the very treatment that may have been a benefit to her’. This is clearly a very important and emotive issue for Josh’s family and it should be considered a point of learning that whether or not SLaM professionals thought they were giving clear advice, the family feel they were misinformed and left in a confused state about what home treatment was available. 5.2.18 As mentioned in paragraph 2.3.7 above, as well as the SLaM Agency Report, the SCR was also provided with a document entitled Acute Comprehensive Mental Health Level 2 Report, which was the product of an internal investigation by SLaM. When dealing with the episode relating to the provision of home treatment for Josh's mother, the SLaM investigators agreed that the family members were not given a clear explanation of what was available. In fact they were of the view that the registered mental health nurse who explained to the family what home treatment was available should have been clearer both in her description of the home treatment team and what interventions they could offer. The internal investigation report lists 23 potential 'interventions' that can be provided as part of home treatment but concludes, 'the full spectrum of home treatment interventions were not discussed with [the family] to allow them to make an informed decision about a referral to the team.' The internal investigation also concluded that there was 'poor awareness of the principles of sharing information with service users'. 5.2.19 The list of 23 potential interventions includes some activity which might arguably have been very relevant to Josh's safeguarding needs. For example the Home Treatment Team offers: Care planning, including working with the service user's family and carers Assistance with arranging childcare Child risk assessment Ongoing education and support to family members and carers CONFIDENTIAL Josh - Serious Case Review 33 Interventions aimed at maintaining and improving social networks 5.2.20 It is important for the SCR to seek to establish why the information provided to Claire on 17th December 2012 was so incomplete. The workload and management situation within the team during December 2012 was highly unsatisfactory as outlined in paragraph 5.1.29 of this report. The SLaM internal investigation report also refers to considerable pressures within the SLaM Community Health Team caused by that team having the 'highest activity' within the Trust. It is also reported that during December 2012 there was a specific performance related problem with the Team Manager who in fact was suspended the following month. This might have contributed to a general lack of supervision for team staff, such as the duty Registered Mental Health Nurse who interacted with Josh's mother on 17th December 2012, as well as perhaps a general malaise in terms of properly recording referrals in and out. Having said that, the problems being experienced by the team cannot explain the lack of clear information being given to Claire and it is unacceptable that the family were apparently misled about what exactly the Home Treatment Team could potentially have done to help Claire and Josh. 5.2.21 A lesson learnt and accepted by South London and Maudsley NHS Trust is that as well as a verbal explanation, there should have been be a leaflet available to their duty mental health professionals which could be given to service users to help outline and explain all services available to them. This idea is included as a recommendation contained within the SLaM Acute Comprehensive Mental Health Level 2 Report. Since some of the services available relate to the safeguarding of children within families, LSCB should audit the introduction of this leaflet. Recommendation 6 5.2.22 In respect of the services provided in Rotherham, the RDaSH Agency Reviewer highlighted examples of good practice by the RDaSH Crisis Team clinician. The good practice cited includes, for example, that the assessment was thorough, that it gave proper attention to the parenting responsibilities for Josh, to Claire’s own health needs and the arrangements in place to care for the child whilst her mental health was poor. The RDaSH Crisis Team worker also ensured that the Grandmother had information regarding how to access further help should her daughter’s mental health deteriorate. 5.2.23 Whilst it is clear that the RDaSH Crisis Team clinician did make the correct referral to the SLaM Community Health Team, it is regrettable that somehow this referral was not properly recorded on the SLaM Community Health Team system, or acted upon, until the GP independently made contact the following day. There was undoubtedly a system/recording failure which, had it not been for the CONFIDENTIAL Josh - Serious Case Review 34 independent referral from the GP, may have meant that Claire was not seen by anyone on her return from Rotherham after the serious attempt to end her life. 5.3 The prescription of medication 5.3.1 During her conversation with members of the Review Team, Josh’s Grandmother said that she felt that Claire’s excessive medication was partly to blame for her poor mental health, and she was particularly critical that doctors kept ‘upping the dose’ when a particular medicine was not having the desired effect. Claire’s natural father was also asked to contribute to the Review and an interview was conducted by the Independent Panel Chair over the telephone. His main concern was expressed as, ‘The services ain’t no good. It’s the doctors and the psychiatrists who gave her the stronger and stronger tablets so she took her own life.’ In as much as Claire’s general anxiety affected her parenting capacity for Josh it is important for this Review to explore the concerns expressed by her Mother and natural Father. 5.3.2 It is clear that the various medical professionals treating Claire tried several different medicines in an effort to treat her. Claire tried and abandoned medication quickly, the pattern of use of medications is important to note here. Claire did not take any medication consistently and for a long enough period for them to be properly effective and for any side effects to settle down. The family GP confirmed that Claire was first prescribed anti-depressants in June 2012. The GP went on to describe the medication that Claire was prescribed. It was noted at the Learning Event that the GP tried to be very effective with the prescription of various medication, and sought appropriate advice as to which medication to try next and at which dose. The list provided by The GP is as follows, together with the effect. 1. Citalopram - problem of spontaneous bleeding on this medication. This medication is a first line drug which is usually prescribed by GPs. 2. Sertraline – problem of bruising on this medication. This medication is more of a calming type. 3. Citalopram – Claire was prescribed this drug after her A&E attendance (this was prescribed by a colleague of the GP). Claire was on this for a long time. 4. Venlafaxine – uncertain if the patient took enough doses to determine if this was effective or not. 5. Mirtazapine – due to not sleeping, but Claire did not react well to this. CONFIDENTIAL Josh - Serious Case Review 35 6. Pregabalin – trialed this, but Claire experienced hallucinations and reported that her anxiety increased. The overdose in December was included Pregabalin. 7. On 17th December 2012, Claire was prescribed Promethazine and Citalopram 20mg was to continue. 8. Claire was also prescribed Propranolol (to take 3 times a day) 5.3.3 At the SILP Learning Event, The GP was told that her Mother felt Claire was wrongly prescribed increased doses of medication but the GP noted that dosages in the medication prescribed were not increased beyond the starting dose and that Claire was not on the medications long enough for this to occur. 5.3.4 The GP confirmed treatment doses do vary between person to person and it is not considered unusual to have to change medication as it is about finding the right drug for each person. The GP explained that if in doubt, she was able to telephone the medication review service for advice on medication. There is evidence that sometimes dosages were increased, for example on 4th December 2012, when Claire was seen by CT1 psychiatrist, he was concerned that she was being prescribed a sub-therapeutic dose of Pregabalin by the GP. CT1 psychiatrist called the GP to discuss increasing the dose of Pregabalin. Trying to find out ‘what works’ for a particular patient can involve raising or lowering medication levels, so there is nothing particularly unusual about suggesting an increased dose of a particular medication even though this may have seemed alarming to Claire's family. 5.3.5 At the SILP Learning Event, a Private Psychiatrist described Claire as not open to persuasion to medication and as having had negative experiences of medication, adding that it is difficult sometimes to separate whether it is anxiety or a side effect of the drug. He also explained that people have varying tolerance to medication and may be sensitive to certain drugs. He did not feel that there was any evidence of medical professionals wrongly ‘upping the dose’ in the way perceived by Josh’s Grandmother. 5.3.6 During her conversation with the Independent Reviewers, Josh’s Grandmother said that the care the family had received from the GP had been ‘fantastic’. It is noted in the GP Agency Report that The GP had many discussions with Josh’s Grandmother who was extremely concerned about her daughter. She would contact the GP to provide an update of the home situation and progress, while the GP would talk with her about medication management at home. It is not recorded that any concern was raised during these meetings about increases in the medication prescribed. CONFIDENTIAL Josh - Serious Case Review 36 5.3.7 Finally, the GP Agency Reviewer has made no adverse comment about the medication used to treat Claire, either in respect of the type or the amount. 5.3.8 Despite the perception of both her parents, based upon all the evidence presented to this Review there is no reason to conclude that the medication prescribed to Claire was incorrect in either type or quantity. 5.4 Sessions with private consultant clinical psychologist 5.4.1 On 18 September 2012, Claire attended a consultation with a Consultant Private Psychiatrist after a referral by her GP due to a bad experience with her anti-depressants. The services provided to Claire were an initial psychiatric consultation with advice on medication and therapy, and a referral to a Private Consultant Psychologist who saw her for five sessions of psychological therapy. 5.4.2 The ending of therapy was rather fragmented, with the rescheduling of appointments and Claire not attending as she was unwell. The family made contact with the service at the end of November 2012 to advise that Claire did not wish to continue and her last actual session with this service was on the 2nd November 2012. 5.4.3 At the SILP Learning Event the Private Psychiatrist explained that consultation included taking a full background history from Claire. Positive comments were provided showing the love for Josh, him being the most important person in her life and a commitment to look after him. The overall focus with the session was to address the Mother’s needs but the Private Psychiatrist did not feel that anything said in the sessions with either himself or the psychologist should have triggered a referral about concerns for Josh. The presence of the Grandmother as a family support indicated that Josh was safe and raised no alarm bells. The Private Psychiatrist was asked what he would do if he did have a concern regarding a child, and he advised that the route he would take would be to raise any concerns through discussion with the GP. 5.4.4 A letter was sent to Claire’s GP acknowledging the premature ending of therapy. As there were no concerns for Josh or anything that stood out regarding her parenting, this was not raised in the correspondence to the GP. 5.4.5 The overall focus of the sessions was to assess Claire and her son was seen as a motivating factor. It was noted during her sessions with the Psychologist that she appeared to have some separation anxiety in relation to her son. Claire indicated that she continued to sleep with Josh and felt scared when she was away from him or her Mother and wanted to be with them all the time. In her therapy CONFIDENTIAL Josh - Serious Case Review 37 sessions she talked about how important her son was to her indicating that Josh was the only thing that she was really motivated and committed to. 5.4.6 There is no evidence that at this point Claire had attempted or discussed suicide, the first such occasion occurring some 11 days after her final therapy session. Whereas an attachment to Josh may well be seen as a positive factor, it could also be argued that such a dependence on him, combined with thoughts of suicide, may be considered a risk factor for the child. 5.4.7 It is noted that a ‘full outcome statement’ was shared with Claire’s GP and the report from Private Psychiatry for the current Review indicates that there was ‘good communication between the psychologist and both consultant psychiatrist and GP at the end of therapy’. It is not however known whether the specific comments outlined in Para 5.4.5 above were shared. Had they been, this should have triggered a closer analysis of the safety of Josh when the GP later became aware of Claire’s suicidal thoughts and serious attempt at suicide over the next few weeks. It might be reasonable to suggest that a potentially active suicidal patient with an apparently extraordinary reliance on her child as the reason to live and be motivated should cause professionals to consider the safety of that child. However, at the SILP Recall Event, CT1 psychiatrist offered the view that he would not have interpreted this reliance on Josh as making it more likely that he was at risk from his mother, but rather that he would have seen Josh as a protective factor in keeping her alive. 6. Conclusions and Summary of what has been learnt 6.01 The death of Josh could not reasonably have been predicted by any agency or individual who knew them or had any information about them. This Serious Case Review concludes that no professional, nor any family member, had any child protection concerns for Josh during the period covered by the Review. A psychiatrist (CT1) from a SLaM Community Mental Health Team did have concerns about how the atmosphere in the family home might be affecting Josh but did not himself have any real concerns for his physical safety. 6.02 Although some procedural and individual failings were identified by the current Review, there is no evidence to reasonably suggest that any agency providing Josh or his family with a service failed in any way which had a bearing on the outcome for him, to fulfill their responsibilities, statutory or otherwise, to safeguard and promote his welfare. CONFIDENTIAL Josh - Serious Case Review 38 6.03 There is evidence that a failure in the processing arrangements within Children’s Social Care in respect of a referral from a Psychiatrist, led to a missed opportunity for Josh’s needs to be properly considered by an Initial Assessment, and potentially for the family to be offered support with parenting for Josh. It is however unlikely that the standard discussions between partner agencies and the family which would have been triggered by such an assessment, would have revealed any concerns of a child protection or safeguarding nature. 6.04 It is an example of good practice that the Psychiatrist treating Claire recognised the possible effect her condition may have on Josh and that he made a referral to Children’s Social Care in order to better assess his wellbeing and needs. 6.05 Mystery surrounds an apparent second referral to Children’s Social Care from the same Psychiatrist. It is reported by the Psychiatrist that the referral was made on 18th January 2012 after a missed appointment by Claire. There is no record of the referral in the Children’s Social Care or SLaM systems and it appears to have been completely ‘lost’. Needless to say, no action was taken. 6.06 The referral system in Children’s Social Care has been tightened up and a monitoring system which is routinely operated is now in place and no referral can be classified as 'No Further Action' without being assessed by the Duty Team Manager. In addition, a Multi Agency Safeguarding Hub (MASH) has been operational within the local authority area since October 2013. A health representative will sit in the MASH and as a result a referral from a health professional to Children’s Social Care should result in a more streamlined process. 6.07 The family GP’s input into Claire’s life, as well as the life of the family as a whole, was hugely beneficial and the GP received a great deal of praise from the family for her support and health care. The GP agency review however, has identified that the consideration of Josh’s needs was lacking. A view was expressed at the first SILP Learning Event that the GP did not consider that other agencies needed to know the information that the GP held about Claire, and the potential impact on her parenting capacity. In particular, this was not shared with the Health Visiting Service and this was a missed opportunity to potentially discuss with Claire the possibility of providing her with additional parenting support. 6.08 There were examples of good practice by the staff at Rotherham General Hospital and Rotherham, Doncaster & South Humber Crisis Team. The good practice included prompt emergency care, a prompt assessment of Claire’s needs and a good follow up with professionals in her home area. However, there is evidence that Rotherham Hospital did not sufficiently ‘Think Family’ in their assessment, and CONFIDENTIAL Josh - Serious Case Review 39 although they made good follow up with SLaM in terms of the mother, they did not follow up with Croydon Community Health Services in terms of the child and the mothers parenting capacity. 6.09 A referral from the Crisis Team at Rotherham to mental health professionals in Croydon was not properly recorded and no record of it could be found in SLaM systems. It is clear that a referral was made so together with the failure to locate any information about the January referral to Children's Social Care it can be concluded that the system of recording referrals both into and out of the SLaM Community Mental Health Team was dysfunctional and needs to be tightened up. 6.10 There was no evidence of any error by medical professionals in respect of prescription of medications to Claire, but it is likely that she failed to stick with some medications for long enough for them to have the anticipated effect on her wellbeing. Since those family members caring for her perceived that an excess of medication was detrimentally affecting Claire, there was a need for those prescribing medication to better explain to Claire and her Mother that if the medicine was not used for the recommended period of time it may have no effect, or it may actually appear to be making the patient feel worse. 6.11 Family members were confused by some apparently inconsistent and misleading advice given by SLaM mental health staff about the availability of medical care and other support within the home for Claire and her family. Specifically, a duty Registered Mental Health Nurse failed to explain to Claire and her family the full range of services offered by the Home Treatment Team. This confusion caused great anxiety to those caring for Claire and led the family to continue accessing private mental health providers because they had lost faith in NHS providers. CONFIDENTIAL Josh - Serious Case Review 40 7. Recommendations for Croydon SCB These recommendations should be read in conjunction with the Action Plan which provides detail about methods of implementation and timescales. Recommendation 1 The LSCB Chair should request a report from Children’s Social Care which fully explains the improvements made in the referral system within that agency, and the Board should audit the improved system to ensure that referrals are promptly assessed by a social work manager or practitioner rather than solely by a screener with no social work background or training. Recommendation 2 The LSCB should ensure that the safeguarding training provided for adult mental health professionals includes the specific requirement to follow up any referrals made in the event that an acknowledgement of the proposed action is not received. The LSCB should request that each relevant employer disseminates a memorandum to this effect to all medical staff who have already received the full training available. Recommendation 3 The LSCB should ensure that the safeguarding training provided for adult mental health professionals includes learning about the level and amount of information required by Children’s Social Care, as well as the need for clarity about what action the referrer feels may be needed in a particular case. Recommendation 4 Although there is clear evidence that his extended family provided the best possible care for Josh, without knowing anything about her, assumptions were made that the Maternal Grandmother was able and willing to take on the parenting responsibility and was a ‘protective factor’ in Josh’s life. The LSCB, through its training, should stress the need for all professionals to challenge assumptions regarding the protective effect of family members in the absence of an in depth assessment or legal order relating to the situation. CONFIDENTIAL Josh - Serious Case Review 41 Recommendation 5 The LSCB Chair should seek a letter of clarification from South London and Maudsley NHS Foundation Trust explaining how the recording system of incoming and outgoing referrals to and from SLaM has been improved to ensure that in future details of such referrals can be quickly located. Recommendation 6 The LSCB should monitor the development and introduction by SLaM of their proposed leaflet designed to help clinical staff clearly explain to service users the various home treatment possibilities available. 8. Recommendations for individual agencies The preparation of individual agency recommendations is not the responsibility of the Independent Overview Report Author but they are contained in the Individual Management Review Reports. The recommendations were drafted by the Author of each report and have been accepted as SMART by the senior officer signing off the Agency Report on behalf of each agency. Bromley Healthcare Recommendation 1 It would be beneficial for safeguarding children training to include more about attachment and parent-infant relationships. Action: To highlight this to trainers within Bromley Healthcare for immediate inclusion. British Transport Police Recommendation 1 Officers from South Yorkshire and from the Metropolitan Police should have created referrals in relation to contact with a vulnerable child. PPU managers in BOTH Forces to be advised of the circumstances of the deaths and cascade learning across Force areas. Croydon Health Services Recommendation 1 CONFIDENTIAL Josh - Serious Case Review 42 For Community Midwives who visit women who have delivered at a hospital other than Croydon University Hospital to make a copy of the record of care they have delivered to the baby and mother before sending the records back to the hospital where antenatal care and delivery was provided. This will allow a robust trail of documentation to be held in archive of the intervention that took place between the Community Midwife employed by Croydon University Hospital and the baby and mother. Recommendation 2 The use of prompts (to remind staff treating adults who may be parents or carers, to consider parenting capacity in relation to reason for attendance and identified vulnerability) to be embedded into practice within the adult emergency department. Recommendation 3 CUS to review the Family Health Needs Assessment documentation in relation to recording evidence of mental health assessment. Recommendation 4 To ensure that where two or more services are responsible for the overall needs of a parent or care, there is a robust communication between all parties to ensure that the risks that this parent or carer may pose to a child have been considered. There needs to be a greater understanding of the governance structures in place between Croydon Health Services NHS Trust and South London and Maudsley NHS Trust. This is particularly in relation to the Psychiatric Liaison Nurse Team based IN ED at Croydon University Hospital. Recommendation 5 The CUS team needs to improve links with GP’s to raise awareness of the need to share information in particular when an adult who is a parent or carer is receiving treatment and support for any health issue that may impact on their parenting capacity. Children’s Social Care Recommendation 1 That Children’s Social Care reviews the ICS to ensure that no referral can be filed without being reviewed and signed off by the Duty Manager. This should be undertaken by the ICS Manager (to be completed by September 2013) The outcome: to ensure that no CONFIDENTIAL Josh - Serious Case Review 43 referral is missed, which requires follow up action , where there are child protection concerns. Recommendation 2 That Children’s Social Care considers undertaking an audit of referrals received by the Duty Team to ascertain that no referral has been missed where there are potential child protection concerns. To be commissioned by the Head of Safeguarding and Quality Assurance (to be completed by December 2013). The outcome: to offer reassurance that referrals are being appropriately assessed Croydon CCG - Independent Contracted Services Recommendation 1 It is vital to ensure that the lessons learnt from this review are disseminated to all GPs and relevant practice staff in order to provide the opportunity to learn from the findings of the review and develop their confidence and competence in managing such cases. Recommendation 2 Consideration must be given as to how GPs are able to access advice, safeguarding supervision and case reflection in order to provide support and guidance at an early stage in their work with vulnerable families. A suitable model must be identified and embedded in practice with time made available for reflection, comprehension and discussion. Recommendation 3 All GPs should have up-to-date information on the location and contact details of Health Visitor’s to ensure appropriate and timely communication regarding clients with safeguarding concerns. Consideration must be given as to how relationships between community practitioners can be enhanced in order to improve relationships and multi-agency working. Recommendation 4 The concept of ‘Think family’ and the need to consider the impact of historical issues on parenting capacity and current risk must be included in safeguarded children training. This will need to be completed in partnership with NHS England who have responsibility for the co-ordination and funding of safeguarding training for GPs. Recommendation 5 CONFIDENTIAL Josh - Serious Case Review 44 There needs to be thoroughness in assessment, in order to assist practitioners in missing potential vulnerabilities and risk factors. Recommendation 6 GPs should consider inviting Health Visitors to their practice meetings in order understand assess and analyse risk factors in vulnerable children and their parents carers Recommendation 7 Staff involved in this review must be debriefed on its findings and supported through the process of learning. London Ambulance Service The Trust is of the view that the attending ambulance staff should have submitted a safeguarding referral to the local social services department following the 999 calls on 17 January and 22 March 2013.On 22 March 2013, a referral to local social services would have been the normal course of action following a sudden and unexpected child death. This was not done on this occasion as the crew on scene had no details about the child and mother (no address, names, DOB etc). However, we acknowledge that the reasons for not completing a referral should have been documented on the patient report form. Staff have been provided with safeguarding supervision by the local management team regarding the non completion of the referrals and the importance of documenting that safeguarding concerns have been considered in all cases involving children. The Head of Safeguarding Children is currently rewriting the SUDICA Guidance and this will be circulated to all staff before the end of July 2013. Rotherham, Doncaster & South HumberNHS Foundation Trust Recommendation 1 A Standard Operating Procedure (SOP) to be developed within the Crisis Team to direct staff in cases of out-of-area referrals to verify that the referral has been received. Recommendation 2 An audit of the usage of the above Standard Operating Procedure (SOP) to be undertaken. Rotherham NHS Foundation Trust In recommending improvements in the area, there requires an increased awareness and understanding of how acute illness will CONFIDENTIAL Josh - Serious Case Review 45 affect parental capacity, and to ensure a child in the family is safe during this period. The Safeguarding Team at Rotherham Hospital will plan with the Departmental Manager to offer a group supervision session around the case. This session to give staff the opportunity to add to a pathway of what to do/approach if an adult is admitted with a condition which may affect parenting capacity. This pathway to be in line with Rotherham Safeguarding Procedures and The Rotherham NHS Foundation Trust Safeguarding Children Policy. Care Plans in acute areas to include information regarding a child within the family and other significant family members. Also, if there are any other agencies working with the family who will be need to be contacted. The Rotherham Foundation Trust has a Discharge Planning Protocol in place. This also includes adult areas where a situation may affect parenting capacity. This is due for renewal September 2013. The adult patient and parent will be renewed to add clarity to the process, including when the family originate in another area. SLAM Recommendation 1 It is recommended that a more robust administrative systems to be put in place within the Community Mental Health Team to enable the recording of case allocation and appointments not attended. This is due to evidence of sporadic poor recording of missed appointments and some key correspondence. Recommendation 2 Staffing within the Community Mental Health Team also needs review due to the number of clients held within the outpatient clinic. What is of note is that although Claire had not been allocated a care co-ordinator she was seen and assessed when she presented at the team base. It is evident that the team included the family in the assessment but there were missed opportunities to fully and meaningfully assess the family as a protective factor. Recommendation 3 Record keeping across the teams needs review as IAPT notes and information were not routinely recorded within the central electronic notes system which makes it difficult for teams within the Trust to have a clear picture of what each other is doing and how a service CONFIDENTIAL Josh - Serious Case Review 46 users presentation to one team might impact on the assessment of another. Recommendation 4 IAPT should review their process of closing cases when there is no response to a single opt-in letter as this may inadvertently disadvantage vulnerable service users and lead to missed opportunities to support and engage those in need of the service. Recommendation 5 Analysis of risk to children should be comprehensive and explicit in order to fully account for risks but also to ensure there is accountability and clarity in decision making processes. There is clear evidence that the team junior doctor made a good assessment of the welfare of Josh. However a key opportunity was missed as the doctor did not follow up the outcome of the referral. There is also evidence of some confusion regarding the terminology of the referral. Recommendation 6 Trust services need to improve the focus on Think Family within assessments and risk assessments. This is particularly relevant when assessing the protective function of families. These assessments need to be explicitly recorded and include a clear rationale of decisions. These assessments whilst including families, need to include individual assessments to inform practice. Within the Think Family agenda practitioners should also be mindful of partner agencies with whom information could be shared for example in this case the health visitor. Recommendation 7 The Trust system of monitoring referrals to Children’s Social Care needs to be reviewed within the Community Mental Health team to ensure it is consistently effective. A key opportunity was missed as the team junior doctor did not follow up the outcome of the referral and the referral monitoring system which each team is expected to have implemented and be monitoring should safeguard against this happening again. At the time of this incident, this referral monitoring system was in its early stages however the team should take action to reassure the Trust that this system has been implemented and is consistently monitored by the team South London Healthcare Trust CONFIDENTIAL Josh - Serious Case Review 47 Recommendation 1 Safeguarding training at all Levels to continue to embed learning from SILP. Recommendation 2 Assessment of Vulnerability Checklist in ED will highlight impact of parenting capacity and actions taken. Recommendation 3 Improve information sharing with Croydon Children’s Health Services. CONFIDENTIAL Josh - Serious Case Review 48 Appendix A Terms of Reference CROYDON SAFEGUARDING CHILDREN BOARD SIGNIFICANT INCIDENT LEARNING PROCESS SUBJECT : JOSH BORN : 16.03.10 SCOPE Only the subject child Time period : Early June 2012 (date of first presentation to GP with anxiety related issues) To 22 March 2013 (date of incident) Agencies are asked to provide relevant information relating Claire’s pregnancy and antenatal period and to the 3 head injuries sustained by Josh even where these fall outside the scoping period. FRAMEWORK Serious Case Reviews and other case reviews should be conducted in a way in which : Recognises the complex circumstances in which professionals work together to safeguard children; Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; CONFIDENTIAL Josh - Serious Case Review 49 Is transparent about the way data is collected and analysed; and Makes use of relevant research and case evidence to inform the findings (Working Together para 10, March 2013) AGENCY REPORTS TO BE COMMISSIONED 1. British Transport Police (incorporating analysis of response of metropolitan police) 2. Ambulance 3. SLAM Psychiatrist 4. Private psychiatrist 5. CBT Practitioner 6. Princess Royal Hospital 7. Croydon University Hospital 8. Rotherham Hospital 9. Childcare 10. Children’s Social Care TERMS OF REFERENCE Generic Terms of Reference None Agency Specific Terms of Reference 4. What was known and identified by professionals about Claire’s and Mr T’s parenting capacities and possible risks to Josh? 5. Did assessment and care plans take account of the whole family and potential risks to Josh and how was information shared with relevant agencies? 6. What was the outcome of the referral to Children’s Social Care and the rationale behind the decision making process? CONFIDENTIAL Josh - Serious Case Review 50 Appendix B Written Contribution from Maternal Grandmother (Anonymised and attachments not included due to personal information therein) SERIOUS CASE REVIEW: MY DAUGHTER & MY GRANDSON From May 2012 to September 2012 my Daughter started having panic attacks and became increasingly anxious, my Daughter was prescribed medication, the medication started to have a detrimental effect on her physical wellbeing, my Daughter on occasions had suicidal thoughts and at times looked in a trance like state palpipations etc. I took her to see a psychiatrist because by now I was extremely concerned about her wellbeing On the 14th December whist visiting friends in Rotherham my Daughter made a serious attempt on her own life, she was taken to intensive care where she was cared for by a mental health professional see attachment (1).On our return we visited our GP on the 17th who made us an appointment at the Community Mental Health Team my GP believed we would be seeing a psychiatrist we were seen by a CPN nurse and explained that the mental health professional recommended home care for my Daughter this would have been highlighted on the letter he had faxed to Croydon, CPN nurse response was to tell us that home care was unavailable at the Community Mental Health Team. my Daughter was prescribed further medication which included Olanzipine. Following a visit to my Daughters GP she stopped my Daughter using this medication because she had not been advised that my Daughter had been prescribed it and why. Prior to the 14th December and my Daughter’s attempt on her life, my Daughter was on medication and was receiving CBT which I funded myself I took this course of action as it was explained to me the NHS list was long and that my Daughter required prompt treatment. By now I was becoming very concerned about My Daughter’s state of mind and behaviour even going to the extent of holding a knife to her throat on occasions and we always had to be vigilant when my Daughter was at home to ensure she didn’t leave the house without our knowledge because of the constant threats she made against herself. CONFIDENTIAL Josh - Serious Case Review 51 At our first meeting with SLAM I raised the subject of lack of home care and was told by a Doctor who was present that home care was indeed available to my Daughter. You can imagine my shock on hearing this because I believed along with our GP this could have solved many of my Daughters problems as it was because of the CPN nurse’s lack of knowledge my Daughter was denied this treatment. Whether or not this treatment would have been suitable is not the issue - the issue is why was this nurse so badly informed my experience is that my Daughter had absolutely no continuity of care and met no one she had confidence in other than the mental health professional There appeared to be no care plan for my Daughter and a complete lack of any professional management I would like to note my Daughter had joined the waiting list at number 86 on our return from Rotherham and following intervention and a member of staff of SLAM my Daughter was told following a telephone call she was near to the top of the list. Some days later a letter arrived saying they had not heard from her she had been taken off the list, a further phone call reinstated her to number 49. During our visit on the 17 December my Daughter was prescribed medication and to carry on waiting for CBT. I would like to make it clear that in no way did I believe private CBT would be superior to NHS CBT I was frantic to get treatment for my daughter as I did not want another attempt on her life. I would like to say there was never any care plan discussed with my Daughter and myself for the best way forward to treat My Daughter, I would describe the care my Daughter received in this place as sticking plaster treatment and I would like an answer to the question that when a person accepts private treatment are they regarded by the NHS as a patient who’s treatment is finished. The loss of my Daughter and my Grandson cannot be put into words and my belief is a result of a department lacking any proper management, lacking direction, disinterested and ill-informed staff whose lack of training denied my daughter home care the very treatment that may have been a benefit to her. CBT Firstly I was directed to a CBT register where I had the task of selecting a therapist, how was I supposed to make an informed choice when I had no knowledge of CBT. I have no knowledge of regulations or qualifications? Having studied CBT registration documents relating to the NHS I can see it is a rigorous screening programme to decide on suitability there are also sections that relate to childcare & child safety I have requested my Daughter’s records from my Daughters CBT therapist CONFIDENTIAL Josh - Serious Case Review 52 to see if the same type of process was followed with the care she provided. If so is it possible there may have been some early warning signs to my Grandsons safety and my Daughters suitability for CBT. I enclose samples of various NHS forms that would give a therapist a lot of information when completed see paragraph below Please see attachment (3) private CBT registration form From what little I have learnt from CBT on the NHS I do believe that the level of care and expertise is somewhat greater than when one has to seek private therapy see copied samples of registration forms Please see page 4 attachment (2) most important bold type We are not a crisis service we are not able to meet the needs of people who are actively suicidal (yet 24 hrs out of intensive care my Daughter was still being recommended for this type of treatment) my Daughter was originally offered ten sessions she did not take this up as she felt it was not enough to treat her condition she should have been informed at this point that she could self-refer and have more treatments this would have given my Daughter more confidence because she would have been aware that she could have had more sessions if the treatment was benefiting her. See attachment (4) following the call my Daughter received I had a conversation with someone at Purley but I was not made aware that if my Daughter felt she required more sessions at the end of the course she could self-refer. Enclosure if this is accurate about my Daughters state of mind would CBT have been suitable treatment I am asking this question for my own piece of mind whatever the answer may be. Care for My Grandson With regard to my Grandson I had no inkling of any danger to My Grandson because my Daughter was always a loving mum and at no time did she did she appear any sort of threat to her son if anything she always said she lived for my Grandson. When my Daughter was at her worst and couldn’t cope we took over my Daughter was never left alone with my Grandson, my Grandsons life did not change when my Daughter wasn’t well my Grandson always gave his mum a kiss in the morning before he went to his child-minder and before he went to bed at night, he saw his mum on a daily basis even though my Daughter was unwell There was no contact with any children’s services, I assume it was accepted that my Grandson was well cared for, but how did they know they never saw him at home with his mother, considering that my Daughter had a mental illness and took my Grandsons life should the service be more proactive better still his mum should have had her treatment she had a little boy to look after. CONFIDENTIAL Josh - Serious Case Review 53 I would like the enquiry to look into how much information was shared among agency’s regarding my Grandsons safety and wellbeing, were the child care agency’s aware of my Daughters illness and an attempt on her life Why so little involvement by childcare for a child with a suicidal mum Protection of children act requires agency’s to share information amongst agency’s what evidence is there of any communication between SLAM and the relevant childcare departments. Why was there no contact from childcare to my Daughter and myself. If there is statutory requirement for health care and childcare agency’s to communicate for protection of children, who decided in this case that intervention by child care was not needed. Reference the LSCB Chair’s letter 22.7.13 it is really not satisfactory as it doesn’t answer the issues I raised in my email it took a further two weeks for him to reply after prompting, we fully understood the protocol of this meeting and excepted that the original letter gave no hint of the fact that I would be unable to bring someone of my choice hence a considerable amount of wasted time however LSCB Business Manager’s behaviour given my circumstances was inexcusable. Further to this I am still waiting for a reply to the two emails I sent her regarding this matter, she did say this was the first case of this kind. Correspondence We are still searching for the letter following our visit on the 17 December from Community Mental Health Team, to the GP so far this letter has not come to light and we cannot locate it, this would have been a most important letter because it was the first visit to Community Mental Health Team since my Daughters attempt on her life on 14 December both myself and the doctor have doubts to such a letter was written otherwise why can it not be found I would like to say our wonderful GP had treated both my Daughter and I through the most appalling times of our life has always been available and given us a huge amount of time during our numerous calls and visits. I would also like to mention all the other people working at the practice for their kindness. I would also like to commend the mental health professional for his professional approach and my belief in his diagnosis of my Daughters condition and how ill my Daughter really was, I would also like to draw attention to the lack of respect shown to my Daughter and myself by a member of staff that told my Daughter she was lucky to have a roof over her head, its more due to the fact that I work to pay my mortgage are staff not trained to keep this sort of comment to themselves. CONFIDENTIAL Josh - Serious Case Review 54 With reference to the CBT Therapist I would like to say how professional and dedicated she was with my Daughter’s treatment and to note how helpful and cooperative she has been. Due to the understandably long wait for counseling for myself I found a charitable bereavement counseling service in Bromley there I see a member of staff who previously worked at Bethlem and has been an enormous help to me, she used two words to me, urgent and compassion. Which I have not heard from anyone else. I am making these comments so that future victims of suicide can receive prompt help that is proactive not reactive Our lives are destroyed, I wish no one would ever have to lose a child, that’s why I want to share with you what it is like for us as a family as a mother you give birth to your child look after them bring them up encourage them and then they become ill and are in the hands of someone else and you hope and pray they will help them get better in this case it didn’t happen as a mother the disbelief that this really happened how could this happen? My Daughter would not harm anyone and not my Grandson. The awful yearning of wanting to pull them back and you know you can’t, no more kisses no more hugs every day that constant loss, not being able to see her smile not hearing her laughter no girly chats not seeing my Daughter and Grandson having fun together. My Daughter was always there for us and the spats a mum and daughter have, never to have proud moments a mum has while their children are growing up, never to be a grandmother herself one day I always thought we would grow old together, family get-togethers birthdays and Christmas will never be the same the total sadness and despair I live with every day and will be with us every day gone is our happiness For a sister the companionship always being able to talk to each and having a row that’s family life, the laughter they shared at family get-togethers my daughters are in bits thank goodness my Daughter’s niece and nephew are young people although being very upset are able to get on with their lives a lot better than their mum and aunty no more holidays together my youngest daughter who’s not able to have children not only as she lost a sister, she adored her nephew. Gone is their happiness. Our Grandson, I will never him say nana hear his laughter and see that big mischievous grin. We used to dance to the radio or the TV whenever he heard music he would start dancing, he loved playing in the park he kissed trees and rolled down the hills he loved the garden going on his slide he wasn’t so keen on his swing, playing with his Fireman Sam ball he loved picking the flowers only the heads after he CONFIDENTIAL Josh - Serious Case Review 55 smelt them, he loved playing in his paddling pool no more bathtimes he loved his bubbles and soaking the floor, he loved bedtime stories and we always got a big kiss at bedtime. He loved to sit and watch his favourite TV programmes with you He used to help put a teabag in my cup when I came in from work he thought he was making my tea no more feeling shattered when he wanted you to play with him when you came in from work no days out. No sleepovers at aunty and having treats playing with the dogs, no visits to aunty to see the horses, no more fun with mummy going on holiday and visiting friends. Our happiness gone For my Grandson, he will never go to school, have friends, have birthday parties never have an ice cream, no more holidays the list is endless we will never see him grow up to be a fine young man, his first girlfriend a career getting married and having a family of his own, whilst driving you have to pull over as you are overcome with tears you see an ice cream van with children waiting to buy their ice creams. My Grandson will never do that or pass a playground watching the children having fun, he will never do that its heartbreaking going shopping which you try not to do avoiding all the shops you visited you know you will never be able to buy him clothes or toys having to come out of a supermarket because you get upset seeing the children running around I could go on for us this is never ending Work is our saviour you have to focus unfortunately it’s not 24/7. It is made even more painful by the neglect my Daughter encountered and will always be convinced that the deaths of my Daughter and my Grandson could and should have been PREVENTED. |
NC52234 | Death of a 16-year-old girl in 2018, assumed to be suicide. Child C had experienced adverse childhood experiences, including sexual abuse, and was believed to be at risk of exploitation. History of self-harm and had spoken about ending her life from time-to-time since 8-years-old. Child C was known to the universal services, Police, Children's Social Care, Child and Adolescent Mental Health Service (CAMHS) and local voluntary agencies. In July 2016, she was made subject to a child protection plan under the category of sexual abuse which includes sexual exploitation, until March 2017. In 2018, she stayed in a specialist facility for young people with mental health problems. Diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) at 15-years-old. Ethnicity or nationality not stated. Learning includes: it's essential that practitioners understand parental capacity, strengths and attitudes to increase the effectiveness of interventions and avoid placing additional stress on children and their families; child sexual exploitation (CSE) requires a different focus from other forms of child abuse; adolescents can be exposed to a wider range of risks than younger children and concentrating on a single issue may lead to an over optimistic assessment of risk; assessments should include listening and responding to children's views. Recommendations include: develop a research-based risk management strategy designed to address the specific features of adolescent risk taking and suicidal ideation; promote the concept of contextual safeguarding and ensure that it is adopted by practitioners and managers working within the child protection process.
| Title: Child safeguarding practice review: Child C. LSCB: Cornwall and Isles of Scilly Safeguarding Children Partnership Author: Karen Tudor Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Our Safeguarding Children Partnership for Cornwall and the Isles of Scilly CHILD SAFEGUARDING PRACTICE REVIEW CHILD C Independent Reviewer Karen Tudor October 2019 1 | P a g e Contents INTRODUCTION .............................................................................................................................................................. 3 Summary of events leading to this Practice Review .................................................................................................. 3 Anonymisation ............................................................................................................................................................ 3 Methodology .............................................................................................................................................................. 4 Family Participation in the Review ............................................................................................................................. 5 SUMMARY OF EVENTS .................................................................................................................................................... 5 2015 – Child C is living in Cornwall ............................................................................................................................. 5 2016 - .................................................................................................................................................................... 6 Early Help .................................................................................................................................................................... 6 Referral about Sexual Exploitation ............................................................................................................................. 6 Child Protection Plan .................................................................................................................................................. 7 2017 - ..................................................................................................................................................................... 8 Case Stepped Down to Early Help .............................................................................................................................. 8 Child C is living in County B ......................................................................................................................................... 9 In-Patient Treatment ................................................................................................................................................ 10 2018 - ................................................................................................................................................................. 11 Police Investigate Alleged Assault ............................................................................................................................ 11 Children’s Social Care Assessment ........................................................................................................................... 11 Rape Allegation ......................................................................................................................................................... 11 Child C Returns to Cornwall ...................................................................................................................................... 12 Police Welfare Check ................................................................................................................................................ 12 FINDINGS AND LEARNING ............................................................................................................................................ 13 UNDERSTANDING “PARENTAL CAPACITY” ................................................................................................................... 14 Expectations of Child C’s Parents ............................................................................................................................. 14 Parental Capacity ...................................................................................................................................................... 14 Discharge from in-patient care ................................................................................................................................. 15 CHILD SEXUAL EXPLOITATION AND THE CHILD PROTECTION PROCESS ....................................................................... 16 Frameworks for multi-agency intervention:............................................................................................................. 16 Early Help .................................................................................................................................................................. 16 Child in Need ............................................................................................................................................................ 16 Child Protection Procedures and Managing Risk in Adolescents ............................................................................. 17 2 | P a g e The Focus of the Conference/Assessment ............................................................................................................... 17 Protection and Therapy ............................................................................................................................................ 18 Poly-victimisation ..................................................................................................................................................... 18 The Impact of the CP Process on Child C and her Family ......................................................................................... 19 Step-down to Early Help ........................................................................................................................................... 19 Response to CSE ....................................................................................................................................................... 19 MANAGING TRANSITIONS – SHARING INFORMATION ................................................................................................ 20 Child C moved to County B ....................................................................................................................................... 20 Lost Opportunities for Information Sharing ............................................................................................................. 21 Sharing information when Child C moved back to Cornwall .................................................................................... 22 RESPONDING TO THE “VOICE” OF THE CHILD .............................................................................................................. 23 SUMMARY OF LEARNING ............................................................................................................................................. 24 UNDERSTANDING PARENTAL CAPACITY ................................................................................................................... 24 CHILD SEXUAL EXPLOITATION AND THE CHILD PROTECTION PROCESS ................................................................... 24 MANAGING TRANSITIONS –SHARING INFORMATION ............................................................................................. 25 RESPONDING TO THE “VOICE” OF THE CHILD .......................................................................................................... 26 CONSIDERATIONS FOR THE SAFEGUARDING PARTNERSHIPS ...................................................................................... 26 3 | P a g e INTRODUCTION Summary of events leading to this Practice Review 1. In the autumn of 2018 a sixteen year old girl died; to protect her identity she is known as Child C. 2. During her childhood Child C had experienced sexual abuse, alleged physical abuse, witnessed domestic abuse, the break-up of her parents’ relationship, been the victim of sexual assault and was believed to be at risk of exploitation. Child C had also been warned about her own anti-social behaviour. These events impacted on her relationships, led to her having attachment difficulties, low self-esteem and feelings of despair. 3. Child C had a history of self-harming and, from the age of 8, had spoken from time-to-time about ending her own life. Child C was known to the universal services, Health and Education and to the Police, Children’s Social Care, the Child and Adolescent Mental Health Service (CAMHS) and some local voluntary agencies. In 2018 she spent a few weeks in hospital, in a specialist facility for young people with mental health problems. At the age of 15 she was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD.) 4. Despite her adverse experiences, Child C was an intelligent, engaging child with an exceptional talent for music and singing; she felt things deeply and had a strong sense of justice. During the period of this Review Child C lived at first with her mother, in Cornwall and then moved to be with her father (and older sibling) in County B, where she lived for 15 months. She returned to live with her mother a few weeks before her death. 5. The records indicate that Child C’s parents had troubled childhoods; little is recorded about her father, information about Child C’s mother included a family history of suicide. Child C’s parents separated when she was about 4 years old. 6. At the time of writing the Coroner’s Inquest had yet to take place; prior to her death Child C had made her intentions explicit, it is therefore assumed Child C took her own life. Anonymisation 7. For the purposes of anonymisation the family members are referred to as follows: • Child C – Subject of this Review • Ms CM – Child C’s mother • Mr CF – Child C’s father 4 | P a g e Methodology 8. Following a Rapid Review1 and consultation with the National Panel2, the local Safeguarding Partnership concluded that the case met the criteria for a Local Child Safeguarding Practice Review. An Independent Reviewer was commissioned and a methodology agreed, which is consistent with the principles set out in Working Together 2018. 9. The period under Review is three years from September 2015, just before Child Protection Procedures were initiated, to September 2018 when Child C died. 10. A multi-agency Review Panel3 was established and agreed that the Review should consider the following: • Were there issues within the management of the case by the children’s social care and education services of two local authorities, two police constabularies and several health organisations? • Were there difficulties that arose from Child C moving between different areas in the country? In particular, the review was asked to consider information sharing. • Whether there are any concerns around the response of the services and how information was evaluated and acted upon. • Any vulnerabilities of the young person to sexual abuse and exploitation. • Whether there was an over-reliance on parents managing risk. 11. Chronologies and practice analysis were requested from: • CAMHS, Cornwall and County B including the residential care provider • GPs • Police, Cornwall and County B • Children’s Social Care, Cornwall and County B • Education providers, Cornwall and County B 1 Safeguarding Boards/ Partnerships are required to undertake a Rapid Review into all serious child safeguarding cases within fifteen working days of becoming aware of the incident. The information collated leads to a recommendation about whether the criteria are met for Serious Case Review/Child Safeguarding Practice review. 2 The National Safeguarding Practice Review Panel decides if a Serious Case Review (WT 2015)/Local Child Safeguarding Practice Review (WT2018) is required and informs the local LSCB/Partnership of their decision. 3 See Appendix for list of members. 5 | P a g e 12. Meetings were held in both Local Authority Areas with chronology authors and the practitioners who had worked with the family. The process was overseen by the Review Panel. Family Participation in the Review 13. Child C’s family were invited to participate in this Review. The Reviewer is grateful to Mr CF, Ms CM and Child C’s maternal grandmother who met with the Reviewer and spoke about Child C her character and talents; despite their grief, her family shared their views about the services they received in the hope of raising awareness about the tragedy of teenage suicide. SUMMARY OF EVENTS 14. Child C was born in December 2001 and died in September 2018, aged 16 years and 9 months. 15. Prior to the period of the Review Child C’s mother and her school had expressed concerns about Child C including reference to self-harming and anti-social behaviour. Child C had previously been referred to CAMHS in 2014. 16. During the three year period of this review a number of practitioners from different organisations and disciplines spent hundreds of hours working with Child C and her family; the summary describes the key events in Child C’s life and focuses on opportunities for learning. 2015 – Child C is living in Cornwall 17. In 2015 Child C’s school made a referral to CAMHS who carried out an assessment. Child C was described by CAMHS as “vulnerable” “needing to be in control” “on edge the majority of the time” and unable to control her emotions or behaviour; her mood was described as “dysregulated.” Child C reported that she had stopped self-harming and the risk of harm was assessed by CAMHS as low; they did report their view that Child C was at risk of sexual exploitation based on her previous sexual abuse and some sexualised behaviour. 18. A month after the assessment Child C took an overdose which led to a hospital admission, further assessment from CAMHS led to an offer of family therapy and Child C being offered one-to-one work. 19. In November 2015 referrals were made by the school and by CAMHS for Early Help with a view to enlisting the support of a youth worker to help Child C address her increasing 6 | P a g e social isolation and help her form relationships in the community. Three weeks later Child C was seen by Children’s Social Care as part of an Early Help assessment; the case was closed. There was no further involvement on the basis that a youth worker from the voluntary sector commissioned by the police had already begun to meet with Child C. 20. In December 2015 the school made a second referral for Early Help which led to a Team around the Child meeting in 2016. 2016 - Early Help 21. In January 2016 when Child C was 14, a Team around the Child (TAC) meeting4 was convened and described as “well attended” by CAMHS, the school, police and the commissioned youth worker. The Lead Professional was from Child C’s school.5 Ms CM attended but Child C was not present. Teachers had reported that Child C’s school attendance had dropped to 71% and that she appeared to be disengaging from education. 22. Child C’s “complex needs” were identified and her mood changes and behaviour discussed. The plan arising from the meeting was to continue to provide therapeutic services from CAMHS for Child C and Ms CM. Referral about Sexual Exploitation 23. In February 2016 the police made a referral to Children’s Social Care about possible Child Sexual Exploitation; (CSE) Child C was observed to be very vulnerable and reporting unwanted sexual advances by a 17 year old male. 24. An Achieving Best Evidence6 (ABE) interview took place and a Section 17 Child in Need Social Work assessment was completed. The assessment recognised Child C’s “poor mental health” and “vulnerability to CSE,” Ms CM and her mother (Child C’s 4 Team around the Child meeting, known as a TAC: this is a multi-agency meeting of professionals who are working with a family or may be able to provide a service. The meeting is part of the Early Help approach and its purpose is to devise a plan detailing who will do what and when. It is aimed at those families who would benefit from early help but who do not meet the threshold for intervention from Children’s Social Care. 5 It is the job of the Lead Professional to convene meetings, facilitate planning and make sure notes are taken. 6 ABE, Achieving Best Evidence, is the guidance drawn up for police about the interviewing of children where allegations of abuse are being investigated. The interviews are video recorded and can be used as evidence in criminal and care proceedings. The guidance is intended to ensure that children’s evidence is contemporaneous and interviewers are specially trained in order that children are not influenced by the way questions are asked. 7 | P a g e grandmother) were viewed as “supportive.” The outcome was for help to continue to be provided within the Child in Need Framework.7 25. Coincidentally, at the time of the assessment, Mr CF contacted CAMHS expressing concerns about Ms CM’s parenting. He was advised to seek legal advice and contact Children’s Social Care, although he didn’t progress this further. Mr CF was not included in Children’s Social Care assessment. 26. In March 2016, CAMHS met with Ms CM who discussed some of her family history and reported that a close family friend had recently committed suicide. The chronology author reflected that suicide was “a feature” in Child C’s family history. 27. CAMHS continued to work with Child C and undertook some work with Ms CM. A youth worker from a voluntary agency specialising in sexual exploitation also started to see Child C. 28. In May 2016 Child C was admitted to hospital “hearing voices.” Her school attendance had dropped to 67% and a Section 47 Strategy Discussion8 was held because of further concerns of the risk of sexual exploitation. A Child Protection assessment took place and the possibility of another ABE interview was discussed. Child C was unwilling to engage with the police and reported to CAMHS that she was still having suicidal thoughts “now and again.” 29. The records suggest that during this time Child C was visiting and staying with Mr CF; he was in touch with CAMHS expressing his concern about the pace of safeguarding practice and “wanting to get things moving.” 30. In June 2016 CAMHS were seeing the family every three to four weeks. A professionals’ meeting was held at Child C’s school, the purpose of the meeting was to consider sexual exploitation and the risk to which Child C was exposed. Child Protection Plan 31. In July a further Strategy Meeting was held, and subsequent Section 47 enquiries resulted in a Child Protection Conference taking place. Child C was made subject to a 7 Child in Need, Section 17 of the Children Act 1989 states that it is the general duty of every local authority to safeguard and promote the welfare of children within their area who are in need; and so far as it is consistent with that duty, to promote the upbringing of such children by their families. 8 Where there are child protection concerns (reasonable cause to suspect a child is suffering or likely to suffer significant harm) Section 47 of the Children Act 1989 sets out the responsibility of local authority social care services to make enquiries and decide if any action must be taken. A multi-agency Strategy Discussion is the first step. 8 | P a g e child protection plan. The category of risk was noted as Sexual Abuse which includes sexual exploitation. The Child Protection Plan was in place for nine months, from July 2016 until March 2017. 32. In August 2016 Child C was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). The diagnosis provided an opportunity for the prescription of medication to help Child C with her mood and take advantage of the therapy she was receiving. 33. In September 2016 Child C made further disclosures of sexual assault and reported being threatened with a knife. 34. Child C spent Christmas with Mr CF which she described as a positive experience, and “having fun.” 2017 - 35. At the beginning of the year Child C was described by CAMHS as “settled, brighter and working hard at making changes in her life.” The improvement was considered by the professional team as being partly due to the medication Child C had been prescribed. 36. In February 2017, following difficulties at school, Child C took an overdose of co-codamol and was admitted to hospital. She also reported feeling “pressure from lots of different services.” The overdose was assessed as premeditated with a view to ending life and the risk assessed as “high.” There were a number of professionals involved with the family and one worker spoke about the challenge of managing a “difficult multi-agency team” and the risk of Child C’s voice being lost. 37. In February 2017 when Child C was 15, Children’s Social Care carried out a statutory child protection visit and noted that Child C was not attending school and her “mental health appeared to be deteriorating.” Ms CM contacted Children’s Social Care to say she was struggling and did not feel able to keep Child C safe, CAMHS had difficulty engaging with Child C. Case Stepped Down to Early Help 38. In March 2017 a Review Child Protection Conference was held and the Child Protection Plan was discontinued. The reasons were as follows: • Child C reported that the Child Protection process had increased her stress and isolation; • There was no evidence of the continuation of the risk of sexual exploitation; 9 | P a g e • Child C’s mental health was the primary concern and this was to be supported outside of the Child Protection Process. 39. The Conference recommended that the plan be stepped down to Child in Need status and a date was set for a meeting of the relevant practitioners; however, the record states that following discussion with the Independent Chair, this was not considered necessary as the appropriate services were already in place and could be coordinated through support from Early Help Services. 40. Not all conference participants agreed with the decision to bring the Child Protection Plan to an end but no-one felt strongly enough to escalate their concerns. Early Help intervention was not followed up and there were no further planning or multi-agency meetings. Conference participants did not become aware of this until after Child C had moved to County B. 41. In the summer of 2017 Child C took another overdose, left Cornwall and moved in with her father in County B. The conference stepping-down process and lack of follow-up meant that Child C moved without a plan in place and the case having been closed to Children’s Social Care. Child C is living in County B 42. August 2017, living in County B, Child C had a new CAMHS worker and new assessment and was diagnosed with anxiety and depression. Mr CF had strong feelings that Child C’s ADHD medication was having a negative impact on her and she stopped taking it. 43. In September Child C was described as being Electively Home Educated (EHE) which enabled funding to be secured for her to attend a pre-sixteen course at a local college.9 A month later she reported a sexual assault by a pupil at the same college and stopped attending. 44. The sexual assault was reported by Mr CF to CAMHS who advised him to contact the police. The police investigated and decided there was insufficient evidence to pursue the matter. The police, the college or CAMHS did not consider referring the matter to the 9 Elective home education is a term used to describe a choice by parents to provide education for their children at home or in some other way they choose instead of sending them to school. Individual families do not receive any of the money which is otherwise paid to schools for each registered pupil but in some circumstances funding can be made available to education providers to meet individual need. 10 | P a g e Multi Agency Safeguarding Hub (MASH10) of County B with a view to a Strategy Discussion. 45. In the Autumn of 2017 Child C reported feeling worse and had thoughts of self-harm; reports describe her as “constantly thinking about ending her life” and she asked to be placed somewhere safe. 46. Soon after this, Child C cut herself and was taken to hospital. After liaising with CAMHS, Child C was admitted as a voluntary patient to a hospital which provides acute psychiatric assessment, diagnosis and care for adolescents. In-Patient Treatment 47. In October 2017, for four weeks, Child C was an inpatient on the specialist ward. Almost from the outset, Child C did not want to be there, allegedly rebelling against what she saw as unnecessary restrictions. The staff had difficulties in managing Child C’s behaviour which escalated and included self-harming and tying ligatures, she was also reported to be placing other patients at risk of harm. 48. A series of planning meetings decided that Child C was at less risk in the community than in hospital and she was to be discharged to the care of Mr CF. 49. Although Mr CF agreed Child C couldn’t remain in hospital, he strongly expressed the view that he couldn’t keep her safe or provide the care she needed. The hospital, with CAMHS, made a referral to Children’s Social Care seeking support in the community for Mr CF; Children’s Social Care responded by stating they did not consider there was a role for them and that it was Mr CF’s “responsibility” to care for Child C. 50. Child C was discharged from hospital and returned to her father’s care. A doctor’s report from the hospital stated that “there are no major mental health issues” and no legal grounds (under the Mental Health Act) to keep Child C in hospital. 51. This led to Mr CF’s family withdrawing their support, as their understanding from the hospital was that Child C’s behaviour was not a symptom of mental ill-health but was “attention seeking.” 10 Multi-Agency Safeguarding Hub (MASH): The MASH is the central resource for the county receiving all safeguarding and child protection enquiries. It is staffed with professionals from a range of agencies including police, probation, health, education and social care. These professionals share information to ensure early identification of potential significant harm, and trigger interventions to prevent further harm. 11 | P a g e 52. After Child C’s discharge, County B CAMHS provided prompt and sustained support for the family and the college place was kept open for Child C ready for when she felt able to attend. Towards the end of the year Child C’s mood appeared to have improved although she was also reported to have said that “life is a joke and not worth living.” 2018 - 53. In January 2018 aged 16 years, Child C took another overdose and Mr CF reported being out his depth; Child C had not returned to college (she was still classified as being electively home educated) and Mr CF could not work because he had to watch her all the time; as a result the family were experiencing serious financial problems. Police Investigate Alleged Assault 54. In February 2018 Child C reported her father punched her on the leg and CAMHS made a referral to the MASH. Referral information included some of the background, Child C’s “mental health, vulnerability to CSE and the family’s enormous financial and emotional strain.” 55. Following the referral the police contacted Children’s Social Care with a view to a joint investigation. After repeated attempts without success to get a response, the police made a single-agency visit to Child C and Mr CF; Mr CF was asked to attend the police station to make a statement. As there was no evidence of an assault and Child C withdrew the allegation, the police closed the case. Children’s Social Care Assessment 56. Following up the report of assault, Children’s Social Care made two visits to the family to undertake an assessment. Child C and her father were seen and information was sought from CAMHS. The focus of the assessment was the allegation from Child C that her father had hit her. It was reported in the assessment that Child C was unable to remember the incident. The assessment reports that Child C’s mental health is “stable,” she is engaged with CAMHS and “intends to return to live with her mother.” No role was identified for Children’s Social Care and the case was closed. Rape Allegation 57. In July 2018 Mr CF reported to the police that Child C had disclosed rape by a “much older man” which had occurred in Cornwall, when Child C was on holiday with her mother. The local police investigated the complaint and liaised closely with police in Cornwall, where the reported offence had taken place. 58. Cornwall police undertook a single agency investigation and concluded that Child C, who was over 16, had initially given consent which she then withdrew and due to lack of 12 | P a g e evidence, the case was closed. Child C was referred to an Independent Sexual Violence Adviser (ISVA11) 59. Children’s Social Care in County B (where Child C was still living with her father) were informed of the allegation but, as no “welfare concerns” were identified, concluded there was no role for them. 60. Child C was seen at a local sexual health clinic who offered a vaccination for Hepatitis B and full screening. Child C Returns to Cornwall 61. In August 2018 Child C told CAMHS in County B that she intended to take her own life at her mother’s home in Cornwall and described in detail how she would do this. Child C then went to visit her mother, CAMHS understood this to be for a short holiday. 62. In September 2018, when Child C decided to remain in Cornwall, Mr CF informed his local CAMHS team in County B. The team advised Mr CF to discuss Child C’s comments about ending her life with her mother; they planned to refer Child C back to Cornwall CAMHS but Child C died before this happened. Police Welfare Check 63. On her return to Cornwall Child C was enrolled in college near her mothers’ home. During an introductory visit Child C expressed her anxiety to a friend who was concerned about Child C’s mental state. The conversation was overheard by a member of college staff who called the police. 64. The police then carried out a “welfare check.”12 Child C was seen to be safe and the officer who visited judged Child C to be anxious about starting a new course; they ensured Child C’s mother was with her before they left. The information was passed on to Children’s Social Care who concluded there was no role for them at that point; Child C’s mother was given information about how to seek help through the Early Help Hub. 65. Child C started at college the next day; two days later she told a member of staff about the previous rape allegation expressing her frustration that the police investigation had not led to any arrest and that the alleged offender was still trying to contact her. The 11 ISVAs tailor support to the individual needs of the victim or survivor. They provide accurate and impartial information to victims and survivors of sexual violence and emotional and practical support to meet the needs of the victim or survivor. 12 The police make a visit to see the child to ensure they are not in any immediate danger. Depending on the circumstances, a referral may be made to an appropriate agency. 13 | P a g e staff arranged for Child C to see a police officer who happened to be visiting the college to talk to the students, with a view to seeing if anything further could be done about the investigation. 66. A week later Child C reported unwanted sexual contact with a student from the college and was observed to be withdrawn in class; a staff member offered to talk and asked her what was wrong, Child C was reluctant to say anything but suggested “something had happened” but she didn’t want it “reported.” 67. The following day Child C did not attend college. A staff member telephoned her, spoke to her and Child C said she would probably not attend that day or the following day. Child C was reported to be reluctant to talk any further but agreed to the suggestion of a meeting to consider how best to support her. The staff member asked Child C if she was alone to which she replied she was, but a relative was close by if she needed someone. 68. Later that day Child C took her own life. FINDINGS AND LEARNING 69. Within the three year period of this review (and in the years before) hundreds of hours of professional time were spent with Child C and her family to explore the impact of Child C’s experiences and to plan interventions which could help address her distress and emotional turmoil. 70. Despite some periods of stability and relative well-being, the improvements were not sustained; Child C described herself feeling “trapped and exhausted” and expressed her frustration at the “lack of change.” 71. The learning comes from examination of the multi-agency work done with Child C and her family, identified learning themes are: • Understanding Parental Capacity • Child Sexual Exploitation and the Child Protection Process • Managing Transitions – Sharing Information • Responding to the “voice” of the Child 14 | P a g e UNDERSTANDING “PARENTAL CAPACITY” Expectations of Child C’s Parents 72. During the period under review, two local authority areas worked with Child C and her family, Cornwall and County B. 73. In Cornwall practitioners worked well together and multi-agency meetings were held within the Early Help, Child in Need and Child Protection frameworks. Plans were put in place, which included work with Child C and Ms CM and there was an explicit expectation that Ms CM would care for and protect Child C. 74. Ms CM was expected to play a part in the safety-planning; she attended most of the meetings, at times restricted Child C’s social activities and managed her challenging and self-harming behaviour. Towards the end of Child C’s life, when she returned to Cornwall, Ms CM was made aware of Child C’s suicidal thinking and expected to keep her safe although, at that time, without any professional support or guidance. 75. In County B Mr CF faced similar challenges, yet without the support of a multi-agency team. (see paragraph Transition Arrangements) The “safety plan” developed by CAMHS relied on Mr CF and included reducing the risk of harm at home, for example moving furniture to block off access to a first floor balcony, constantly watching Child C and reducing her social activities. 76. The willingness of her parents to do everything they could for Child C was never in question and it is likely that this distracted practitioners from any detailed exploration of parental strengths or needs. At all times, Child C was the focus of attention, she was consistently described by those who knew her as a very engaging young person, she was bright and bold and made a big impact on people she met. Parental Capacity 77. For both parents their own childhood experiences, their knowledge, skills, attitudes and the factors which influenced their parenting of Child C were not fully known or incorporated into the interventions offered to the family.. Assumptions were made based on their education and own professional backgrounds. 78. The lack of understanding meant that the different ways each parent responded to Child C sometimes led to disagreement with the professionals with a risk of conflict or disengaging with services. 15 | P a g e 79. Mr CF had clear views about prescription drugs and having shared this with Child C, she stopped taking her prescribed ADHD medication; this was in contrast to the view of the CAMHS team in Cornwall who had observed a marked improvement in Child C’s mood when she was taking the medication. Mr CF considered vaccinations unnecessary and Child C turned down the offer of a hepatitis B vaccination against the advice of the sexual health practitioners. 80. The lack of understanding of the parents’ view is particularly evident in County B when Child C was discharged from the inpatient care on the grounds she would be safer in the community. Although Mr CF agreed with the discharge and a number of meetings were held to try and plan the move, he made it very clear that he could not keep Child C safe without help. 81. Although CAMHS were pro-active and referred the family to Children’s Social Care for additional support, Children’s Social Care’s response was that there was no role for them. Discharge from in-patient care 82. The discharge of Child C had a significant impact on Mr CF who was already struggling and had to give up work in order to care for her. The hospital discharge summary included the comment that Child C had no “major mental health issues.” Whilst this may be meaningful to the practitioners (who for example may be thinking of conditions such as psychosis or bi-polar disorder), Mr CF’s family interpreted it as meaning there was no medical reason for Child C’s behaviour, that it was her fault, and they withdrew their practical and emotional support. A more detailed explanation would have avoided the misunderstanding. This highlights the need to be thoughtful about language and to understand the impact, not only of decisions but of the way they are communicated to families. 83. Reflection on the discharge process has identified a missed opportunity to bring this case to the Multi-Agency Resources Panel (MARP) in County B which exists to consider multi-agency planning and resources for young people discharged from adolescent mental health hospital provision. The Panel is currently considering introducing a standing item on their agenda to ensure no young people are overlooked. 16 | P a g e CHILD SEXUAL EXPLOITATION AND THE CHILD PROTECTION PROCESS Frameworks for multi-agency intervention: • Early Help January 2016 – April 2016 • Child in Need April 2016 – July 2016 • Child Protection July 2016 – May 2017 Early Help 84. In 2015 Child C’s school and CAMHS made a referral to Children’s Social Care requesting a meeting within the Early Help framework. Children’s Social Care looked at the case and declined the request on the basis that the appropriate services for Child C, (CAMHS and a commissioned Youth Worker) were already in place. 85. In early 2016 a second referral led to a TAC meeting within the Early Help framework. 86. Although the Early Help process brought practitioners together, the complexity of Child’s C’s presentation meant it had little impact; therapeutic work with Child C was ongoing, her school attendance was declining, she took an overdose and was talking about her thoughts of self-harming. The police were investigating possible violence at school and there were concerns about the risk of sexual exploitation. Child in Need 87. In February 2016 the concerns about the risk of sexual exploitation led to a Section 47 Strategy Discussion; the outcome of the discussion was that an ABE interview would be arranged with Child C and a Section 17 Child in Need assessment carried out by Children’s Social Care. 88. The assessment records that Child C and her mother were seen three times and information was sought from Child C’s school, the police and a youth worker. The assessment is child focussed and concluded that there were concerns about Child C’s vulnerability to CSE. Her maternal family were viewed as “supportive” and services were to be offered within the Child in Need framework. Mr CF was not involved in the assessment and there is no evidence his views were sought. 89. In the spring of 2016 Child C took another overdose and spent a night in hospital describing an experience of “hearing voices.” In July 2016 the risk of CSE to Child C was reported as increasing and a further assessment took place within the Child Protection Framework. Mr CF participated in this assessment. A Child Protection Conference was convened which led to a Child Protection Plan. 17 | P a g e Child Protection Procedures and Managing Risk in Adolescents 90. In 2016/17, for nine months, Child C was the subject of a Child Protection Plan. The category of risk identified was Child Sexual Abuse. (there is no category specifically for CSE) 91. The Child Protection system generally works well for younger children for whom risk is located within the family system and a robust parenting assessment and plan of intervention with measurable outcomes is effective. However, the process is not designed with adolescents in mind. 92. At this time, Child C was 15½ years old and the assessed risks came from environmental or external sources (non-family) which does not sit well within a system which was devised in response to risk, generally from parents or carers, to babies and young children.13 The Focus of the Conference/Assessment 93. The focus of the Child Protection (CP) Plan was the risk of CSE, the actual and ongoing risk of self-harm and suicidal ideation was left to be managed outside of the CP process. 94. There is no evidence that the CP process considered the context of adolescent risk taking, (Contextual Safeguarding14) impulsive behaviour or that research about effective strategies was discussed. There is no evidence that the emerging diagnosis of ADHD and Child C’s emotional and mental health difficulties and the implications of this to the likely success of the plan were considered. 95. The plan focussed on Ms CM providing “stronger boundaries” for Child C and for services to provide the help and support she needed to achieve this. Although there is some comment about Ms CM that she “may not have sufficient parenting skills to keep Child C safe,” there was no further evidence of assessment or exploration of this and the complexity of parenting an adolescent presenting with challenging behaviours. 96. The record indicates that, despite her reservations, Ms CM accepted the Child Protection Plan as “the only way forward”. 13 Bilston 2006, cited in That Difficult Age: Developing a more effective response to risks in adolescence, Research in Practice, 2014 14 See for example Contextual safeguarding, An Overview of the operational, strategic and conceptual framework, Carlene Frimin, University of Bedfordshire, November 2017 14 That Difficult Age: Developing a more effective response to risks in adolescence, ibid 18 | P a g e Protection and Therapy 97. The notes from the initial conference draw attention to the different perspectives of Child C’s family and some of the practitioners; reports indicate there was professional difference about the best approach to help and protect Child C. Some of the practitioners also commented on the number of staff who were working with Child C (seven at one time) which compounded the potential for disagreements in responsibility and approach. 98. Ms CM, and reportedly Child C, warmed towards the therapeutic approaches and found the protective measures heavy handed and restrictive which meant that the family, in effect, disengaged with the CP process. The lack of understanding of the family’s view and where it came from, created potential for conflict between the family and practitioners; at times Child C’s parents say they felt powerless, unsupported, misunderstood, marginalised and angry. 99. Research in Practice in their paper “That Difficult Age: Developing a More Effective Response to Risks in Adolescence,15 discuss alternative approaches to managing risk and highlight that adolescent development impacts on thinking and behaviour. The research points out that experimentation and impulsive behaviour are part of the normal teenage experience and states that “while demands on services are growing, resources are subject to increasing pressures”: the paper states: 100. “It is now widely acknowledged that, as a nation, we do not adequately understand, identify, prevent or effectively reduce the significant risks that some adolescents experience ...this is despite some excellent practice at local level.” Poly-victimisation 101. The paper also highlights that: “Adolescents are exposed to a wider range of risks than younger children. At age 14 they are most at risk of entering the realm of ‘poly-victimisation’ – i.e. being the victim of many different types of maltreatment. Ten per cent of 11 to 17-year-olds in the UK have experienced 12 or more forms of maltreatment during their lifetime.”15 102. The (local) South West Child Protection Procedures16 state that ... 15 That Difficult Age: Developing a more effective response to risks in adolescence, ibid 16Cornwall & Isles of Scilly Safeguarding Children Partnership Procedures Manual https://www.proceduresonline.com/swcpp/cornwall_scilly/p_respond_abuse_neg.html#def_ch_abuse 19 | P a g e “If a decision is taken that the child has suffered, or is likely to suffer Significant Harm and hence in need of a Child Protection Plan, the Chair should determine which category of abuse or neglect the child has suffered or is likely to suffer. The category used (that is physical, emotional, sexual abuse or neglect) will indicate to those consulting the child's social care record the primary presenting concerns at the time the child became the subject of a Child Protection Plan.” 103. It is understandable that case auditing, information collection, statutory reporting and management systems require specific data. However, when working with a child with complex multi-dimensional needs who does not fit neatly into specific categories, this approach risks minimising the complexity and creating a false picture. The model used in Cornwall to reach a decision about whether a Plan is necessary involves participants using Signs of Safety to rate their perception of risk using a score from 1-10, however this still does not reflect the complexity of risks which may be involved for adolescents. The Impact of the CP Process on Child C and her Family 104. As part of this Review Ms CM shared her strong views about the negative impact of the Child Protection process on both her and Child C. Ms CM described feeling blamed, persecuted and unsupported, Mr CF described feeling that he was marginalised. Step-down to Early Help 105. In July 2017 the Conference decided to discontinue the Child Protection Plan, the risk of CSE was said to have been reduced and Child C was reported to be very unhappy at the restrictions imposed on her by the plan. There was an acknowledgment that Child C had ongoing mental health problems, the Conference considered this could be managed outside of the Child Protection framework in line with Child C and her mother’s wishes. 106. The decision of the Conference was that the plan would be stepped down to Child in Need and a meeting was agreed. However, outside the Conference and after discussion with the Independent Chair, this was felt to be unnecessary and because services were already in place the decision was that intervention could be managed within the Early Help framework. Early Help planning never progressed and multi-agency work came to an abrupt end. Response to CSE 107. This Review indicates that it took over six months before agencies within Cornwall viewed information and referrals in the context of risk of CSE. Given what was known about Child C’s history and the emerging concerns, the first Strategy Discussion could have resulted in the implementation of the Child Protection Procedures. 20 | P a g e 108. The initial response to allegations of CSE was inadequate; at the time awareness and understanding of CSE was in its infancy, there has since been a drive within the Partnership to improve multi-agency understanding and response to CSE. 109. The South West Child Protection procedures state that... “When a child protection plan is discontinued, the social worker must discuss with the parents and child/ren what services might be needed and required, based on the re-assessment of the needs of the child and family. A Child in Need Plan or an Early Help Assessment should be developed for any continuing support.” 110. It is not usual practice for involvement with a family to step-down from Child Protection to Early Help without a plan and a systemic failure to progress as agreed meant that multi-agency work ceased altogether. It appears that Child C moved away before the implications of this became clear to those working with Child C and no-one questioned the lack of action. Practitioner discussion during the Review highlighted the risk of removing support too quickly when intervention is seen to be working. MANAGING TRANSITIONS – SHARING INFORMATION 111. Three months after the Child Protection Plan ended, Child C took another overdose, Ms CM described herself as being “completely exhausted” and Child C moved to County B to live with her father. Child C moved to County B 112. By the time Child C moved to County B Children’s Services had closed the case; this meant that there was no system in place for sharing information as there would have been if they were still involved. 113. Child C’s move took place during the summer holidays and although she hadn’t been attending school, information was shared with the college in County B at the start of the new term. CAMHS contacted their counterparts and information was passed on to the new team who carried out an assessment. 114. This meant that within a few weeks Child C and her family went from being supported by a large and active multi-agency team, albeit one Child C and her mother had found to be oppressive, and overwhelming, to help from a single agency (CAMHS) with no ongoing multi-agency risk assessment or plan. 21 | P a g e 115. CAMHS in County B assessed Child C as “depressed and anxious” this was a slightly different description from Cornwall and did not include the ADHD diagnosis. Mr CF appreciated this diagnosis, partly because he felt strongly that Child C should not be taking the medication prescribed to help her emotional regulation after the ADHD diagnosis. Lost Opportunities for Information Sharing 116. Having had what was described by practitioners as a relatively stable period in Cornwall, within a few weeks of moving to County B, Child C was described as struggling emotionally and had reported another sexual assault. 117. At this point an opportunity to share information was lost because although CAMHS, the college and the police knew about the allegation of the sexual assault (Child C was 15½ years old) no-one requested a Section 47 Strategy Discussion which would have led to sharing of information including the Child Protection history. On reflection, practitioners are unclear about why the reported assault was not referred. 118. The police in County B investigated the assault allegation as a single agency without a strategy discussion and decided there was insufficient evidence to proceed. 119. A few weeks after this incident Child C again had thoughts of self-harm and asked to be placed somewhere safe. She cut herself and was admitted to hospital, from where arrangements were made for transfer to a psychiatric facility. Child C remained in hospital for about 4 weeks. 120. In March 2018 Child C reported her father had “punched her leg and shouted in her ear.” CAMHS made a referral to Children’s Social Care which, after a delay of two months, led to an assessment. 121. The Assessment was based on one visit, the report is superficial and no further information was requested from the local CAMHS team, Cornwall Children’s Social Care or the hospital. 122. The assessment recognised that Child C was “suffering with her mental health” makes a passing reference to “incidents of self-harm” and that Child C was not receiving education and was feeling isolated. The report makes no reference to Child C’s recent hospital admission, suicide attempts or history of being at risk of CSE. 22 | P a g e 123. During the assessment Child C described her relationship with her mother as “unsupportive” with “a lack of rules and boundaries” and which had “broken down prior to her move to County B”, yet Child C’s plan to return to Cornwall was not questioned. 124. The assessment appears to have focussed on the single incident of the alleged physical abuse which was quickly discounted. Child C was spoken to alone and reportedly said she “may have imagined it.” 125. In May 2018 the assessment was signed off by a manager and closed on the basis that CAMHS were involved with the family, there was no role for Children’s Social Care and Child C was intending to move back to Cornwall in the near future. 126. In July 2018 Child C reported that she had been raped and sexually abused by an older man whilst on holiday in Cornwall. The police in County B communicated well with the police in Cornwall who investigated the allegation as a single agency without a strategy discussion, but lack of evidence meant they were unable to progress the matter. 127. County B police also passed the information to County B Children’ Social Care however they had already completed their assessment and the case was closed. 128. Two months later Child C moved back to Cornwall. Sharing information when Child C moved back to Cornwall 129. CAMHS in County B were aware that Child C had expressed suicidal thoughts in the days leading up to her move. Although the move was intended, it happened more quickly than expected when Child C decided to stay on after what was planned to be a short holiday. 130. County B CAMHS advised Mr CF to share Child C’s comments about her suicidal intentions with Ms CM; they had intended to share the information with Cornwall CAMHS but were not aware the move was permanent until about a week after it had taken place, the information was not shared before Child C took her own life. 131. CAMHS practitioners advise that referrals containing suicidal ideation are common and therefore do not necessarily prompt an immediate response. 23 | P a g e RESPONDING TO THE “VOICE” OF THE CHILD 132. In the published Serious Case Review “CH” (Haringey 2015) 17 the author promotes the concept of “Thinking Differently about Capturing Children's Experiences” describing the importance of understanding and responding to the child's perspective. 133. Child C had no difficulty in expressing herself; she frequently said she felt suicidal, distressed and frustrated at the lack of change; she said she felt “invisible until she made a mistake”, and felt “trapped, exhausted and unsafe.” When Child C was discharged from the in-patient unit in County B, she was reported to express the view she was “beyond help” and could not be “healed.” Towards the end of her life she clearly put into words her intention to end her life, how, where and when she would do this. 134. The challenge of thinking beyond “hearing the voice of the child” and how to respond to the “voice” is described in detail in the work of Research in Practice “That Difficult Age: Developing a more effective response to risks in adolescence.”18 The paper explains that within safeguarding practice, responses to adolescents are constrained by systems which apply... “traditional definitions of risk and approaches to protection that do not necessarily fit with young people’s lived experience or research.” 135. Although most of the practitioners “heard” Child C and there is no doubt that some were able to build a trusting relationship with her, continuity was difficult to achieve because of: • the number of practitioners working with the family • the marked difference in their approaches (during the CP process) • significant disruption in relationships when she left Cornwall. • staff changes (particularly significant just as Child C was establishing a relationship with County B CAMHS) 136. The response to Child C was informed by established risk assessment models and the need for practitioners to adhere to child protection policy and procedure. Harder to recognise and to respond to effectively was the repeating pattern of Child C’s behaviour. Reviewing the chronology of events, the pattern becomes evident in the number of 17 Child ‘CH’ Serious Case Review, Haringey Safeguarding Children Board, 2015,Alyson Leslie - Independent Overview Author 18 Research in Practice “That Difficult Age: Developing a more effective response to risks in adolescence. Ibid 24 | P a g e times Child C self-harmed, reported a sexual assault, would not comply with a police investigation and then walked away from school or college. 137. Thinking more creatively and responding not just to events and allegations, but understanding patterns is very challenging for practitioners, particularly those working within prescribed child protection processes. SUMMARY OF LEARNING 138. Throughout the process of this Review individual agencies in Cornwall and County B have reflected on learning and made recommendations for practice improvement. For all agencies the learning is as follows: UNDERSTANDING PARENTAL CAPACITY A. Parents play a vital part in safety planning and are expected to work closely with professionals. In order to avoid misunderstandings and conflict it is essential that practitioners understand parental capacity, strengths and attitudes. This will increase the effectiveness of interventions and avoid placing additional stress on children and their families. B. All agencies must be aware of the practical and emotional stress on parents and carers of suicidal and self-harming adolescents. Agencies must ensure parents’ own support needs are considered if necessary in a separate carers’ assessment. CHILD SEXUAL EXPLOITATION AND THE CHILD PROTECTION PROCESS C. When there are multiple practitioners directly involved with the family there can be confusing inter-agency communication and the risk of assumptions being made. In this situation, the number of practitioners involved with the family and the tensions in different approaches undermined the effectiveness of the work. D. Working with adolescents on risk management and safety planning is more likely to be effective if the child has a good and trusting relationship with one worker. E. Considering and making explicit the therapeutic and protective interventions with young people in child protection planning and agreeing priorities, increases the chance of positive outcomes. F. If children are to be subject to Child Protection Planning it is essential to understand any health diagnosis they may have , for example ADHD or emotional dysregulation. Without this explicit knowledge, it is difficult to develop and assess the potential effectiveness of any plans or the ability of the child to engage with the planned interventions. 25 | P a g e G. When a Child Protection Plan comes to an end, an up-to-date risk assessment is required to avoid over optimism based on a single incident or short term improvement. H. The ending of any process (CP or CIN) must include a clear statement about what will follow. If involvement is to be stepped-down, a plan with child-focussed outcomes should be in place and all conference participants should ensure they are clear about their role in any ongoing work. If any conference participants disagree with the conference decision, a discussion with their line manager about whether or not to escalate their concerns will help clarify thinking and contribute to effective decision making. I. CSE requires a different focus from other forms of child abuse. Consideration must be given to the context in which the abuse is taking place and Child Protection or alternative planning should include roles and responsibilities of all relevant agencies or individuals. This needs to be in the context of Working Together 2018, which would have ensured information sharing at least in strategy discussions when allegations of sexual abuse had been made. J. Adolescents can be exposed to a wider range of risks than younger children; concentrating on a single issue may lead to an over optimistic assessment of risk. MANAGING TRANSITIONS –SHARING INFORMATION K. Assessments which are based on a single incident and which fail to consider a child and family’s history are unlikely to provide an adequate assessment of risk. All assessments should include a chronology of events and, where appropriate, information from the area from which a child has moved. L. Reflective supervision and robust management oversight in high risk cases mitigates against the risk of confirmation bias in an assessment and helps ensure a proactive approach is taken to seeking and sharing information with other agencies. M. There is a risk that the involvement of CAMHS with a young person can be seen as a reason for other agencies not to intervene with a family. If CAMHS are working with a child and Children’s Social Care receive a safeguarding referral, it is important that all aspects of the child’s life are considered with a view to a holistic risk assessment. N. Current regulations related to Elective Home Education require an annual visit to be made by a local authority to ensure that the education of a child is satisfactory; there is no requirement to see the child. This means that a child can be “invisible” to education services for up to a year and education are unable to contribute to multi-agency assessment and planning. 26 | P a g e RESPONDING TO THE “VOICE” OF THE CHILD O. When a child requires safeguarding, all assessments should include listening and responding to their views. It is important to find a balance which prioritises safeguarding the child and which also recognises their agency. Considering each child’s individual capacity to understand and participate in their own safeguarding is vital. P. Recognising a child’s pattern of behaviour around reporting and withdrawing disclosures of abuse will enable practitioners to consider the meaning of the behaviour and avoid the risk of responding to individual incidents. Recognising a pattern will enable practitioners to take an overview and think beyond the necessary processes towards more effective interventions. . CONSIDERATIONS FOR THE SAFEGUARDING PARTNERSHIPS 139. The lines of enquiry raised at the beginning of the review process address specific practice issues associated with vulnerability, response to risk and information sharing when a child moves between different areas in the country. Invariably, from such a detailed review, shortfalls in practice will be identified. There is also, within Child C’s story, evidence of commitment, reflection and skilled work from practitioners; Child C clearly made an impression on those who knew her. 140. Recommendations are: • The Review is shared with County B; • The development of an action plan based on the learning; • That consideration is given to the development of a research-based risk management strategy designed to address the specific features of adolescent risk taking and suicidal ideation; • The Partnership promotes the concept of “contextual safeguarding” and satisfies itself that is understood and adopted by practitioners and managers working within the Child Protection Process; • Existing relevant policies and procedures are reviewed to ensure learning from this Review is reflected in guidance. • The Partnership gains an understanding of the work force’s knowledge and skills in practice with vulnerable adolescents, and develops evidence-based learning to meet any gaps. |
NC050515 | Attempted suicide by a 15-year-old in May 2020. Learning themes include: how the voice and lived experience of the child was taken into account by involved agencies; recognising and responding to adverse childhood experiences; the effectiveness of assessments, risk management and decision-making; the significance and support of 'trusted relationships'; information sharing and communication between agencies; and the impact of Covid-19 upon agency responses and support. Recommendations include: outline clearly how children and young people's voices will, or do, influence the work of the local safeguarding children's partnership (LSCP); consider how agencies use chronologies in their work with children and young people, particularly where there is a level of complexity; ensure that all agencies are confident that practitioners have an appropriate understanding of adverse childhood experiences and trauma-informed practice; multi-agency risk assessments should include all relevant professionals and take account of relevant specialisms, such as mental health and exploration of gender identity; all children and young people should have clear genograms and ecomaps on their records; parental consent for intervention should be balanced against children's needs and any risks; education settings should be clear on the pathways available for children presenting with complex needs; and the LSCP should review the processes to support children and young people with significant self-harm presentation and address any gaps.
| Title: Local child safeguarding practice review: Young Person A. LSCB: Plymouth Safeguarding Children Partnership Author: Fergus Smith Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 OFFICIAL:SENSITIVE Plymouth Safeguarding Children Partnership Local Child Safeguarding Practice Review Young Person A Published: April 2022 2 OFFICIAL:SENSITIVE Contents 1.0 Young Person A ................................................................................................................................................. 3 2.0 Serious incident leading to this review ............................................................................................................. 3 3.0 The Rapid Review & Key Lines of Enquiry ......................................................................................................... 3 4.0 Process & contributing agencies ....................................................................................................................... 4 5.0 Family engagement with the review ................................................................................................................ 4 6.0 Background history and professional involvement .......................................................................................... 5 7.0 Contextual information and summary .............................................................................................................. 8 8.0 Young Person A’s views ..................................................................................................................................... 9 9.0 Young Person A’s fathers views ...................................................................................................................... 10 10.0 Analysis ........................................................................................................................................................... 10 11.0 Response to the Rapid Review Key Lines of Enquiry ...................................................................................... 12 11.1 How well was Young Person A’s voice and lived experience taken into account by involved agencies? ...... 12 11.2 How well did agencies recognise and respond to Young Person A’s Adverse Childhood Experiences? ........ 14 11.3 How effective were agencies’ assessments, risk management & decision making? ..................................... 14 11.4 What was the significance & support of ‘trusted relationships’? ................................................................... 15 11.5 Was information sharing & communication effective between agencies? .................................................... 16 11.6 What is the impact, if any, of Covid-19 upon agencies’ responses and support to Young Person A? ........... 17 12.0 Conclusions & recommendations ................................................................................................................... 18 12.1 Conclusions ..................................................................................................................................................... 18 12.2 Recommendations .......................................................................................................................................... 18 12.3 System developments already in place .......................................................................................................... 19 3 OFFICIAL:SENSITIVE 1.0 Young Person A 1.1 Young Person A is now 17 years old and being supported in the care of the local authority. They are looking forward to a future career in animal care. They have worked hard during the last 18 months to understand how their mental distress impacts upon them and have developed skills that enable them to manage this differently and seek support, where needed. They have a keen interest in understanding their world and have been developing their understanding of the diagnoses they have been given. Overall, Young Person A feels more settled, happy and relaxed and enjoys being be closer to their family members. In their spare time, they enjoy doing things like reading, playing games, baking and sewing. *This report refers to Young Person A using the pronouns they/them/their. 2.0 Serious incident leading to this review 2.1 The serious incident involved Young Person A, when they attempted to hang themselves in May 2020; they were 15 years of age at the time. Members of the public intervened and after hospitalisation, Young Person A made a full physical recovery. 2.2 Young Person A was discharged from Intensive Care following assessment and treatment for their physical wellbeing and needs. They were then assessed under the Mental Health Act and met the criteria for a section 2 voluntary in-patient admission for treatment. They then moved to the Plymbridge Unit and were supported by CAMHS and their father. Following a two-week initial voluntary admission to a psychiatric unit, Young Person A, supported by their father, withdrew consent and initially returned home supported by a safety plan that included support from several agencies. 3.0 The Rapid Review & Key Lines of Enquiry 3.1 In accordance with statutory guidance in Working Together to Safeguard Children 2018, a Rapid Review was convened on 15 June 2020 and the local authority, with partners, secured the following: An immediate and comprehensive multi-agency safety plan was put in place for Young Person A and their brother. Agreed together that there was potential for improving or further improving local arrangements for co-ordination of safeguarding and promoting children’s welfare. 3.2 The rapid review examined the period January 2013 to May 2020 and identified the following Key Lines of Enquiry for the CSPR to consider: How well was Young Person A’s voice heard and their lived experience taken into account by agencies? How did agencies recognise and respond to Young Person A’s ‘Adverse Childhood Experiences’ (ACEs)? How effective were agencies’ assessments, risk management and decision making? What was the significance and support of ‘trusted relationships’? Was information sharing and communication between agencies effective? 4 OFFICIAL:SENSITIVE What was the impact, if any, of Covid-19 upon agency responses and support to Young Person A? 3.3 A decision was taken on 24 June 2020, by the Strategic Chair of the Plymouth Safeguarding Children Partnership that a Local CSPR should be undertaken and this was recommended to National Panel. There was a delay in identifying a suitable individual to undertake this review and then further delay in bringing this report to completion. 3.4 An independent lead reviewer, Fergus Smith, was commissioned and worked alongside the Clinical Commissioning Group (CCG)’s Designated Nurse for Safeguarding Children. Partners, independent of the practice at the time, within the CSPR Subgroup have then worked together to finalise this report and recommendations. 3.5 A review rooted in ‘appreciative inquiry’ and ‘trauma-informed thinking’ was intended to identify improvements in the local planning and delivery of services for safeguarding and promoting the welfare of children. 4.0 Process & contributing agencies 4.1 The review has sought information from the following agencies: Livewell Southwest, including Child and Adolescent Mental Health Service (CAMHS) Involved GP Practices Plymouth Children’s Social Care Schools and complementary education that was attended Plymouth City Council’s Targeted Support Services Plymouth’s Inclusion & Attendance Service & Special Education Needs & Disability (SEND) Service Devon & Cornwall Police University Hospitals Plymouth NHS Trust Plymouth City Council’s Youth Work Service 4.2 Consultation events were convened for practitioners and managers. These were virtual due to the ongoing Covid-19 restrictions in place, at that time. Participants were invited to reflect in advance and to identify what had worked well and to consider research, policies or procedures that had influenced their responses, as well as their ideas for improvements. Contributions were subsequently explored at the relevant events and reflected in this report, a brief summary of which, was shared and discussed at a ‘feedback event’ in early June 2021. 5.0 Family engagement with the review 5.1 Young Person A and their parents were invited to contribute to the CSPR. A virtual interview with their father was conducted jointly by the reviewers and the views of Young Person A’s mother sought via her carers (given her ill-health). On advice from the current residential care providers and independent reviewing officer (IRO), Young Person A’s views were obtained via their allocated social worker during the learning review. 5.2 Young Person A then met with their IRO in December 2021 and went through the draft report. They shared their views and these are reflected in this final report. Young Person A said that they appreciated the time that was taken to go through the report with them and they felt comfortable talking with their IRO. The IRO explained to Young Person A the process for the report to be agreed, shared with National Panel and then published on the 5 OFFICIAL:SENSITIVE partnership website, with no plan to draw the media’s attention but ensure the learning from their circumstances was available to practitioners. 5.3 The final report will be shared with Young Person A and their parents prior to publication. 6.0 Background history and professional involvement 6.1 Throughout Young Person A’s early childhood, there had been concerns about the degree of inconsistent care they had received. Initially, this was the result of their mother’s substance and alcohol use. This contributed to ongoing neglect of their basic needs at that time. During 2006, Children’s Social Care undertook assessments in respect of these concerns and this resulted in a period of child protection planning. During this phase of Children’s Social Care involvement, Young Person A went to live with their father who had separated from their mother in 2007. 6.2 Just prior to this, in 2006, Young Person A’s mother was diagnosed with a life-limiting condition (Huntington’s Disease) and she now requires supported accommodation, in light of the reality that this condition will not improve. This is of great significance to Young Person A for a number of reasons including the possible likelihood of them inheriting this condition. Young Person A has had access to this testing but has chosen not to pursue this yet. Health colleagues have advised that they would usually not recommend this testing prior to a young person reaching 18 years old, however there are exceptions and Young Person A could elect to have this sooner if they wished to pursue this. 6.3 Young Person A engaged with CAMHS in 2012, following a referral from school as a result of a self-harm incident. At this time, a number of support offers were made including art therapy and family support. These were not consistently accepted by Young Person A’s father. When the family did engage, this support did have some positive impact. 6.4 Following a further referral to Children’s Social Care in 2012, an assessment was undertaken. This clearly focused on the immediate issues of concern but did not take full account of Young Person A’s lived experience. In addition, the assessment did not sufficiently build on what was known about the family history or take into account the cumulative impact of events and experiences on Young Person A and their family. 6.5 Health professionals from the acute hospital trust, primary health care, education, Children’s Social Care and the police were consistently responding to crisis events, when they occurred. Young Person A required treatment and support following eight episodes of self-harm from 2012 to 2020, each episode escalating in terms of impact on them and treatments required. 6.6 In January 2013, CAMHS records indicate a concern about father’s (unspecified) use of physical restraint and chastisement and in August 2013, Young Person A (aged 9) was seriously sexually assaulted by a family friend who was later jailed for this offence. A referral was made to ‘12’s Company’ (now called ‘FirstLight’) – a source of support and advocacy for victims of sexual abuse. A substantial number of art therapy sessions were provided. Records refer to a sense of Young Person A’s residual guilt because by reporting the man who had assaulted them, they had disrupted their father’s friendship with him. This service was the first to explore Young Person A’s ‘inner world’. 6.7 In 2018, the family accepted the involvement of a youth worker to work directly with Young Person A and this relationship did make a really purposeful impact for Young Person A. During their work together, self-harm episodes ceased for a significant period of time. 6 OFFICIAL:SENSITIVE 6.8 Family therapy was provided in 2018 as Young Person A’s self-harm behaviours escalated. In addition, family mediation was also provided from 2019. 6.9 The single assessment undertaken by Children’s Social Care in 2018, reflected Young Person A’s feelings about being neglected by their father and that he had used physical chastisement; they described him as intimidating. This was refuted by Young Person A’s father. It is possible that exploring this more robustly at the time could have led to statutory intervention by Children’s Social Care. 6.10 Between 2018 and 2020, Young Person A’s self-harm attempts and behaviours escalated in frequency and severity and were increasingly difficult for their family to manage. In 2018 they were found on a bridge and taken home by the police. In 2019 they overdosed with medication and were hospitalised and then discharged home. In 2020, they overdosed again with medication, which resulted in further hospitalisation. On this occasion, Young Person A’s father discharged them from hospital. Agencies provided no challenge of the father’s decision making and no consideration appears to have been given about the impact of the home environment on Young Person A’s emotional well-being. 6.11 By early February 2019, tensions in the family home seem to have risen to the point which resulted in Young Person A staying away from the family home, with a neighbour and the prospect of returning home triggered thoughts of running away. 6.12 During early 2019, Young Person A’s attendance at school had reduced and there was discussion about a possible transfer to an alternative school. Later, at an education meeting in September 2019, attendance had improved to 80%. 6.13 In February 2019, Young Person A, with their father’s support, shared with education colleagues that they wished to be referred to by the male pronoun and shared a chosen name for everyone to use in addressing them. When Young Person A’s gender identity was discussed with CAMHS in 2019, a referral was made to a ‘Gender Identity Clinic’. Services were identified but it was not apparent how the Gender Identity Clinic referral and work would influence the support already in place. There is an apparent willingness to support Young Person A with this work but it is not clear how all agencies planned to ensure there would be a consistent approach from them all. A multi-agency approach could have supported the family and agencies to think about the necessary priorities and services that could support but not overwhelm the family at that time. 6.14 At this time, Young Person A was supported by their allocated youth worker to attend the ‘Out Youth Group’. This group supports and connects LGBTQ+ young people with other young people who identify as LGBTQ+. 6.15 Family Mediation was arranged to support the relationship between Young Person A and their father. They both attended 3 months of mediation (a restorative facilitative process) from April 2019. This was apparently a helpful experience but was terminated at their father’s request in July 2019. It is not clear if Young Person A agreed with this decision at that time. 6.16 There is evidence of Young Person A’s father seeking professional support at times. He reported a deterioration when Young Person A’s youth worker was no longer involved and subsequently contacted the Plymouth Gateway (the local ‘Front Door’ for accessing Early Help or Children’s Social Care). In mid-November 2019, Young Person A cut themselves, 7 OFFICIAL:SENSITIVE reportedly triggered by frustration about computer-based school work. The school alerted father, who in turn contacted CAMHS. 6.17 At other times, there was inconsistent engagement. For instance, CAMHS continued to be in regular contact with Young Person A’s father and sent an appointment for a review with CAMHS for the 7th of February 2020, but that appointment was not attended. Young Person A’s father said that he did not receive this appointment. 6.18 At this time, Young Person A’s father said that he felt increasingly worried about Young Person A and that they were threatening to break into the medication box. There were ongoing discussions about possible options of support available at this time. The CAMHS worker discussed with the CAMHS team possible support from Neuro Crisis and Integrative Therapeutic Assessment & Support Clinic (I-TASC), which the family did not attend. I-TASC is a separate service from the Exeter ‘Gender Identity Clinic’ which is run by another provider and an outreach clinic for the Maudsley in London. CAMHS do not have specialists in gender reassignment; they provide local mental health support for those young people going through gender transition working closely with their specialist colleagues. 6.19 On the 15th February 2020, Young Person A attended the hospital stating they were feeling ‘suicidal’ and were transferred to Paediatrics. Young Person A said they had locked themselves in the bathroom with the intention of finding razors but had failed this time. They had burned their forearm which they said they ‘did not regret’ and were prepared to self-harm again, though had no active thoughts of suicide. Young Person A was noted to be under CAMHS and gender identity disorder was discussed. On the same day, CAMHS assessed Young Person A within 24hrs of presenting at hospital. This is standard practice for all admissions to hospital where self-harm is a concern. The CAMHS report discusses self-harm but the CAMHS assessment also refers to suicidal thoughts with no active self-harm. Young Person A was taken to hospital to keep them safe, as their father was unwell at this time too. 6.20 On the 25th February 2020 Young Person A’s father took them to the Emergency Department again saying he was not managing Young Person A’s behaviour. They had become increasingly distressed and locked themselves in the bathroom. Young Person A’s father had ensured there were no sharp objects in the bathroom to prevent the likelihood of self-harm taking place. 6.21 An ‘Intercom Trust’ referral for the ‘Gender Dysphoria Clinic’ was completed. At the time, there was a 2 month waiting list. Young Person A was seen on the 27th February 2020 at home by CAMHS and the Outreach Team as a follow up appointment to the hospital attendance. 6.22 CAMHS undertook a school observation of Young Person A on 11th March 2020 and a home visit on the same day was completed by the CAMHS Outreach Team. 6.23 On the 18th March 2020 CAMHS provided telephone support for the family whilst the services were adjusting and implementing revised processes for Covid-19 working. 6.24 On the 6th April 2020 there was a conference call between CAMHS, Young Person A and their father with a newly allocated worker from CAMHS. They both engaged and Young Person A’s care plan and safety plan was reviewed. Young Person A and their father reported that no self-harm had occurred in the past two months. 8 OFFICIAL:SENSITIVE 6.25 On the 14th April 2020, Young Person A’s father rang the CAMHS telephone line and reported that Young Person A was stable in mood apart from one day since the last conversation and no self-harm. Young Person A was asleep on this occasion and their father did not want to wake them. 6.26 During a video therapy session held on the 23rd April 2020, Young Person A said they felt the impact of the Covid-19 restrictions in the session saying they felt the lack of social contact. A very in-depth session was undertaken and agreement secured from Young Person A to meet again and undertake further therapy. The risk assessment and care plan were reviewed. 6.27 Video therapy was undertaken between the CAMHS worker and Young Person A on the 30th April 2020. Young Person A remained engaged and stable and was collaborating on next therapeutic steps, this continued into May 2020. 6.28 On the 25th May 2020, when Young Person A had gone missing from home their father reported that they had been experiencing a low mood for a few days and had cut their wrist at the weekend but not needed medical treatment. He reported being unable to contact CAMHS Outreach. Young Person A’s mood varied but they had become distressed screaming and shouting that they just wanted to die. 6.29 CAMHS clinicians report that they were assessing risk within every contact and had there been any worrying signs of lack of engagement or an increase in risk reported by the parent or young person, further assessment and a face to face appointment would have been offered. 6.30 Young Person A’s father had spoken to CAMHS throughout May 2020 and was present and contributing whilst Young Person A was having appointments during this time. A 24 hour CAMHS crisis line had been implemented at the request of NHS England as a response to the impact of Covid-19 and the number provided to them. CAMHS report that this was answered 24 hours a day. 7.0 Contextual information and summary 7.1 Young Person A experienced several incidents of neglect, trauma and abuse during their childhood. Over time, these experiences have contributed significantly to their capacity/resilience to understand and cope with their evolving mental health challenges and gender dysphoria diagnosis. 7.2 The lack of consistency in Young Person A’s care during their formative years would have impacted on their sense of self and emotional wellbeing. 7.3 Young Person A’s maternal uncle died in late February 2019 as a result of the same condition as Young Person A’s mother. His death was very upsetting for Young Person A. 7.4 Young Person A’s relationship with their mother whilst in her care was challenging and their mothers use of substances and alcohol would have meant Young Person A’s need for consistent care, emotional support and basic needs were not met consistently during their formative development stages. 7.5 The genetic condition of Young Person A’s mother has meant she is currently managing in an adult supported care arrangement. This is likely to have a significant impact of Young 9 OFFICIAL:SENSITIVE Person A’s sense of self and their future plans. Young Person A has chosen not to be tested for this condition to date, but will be supported when they want to progress this as they move into adulthood. 7.6 The incident of being sexually abused in 2013, at aged 9, would have also significantly impacted upon Young Person A’s emotional well-being. 7.7 Records of self-harm episodes provided by Young Person A’s education setting refers to Young Person A’s report of three precipitating factors: bullying at school, the probability of inheriting their mother’s medical condition and frustration at being unable to recall things. Young Person A repeated these challenges on more than one occasion as their self-harm and challenging behaviours began to escalate. 7.8 The cumulative effect of unresolved and painful experiences that Young Person A was subjected to through their formative childhood years and subsequent developmental stages would all have contributed to their escalating behaviours and self-harm. Often this is the only way young people can express and manage the pain and trauma that sits within them every day. 8.0 The views of Young Person A 8.1 As outlined earlier in this report, Young Person A met with their allocated IRO and discussed the Child Safeguarding Practice Review process and offered them the opportunity to reflect on events. Young Person A understands the review taking place and the views they shared are summarised here. These reflections are triggered by events set out in the draft report seen by them. In general, Young Person A felt the proposed report was well put together and well written, highlighting what was not done in the right way and what was done in the wrong way. 8.2 Young Person A described their experience of interactions with the police negatively, using words such as ‘scary’ and’ intimidating’. Young Person A stated they felt that they were treated like a criminal at times, and not a person in need of support. They feel that the police lack mental health understanding. Young Person A accepted that there were times when their behaviour posed a risk to their father, themselves, their home and other people; therefore accepted that actions were taken by police to protect themselves and others. 8.3 Young Person A felt that they received some professional support when they were harming themselves, but when they spoke of harming others no support was given and they could read in the body language of practitioners, that they were disgusted with Young Person A and didn’t trust Young Person A. 8.4 Young Person A has stated that they felt listened to by their father and teachers but not by CAMHS or any of the services that were meant to listen. Young Person A reflected themselves that this may not have been the case at the time, they may have listened or may not have done, but this is how this felt to them. Young Person A gave an example. They picked up on a reference made at hospital that they (Young Person A) appeared ‘dissociated’. On reflection, Young Person A said that it is interesting how statements like this were said about them, but then nothing happened to ask them of their opinion about that statement. Young Person A said that they can ‘laugh about it now as I’m better in myself but I didn’t feel like that then’. 10 OFFICIAL:SENSITIVE 8.5 Young Person A shared their awareness that their father had a dislike for Children’s Social Care and CAMHS and the possible impact of this in getting consistent help. They said that they were not aware that their father had declined a number of assessments/support. 8.6 Young Person A advised that their father has admitted hitting them a number of times when younger. They reflected that they feel their father didn’t really get the support to understand how to care/support them in the best way and feels this is something their dad still needs, although noted that dad would likely turn this down as he doesn’t feel he needs the support. This is important learning to reflect on for the agencies involved as Young Person A clearly articulates, from their perspective, what could have been more helpful for them and their father at times of crisis. 8.7 Young Person A has noted ‘it is just sad that there has to be a big event for people to recognise something is wrong’. 8.8 Young Person A wished to share a summary of how they view support services. They described feeling like they were in a big forest full of lots of trees, that they couldn’t see which way to go and professionals should have been there to guide them out of this, help them to find the path again so they could lead themselves out. They said that sometimes professionals appeared when they really needed them at a point of crisis, when they didn’t know which way to go. Young Person A lost sight of them because professionals were then not there to help anymore and they remained lost. 8.9 Young Person A feels it is the role of those professionals, those who have more understanding to help them get through the forest and find that path again, and this is what they felt they did not have for a long time. 9.0 The view of Young Person A’s father 9.1 Young Person A’s father was clearly endeavouring to look after Young Person A and tried to respond to their escalating self-harm and behaviours. It is not clear how agencies have worked together to support him to understand the cumulative impact of challenges that Young Person A was experiencing and expressing through their behaviours and self-harm. 9.2 He has said he did not feel well supported by CAMHS on some occasions and recalled the frustration and anxiety he felt sometimes, associated with delays and his perception of ongoing confusion in CAMHS responses. 9.3 Young Person A’s father speaks positively about the art therapy offered, family mediation service and the period when a youth worker was allocated to Young Person A. Particularly as during this period self-harm episodes ceased. 9.4 Young Person A’s father says he has a dislike of Children’s Social Care intervention at any time or level. It is likely this negative view of Children’s Social Care has prompted him to decline ongoing assessments on more than one occasion. 9.5 The possibility of assessments resulting in a diagnosis of ‘ADHD’ was, according to father, to have been further evaluated and this has remained unresolved in all agencies records. 10.0 Analysis 11 OFFICIAL:SENSITIVE 10.1 Prior to the serious incident that triggered this review, Young Person A was exposed to a significant number of adverse childhood experiences (ACEs). This included physical abuse, emotional abuse and neglect. They experienced the impact of parental mental and physical ill-health, the impact of their mother’s substance and alcohol use, parental domestic abuse, parental separation, separation from sibling, sexual abuse and a developing and latterly chronic and constant anxiety about a possible future diagnosis of the condition their mother is experiencing (and from which a maternal uncle has died). All of this has contributed to this young person struggling with their emotional well-being and experiencing a number of challenges in the community and at home. 10.2 These experiences and exposure to them at different stages in their developmental journey through childhood to the present day would have impacted upon their resilience and sense of self and self-worth, as demonstrated through mental health and self-harming episodes outlined above. 10.3 Whilst several approaches such as art therapy, youth work, family mediation and un-specified forms of psychotherapy from CAMHS were provided, efforts were fragmented and most agencies knew only a proportion of Young Person A’s experiences, particularly at times of significant crisis. 10.4 Young Person A’s ‘story’ did not travel with them and Young Person A reports that only their father made the time and truly listened. Of an estimated 100 contacts with involved agencies, most were entirely or primarily influenced by Young Person A’s father. Young Person A’s mother has reported that their own (limited) re-involvement in Young Person A’s life began only when Children’s Social Care became involved in 2020. 10.5 Children’s Social Care assessments should have been underpinned more robustly by the history of the family and events, to secure an evidence based view of Young Person A’s lived experience including risks and needs that all required a response at different levels. 10.6 There was a single assessment undertaken between 26/05/2020 and 06/07/2020. This was undertaken to consider the impact of Young Person A’s early life experiences upon her emotional wellbeing and to consider a safety and support plan following the serious incident where they had been found hanging by a tree. In discussion with the social worker, they acknowledged the previous assessments were brief and did not give due consideration to Young Person A’s complex and lengthy history. In addition, previous assessments focussed on single incidents that had triggered the referral and were more parent focussed than child focussed. 10.7 The assessment outlines that little consideration is given to the impact of historical adversity on Young Person A, their emotional or behavioural development, and on the personal relationships between Young Person A and their father in particular. Children’s Social Care assessments did not consider the cumulative effects of Young Person A’s experiences of loss and trauma. They were too brief and limited and did not offer analysis or challenge of the reasons why their behaviour was manifesting in the way it was. In addition, there was little challenge or support to their father to overcome this and professionals were too ready to accept his view to not access support from Children’s Social Care. 10.8 There was a strong focus on Young Person A’s mental health and escalating self-harm episodes and behaviours. However, this focus led to agencies not prioritising some emerging safeguarding concerns. 12 OFFICIAL:SENSITIVE 10.9 Young Person A has expressed concerns about their relationship with their father on more than one occasion and has clearly stated they required help. They have not felt that services took account of this broadly enough, to actually help their father be able to respond to their presentation as effectively as possible. He has worked hard to help Young Person A be safe but we have to reflect back on what agencies provided and if understanding history, trauma and impact of ACEs could have enabled their father to access services and support that potentially would have made a greater difference to lived experience of Young Person A. 10.10 Of note, is the absence of Young Person A’s younger and older siblings as the situation escalated, their voices are not heard in the records of agencies and the incidents would clearly have had an impact on them and Young Person A. 10.11 Extended family are also absent in the assessments and support packages, apart from more recently paternal grandfather, to whom Young Person A feels very close. There were opportunities to provide Young Person A and their father respite or time out to enable them space from each other, to work through some of the challenges in the household independently. This was never considered formally or integrated in any of the safety planning or interventions. 10.12 In addition there is a lack of attention, by all agencies, to the impact of Young Person A’s relationship with their mother and what impact this potentially was having on their development and sense of self. 10.13 There were missed opportunities for multi-agency working to robustly assess, support and intervene collaboratively throughout the period particularly 2012 to 2020, where predominately single agency approaches were undertaken. These required a higher level of challenge to ensure issues of potential risk and harm were being assessed in context alongside the presenting behaviours and self-harm episodes. 10.14 Engaging Young Person A’s father proved challenging and as a result the work only resulted in child in need recommendations by Children’s Social Care, which facilitated Young Person A’s father in his decision to not continue with Children’s Social Care support and intervention. 10.15 Education colleagues and services, whilst supportive of the family and Young Person A, could not evidence completion of Young Person A’s Education Health and Care Plan. There is no evidence of consideration of “missing school” due to physical or mental health guidelines being applied or considering if a more specialist resource was required to enable Young Person A to feel safer and better engaged in their education. 11.0 Response to the Rapid Review Key Lines of Enquiry 11.1 How well was Young Person A’s voice and lived experience taken into account by involved agencies? 11.1.1 Records and reflection have identified some positive examples of Young Person A’s ‘voice’ being heard and responded to: Ongoing and sensitive internal arrangements within their education setting, following a transfer there in Summer 2018, reflected their voice well in records. 13 OFFICIAL:SENSITIVE Young Person A had asked for the youth work to continue as it was helping them, this extension was agreed beyond the standard 12 week commitment that was in place, at the time. The successful negotiation by the hospital during the admission of May 2020, of prolonging their stay pending a pre-discharge assessment by the CAMHS consultant. 11.1.2 Those positive examples are out-numbered by other examples where Young Person A’s father expressed views and/or conduct were accepted with little apparent challenge which could be seen as resulting effectively in the marginalisation of Young Person A’s on these occasions: Young Person A’s father, in 2013, declining the offer of ‘family therapy’ at the same time that Young Person A was reporting a continuation of physical punishment (his record of alleged domestic abuse of his ex-partner appears to have been overlooked or diminished); later withdrawal from mediation offers a further example. Young Person A’s father’s decline of a formal assessment during 2017 and ongoing decline to access child in need services or early help services, when offered. He reported his dislike of Children’s Social Care. Young Person A’s reports in summer 2018 of their father’s aggression were not directly addressed (with agencies’ attention seemingly diverted by the recently offered diagnoses of anxiety and depression, autistic spectrum condition and an attachment disorder). There was no professional challenge or evident curiosity about what impact this report might have on Young Person A. The insufficiency of agency capacity to further extend the valued relationship with the youth worker in summer 2019. Young Person A valued this relationship and incidents of self-harm were not reported during that time. Young Person A’s voice was difficult to see, hear and feel through the agency records as decisions being made about their safety and well-being were continuously deferred to their father. This continued even on the occasions when Young Person A clearly reported that they felt angry with him,. 11.1.3 Young Person A’s lived experience was not at the fore front of agency assessments and interventions, as noted above. Individual agencies were enabling access to services and support on an individual basis and, even when working together, their approaches are evidenced as singular in issue, with a lack of evidence that history, trauma and Young Person A’s views were influencing factors regarding the decisions being made. 11.1.4 It is important to note in this context that Young Person A has reflected that at times, when younger, they didn’t feel able to share their views so their father did this on their behalf and the response was that it needed to come from Young Person A and not their father. 11.1.5 Young Person A stated that “it shouldn’t matter who it comes from”, if they aren’t comfortable sharing that, it should be accepted from their father. When this hasn’t happened Young Person A has also felt invalidated and not listened too. Young Person A hopes that this report will change things for other people like themselves so this does not happen again. 14 OFFICIAL:SENSITIVE 11.2 How well did agencies recognise and respond to Young Person A’s Adverse Childhood Experiences? 11.2.1 An important discovery that emerged from the practitioners’ event was how partial each agency’s knowledge and appreciation of Young Person A’s experiences and needs were. Most of the involved agencies were dependent upon what Young Person A and/or their father felt able to say (and that attendance / engagement with them was always deemed to be voluntary), it was and remains of critical importance that all available information is contained within any referral form / subsequent assessment and that ‘professional curiosity’ is maintained. 11.2.2 Striving to understand a young person’s lived experience and the impact it has had/is having on them, means we should “get in their shoes” and actively listen to what they are trying to communicate through language, behaviours, emotional, physical and mental health presentation. 11.2.3 Despite the many agencies offering support and intervention, at different times for Young Person A, it is apparent that they could have more robustly shared information with each other, particularly at times of crisis. This could have secured an earlier, more robust evidence based decision together, that could have addressed Young Person A’s presenting needs more effectively. This should have included education, youth worker, specialist clinics, police, health, CAMHS and Children’s Social Care. 11.3 How effective were agencies’ assessments, risk management & decision-making? 11.3.1 In the view of the Educational Psychology Service, acknowledged difficulties within Young Person A’s education setting, rendered it difficult to generate sufficiently clear detailed information for the use by the SEND 0-25 and s.19 teams. The s.19 process was also reported to have been frustrated by lack of timely CAMHS responses. 11.3.2 The lack of timely and reliable responses by CAMHS remains Young Person A’s father’s most significant criticism and it remains uncertain on what basis (a later rejected) diagnosis of ASD was formulated. 11.3.3 There is a clear diagnosis noted in the contextual information but as stated sharing information across all the agencies was less than satisfactory. 11.3.4 CAMHS have evidenced a robust approach to supporting Young Person A and it is acknowledged that Children’s Social Care input remained at offers of child in need or early help, as Young Person A’s father was not consenting to their involvement. 11.3.5 The education impact and outcomes remain challenging to evidence given the EHCP remained incomplete. 11.3.6 Children’s Social Care assessments would have benefited from being explicit in terms of the neglect Young Person A felt they were experiencing from their father, they should have considered what this looked and felt like for them and what they felt needed to change in their lives. 11.3.7 It is clear that if workers in all agencies had considered and detailed a chronology and experiences of Young Person A, they would have enabled themselves to have a greater 15 OFFICIAL:SENSITIVE understanding of their father’s reluctance to engage with Children’s Social Care. This should have supported agencies to be more persistent in terms of advocating the need for a co-ordinated multi-agency plan or even consideration of child protection planning as concerns regarding parenting started to emerge. 11.3.8 Police colleagues were supporting Young Person A through a number of traumatic events and whilst securing Young Person A in safe places together with their father, hospital or family friends, it would be helpful to understand how they de-brief from these challenging circumstances and share reflections and learning with other agencies that might be offering or able to offer support to the family. 11.3.9 Police appropriately submitted their concerns on a ViST Vulnerability identification Screening Tool), however when no further action was decided by Children’s Social Care, partner agencies seemed to accept this was the position and there is a lack of evidence of this being challenged by any organisation. 11.3.10 Education colleagues were supportive of the family and Young Person A, however their intervention and assessments appear to be incomplete and take too long. Resulting in Young Person A‘s being missing from education for prolonged periods with no plan identified or shared for supporting their access to education. 11.3.11 An incomplete EHCP remains unresolved and therefore education opportunities that may have assisted Young Person A in managing more effectively the escalation of their behaviours and self-harm episodes were not identified. 11.3.12 CAMHS intervention support and assessment was comprehensive, in the main timely and several periods of therapy and access to additional resources were extended. 11.3.13 On reflection, engaging more colleagues from partner agencies, at an earlier time of Young Person A presenting self-harm and unregulated behaviours, could have resulted in a de-escalation sooner for them. Had all agencies involved robustly challenged the parenting and considered the impact of cumulative life experiences, there was potential to collaborate and work together from a stronger evidence based position to address Young Person A’s needs. 11.3.14 In isolation, each agency dealt with the presenting issue, which meant their responses were singular and not collaborative, so not providing a safety net across them and the community. As Young Person A’s presentation became increasingly challenging for all involved including Young Person A and their family, agencies did not understand their lived experience fully enough to be able to address the underlying causes of their distress being displayed in different ways. 11.3.15 A multi-agency approach was needed much earlier for Young Person A and their family to offer Young Person A and their family a clear understanding of what their needs were and how best they could be met, potentially utilising the wider family support network. 11.3.16 Young Person A’s brother was also exposed to the challenges and it remains unclear what impact it had on him and his relationship with Young Person A. 11.4 What was the significance & support of ‘trusted relationships’? 11.4.1 It is true that during the period of engagement with their allocated youth worker, Young Person A initiated no self-harm or suicide attempts. Not since the provision of ongoing art 16 OFFICIAL:SENSITIVE therapy by ‘FirstLight’ years earlier, had Young Person A benefitted from such a prolonged relationship with an individual professional. 11.4.2 The description of the arrangements and flexibilities at the education provision suggests that they also gained a good deal from the sensitivity, insight and commitment that is apparent in its account of service provision (a perception reinforced by Young Person A’s father’s contemporary comments). 11.4.3 Agencies did not demonstrate an appreciation of this factor during their interventions and made some assumptions about who Young Person A’s trusted people were. 11.4.4 Young Person A has a close relationship with their grandfather but this review could find no records of attempts to bring extended family together to consider safety plans and interventions from them that could have supported Young Person A to feel safer themselves. Young Person A had stayed with him when younger so already had identified him as one of their trusted persons. 11.4.5 The evidence reflected that for Young Person A the positive impact of a key and trusted worker who can remain a point of consistency when other areas of life are uncertain was important in helping them manage their emotional well being 11.4.6 The value of a trusted and consistently available person (in this case exemplified by the allocated youth worker and the team of staff and its sensitive deployment within Young Person A’s education provision) demonstrated good practice and the benefit of relationship building being a key support for Young Person A. 11.4.7 The inconsistent approach across the agencies did not facilitate the ability for a core group of workers to be able to build these trusted relationships alongside Young Person A or fully utilise the trusted relationship in place, to effect change. 11.5 Was information sharing & communication effective between agencies? 11.5.1 There are examples where agencies had opportunities to meet together and share their expertise about the family and compliment this understanding by working through their specialist lens and enabling a holistic picture to be secured. 11.5.2 There were missed opportunities on more than one occasion when the lead agency at the time of crisis presentation did not always seek support, advice or guidance from their safeguarding partners. There was a lack of timely referrals into services that could have supported Young Person A and their family. 11.5.3 There was a lack of appropriate referring into Children’s Social Care during some crisis episodes and it reflected a lack of confidence perhaps in the response that might be received in terms of recognising and responding to safeguarding matters for Young Person A and their sibling. 11.5.4 In addition, when Young Person A was subject to Children’s Social Care assessment, there was a lack of engagement of all relevant partners and their father’s refusal to engage in working with Children’s Social Care was not challenged effectively, often resulting in Children’s Social Care stepping away, as he requested. 11.5.5 This resulted in other agencies considering a new referral to Children’s Social Care as something Young Person A’s father would not respond well to or accept. 17 OFFICIAL:SENSITIVE 11.5.6 This resulted in a lack of attention to the chronology of events known about Young Person A’s family and home life. Negating the likelihood of analysis and understanding about the impact of inconsistent parenting and its impact on Young Person A’s presentation. 11.5.7 The focus on Young Person A’s mental health and self-harm episodes resulted in responses and interventions being single-issue outcomes. 11.5.8 It is likely that a multi-agency safeguarding plan, could have managed and offered a breadth of services and interventions including sensitive challenge and support for Young Person A’s father and mother in understanding the potential impact of their well-being and parenting approaches in influencing Young Person A’s sense of self and emotional well-being. 11.5.9 Sharing information within health provisions was also not consistent, reducing the likelihood of a consistent response to Young Person A’s escalating emotional challenges. 11.5.10 Young Person A’s ‘pupil passport’ was not supplied ahead of their transfer resulting in their education provision not having timely access to significant information. As a result, their planning for education and social support would not have been as well informed as you would expect, particularly for a young person with such challenges in their formative years. 11.6 What is the impact, if any, of Covid-19 upon agencies’ responses and support to Young Person A? 11.6.1 Complying with regulatory restrictions and recommended professional approaches inevitably impacted upon agencies’ ability to support Young Person A. It seems probable that for many individuals denied the opportunity to socialise at school or work, the psychological pressures may have increased throughout 2020. The restrictions will also have meant further complexity of task and more anxiety to those professionals operating from home or in circumstances that were more isolated. 11.6.2 All services that Young Person A was accessing had individual risk management and assessment plans to respond to young people and family’s needs particularly during lockdowns and always maintained a high level of contact with them and their family. 11.6.3 Covid- 19 restrictions resulted in Young Person A no longer being able to attend their education provision. During April 2020, a CAMHS I-TASC (therapeutic) clinician twice contacted Young Person A and their father via video calls. Young Person A was ‘unavailable’ for two further calls, thus diminishing the potential for early indicators of self-harming thoughts / intent to be detected. 11.6.4 Without direct contact with the individual, it remains impossible to conclude how ‘Young Person A’ experienced the Covid-19 constraints. Young Person A has subsequently shared they found the lack of social contact difficult. 11.6.5 Reflective feedback from participating agencies indicates that with the loss of individual or group work face-to-face, some developed or refined their use of text, WhatsApp, Zoom calls with/without cameras, as well as ‘doorstep’ exchanges. It is thought that this increasing diversity in the means of communication may be here to stay and/or be accompanied by what have been described as ‘blended’ approaches. 18 OFFICIAL:SENSITIVE 11.6.6 There was evidence to suggest that whilst face-to-face visits had to reduce during some periods, particularly lockdowns, all agencies endeavoured to retain a high level of contact by other means ensuring there was an ongoing level of contact and access for Young Person A and their father. 12.0 Conclusions & recommendations 12.1 Conclusions 12.1.1 All partners have actively engaged in this review and committed to understanding how their safeguarding approaches and interventions could be strengthened and improved for young people presenting with complex needs, trauma experiences, mental health and self-harm presentation and exploration of gender identity. 12.1.2 There were some valuable and effective responses to Young Person A’s emotional needs especially from the local voluntary sector therapeutic service providers, youth worker and the education provision. 12.1.3 Trauma-informed practices could not be evidenced as consistently embedded across the partnership, agencies did not consider the accumulative impact of Young Person A’s experiences and how they may have been affecting their presentation, including emotional distress and self-harm. 12.1.4 It is positive that Young Person A has been able to give their view about their circumstances and their insight and candour about the experiences they recounted is appreciated. The partnership should take them on board as an opportunity for partners to learn and improve experiences for children and young people in the future. 12.2 Recommendations 12.2.1 The child or young person’s voice should always be heard and central to work undertaken with them. Agencies should review their policies and procedures internally to assure themselves this is in place throughout and that practitioners and supervisors are expected to demonstrate this is clearly recorded and considered. 12.2.2 The Partnership (PSCP) should ensure that it outlines clearly how children and young people’s voices will/or do influence the work of the Partnership. 12.2.3 All agencies should consider how chronologies are used in their work with children and young people, particularly where there is a level of complexity. They should ensure they are able to identify Adverse Childhood Experiences and traumatic events and consider the potential impact on the child or young person. They should be confident they have a clear overview of the child/young person’s lived experience, including the cumulative impact of events, as well as processes in place to work with other agencies to combine chronologies, where appropriate, to allow agencies to work together to fully understand the lived experience of children and young people and then work with them to achieve the changes needed. 12.2.4 The Partnership (PSCP) needs to be assured that all agencies are confident that practitioners have an appropriate understanding of Adverse Childhood experiences (ACEs) and Trauma-informed practice. 19 OFFICIAL:SENSITIVE 12.2.5 Multi-agency risk assessments and subsequent interventions should include all relevant professionals and take account of relevant specialisms, such as mental health and exploration of gender identify. 12.2.6 All children and young people should have clear genograms (family tree) and ecomaps (support network) on their records that also identify friends and trusted persons. This supports their inclusion (with the appropriate consent), in any safety or support plans for the child or young person at that time. 12.2.7 This learning review serves as a reminder to agencies to seek and share all relevant information with each other when assessing a child or young person with complex needs, including self-harm. This supports effective support and safety planning. 12.2.8 Parental consent for intervention should be balanced against the needs and risks of children and young people. Where consent is refused, this should be understood, explicitly considered with other agencies that are directly involved, and recorded. Alongside efforts made to encourage and support parents to work with the proposed assessment/ intervention. The voice of children/young people needs to remain heard within this. 12.2.9 Education settings should be clear on the pathways available for young people presenting with this level of complex need and review at what point they should seek additional guidance to ensure they are offering the appropriate support and if necessary ensuring the right multi-disciplinary approach to meeting the young person’s needs. 12.2.10 The Partnership (PSCP) to review the processes, procedures and strategic commitment to support children and young people with significant self-harm presentation. Any identified gaps should be addressed. 12.3 System developments already in place 12.3.1 Triggered by reflections on the actual delivery of services and what might be the optimal arrangements for young people in Young Person A’s situation, the following changes have already been implemented by the partnership: The ‘Targeted Support’ part of Plymouth City Council was reviewed immediately and staff merged to create an ‘Early Help Advice and Support Team’ with youth and family support workers offering advice and support to settings as well as a key worker on a 1:1 basis or via group work. They had been delivering support during the Covid-19 pandemic via MS Teams, WhatsApp and phone, the offer in 2021 has evolved into a ‘blended’ offer of face to face or virtual contact, dependent upon individual need. The historically distinct and complex functions within CAMHS have been re-modelled. Rather than first-line therapy for an individual, the approach has become ‘externally’ (rooted in trauma-informed and holistic appreciation of presenting symptoms) to support the efforts of the family and professional network and - ‘internally’, to co-ordinate by means of multidisciplinary ‘core meetings’, the specialities within the wider CAMHS. The hospital now has the benefit of a ‘Mental Health Care Pathway’ which can call upon the assistance of an ‘enhanced care observation team’ for 1:1 care of children and young people. 20 OFFICIAL:SENSITIVE All children who present to the Hospital’s Emergency Department following deliberate self-harm or concerns for emotional health are communicated to ‘Children’s Gateway’ and considered as a potential referral for Children’s Social Care intervention. This needs to be considered further as a Partnership to ensure there is a shared understanding of when these situations should ‘automatically’ result in a referral or result in a conversation about what might be appropriate. The Police have adjusted their approach in recent years to one that is more child and family centred. |
NC51265 | Abduction from the United Kingdom of an almost 3-year-old girl in December 2016. Child T was subject to a Full Care Order with Looked After Child (LAC) placed at home status. She was abducted by her birth parents which is a crime as the Care Order meant the Local Authority shared parental responsibility for Child T. The Care Order had been granted due to concerns about mother's ability to parent previous children who were in local authority care outside Salford. Parents had been under investigation by a Criminal and Financial Investigations Team relating to illegal immigration and money laundering. Mother is Polish, father an asylum seeker from Iran. Learning: effective information sharing and communication are vital if children are to be safeguarded when their parents are involved in serious crime; practitioners working with LAC placed at home should be alert to their vulnerability and ensure they understand their responsibilities towards safeguarding them and meeting their needs; multi-agency practitioners need to ensure they are clear about the content of parental written agreements; always be alert to the possibility of disguised compliance even when parents present as fully engaged and working well with agencies. Methodology: multi-agency concise review (MACR). Recommendations include: Greater Manchester Police and Children's Services should assure the LSCB that strategy meetings or discussions are always held when a child has been subject to a Police Protection Order; partner agencies to assure the LSCB that the learning from this review has been implemented and embedded into practice.
| Title: Child T: multi-agency concise review (MACR): executive summary. LSCB: Salford Safeguarding Children Board Author: Melanie Hartley and Jane Carwardine Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child T Multi-agency Concise Review (MACR) Executive Summary Independent Reviewers: Melanie Hartley and Jane Carwardine 24th June 2018. Page 2 of 8 EXECUTIVE SUMMARY. 1. Introduction: This Multi-agency Concise Review (the review) followed an incident in December 2016. Child T (female and almost 3 years old), who was subject to a Full Care Order with Looked After Child (LAC) placed at home status, was abducted from the United Kingdom (UK) by her birth parents. The crime ‘Abduction by Parent’ had been committed as the Care Order meant the Local Authority shared parental responsibility for Child T. Parents were not allowed to remove Child T from the UK without written permission from the Local Authority. This had been clearly explained to them through the Care Proceedings, the Final Care Order and at LAC Reviews. The review identified 9 areas of good practice and it was apparent that practitioners did their utmost to safeguard Child T and meet her needs. 2. Case summary and key learning: The Care Order had been granted due to concerns about mother’s ability to parent previous children, who were in Local Authority care outside of Salford. This Local Authority had instigated the Care Proceedings for Child T who was father’s first child and no concerns about his parenting capacity were identified. He was deemed the ‘primary and protective’ parent during the Care Proceedings. A key requirement on conclusion of the Proceedings was that Child T was not to be left alone with mother until she had attended counselling as recommended in an Independent Psychologist’s report for Court. The report indicated that 6-10 sessions were likely to be needed. Child T’s mother was a Polish migrant to the UK and father was an asylum seeker from Iran. Their relationship commenced around March 2013 and, shortly before Child T was born in January 2014, mother moved to Salford to live with father. 3. Salford City Council became the Designated Authority on conclusion of the Care Proceedings in February 2015, 22 months prior to the incident. No concerns were identified about the care provided to Child T by either parent during that time. Agencies with most involvement including at 6 monthly statutory LAC Review meetings were Children’s Services (LAC Social Workers and Independent Reviewing Officer), a Local Authority Day Nursery which Child T attended from May 2015 onwards and Health Visitors. Other agencies who had involvement prior to events in the week leading to the incident were a GP Practice and a Housing Officer. 4. Both parents had presented as fully engaged with Child T’s Care Plan and a written agreement put in place by Children’s Services. The written agreement was signed by both parents and a hard copy was provided in Farsi. It stipulated mother was not to have sole care of Child T until she had attended the counselling and that parents would work openly and honestly with services. It was understood by the practitioners at LAC Reviews that mother was attending appointments but that 2 counselling sessions were still required. Child T was considered to be securely attached to both parents and progressing well. The Local Authority plan was for discharge of the Care Order in light of positive progress and the application for this had been made in October 2016. 5. However, involved practitioners were unaware that, since March 2016, parents had been under investigation by a Specialist Home Office law enforcement Team - a Criminal and Financial Investigations (CFI) Team. They were both suspects in a large-scale investigation into the facilitation of Iranian nationals into the UK and money laundering by an organised crime group within which father had a lead role. 6. The Investigating Officers were reliant on Greater Manchester Police (GMP) as the local Force for safeguarding information and had been advised there were no concerns on the GMP systems. Child T’s LAC status was not identified as, nationally, Police Forces do not have systems to flag these children in the same way as they flag children subject to Child Protection Plans. CFI Officers didn’t identify any safeguarding concerns when Child T was observed in her parents’ care. These Officers make decisions on the safeguarding risks posed to dependent children on a case by case basis Page 3 of 8 through available information, organisational safeguarding guidance and the Police National Decision Model. In this case the parental criminal activity was not deemed to pose a serious risk to Child T. CFI Officers made a decision not to inform Children’s Services of the planned arrests given no known safeguarding concerns and the need to maintain the investigation’s security. Parents were arrested at around 6.30am on December 5th 2016 by CFI Officers with support from GMP Officers. 7. On being asked about Child T, mother said there were no suitable family members to care for her whilst they were under arrest. Because of this, and the fact that Child T’s LAC status was not known to GMP/CFI Officers, she became subject to a Police Protection Order (PPO) and placed with foster carers. The next day, December 6th, following discussions between a GMP Public Protection Investigation Unit (PPIU) Officer and a Children’s Services LAC Practice Manager and then further discussions within the Children’s Services LAC Team, Child T was returned to parents’ care following their release from custody on Police bail. A second written agreement was put in place, the key stipulation of which was that parents must inform the Local Authority if they intended to leave the local area overnight or longer. 8. A major issue was that no practitioners involved in either the arrests or in making the decision to return Child T to parents’ care, understood the full picture. Key information unknown to CFI and GMP Officers was Child T’s LAC status. Key information unknown to Children’s Services practitioners at the point of determining whether to return Child T to parents’ care was the detail of the serious crime Child T’s parents were suspected of. The investigation was led by CFI Officers and details of it were recorded on CFI electronic recording systems. Involved GMP Officers had only a limited understanding of the investigation with no details available on GMP electronic recording systems. However, it was GMP Officers who had established communication processes with Children’s Services and took the lead in these communications. GMP Officers also secured the PPO due to CFI Teams not having the necessary Police powers to obtain these. 9. Also, the review process itself identified evidence, unknown at the time, of parents not complying with key aspects of the Care Plan and first written agreement: Mother had been caring for Child T alone at times including taking her to see a GP on 2 occasions in March 2015 shortly after the first written agreement was put in place; Parents had taken Child T out of the UK on 8 occasions between May 2015 and September 2016 without seeking Local Authority permission despite having been made aware of this requirement on a number of occasions. Practitioners understood that parents had no passport for Child T and Children’s Services had not supported them in applying for one as is required for a child subject to a Care Order. In reality, parents had both Polish and Iranian passports for Child T. No evidence of mother having attended any counselling sessions could be identified. Had any of this information been known to Children’s Services, further actions would have been taken prior to returning Child T to parents’ care and the agreed plan to discharge the Care Order would have been reviewed. 10. On December 9th, late in the evening, parents attempted to leave the UK with Child T via a Ferry Port. However, they were stop-checked by a Merseyside Police Special Branch Ports Unit Officer (Ports Officer) who identified the Police bail conditions on the Police National Computer. The Ports Officer made several attempts to contact the Investigating Officer to discuss the suspected offences and breached Police bail conditions and to agree further actions. These attempts were unsuccessful as the contact details available on the Police National Computer were those for a GMP Officer supporting the arrests and not the CFI Investigating Officer. The Ports Officer sought supervision and actions were Page 4 of 8 taken which prevented the family from leaving the UK at that time. The Ports Officer then carried out further investigations on return to duty and clarified on December 12th that the investigation was being led by the CFI Team. 11. This Team was informed immediately and there was then very prompt communication with Children’s Services after which all possible actions were taken to locate the family and the Greater Manchester Children Missing from Home and Care procedure was followed. However, it was subsequently identified that the family had left Salford on December 11th by travelling through the Common Travel Area, Scotland, Northern Ireland and then to the Republic of Ireland from where they flew to Iran via Munich on December 12th. 12. There were 4 points in the review timeline at which different actions could have been taken: Key Point in Timeline Significant Issues The planning of the arrests by the Home Office CFI Team No flags for LAC on any Police systems. CFI Officers unaware of Child T’s LAC status. CFI Team reliant on local Force information for safeguarding checks- this is not a robust process. Children’s Services are the lead agency for safeguarding children. CFI Officers unaware of any safeguarding concerns for Child T and parental criminal activity not deemed to pose a serious risk to her- decision made by CFI Team not to contact Children’s Services prior to the arrests. Children’s Services were unaware of the parental involvement in serious crime. Had Child T’s LAC status been known, there would have been contact made with Children’s Services at this point by CFI Officers prompting multi-agency assessment and planning prior to the arrests. Children’s Services Care Planning would have been informed by a good understanding of the parental involvement in serious crime. The arrest of Child T’s parents at around 6.30 am on December 5th and Child T being made subject to a PPO Arresting Officers (CFI & GMP) unaware of Child T’s LAC status and mother said there was no suitable adult to care for her. PPO deemed necessary which had to be secured by GMP as the investigating CFI Team did not have the necessary Police powers. Children’s Services became aware of parents’ arrests on the day and were informed the PPO had already been secured. Safeguarding decisions had to be made quickly at the point of the arrests. Page 5 of 8 GMP took the lead role in safeguarding communications but was not leading the investigation and Officers were unaware of detailed information. Had Children’s Services been made aware prior to the arrests, there would have been multi-agency decision making and planning. The PPO was not necessary given Child T’s LAC status and alternative plans could have been made for her care. Decisions would have been made by all the key practitioners in a timely and coordinated manner. Children’s Services Care Planning would have been informed by a good understanding of the parental involvement in serious crime. The return of Child T to her parents’ care on December 6th GMP PPIU Officer had discussions with Children’s Services due to GMP having established communication processes in place. Information held on the GMP log did not include any safeguarding concerns for Child T in relation to parents’ arrests and detail of the CFI led investigation was not on the GMP systems. Children’s Services made a decision to return Child T to parents’ care in light of the positive progress in the case and being unaware of key information. The requirement for a Strategy Meeting or Discussion to always be held prior to a child being released from a PPO was not met. A multi-agency Strategy Meeting involving both CFI and GMP Officers at this point would have enabled multi-agency decision making and ensured correct procedures were followed for a child made subject to a PPO. The meeting would have facilitated multi-agency discussions about the risks to Child T of both parents being involved in serious criminal activities, the nature of the activities and father’s lead role, flight risk, the need to seize travel documents, the Police bail conditions and the implications of these being breached. A multi-agency plan would have been agreed and may have included Section 47 enquiries once all known information had been shared. Page 6 of 8 The first attempt to leave the UK on December 9th Ports Officer unable to contact the CFI Investigating Officer due to the Police National Computer including only the details of a GMP Officer involved in the arrests. Ports Officer identified the CFI Team was leading the investigation on December 12th by which point the family had already left the UK. Had the Ports Officer been able to inform the Investigating Officer of the family attempting to leave the UK on December 9th, there would have been prompt information sharing and multi-agency planning in light of the significant, new information. 13. Learning has been identified in the following areas: The interface between parental serious crime and safeguarding- criminal investigations into serious and organised crime are highly sensitive and complex. Actions required to safeguard the child have to be considered alongside ensuring complex criminal investigations are not put at risk. The risk assessment of the impacts of such crime on dependent children requires consideration of all risk and protective factors known to involved agencies. Children’s Services are the key agency to contact in relation to clarifying known safeguarding concerns. In this case, whilst the CFI Team led the investigation, GMP and a Merseyside Police Special Branch Ports Unit Officer were also involved. The review has highlighted the following significant challenges nationally in the Home Office systems which impacted on communication processes and safeguarding decision making in this case. The involvement of 3 law enforcement agencies added further complications to an already complex situation: There is no system for flagging children subject to Care Orders on Police systems. CFI Officers obtain safeguarding information from the relevant local Police Force systems to inform safeguarding decisions. In this case, the checks could not identify that Child T was subject to a Care Order. Whilst local Force systems would identify children who are subject to Child Protection Plans, they would not identify all vulnerable children known to Children’s Services. Differing Police powers- although leading the investigation, the CFI Team did not have the required powers to secure the PPO. The Police National Computer system did not include contact details for the Investigating Officer. This case has identified the importance of information held on the Police National Computer containing sufficient detail to enable timely contact with Investigating Officers including outside of standard office hours- see Recommendation 5. Children subject to Care Orders and placed at home- these children are extremely vulnerable given that they are living with parents when there has been sufficient concern about parenting capacity to warrant Care Proceedings. The review has identified the importance of practitioners understanding that children can be LAC and placed at home, their vulnerability and the terminology used. It has also identified that effective multi-agency working is required to safeguard them and that current systems in place do not always support this. For example, Police Forces not flagging LAC on their systems in the same way as they flag children subject to Child Protection Plans. Local action has been taken by Page 7 of 8 Children’s Services and GMP and all LAC placed in Salford are now flagged on GMP systems- see Recommendations 2 and 3. The use of written agreements- prior to the review, Children’s Services had reviewed the use of written agreements and was implementing an action plan which includes the development of a policy. Good practice was seen in this case through ensuring the agreement was translated into the language of parents’ choice. The review highlighted the importance of key partner agencies understanding the expectations of written agreements- see Recommendation 1. Children made subject to PPOs- expected practice is there must always be a Strategy Meeting or Discussion before a child is released from the Order which didn’t happen in this instance- see Recommendation 4. Identification of parental disguised compliance- the review has highlighted there can be disguised compliance even in cases where parents are presenting as fully engaged with all services. It is important to obtain confirmatory evidence wherever possible in addition to parental assurances that required actions have been completed. Seeking such evidence can support professional opinions of good engagement or disprove these. Conclusion: The following key messages have been identified for practitioners through the review: Effective information sharing and communication are vital if children are to be safeguarded when their parents are involved in serious crime- robust risk assessment and planning can only take place once all relevant information is known and understood. The possibility of flight risk should be actively considered in these cases. Practitioners working with LAC placed at home should be alert to their vulnerability and ensure they understand their responsibilities towards safeguarding them and meeting their needs. Whilst parental written agreements are put in place by Children’s Services, involved multi-agency practitioners need to ensure they are clear about the content, that this is documented within agency records and that they understand their responsibilities towards written agreements when working with families. Always be alert to the possibility of disguised compliance even when parents present as fully engaged and working well with agencies. The following recommendations for the SSCB have been made: Recommendation 1: Children’s Services to provide assurance to the SSCB to ensure the policy on written agreements reflects the learning from this case. This should include evidence of review, compliance and expectations for partner agencies. Recommendation 2: Information sharing arrangements between Children’s Services and GMP regarding LAC to be formally agreed and reflected in the updating of Salford Children’s Services internal notification procedures. All agencies will need to confirm how they record if a child is LAC. Recommendation 3: The SSCB Training Coordinator to review relevant SSCB courses including Basic Awareness, Foundation and Refresher courses to include reference to the different Care Orders and what they mean. Recommendation 4: GMP and Children’s Services should assure the SSCB that Strategy Meetings or Discussions are always held when a child has been subject to a PPO. Page 8 of 8 Recommendation 5: Home Office to provide assurance to the SSCB that the systems issues, relevant to the organisation, have been considered, systems strengthened and the learning has been disseminated to relevant departments. Recommendation 6: Partner agencies to assure the SSCB that the learning from this Multi-agency Concise Review has been implemented and embedded into practice. |
NC52279 | Non-accidental injury to a 4-month-old child in 2018, attributed to shaking. Mother received a custodial sentence. Learning includes: provide child impact chronologies to understand the daily lived experience of children; the views, wishes and feelings of children are critical to effective interventions; a trauma informed approach to assessment, incorporating a strengths based methodology, can be invaluable when adverse experiences in childhood have been identified; cannabis use, particularly if prolonged, is a significant feature contributing to poor mental health and compromised parenting; family engagement is critical to keeping children safe; consider the possibility of abusive head trauma in cases where there are young babies and children and domestic abuse is present. Recommendations include: planning and interventions should be informed by a conceptual model of change, particularly when working with families struggling with interrelated mental health issues, alcohol or substance misuse; ensure that a trauma informed approach to planning and interventions is embedded into practice, particularly where adverse childhood experiences have been identified.
| Title: Chid W serious case review. LSCB: Manchester Safeguarding Partnership Author: Rafik Iddin Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Manchester Safeguarding Partnership Child W Serious Case Review This report was commissioned and prepared on behalf of the Manchester Safeguarding Partnership Independent Reviewer: Rafik Iddin Ratified by MSP Children’s Executive on 11th May 2020 Published by the MSP on the 22nd September 2020 2 Contents 1. Introduction 2. Planning and Methodology 3. Overview of what was known to Agencies 4. Analysis of Practice 5. Learning from the Review 6. Recommendations Anonymisation Key Designation Referred to as: Subject Child Child W Mother of subject child WM Father of subject child WF Sibling 1 S1, 1st child of WM Sibling 2 S2, 2nd child of WM Father of S1 Father of S2 S1F S2F Paternal Grandmother FM 1. Introduction 1.1 Child W is the third child born child to the mother (WM), and the first child of WM and father WF. Child W sustained a non-accidental injury when aged 4 months, at 3 which time Child W lived with WM and two half siblings, S1 aged 10 years and S2 aged 7 years. 1.2 In November 2018 paramedics were called to WM’s home address, due to reports from WM that Child W was convulsing and had stopped breathing. Child W was revived by paramedics at the scene and admitted to hospital. Shortly after admission and following further examination, it was suspected that Child W had suffered a non-accidental injury, consistent with being shaken. Following completion of the MRI Scan the next day it was concluded that Child W had suffered subdural bleeding, consistent with being shaken without an impact. 1.3 At the time of the incident Child W was subject to a Child Protection Plan, as were S1 and S2, an Initial Child Protection Conference having been held on the 24/9/18. 1.4 Greater Manchester Police were alerted to the incident through the ambulance service and hospital and commenced an immediate investigation into the circumstances of Child W’s injuries. WM was subsequently charged with a Section 18 assault, contrary to the Offences Against the Person Act 1861 (Inflicting Grievous Bodily Harm with Intent) and remanded in custody to Court. WM subsequently pleaded guilty to a Section 20 assault, contrary to the Offences Against the Person Act 1861 (Inflicting Grievous Bodily Harm without Intent) and was sentenced in June 2019 to 20 months imprisonment. 1.5 The circumstances of the incident were considered by the Manchester Safeguarding Children Board Serious Case Review Panel (now known as Manchester Safeguarding Partnership) and subsequently the Chair of the Board. A decision was made to convene a Serious Case Review in line with regulation 5 of the LSCB Regulations 2006. For this Serious Case Review Regulation 5(2) (a) and 5(2) (b) (ii) applied, that being that the abuse or neglect of a child is known or suspected and serious harm is caused: and there is cause for concern as to the way in which the Authority, their Board partners or other relevant persons have worked together to safeguard the child. 4 2. Planning and Methodology 2.1 An independent reviewer was appointed to facilitate the review and complete the overview report. A first meeting of the Serious Case Review (SCR) panel took place in September 2019. The panel carefully planned the review process and set all milestone dates with the intention to complete the SCR by February 2020. 2.2 An initial multi-agency chronology of key interventions with Child W, the siblings and parents was compiled and through this the panel established that the optimum opportunities for learning about practice arose between September 2017, the date when WM became pregnant with Child W, and mid-November, the time of the non-accidental injury. It was also agreed that any periods of multi-agency work with the family prior to this timeframe would be considered, but only in so far as it impacted on any assessment within the identified reference points. In that respect it is acknowledged that there is additional information in relation to both S1 and S2 prior to this timeframe in respect of the circumstances leading up to the injuries to Child W. However, these events are significant in so far as determining how that history had informed any subsequent assessment of risk in relation to Child W. 2.3 The review panel agreed the following key lines of enquiry to be addressed within the review: ● To review the approach to domestic abuse and how needs were assessed and met from the perspective of a victim, perpetrator and child. ● To what extent did assessment follow a strengths based model and consider the approach to building resilience within the family unit. ● To what extent was the presence of drugs and alcohol and mental health factored into any assessment and planning? 5 ● What approaches were taken to engage the family and was non-compliance addressed within the multi-agency approach. ● To consider the purposefulness and effectiveness of the Child Protection Plan and its delivery across the multi-agency partnership. ● To what extent was the risk of abusive head trauma in the mind set of professionals It was also agreed that the terms of reference would be reviewed at each meeting pending any further information being submitted. 2.4 Each participating agency completed a detailed chronology and a reflective account from this of the issues they considered to be key for their own agency. 2.5 The methodology adopted by the review panel was committed to engaging with key practitioners and family members where possible and in particular, achieving a review that complied with statutory guidance contained in Working Together 2018. This requires the Serious Case Review to understand practice from the perspective of the individuals and organisations involved at the time, rather than relying on hindsight, and to recognise the complex circumstances within which professionals work together to safeguard children. 2.6 The Review provided a briefing session for key professionals involved in the case in November 2018. The purpose of this was to introduce practitioners to the methodology of the review, offer some re-assurance about a process that can invoke considerable anxiety and to facilitate a deeper analysis of the pertinent practice issues that were relevant to the case. Practitioners then committed to participate in structured individual conversations about the case with members of the review panel. 2.7 The Lead Reviewer along with the Safeguarding Partnership Coordinator, met with both WF and FM, Child W’s father and Paternal Grandmother, to explain that a Serious Case Review had commenced and how this would be conducted. The review also sought to 6 elicit the views of both WF and FM as to the quality of services that Child W and the family had been in receipt of. 2.8 The Lead Reviewer, along with a Prison based Family Intervention Worker, met with WM, again to explain that a Serious Case Review had commenced, how this would be conducted and how WM, as Child W’s mother, had experienced the intervention of professional agencies. 3. Outline of how Child W and family was known to Agencies 3.1 The agency history dates back to 2008 when Child W’s father WF, was convicted of the possession of a bladed knife and controlled substances (Cannabis). Following a number of further offences in 2009 and 2010, WF received a 10 week custodial sentence for failing to comply with Community Orders. In 2012 WF received a further custodial sentence for threatening behaviour. 3.2 In December 2009 WM reported that she had been the victim of Domestic Abuse from S1’s father, S1F and also from S1F’s father, S1’s Paternal Grandfather. However, it is not clear what risk was posed to WM and S1. At this time WM was referred to Mental Health Services but was discharged due to not attending appointments. 3.3 The following year S1 was referred to the Children’s Community Nursing Team regarding constipation, although the agency could not contact either parent to arrange an appointment and S1 was consequently discharged. 3.4 In January 2014, WF was referred for an Autistic Spectrum Condition (ASC) assessment. A letter was also written to WF’s GP, requesting a referral for Anger Management. WF did not meet the diagnosis for ASC although was later assessed by the Psychological Formulation Clinic in 2016 and 2017. This clinic offers an assessment in respect of complex relationship difficulties, including a relevant management plan, and signposting to 7 appropriate therapy or other services. This assessment concluded that WF did not meet the criteria for a diagnosis of any specific personality disorder although in 2017 WF was accepted into an extended service under the ADHD clinic, and was seen on a 1:1 basis. The treatment plan was to assess and treat ADHD under NICE guidance medication although WF’s attendance was inconsistent. Whilst this is not unusual for someone with an ADHD diagnosis, WF responded well to assertive follow up, if appointments were missed. 3.5 In July 2013, S1 did not attend an appointment with Audiology Services and was subsequently discharged. 3.6 In December 2013, WM made a number of complaints regarding noise and drug use near the family home, which WM alleged was impacting on S1’s attendance at school. WM also reported being threatened by neighbours. WM’s behaviour was noted to be erratic when making the reports and was of sufficient concern for Housing Officers to consequently record their concerns about her mental health. 3.7 Due to corroborated evidence from a neighbour that WM’s life had been threatened, a decision was made to award priority for the family to move due to safety concerns. However, WM did not move until November 2014 and when questioned about this reported that she was waiting for a suitable property in an area where she was close enough to get family support. Surveillance was also actioned but no evidence of drug related activity was identified. Throughout 2014 WM continued to report concerns regarding noise, gang and drug related activity and nuisance behaviour which was impacting on the children’s sleeping. In November 2014, WM, S1 and S2 were rehoused to the address where the non-accidental injury to Child W took place. 3.8 During this period School raised concerns regarding the vulnerability of S1 and in June 2014 made a referral to Children’s Services regarding the safeguarding issues related to the property and S1’s poor attendance. Concerns were also raised regarding S1 not being 8 taken consistently to health appointments. This resulted in a professionals meeting at school although no further information was available to the review regarding this. 3.9 In March 2015 concerns were raised that WM had threatened a number of students who were living in the neighbourhood, and about whom WM had reported noise and nuisance behaviour. WM had also threatened to “break the students’ fingers” if they continued to behave in this manner. WM’s behaviour was reported to have been disproportionate to the disturbances which had been alleged and there were concerns that WM would act in the way that the witnesses had described and follow through on her threats. 3.10 Consequently a referral was made to Children’s Services concerning WM’s erratic behaviour and the impact that this might be having on the children. Concerns were raised that WM was violent and aggressive but then quickly calmed down. The Multi Agency Safeguarding Hub (MASH) recommended further assessment, however the case was closed without an assessment being completed. 3.11 At the same time WM reported to her GP that she had been having suicidal thoughts and that she would end her life if there was someone to look after the children. WM was consequently prescribed anti-depressants and referred to the CRISIS Team. A referral was also made to the Mental Health Home Treatment Team, although when contact was made with WM she reported no longer having any suicidal ideation although GP records noted a high risk of self-harm. 3.12 In November 2015, S1’s father made a referral to Children’s Services. Whilst asking to remain anonymous, he raised concerns that WM was using drugs and misusing alcohol. The referral also referenced concerns regarding WM’s mental health and allegations of erratic behaviours. Whilst further assessment was recommended the case was closed, following a duty management decision that the threshold for Level 5 was not reached and that support could be provided by school under the auspices of an Early Help Plan. 9 3.13 In April 2016 a further referral was made to Children’s Services by S1’s father, reporting that an incident had taken place between himself, WM and WM’s sister which resulted in the Police being called. This resulted in WM and her sister being arrested and sustaining bruising, which WM and her sister alleged was from the Police Officers. The circumstances of this incident, whilst outside the time frame of the review are concerning. It is reported that S1’s father S1F, had returned S1 to WM’s home address but there had been no suitable adult at the address. S1F had then returned a short time later and WM and her sister had then attempted to assault S1F, causing damage to his car whilst he was sat inside. S1F had then reversed at speed and collided with several cars in the process. As members of the public had then contacted the Police, officers attended S1’s home address and both WM and her sister are arrested for a Section 47 assault. Both WM and her sister then attempt to assault the officers which result in CS gas having to be deployed. Both WM and her sister are then further arrested for assault with intent to resist arrest and criminal damage. WM is additionally arrested for the possession of cannabis. A Child and Family Assessment was completed although both parents gave differing accounts of what had taken place. WM had also alleged that S1’s father had been violent towards her and that if he was now seeking contact with S1 this would now need to be agreed in Court. The children were seen who did not report any concerns and the home conditions were noted to be appropriate. The school also reported a good relationship with WM and the case was closed on the 20/7/16. 3.14 On the 22/8/16, WM contacted her GP and spoke to reception stating that “she gets angry with her husband”. WM insisted on seeing the GP and was given an appointment which then took place on the 9/9/16 WM. Information provided by WM also suggested that she had been violent towards previous partners. A safeguarding referral was made but no further information was recorded. No further information is available regarding this. 3.15 In December 2016, S1 was referred to the Children’s Continence Team, although there were a number of missed appointments, which were a feature of the period between December 2016 and September 2018. Records note that the reason given for a missed appointment on the 21/5/18 was that WM was “heavily pregnant and was unable to 10 attend until after the baby was born”. Concerns have also been expressed in the Learning Review as to why S1, who had presented with a history of chest pains, fatigue and blue lips, was not brought to a cardiology appointment. Whilst this referred to the period between November 2016 and November 2017, this does suggest non-compliance. 3.16 In January and February 2017, S1 sustained three bruises which were located on the wrist, arm and head. S1 did not know how the arm and wrist bruises were caused and these were observed in school. These were not reported to Children’s Services and no further action was taken. 3.17 On the 6/9/17, WM arrived late to collect the children from School and presented as under the influence of alcohol. School staff were of the view that she was not too drunk to care for the children and reported that WM was distressed due to meeting up with her father. WM had also reported that her relationship with her previous partner had just ended. Consequently, WM was asked to “get some fresh air” and return within the hour. S1 was distressed due to WM’s presentation and it was suggested to S1 that, “if frightened when back at home to call 999”. As WM did not return to school as agreed it was proposed that school staff would meet WM on the cycle path later that evening. School staff also contacted S2’s father S2F, who attended and it was agreed, after S2F had contacted WM, that S2F would take the children for the night. S2F also expressed a concern as to how “out of it” WM appeared to be. 3.18 When WM was visited as part of the review, she reported that she had been drinking on this occasion as it had been the anniversary of a miscarriage. 3.19 A referral was then made to Children’s Services the following day, the 7/9/17, resulting in a Child and Family Assessment which highlighted concerns regarding WM’s mental health, challenging and violent behaviour and ”potential” alcohol and drug use. WF’s cannabis use was also referenced in terms of how this might be impacting on the children. WM also reported that the episode at school with alcohol was a “one off” incident. The case was closed to Children’s Services on the 25/10/17. 11 3.20 However, within this period, during a meeting on the 3/10/17 between WM, S2F and the Social Worker (SW1), the Social Worker recorded that WM was acting erratically, in a way that was consistent with amphetamine use. The school had also recorded at this time that there were concerns regarding WM’s presentation, that she sometimes appeared “manic or high”, but that, “she is different to other parents and assumptions can be made that has taken something”. The school records also noted that there were two previous incidents related to WM’s alcohol use, in June 2016 and July 2017, but not enough to raise concerns. 3.21 On the 29/11/17 a request for Social Work Support and a pre-birth assessment was made by midwifery to Children’s Services. This related to conflicting and inconsistent information regarding WM’s alcohol use and that there had been a history of maternal cannabis use during previous pregnancies. WM had also reported ongoing anxiety related to a previous termination, a miscarriage and the impact on her of her father’s poor mental health. This was a precise and well written referral, clearly identifying risk which resulted in a further Child and Family Assessment recommending Child in Need planning. Whilst WM was initially extremely resistant to further assessment visits were completed although on the 20/12/17 concerns were expressed, during a conversation with the Social Worker and the School Safeguarding Lead, that WM had been “telling professionals different stories”. This appeared to be in relation to substance misuse and it was later confirmed, in July 2018 that WM had been using cannabis until 25 weeks gestation. The case was closed on the 22/1/18, although the school expressed concerns that Social Work involvement had not continued. Within this period, on the 15/12/17, at a booking appointment for midwifery at St Mary’s hospital records also noted that “safeguarding concerns” had been identified, and that this had been referred to Children’s Services. Records noted that WM was upset about the referral and extremely agitated on the phone. 3.22 In late January 2018, concerns were expressed by school during a “Bridging the Gap” meeting regarding WM’s mental health, S1’s attendance, which had dipped to 92%, and 12 S2’s attendance and frequent lateness. “Bridging the Gap” aims to resolve issues and concerns at an earlier stage via the facilitation of discussions between Schools, Social Care and Early Help. This is provided via a regular “Clinic” based approach, which aims to develop partnership working and respond quickly to concerns where the key focus is “the right service at the right time”. Following this meeting the School were advised to share concerns with Children’s Services and the Social Worker (SW1) was e-mailed. 3.23 A self-referral had been made by WM to CGL (Change, Grow, Live) and an appointment was made for the 10/1/18, however WM did not attend. A follow up letter was sent on the 25/1/18 encouraging WM to make contact. As there was no response the case was closed on the 26/3/18. 3.24 On the 25/5/18, WM attended the GP Surgery but left without being seen, as she was called 15 minutes past her appointment time, due to complications with the previous patient. It was also reported that WM was “verbally challenging” towards the receptionist and consequently a chaperone was recommended for midwifery visits. Records also note that there were a number of failed appointments with health professionals at this time. 3.25 On the 20/6/18 following a conversation with WM regarding S2’s behaviour in school, the school noted that WM’s approach towards S2 was inconsistent, “loving one minute and threatening to send them to their father’s the next”. It was noted that WM was having a new baby and that she was stressed. It was also noted that school decided to document the concerns rather than refer to Social Care, to avoid adding to WM’s stress. 3.26 On the 2/7/18, Child W was born at St Mary’s Hospital. Child W was born by Caesarean Section, due to foetal distress and WM reported to school on the 6/7/18 that she had been traumatised by the delivery and she had nearly lost the baby, but that she had been offered counselling to help cope. During a telephone consultation with the GP Surgery a few days later, WM reported that she had asked WF to move out, that she was stressed and that the only things that made her happy were her children. 13 3.27 On the 10/7/18 WF was reported as missing from home by his mother FM who reported that, “he was suicidal following a split from his girlfriend”. He was located by Police at a nearby water park and disclosed that he had not been taking his medication and that he also had a “cannabis addiction”. FM reported that following an argument with WM he thought he would not see his 10 day old baby again and Greater Manchester Police (GMP) consequently made a safeguarding referral. However, during a new birth visit on the 12/7/18, the Health Visitor (HV) noted that “a close bond was observed between mother and baby”, that Child W was gaining weight and was assessed as “well cared for”. 3.28 On the 16/7/18, a further referral was received by Children’s Services from FM, as WF had told his mother that he wanted to kill himself and that the relationship between himself and WM was under immense strain and was also volatile. On the 19/7/18, WM contacted the Police to have WF removed from her address following a verbal argument. No offences were disclosed by either party. On the 21/7/18 a domestic abuse incident was recorded, due to WM having ended her relationship with WF, whilst he was at her address to see Child W. WM had reported that WF was sat with Child W in his arms, verbally abusing WM, who then took Child W from him and left her address. WF then contacted the Police, expressing concerns that WM had post-natal depression and that she was “rough” with Child W. 3.29 The following day WM again contacted GMP, as WF had again attended her address, despite being asked to leave the previous day. However, WF reported to the Police that after he had been advised to leave the property the previous day, WM had phoned him, “begging him to come back”, which he did. WF reported that they then spent the evening together before WM demanded that he leave the property in the morning. WF reported that he told WM that he could not cope with her mood swings, to which WM told him to “go and kill himself”. WF was located, found to be in possession of a bag of cannabis and detained at hospital under S136 of the Mental Health Act. It was also noted that there was difficulty in ascertaining who the victim was, due to both parties “potential mental health issues”. WF was assessed by the Mental Health Service and discharged home. 14 3.30 It is also recorded that WF had attended Accident and Emergency on the 23/7/18, presenting with a superficial abrasion to his face and head and an open wound to his right hand and right knee. WF reported that a glass light fitting had fallen on his head and there were no indicators of domestic abuse. 3.31 Police information however noted that WM had reported that WF was, “smashing the house up and would not leave”, consequently Police attended and removed WF. WM also disclosed that she had been assaulted by WF “three days ago” which she had not reported and was in respect of cannabis. WM alleged that WF had “punched her in the back causing a small bruise”. 3.32 Whilst WM refused support from Children’s Services and would not attend Court. WF was arrested for the assault but was intoxicated at the time. WF’s father was also in attendance as an Appropriate Adult, due to concerns raised by FM that WF had been “diagnosed with Autism and ADHD, that he was suicidal and that he was suffering with PTSD”. When interviewed, WF denied the assault, citing self-defence and that he had been the victim of numerous unreported assaults by WM, including a broken nose in January 2018. WM reported that on the 25/7/18, WM had threatened not to name him on W’s birth certificate “unless he returned home”. WF reported that during the night an argument then occurred over him making too much noise and WM had attacked him and that consequently during this, he “caught WM on the side of the ribs in self-defence”. WF also reported that on the 22/7/18, WM had “thrown a mirror at him”. Due to the absence of any independent witnesses no further action was deemed appropriate by the CPS. 3.33 On the 28/7/18, Children’s Services received Police information confirming that there had been 5 domestic incident reports over three weeks. Whilst a further Child and Family Assessment was initiated, no Strategy discussion or Section 47 Enquires had taken place. In addition, no immediate action was taken to safeguard the children and there is no evidence that a Child Protection Conference was considered. Records note that WF was bailed until the 25/8/18 not to attend WM’s address. Following WF’s release from custody with bail conditions, the matter continued to be investigated and a prosecution file was 15 submitted to the Crown Prosecution Service (CPS). However the CPS made a decision not to charge WF as there was insufficient evidence. WF was then advised of the decision and bail cancelled. In addition, whilst the case was being managed on a CIN basis, there was only one CIN Meeting, which was held on the 23/7/18, which suggests that CIN processes were not sufficiently robust. 3.34 On the 7/8/18, an e-mail from a Community Midwife to the HV reported that WM had denied domestic abuse in the relationship, but reported that WF was argumentative. During a HV appointment on the 13/8/18, an assessment of WM’s mood for Post Natal Depression “did not show any issues”. It was reported by WM that “the parents had now separated”. 3.35 On the 31/8/18, a 3rd party reported to the Police (GMP) that “he could hear screaming” from WM’s address and “a female shouting for the Police”. Police attended and WM reported that WF had forced entry to her bedroom and “slapped her twice on the face causing swelling on her lip”. WM reported that WF then threw step ladders at her as she ran down the stairs. WM also reported that she ran out of the house, called for help and shouted for someone to call the Police although WF then threw her against the stairs. However, WM declined to make a statement and said that she was going to move back to Blackpool to be nearer her mother. It was noted that Child W, only two months old at the time, was present during the incident, although both S1 and S2 were away on holiday. 3.36 On the 1/9/18 GMP completed a Multi-Agency Risk Assessment Conference (MARAC) referral due to the severity of the incident, as WM had sustained injuries resulting in a swollen lip, bruising to the wrist and pain to the back. 3.37 A referral was made to Children’s Services, a Strategy Meeting was arranged for the 7/9/18 and joint Section 47 Enquiries were initiated. WF was arrested although a “no comment” interview was provided. The Section 47 Enquiry recommended that an Initial Child Protection Conference (ICPC) be convened for all three children and a referral was received for an ICPC on the 11/9/18 by the Manchester Safeguarding and Improvement Unit (SIU). The concerns noted were the volatile relationship between WM and WF, the 16 number of Police call outs where Child W was present and WF’s alcohol and criminal history. 3.38 On the 6/9/18 the Independent Domestic Violence Advocate (IDVA) received the referral for MARAC. This service works with cases that are deemed to be at high risk of serious harm or homicide that have been referred to the MARAC. Support and advice are offered to victims of abuse and children, aiming to reduce risk and increase safety. However, there was a 5 day gap between the incident and the receipt of the MARAC referral by the IDVA. 3.39 On the 19/9/18 the case was heard at the MARAC and it was agreed that the SW would discuss with WM if support was required from the IDVA, including assistance regarding an application for a non-molestation Order. However, there was an 11 day gap between the incident and the IDVA’s first attempt to call WM. On the 21/9/18 the case was closed to the IDVA, as WM indicated that she did not want any further support. 3.40 On the 7/9/18 the HV requested an update from the SW regarding the ICPC, as it was apparent that WF was staying over at WM’s address. The HV noted that there have been 4-5 incidents in 9 weeks which were, “the length of W’s short life so far”. The elder children had also indicated that they would prefer WF not to be at the house, due him being argumentative. 3.41 On the 10/9/18 Child W was seen at the Baby Clinic with WM. It was noted that Child W was appropriately dressed and that there was evidence of a good attachment. WM reported that despite the concerns regarding domestic abuse, she did not want to apply for a non-molestation Order in case WF breached it, which meant that he would go to prison. On the same date, WM reported to the GP Surgery that whilst the Local Authority were involved, there was no threat to herself, either physically or verbally. 3.42 The Child in Need (CIN) Meeting scheduled for the 14/9/18 was then cancelled as safeguarding procedures had been invoked. 17 3.43 On the 24/9/18 an ICPC was held. All three children were made subject to CP Plans under the category of neglect. The outline plan specified that WF was not to visit WM’s address and that if he did, WM was not to let him in and to call the Police. The GP report for the Initial CP Conference did not reference domestic abuse. 3.44 On the 1/10/18, WM contacted GMP to report that WF was at her address stealing her belongings. WM was not at her address at the time of the call, however when officers attended the address there was no sign of WF or of any forced entry. Whilst GMP completed a MARAC referral for a repeat incident, it was noted that there was no evidence that WF had been at WM’s address. 3.45 During a home visit by the HV on the 9/10/18, it was observed that Child W was calm, interacting well and sleeping independently. WM confirmed that her relationship with WF had ended and that she was now feeling much better, although GP records noted that there were no records of primary immunisations for Child W. 3.46 On the 22/10/18 the case was allocated to the IDVA. There was a 13 day gap between receiving the referral and allocation. On the 26/10/18, four days following allocation, the IDVA attempted to contact WM. This was unsuccessful as the call just “rang out”. 3.47 On the 27/10/18, a 3rd party reported to GMP that WM had run to their address stating that she had been assaulted by WF. This incident followed WF and WM having spent the day together, although WM had become angry with WF as he was going to work the following day and was not spending time with W. WM reported that WF had picked up a vase and had attempted to hit her with it, and then kicked WM twice, whilst she attempted to leave the room and as she was carrying Child W. WM reported that she went upstairs, picked up S2, managed to get past WF and then ran to her neighbour’s house who called the Police. 3.48 WF had also sustained a wound to his chest, which he reported had been caused by WM as she attacked him with a bottle. WF reported that WM had fabricated the allegation that he had assaulted her, although WM reported that WF had stabbed himself with a 18 shard of glass. As WM had left the address and had recently reported 2 domestic abuse incidents, she was treated as the victim. Due to counter allegations and no independent witnesses to the assault the CPS made a decision not to charge. 3.49 WF had also made an emergency 999 call reporting that he had “been bottled”. The call taker noted that WF appeared to be intoxicated and consequently a safeguarding concern was raised for the children. However, whilst at hospital, WF provided his home address, which was not Child W’s address and Child W’s date of birth was recorded incorrectly. WF was also unwilling to provide further details and whilst indicating that he had a partner at home with children, including Child W, WF reported that he was “afraid of breaking up the family”. This was followed up by the MFT Safeguarding Nurse on the first working day following the incident, who attempted to locate the children via a comprehensive system check. This was unsuccessful as inaccurate and limited information had been provided by WF. Again, on the 5/11/18 the same nurse made a further attempt to identify the partner of WF and Child W and contacted WF’s GP. This was a different GP based in Trafford and on the basis of the information reported by WF, the children could not be identified. Consequently, it was agreed that no further action would be taken. A risk assessment was completed and submitted to MARAC noting the concerns regarding domestic abuse and details were provided to WF regarding a men’s “advice line”. This was good practice and the Safeguarding Nurse made more than one attempt to locate the children based on the address, date of birth and GP details provided. 3.50 However, whilst Child W was subject to a Child Protection Plan, no Strategy or legal planning meeting took place, which would have considered the immediate safety of the children. 3.51 Whilst the IDVA made eventually made contact with WM on the 29/10/18, there was some confusion as to the identity of the primary victim in the relationship. On the 29/10/18 the IDVA agreed to call WM back on the following day. However this was unsuccessful. 19 3.52 On the 29/10/18, WM reported to school that WF was the perpetrator of the assault and that the police had confirmed that WF’s wound was self-inflicted, although GMP had no evidence that this was the case. The CPS reported that both the accounts of WF and WM were plausible, but as there was no CCTV or witnesses and because the scene was consistent with both versions, it would be difficult to prove beyond reasonable doubt. However, WM reported that S2 had also witnessed the incident, including a threat from WF to “kick her face in”. WM also reported to school that the SW had agreed that WF could be allowed back in the house. On the 29/10/18, WF also reported to the GP that she “had not let WF near the children”. 3.53 On the 30/10/18, a Core Group was held, where a number of concerns were discussed, particularly that a core element of the Child Protection (CP) Plan had been breached. It was confirmed that WF would not be having any contact with Child W until a risk assessment had been completed. 3.54 On the 5/11/18 (Monday) S2’s father, S2F, contacted Children’s Services to report that S2 had told him that WM had stayed at WF’s address on the Friday evening (2/11/18) and looked after S2 on Saturday (3/11/18). The SW visited S2 in school and whilst S2 denied that WF had been at the family home (and that S1 looked after him and Child W), S2 then subsequently told school staff that they had seen WF, but only for a few minutes. It was also noted that S2 was unsettled in class and was complaining of various illnesses. 3.55 On the 7/11/18 the SW2 reported to the IDVA that the case was being taken to a Legal Gateway Panel. The SW reported that WM had become very upset at hearing this, and stated that that “if her children were removed she would kill herself”. 3.56 On the 9/11/18, a report from the Psychological Wellbeing Service (PWS) noted that the SW had been called who then informed the PWS that “WM is quick to lose her temper, often with partners and around the children”. The SW confirmed that “two weeks ago WM had a very physical altercation with her partner in front of the children”. 20 3.57 The SW reported that legal advice was being sought regarding the children, but that there was a concern that WM would self-harm if the children were “taken off her”. Consequently, WM was assessed by PWS and it was concluded that there were “no self-harm thoughts or thoughts of harming others”. However, whilst WM was assessed as not having any risks, she told the PWS that, “this will change if the children are taken off her”. 3.58 On the 14/11/18 paramedics were called to WM’s home address due to reports from WM that Child W was convulsing and had stopped breathing. Child W was revived by paramedics at the scene and admitted to hospital. Shortly after admission and following further examination, it was suspected that Child W had suffered a non-accidental injury, consistent with being shaken. Following completion of the MRI Scan on the 15/11/8 it was concluded that Child W had suffered subdural bleeding, consistent with being shaken without an impact. 4. Analysis of Practice 4.1 The analysis of the practice is informed by the written agency records, the reflections of practitioners who had direct involvement with Child W and the key adults around the child, the experience and local knowledge of the members of the SCR review panel and the lead reviewer’s independent contribution. 4.2 Prior to September 2017 there was a significant although not extensive history of agency involvement with WM which dated back to 2009 including WM being a victim of domestic violence and having been a Looked After Young Person. 4.3 Concerns were also recorded from this time regarding WM’s mental health and this is referenced following the complaints that WM had made regarding nuisance behaviour in December 2013. In 2015 a referral was made to the Local Authority in respect of 21 WM’s mental health, which included suicidal ideation, and her challenging and potentially violent behaviour. 4.4 In December 2014 concerns had already been raised regarding the vulnerability of S1, a number of missed health appointments for S1 and the housing situation, which resulted in a professionals meeting at the school, although there is no further information regarding this. Missed health appointments for S1 are also a consistent feature between 2016 and 2018. 4.5 These elements suggest that WM was struggling to parent and that there had been a number of adverse experiences during her earlier years. It has been difficult for the review to precisely identify the nature of any early help that was offered during this time, although there were three referrals to Children’s Services in 2015 and 2016 which resulted in no further action, or assessment followed by case closure. 4.6 The incident at school which took place in September 2017, whilst resulting in a referral to Children’s Services the following day, suggested concerns relating to both WM’s mental health and alcohol use. The case was closed 6 weeks later in October 2017, although a further referral was made by midwifery in November 2017 due to WM reporting regarding alcohol use during pregnancy which contradicted previous disclosures. Whilst this referral was both comprehensive and timely, the case was again closed in January 2018 despite concerns regarding S2’s attendance at school and frequent lateness, that WM had been “telling different people different stories”, further safeguarding concerns being raised by midwifery in December 2017 and WM’s resistance to interventions. By this time WM was now pregnant with Child W, which was an indicator that interventions should have continued. 4.7 Of particular concern is the observation made in October 2017, by the Social Worker (SW1), where WM’s presentation is noted to be consistent with amphetamine use, although this matter is not pursued. 22 4.8 Following the birth of Child W in July 2018 there were a number of incidents which warrant further analysis. The volatility of the relationship between WM and Child W’s father WF is particularly evident during this time and there were at least two occasions where WF was distressed and had indicated suicidal ideation. This does not appear to have triggered an assessment of the family’s circumstances, and in particular the impact of WF’s presentation and mental health on the children, which, given the history would have been appropriate. Previous concerns regarding WF’s anger management, cannabis use, poor impulse control and his possession of weapons are also referenced at this time. Consequently, it was noted that there was an ongoing concern for the safety of WM and the children and whilst there is reference to a Strategy Meeting in the Police records, it is unclear as to whether any assessment then took place by Children’s Services. 4.9 By late July 2018 there had also been two further domestic abuse incidents which had taken place at WM’s address and which had involved both WM and WF, whilst Child W was present. Whilst this initiated a fresh assessment, no Strategy discussion leading to any Section 47 Enquiries took place, which would have been entirely appropriate, particularly given that Child W was less than a month old at this time and was extremely vulnerable. Given the previous referral history, the concerns regarding alcohol and cannabis use, WM’s resistant, volatile and challenging behaviours and lack of engagement, the concerns regarding WF’s mental health and the level of domestic abuse already taking place within the family home, this would have been an opportune moment to undertake robust safeguarding enquiries and to holistically assess the family’s circumstances. 4.10 Whilst WF had been bailed until the 25/8/18 with conditions not to attend WM’s address and files were submitted to the CPS, the CPS were of the view that there was insufficient evidence to agree a charge. Whilst consideration was given to an investigation under the Serious Crime Act 2015 regarding controlling or coercive behaviour in a family relationship, information from FM and a friend of WF suggested, even at this point, that this was not the case. 23 4.11 Four of the incidents reported in July 2018 were not reviewed by GMP until the 28/7/18 and referred to Children’s Services on the same day. The triage unit had a considerable number of medium risk domestic abuse incidents requiring review during this period which accounted for the number of days taken to process the incidents. In that respect there was clearly a capacity issue although officers had recognised the need for these incidents to be referred to Children’s Services, which under a revised protocol would now ensure that incidents are referred immediately to the MASH. In July 2019 GMP introduced a new IT system (IOPS). This requires the attending officer to submit a care plan to the MASH at the time the incident is updated. Incidents in all three Manchester Divisional Safeguarding Teams (DSTs) are now discussed as Domestic Abuse Child Concern (DACC) Meetings. 4.12 It has also been very difficult for the review to specify the nature and robustness of any Child in Need (CIN) planning during the period up to July 2018, both in terms of the frequency of meetings and the quality of any CIN plan. In that sense it has also been difficult to see how any previous interventions or concerns, which have been referred to earlier and which resulted in either no further action or case closure, had impacted on the assessment and planning within the review period. It was evident that there had been several child and family assessments which had been completed to address referrals from professionals, family members and the wider public and that there had been ten referrals made to Children’s Services from June 2014 up to the incident on the 31/8/18 which triggered Section 47 Enquiries and the convening of the ICPC. Whilst four of these referrals took place prior to September 2017, the start point for the terms of reference of the review, this information provided a historical and contextual base in which to understand and respond to the more recent concerns and would therefore have enabled a more holistic overview and analysis. As referenced earlier there was just one CIN meeting held, on the 23/7/18, which suggests that processes were not sufficiently robust. However, information was provided to the review which indicated that a more rigorous approach is now taken with CIN planning and review and that CIN meetings must now take place within 20 days of initial contact where an a decision to assess has been made. 24 4.13 The high gravity domestic abuse incident which took place at the end of August 2018 resulted in a referral to children’s services, a Strategy Meeting and joint Section 47 Enquiries being initiated. An ICPC was arranged for the 24/9/18, however the review has not been able to confirm that a safety plan or risk management plan was implemented prior to the Conference, which took place nearly 4 weeks after the incident. This is concerning as the HV had reported in early September 2018 that WF was continuing to stay at WM’s address. The only reference to any pre-conference activity was the cancellation of a Child in Need Meeting on the 14/9/18, due to the implementation of Child Protection procedures. 4.14 Whilst a MARAC referral had been completed on the 1/9/18, there were delays in both the time between the date of the incident and receipt of the referral (5 days) and the date of the incident and the IDVA’s first attempt to contact WM (11 days). This is outside the 48 hours recommended by Safe Lives although information provided at the Practitioners Event suggested that capacity issues within the service had impacted on the timeliness of responses. Had the IDVA contacted WM within this timeframe, it may have resulted in further action to minimise any risks. However, this is speculative, particularly given the information which suggested that WM was resistant to interventions and was complicit in a manipulative dynamic regarding WF. 4.15 Whilst the case was heard on the 19/9/18 and again on the 14/11/18, the date of the incident, both of these noted WM as the victim and WF as the perpetrator. After the date of the non-accidental injury to Child W, there were three MARAC hearings and all but one referenced WF as the perpetrator and WM as the victim. This had been a feature of the case during the review period even though there was information to suggest that WM was complicit in initiating at least some of the violent exchanges. This is reflected in the fact that it was WF who had attended Accident and Emergency following the domestic abuse incidents. As WF was not present at Conference this limited the ability of Conference to explore this matter further and the assumption remained that WF was the perpetrator of any domestic abuse. 25 4.16 Information provided to the review by WF’s mother FM, and which is also contained in Police records, suggest that WF was “thrown out” by WM on several occasions but then was accused of being a “bad father for leaving” and that WM then insisted that he return. FM reported to the review that her son was struggling with this dynamic in the relationship before Child W was born and that WM’s behaviour in this respect was both manipulative and coercive. Health Professionals from the Extended Service also reported that on one occasion WF received at least 50 text messages from WM during an appointment, which WF struggled to manage and respond to. 4.17 Whilst WM had reported that WF’s parents were supportive of her, this view was challenged by FM, who reported that WM was controlling and manipulative. Whilst FM had arrived at Conference, WM had refused to allow FM to attend. FM reported to the Review that she had not participated in any meetings other than having had a conversation with the Chair of the ICPC, prior to Conference. FM reported that WF was “manipulated” into not going to meetings by WM. 4.18 FM reported that WF had been diagnosed with Attention Deficit Hyperactivity Disorder and had “autistic traits” and that he found WM’s behaviours particularly distressing, but was perceived by professionals as being aggressive and challenging. This will have further reinforced the prevailing view that it was WF who was the sole perpetrator of any domestic abuse. 4.19 The Child and Family Assessment undertaken for Conference does not consider these issues, particularly as WF’s mental health was impacting on his presentation which was also described by both WM and S1 as very aggressive. Nor does it consider WM’s volatility, erratic behaviour, alcohol use or possible drug use, the daily lived experience of the children and consequently these elements are not addressed in any depth. The assessment also relies heavily on self-reporting, particularly from WM and does not take into consideration the family history referenced earlier or any Child Impact Chronology, particularly given the episodes referred to above. 26 4.20 Information provided to the Practitioners Event suggested that both S1F and S2F, the fathers of S2 and S1, were frightened of WM and that this had impacted on dynamics within the family and arrangements regarding contact with the other children. This was not considered as part of the assessment provided to the ICPC and whilst S2F was present at Conference, in a capacity to support WM, this was an issue that could have benefitted from further exploration. 4.21 The GP was not consulted with regarding the assessment and did not attend the Initial Conference, which is a significant omission, particularly given that the GP had information regarding the number of “was not brought appointments” which included important appointments to see a cardiologist and an ophthalmologist. There was also a GP history of mental health difficulties, anxiety, panic episodes, low mood, aggressive and challenging behaviours and self-harm. Importantly, there had been disclosures by WM that she had been violent towards previous partners and that this had included WF. Of particular concern was information provided to the GP which suggested that in 2016 WM had assaulted a previous partner and that the matter had been placed before the Court. Given the critical importance of GPs as “lynchpins” in families, which is acknowledged in NSPCC thematic review findings (Learning from Case Review Findings, 2018), the lack of involvement of the GP in the assessment, planning and Conference process is a significant omission. 4.22 The GP learning review also acknowledged that the “Think Family” perspective, which considers family context and in particular the lived experience of the children, could have been considered more broadly and may have led to earlier progression and referral. The GP had considerable information regarding WM’s difficulties regarding relationships, anxiety, mood swings around the children, anger management and missed appointments. However, it is not clear whether referrals were made to Early Help or to the MASH. The GP was also of the view that fundamentally, WM was a protective mother, who presented well and would respond vociferously to any criticism regarding her care of the children. In that sense therefore the involvement of the GP in the assessment, planning and Conference process would have provided additional and critical information regarding WM’s behaviours and presentation. 27 4.23 Similarly, the Extended Service, which was providing interventions for WF regarding ADHD, was not invited to Conference or consulted with as part of the assessment. This would have provided valuable insight regarding WF’s functioning, particularly when under stress and would have facilitated a more robust analysis of parental and family dynamics. In that sense there was a failure to properly assess and consider how WF’s needs and vulnerabilities were impacting on his parenting abilities, which was further compounded by a poor analysis of the domestic abuse dynamic. 4.24 One Manchester Housing, which had considerable involvement with WM regarding tenancies and a number of complaints, was not invited to attend conference or involved in any previous assessment, which would have provided relevant information regarding WM’s non-engagement, non-compliance and erratic and threatening behaviours. Information regarding WM’s patterns of behaviour particularly regarding her allegations of anti-social behaviour in the neighbourhood, often made after concerns had been raised regarding WM’s parenting or behaviour, would have been valuable. One Manchester Housing had been unaware of the non-accidental injury to Child W until attending the first SCR Meeting in September 2019. 4.25 The category of planning, whilst noted as a primary concern in respect of neglect, was not appropriate, as given the issue regarding high gravity domestic abuse and the age of Child W, it would have been more appropriate to reference the risk of physical and emotional harm. 4.26 Whilst the CP Plan specified that WF was not to visit WM’s address a further high gravity domestic abuse incident took place on the 27/10/18. This occurred at the weekend during the early hours of the morning. However, whilst four referrals were received by the Contact Centre from various agencies regarding this incident, the information was not passed to the Emergency Duty Service (EDS), which was a significant omission. The rationale for this appears to be based on the fact that as WM remained at home and WF was taken to hospital there was therefore no risk to Child 28 W. The assumption was therefore made that there was no need to refer into the EDS. In all cases the information was passed directly to Central Court and Locality Team 3, to provide a response during core business hours. 4.27 This information should have been communicated to the EDS by the Contact Centre, as a matter of urgency, particularly given that all the children were at this time subject to Child Protection Plans and a key requirement of the plan had been breached. None of the contacts were appropriately reviewed or provided with sufficient oversight and consequently no consideration took place to ascertain whether further or immediate enquiries were necessary to ensure that Child W or the other children were adequately protected, or what further action was required. This is a critical juncture in Child W’s history and suggests that a more robust approach was required at this point. 4.28 Consequently the only involvement that the EDS had in respect of Child W was in November, on the date of the non-accidental injury. However, it must also be noted that WF had previously refused to provide Child W’s name, address and correct birth date to the hospital which inhibited the ability of the hospital to correctly identify any of the children, who were all at this point subject to Child Protection Plans. 4.29 Whilst this breaching of the plan was discussed at a Core Group on the 30/10/18 and a further stipulation made that WF would not be having any further contact with Child W until a risk assessment had been completed, further information from S2, via a referral by S2’s father, also suggested that WF had been at the family home during the first few days of November 2018. At the time of the injury to Child W, Child W was still residing at the family home with WM. Whilst it had been agreed that a Legal Gateway Meeting was to be convened, and this had been communicated to the IDVA by the SW (SW2) on the 7/11/18, there had already been a period of eleven days since the date of the domestic abuse incident on the 27/10/18. Information provided to the review indicated that a referral had been made to the Legal Gateway Panel, but that following oversight by a manager, this required further work which resulted in a delay. Again, this is a critical juncture in Child W’s history and whilst WM had indicated that she 29 would end her life if the children were removed, which would have understandably created some reticence regarding professional responses, a more timely and robust arrangement was necessary. 5. Learning from the Review The terms of reference for the review are specifically addressed below from which the key findings are drawn. 5.1 Key Line of Enquiry 1 Review the approach to domestic abuse and how needs were assessed and met from the perspective of victim, perpetrator and child. 5.1.1 In recent years there has been an increasing recognition of the costs of domestic abuse in society. The cost to children was recognised by the amendment to the definition of significant harm in Section 31(9) Children Act 1989 in 2002 to include the “impairment suffered from seeing or hearing the ill treatment of another”. A holistic approach to domestic abuse requires services to address three core elements, a programme to work with perpetrators, a programme of support for victims and access to expert risk assessment for those affected by domestic abuse. 5.1.2 This review has evidenced that these services are in place in Manchester and able to respond in collaborative manner to the needs of a whole family. This is particularly evident in the “Safe and Together” approach which was implemented in October 2017 and which emphasises keeping children safe, partnering with the non-abusing parent and undertaking focussed interventions with the perpetrator. It has also been proposed that a “Safe and Together” Clinic takes place which provides an opportunity for discussing complex cases. 30 5.1.3 However, there were key factors that obstructed a clearer analysis of the abusive dynamic in the relationship between Child W’s mother and father. This was primarily, but not exclusively, a reliance that WF was the perpetrator and that WM was the non-abusive parent, exacerbated by WF’s presentation which was often challenging, due to the complexity of his needs. This perspective was also reinforced by agency perceptions of WM, particularly the school and the GP, which suggested that WM presented well and had her children’s best interests at heart. 5.1.4 The domestic abuse incidents, notably during July, August and October 2018 were characterised by allegations, made against WF by WM, and then counter allegations, made by WF against WM, which impeded the possibility of any prosecution. There does not appear to have been any referral of WF to a perpetrator programme or further support systems. WF reported to the review that he had not received any help or support during this time. 5.1.5 As described earlier in this report, strenuous attempts were made by the MFT Safeguarding Nurse to identify Child W, S1 and S2. However this was unsuccessful as limited and inaccurate information had been provided by WF. 5.1.6 Whilst WM was referred to the IDVA, this service was not taken up, although a lack of clarity regarding the identity of the perpetrator and victim resulted in a delay in the initial contact with WM. There was also a lack of oversight and a proper consideration of WF as a victim. Whilst this was exacerbated by capacity issues within the service, management oversight and audit arrangements have now been strengthened to ensure a more accurate identification of the origin of any risk and to ensure a more timely response. It has also been proposed that Women’s Aid will attend the DACC meetings from March 2020. 5.1.7 The lack of family history in the Child and Family Assessment to the ICPC in September 2018, including the number of previous referrals and assessments, was also a critical 31 omission as this suggested that there were concerns regarding WM’s violent and challenging behaviours as early as 2015 and 2016. The contributions of the fathers of S1 and S2, who were frightened of WM, are also missing and would have provided a more holistic perspective regarding WM’s behaviours. 5.1.8 The lack of attendance, not only at the ICPC, but also at any previous multi agency meetings by the GP, One Manchester Housing and the Extended Service precluded a clearer analysis of the complexity of the dynamic between the parents and the way in which this was impacting on not just Child W, but also on S1 and S2. This inhibited a clearer evaluation of the risks to Child W which was reinforced by a lack of child impact chronology and an over reliance on self-reporting from WM. This rather “skewed” analysis of the family circumstances contributed towards a category of plan that was therefore inaccurate. The GP had provided a comprehensive report to the ICPC although the issue of attendance needs to be considered in the context of busy GP schedules. It has been confirmed to this review that GPs have practice diary space, which can now be utilised to discuss concerns with Child Protection Conference chairs and Social Workers. In this respect the Practice Manager is key in securing discussion/meeting time and ongoing work has been undertaken to develop greater collaborative working with GPs, whether in face to face meetings or via telephone liaison. 5.1.9 The attendance at hospital by WF on the 27/7/18 with glass injuries to his head, knee and hand resulting from a domestic abuse incident, did not result in a domestic abuse response, which may well have been triggered if the victim had been female. As a result of this review, a review of training and development packages regarding male victims of domestic abuse is now taking place within the Manchester University Hospitals Foundation Trust (MFT). 5.1.10 Importantly, the domestic abuse incidents which took place in July 2018, did not result in any consideration regarding a multi-agency Strategy Meeting, or discussion and a possible Section 47 Enquiry. This was a significant omission, particularly given Child 32 W’s vulnerability and whilst the reasons for this are unclear, given the prevailing assumptions regarding WM as the non-abusive parent in the relationship, it is likely that there was a rule of optimism in play (Dingwall, Eckellar and Murray, 1983). This is a tendency towards rationalisation and under responsiveness in certain situations, where practitioners focus on strengths, rationalise evidence to the contrary and interpret data in the light of this optimistic view. Participation is thus often viewed as co-operation. However it is critical to understand that practitioners work within contexts in which difficult decisions have to be made on the basis of imperfect, limited and fragmented information (Dingwall, 2013, The Rule of Optimism 30 years on). 5.1.11 This is particularly evident in the records made by the school regarding WM which noted that WM “can act inappropriately at school and makes her own set of rules, we do treat her differently but this due to her being her”. 5.1.12 The domestic abuse incident which took place during October 2018 and which did not result in a referral to the EDS from the Contact Centre is a significant concern. This suggests that arrangements will need to be made for a more robust overview of decision making, regarding appropriate “routing”, particularly those contacts where domestic abuse is a feature. 5.1.13 The lack of information regarding the daily lived experience of the half sibling children S1 and S2, with particular reference to their views, wishes and feelings, also precluded the ability of the professional partnership to understand the impact of WF and WM’s violent relationship on their day to day lives. Ascertaining and understanding the narrative of children and young people, particularly as it relates to domestic abuse, is critical in shaping any planning and interventions and providing effective risk management. Learning Opportunity 33 ● That any previous family and agency history, including any previous assessments, are always taken into consideration when undertaking planning and interventions. ● That domestic abuse referrals, especially involving new born children, are always subject to multi agency Strategy Meetings or discussions, and that Section 47 Enquiries are always considered. ● That parental self-reporting is subject to evidence based triangulation to enable accurate analysis of parental and family dynamics. ● That all relevant agencies, including GPs, Housing and Adult Mental Health Services are consulted with as a matter of course in the assessment and planning process. ● That all relevant agencies, including GPs, Housing and Adult Mental Health services are invited to any multi-agency planning meetings including Child Protection Conferences ● That child impact chronologies are provided to understand the daily lived experience of children and that the views, wishes and feelings of children are critical to effective interventions. ● That arrangements in the Contact Centre are reviewed to enable appropriate oversight and decision making. ● That Child in Need processes regarding case closure are subject to multi-agency consensus 5.2 Key Line of Enquiry 2 To what extent did assessments follow a strengths based model and consider the approach to building resilience within the family unit. 5.2.1 A strengths based approach focuses on identifying the strengths or assets, as well as the needs and difficulties of children and families. It is this asset based approach which enables families to appreciate that their strengths are being recognised but also that risks are being addressed in a fair and “non-judgmental” manner. It includes an acknowledgment of “signs of safety” and essentially views parents and carers as resourceful and resilient in the face of adversity (A Strengths Based Approach to Child Protection, BASW 2015). 34 5.2.2 It has not been possible to interview the Social Workers involved with Child W’s case as both have now left the Authority. However, the Child and Family Assessment provided to the ICPC relied extensively on self-reporting from WM and there was a deficit of external evidence and information from partner agencies. This was reinforced by the absence of key agencies at the ICPC such as the GP, the Extended Service and One Housing. There was no thoughtful consideration of family history or chronology in the assessment which would have allowed a more incisive analysis of family functioning and a more evidence based analysis of the family’s strengths. Key concerns noted in the chronology regarding WM’s volatility, erratic behaviour and alcohol use are not addressed in any depth, so it was not even possible to provide a holistic and accurate picture of the family’s functioning and wider context. 5.2.3 The ICPC was described at the Practitioners event as positive, although this will have been reinforced by WF’s non-attendance, WM’s refusal to allow FM into the Conference and the non-attendance of agencies who had critical information. The weak assessment and analysis will also have contributed towards an incomplete view of the family’s circumstances, which in turn led to an inaccurate category regarding the Child Protection Plan. 5.2.4 There was insufficient consideration given to the views of S1 and S2’s fathers in assessment, particularly as information was provided by external agencies that both fathers were fearful of WM and that their contact with the children would be affected if WM’s wishes were not complied with. This lack of consideration regarding wider family systems contributed to a lack of clarity in respect of external support systems for WM. 5.2.5 The review could not identify any assessment, including the assessment to the ICPC, which explored in any depth the adverse childhood experiences (ACEs) that WM had experienced as young person. This included at least one period as a Looked after Young Person, previous domestic abuse and significant grief and loss. Whilst these 35 incidents were outside the timeframe for the review they are helpful in understanding a “trauma informed” approach to assessment, practice and intervention. Research has indicated that there is a close relationship between ACEs and poor mental and behavioural health, including a propensity towards violence. Sustained or prolonged exposure to stressful or traumatic circumstances without the buffering care of a supportive adult can also impact on neurological functioning, impulse control, contributing towards a defensive and “offensive” positioning and posture. It is therefore important to use protective factors to build resilience, develop secure attachments, maximise and create opportunities for positive activities and build supportive networks ( Vincent Felitti, “The Relation between Adverse Childhood Experiences and Adult Health: Turning Gold into Lead”, 2002). A trauma informed approach to assessment and intervention has been successfully piloted in a district of Manchester and ACE awareness and training is now being developed and provided across the wider Manchester area. However, success will often depend on consistent relationships between Service Users and professionals and will be impeded by constant changes in workers, due to thresholds or staff turnover. 5.2.6 There is no in depth analysis of WF’s mental health, the way that complex needs were impacting on presentation and the way in which episodes of mental health deterioration, particularly in July 2018, just after Child W was born, were impacting on the wider tasks of safe parenting and relationship management. This was critical in understanding and acknowledging WF’s strengths as a father as there was information presented to the review from health professionals, that WF wanted to care for both WM and Child W and that WF was genuinely delighted that he was a new father. Learning Opportunity ● That when Adverse experiences in Childhood have been identified, a trauma informed approach to assessment, incorporating a strengths based methodology, can be invaluable 36 ● That training and development across the multi-agency partnership, regarding trauma informed approaches, are invaluable in embedding a strengths based approach ● That all relevant agencies are involved in assessment and planning, particularly adult mental health and support services. ● That wider family members are routinely consulted in assessment and planning, to assist the development of more robust support systems and networks. 5.3 Key Line of Enquiry 3 To what extent was the presence of drugs and alcohol and mental health factored into the assessment and planning? 5.3.1 The relationship between substance misuse, mental health and child safety is well documented and research has provided a strong correlation between parental substance misuse, poor mental health and domestic abuse. The potential for parenting capacity to be undermined and children’s health and development to be harmed is considerable (Cleaver et al, 2011 “Children’s Needs, Parenting Capacity. The Impact of Parental Mental Illness, Problem Alcohol and Drug Use and Domestic Violence on Children’s Safety”, DfE), (Horgan 2011, “Parental Substance Misuse. Addressing its Impact on Children, National Advisory Committee on Drugs”). If children are exposed to parental substance misuse and other risk factors such as poor mental health and domestic abuse, there is also an increased likelihood that they will also display similar symptoms in later life (Velleman 1993, “Alcohol and Drug Related Problems and the Family”, Institute of Alcohol Studies). 5.3.2 Concerns regarding WM’s alcohol use and mental health were raised by S1’s father as early as November 2015, via a referral to Children’s Services. Whilst further 37 assessment was recommended, the case was closed following a management decision that the threshold for Social Work intervention had not been reached and services could be provided by the school under the auspices of an Early Help Plan. 5.3.3 The incident at school in September 2017 suggested that alcohol misuse was a concern and a referral was made to Children’s Services the following day which resulted in an assessment. S2’s father had also expressed a concern as to how “out of it” WM appeared to be at the time although WM reported that this was a “one off incident” and the case was closed at the end of October 2017. This was despite observations by the Social Worker, made earlier in October that WM was acting erratically, in a way that was consistent with amphetamine use. The school also reported that WM had “appeared to have taken something which made her high” but also stated that WM’s presentation is “different to other parents and assumptions may be made that she is on/taken something”. School also reported that there had been two previous incidents when WM had appeared under the influence of alcohol. Information from the practitioner’s event suggested that drug and alcohol use were “mentioned regularly” at this time. 5.3.4 The timely referral by the midwife in November 2017, a month after the case had been closed, also suggested that ongoing alcohol and cannabis use was a concern and that WM’s poor mental health, due to significant loss and her relationship with her father, was also evident in episodes of panic and anxiety. Whilst a further assessment was undertaken, the case was again closed in January 2018. School were also raising further concerns regarding WM’s mental health In January 2018 and by June 2018 these concerns remained, although it is noted that the school did not refer to Children’s Services to avoid increasing any stress to WM. 5.3.5 The relationship between cannabis use and poor mental health and psychosis is well documented (Royal College of Psychiatrists, 2017). The incidents in July 2018 indicated that WF “had a cannabis addiction”, which is supported by information held by the Mental Health Team as early as February 2017 and which suggested that WF was using significant amounts of alcohol and cannabis, on a daily basis and that his mental health 38 had deteriorated significantly, resulting in suicidal ideation. Even at this point it had been reported by a previous partner that WF could become verbally aggressive and “enraged very quickly”. WM reported in July 2018, following a domestic abuse incident that WF had previously assaulted her “over a bag of cannabis” and reported to the review that WF was spending in excess of £500 per month to sustain his habit. WF was also intoxicated both at the time of his arrest on this occasion and following the domestic abuse incident on the 27/10/18. 5.3.6 Whilst WM’s alcohol use, volatility and erratic behaviour were referenced in the chronology, these issues were not addressed in any depth in the Social Work assessment presented to the ICPC and there was no reference to WM’s cannabis use or possible amphetamine use. Additionally, there was no in-depth analysis of WF’s mental health. 5.3.7 This suggests that alcohol, substance misuse and poor mental health were not sufficiently factored into the assessment and planning processes. The number of repeat referrals, followed by assessment followed by case closure, as a pattern suggest an ongoing superficial level of intervention, compounded by parental non-compliance, a rule of optimism and a shallow level of analysis within the assessment process. Given the difficulties in ceasing or moderating any kind of substance misuse, the impact of alcohol use, drug use and poor mental health on parenting capacity, particularly during July 2018 when Child W was only a few weeks old, a far more robust intervention would have been necessary which adequately addressed these issues. 5.3.8 During the period from September 2017 to August 2018, which is characterised by some multi agency involvement, albeit on a Child in Need basis, there was also insufficient attention given to the process of change. Research suggests that change is a complex but necessary process in safeguarding children that can supported and promoted through multi-agency working, however it cannot be imposed (DfE 2014) and therefore inevitably takes time. Research findings also indicate that professionals need a conceptual model of change, as a framework to enable thorough analysis of a family’s circumstances and greater understanding of the 39 factors that influence parental capacity for change. A widely used model for change (1992 Prochaska, Di Clemente and Norcross, “In Search of How People Change”) outlines six psychological stages through which individuals advance during intentional change behaviour – pre-contemplation, contemplation, preparation, action, maintenance and relapse. The model also warns that relapse should be seen as the rule, rather than the exception regarding chronic behavioural disorders and which include addiction. This serves as a reminder to be realistic about the length of time to embed change and that interventions should be of sufficient longevity to facilitate this process. Learning Opportunity ● That alcohol use, substance misuse and poor mental health must be given significant consideration within assessment and planning, providing in depth analysis which reflects current research, good practice and which enable time for sustained change. ● That cannabis use, particularly if prolonged, is a significant feature contributing to poor mental health and compromised parenting ● That the use of a conceptual model for change is valuable in providing a framework for assessment, analysis, planning and interventions. 5.4 Key Line of Enquiry 4 What approaches were taken to engage the family and was non-compliance addressed within a multi-agency approach 5.4.1 Meaningful engagement with the family provides practitioners with a broader, deeper range of data which support more informed decisions regarding child safety and well-being. Family engagement, including the wider family is a major key to success and will depend on the development and maintenance of dynamic 40 and focused relationship building, even within the context of challenging and difficult conversations (DOH, “The Challenge of Partnership in Child Protection”, 1995,HMSO) 5.4.2 There is considerable evidence that WM was reluctant to engage with a number of agencies as early as 2015 and 2016 and this is reflected in information from the NHS Foundation Trust. This included not following advice, non-attendance at appointments and asserting that the involvement of midwifery had caused a previous miscarriage. School reported that WM would lose her temper with staff when issues were addressed with her and this would often result in WM shouting at the Head Teacher over the phone. WM had also threatened one of the midwives after she had made a referral to Children’s Services in December 2017. Consequently, two midwives would visit WM, which is unusual. Whilst WM subsequently made a self-referral to Change, Grow, Live, following concerns in respect of her alcohol use, the appointment was not attended and as there had been no contact the case was closed in March 2018. The Health visitor reported to the review that her first contact with WM was a telephone call where WM was “yelling at her”, although when visited WM presented differently. A feature of WM’s presentation was that she would initially appear very agitated and hostile but would then calm down. 5.4.3 Despite concerns discussed between the school and the Social Worker, in December 2017, that WM had been “telling professionals different stories”, the case, which had been open on a Child in Need basis since the midwifery referral, was closed in January 2018. 5.4.4 There is also considerable information which suggested that whilst WM would report that WF had been violent towards her, particularly in contacts with the Police, she would then report to other agencies, such as midwifery, that this was not the case. This was apparent following the incidents during July 2018, with WM then reporting to the GP, in September 2018, that there was no threat to her, 41 either physically or verbally. WM was also resistant to make any application for a non-molestation order in case WF “breached it and was sent to prison”. 5.4.5 Following the domestic abuse incident in October 2018, which involved WF attending WM’s address and which was a breach of the Child Protection Plan, WM reported to the school that the Social Worker had agreed that WF could be allowed back in the house, which was untrue. A further referral from S2’s father on the 5/11/18 also suggested that WF had been continuing to stay at WM’s address during the weekend of the 2/11/18. 5.4.6 The number of periods of intervention, followed by case closure, particularly during the timeframes for the review, suggest that efforts to engage the family were at best superficial and did not provide the time needed to address deeply entrenched patterns of resistant behaviour. This was compounded by less than robust multi-agency planning, particularly on a Child in Need basis. This did not take into consideration WM’s resistance to agency intervention and the inconsistent way in which WM was presenting to different agencies although information sharing between Health Visiting and Midwifery was good. Whilst some agencies reported that WM was coercive and controlling, the Continence Nurse by contrast, was “staggered” at what had subsequently taken place with Child W. When WM was seen with Child W by agencies such as Health Visiting, interactions appeared to be good, Child W appeared well cared for and bonding and attachment appeared to be strong. Information from the GP and the Independent Chair of the ICPC also suggested that WM presented well and appeared to have her children’s best interests at heart. Whilst these observations were undoubtedly positive, they will have contributed towards an over optimistic view regarding WM’s capacity to engage and the family’s circumstances and dynamics. 5.4.7 Importantly, non-compliance with the Child Protection Plan regarding WF visiting the family home, whilst discussed at a Core Group on the 30/11/18, did not result 42 in immediate action to safeguard Child W and there was a considerable delay in convening a legal planning meeting, Whilst the impact of WM reporting that she would “kill herself if the children were taken off her” cannot be underestimated, this was a critical juncture in the planning process. 5.4.8 Engagement with the wider family which included the fathers of S1 and S2 and Child W’s Paternal Grandmother FM, were also superficial and would have provided a helpful perspective regarding family dynamics and functioning. 5.4.9 Parental resistance is a persistent feature of child and family Social Work and research has identified five principle causes why parents may be resistant. These include social structure and disadvantage, the context of child protection work, parental resistance, denial or minimisation and the behaviour of the Social Worker. It is argued that Motivational Interviewing (MI) provides particularly useful skills and concepts for firstly reducing the Social Worker contribution to resistance and secondly, maintaining a focus on the child’s welfare and safety. MI balances being directive with being supportive and non-judgmental and offers an opportunity to improve practice by increasing parental engagement, combining an attention to broader social structures with the micro skills required in social work interviews. There are four key parts to MI which consist of open ended questions, affirmation, reflection and summary (OARS) (Forrester and Westlake, 2012, Parental Resistance and Social Worker Skills: Towards a Theory of Motivational Social Work: Child and Family Social Work, Guthrie 2018). Learning Opportunity ● That family engagement is critical keeping children safe ● Professionals will enhance safeguarding practice by adopting a “whole family” approach and mind-set throughout assessments, and by adherence to multi-agency guidance which addresses information sharing and addresses parental resistance. 43 ● That where parental resistance and non-compliance are evident, then Motivational Interviewing (MI) can be a helpful tool. ● Supporting professionals into better standards of critical thinking will enhance the quality of interventions in order to better assess the impact of harm or risk to children. ● That multi-agency planning is effective when a holistic analysis is provided regarding parental resistance and time is allowed for sustained change. 5.5 Key Line of Enquiry 5 Consider the purposefulness and effectiveness of the Child Protection Plan 5.5.1 The overall aims of the Child Protection Plan are to ensure that the child is safe and to reduce any risk or likelihood of harm by supporting strengths, addressing vulnerabilities and risk factors, and enabling parents or carers to meet the child’s unmet needs. Developing a meaningful safety plan is a collaborative endeavour involving all relevant agencies, parents and where possible, children and young people (Iannos and Antcliff, 2013 “Planning for Safety with At Risk Families”). 5.5.2 Maslow’s Hierarchy of Needs suggests that people are unlikely to focus on family relationships if survival and safety needs are being threatened. Therefore families with complex problems may not have the capacity to engage in parenting interventions if they still being exposed to domestic violence. 5.5.3 Whilst the Child Protection Plan was strong in that it appropriately referenced strategies to support WF and WM to manage their mental health and WM’s anger management, there is no evidence of support services responsibilities within the plan for the children. This is pertinent as there was evidence to indicate that both parents were finding the parenting of a new baby highly stressful. This was exacerbated by the fact that WM was highly resistant to professional interventions and the involvement of wider family as a support mechanism. When WM was seen as part of the review, a particularly salient point was when, in acute distress, she 44 described how hard she had found parenting and that her actions in mod-November were “just a blip”, as Child W had been unwell, constantly crying and she was at the end of her tether and was just struggling to cope. 5.5.4 In that respect though, the Child Protection Plan addressed the key concern regarding domestic abuse in the relationship and stipulated that as a fundamental requirement, WF was not to attend WM’s address. This was clearly not adhered to and the domestic abuse incident at the end of October 2018 occurred in the context of WF having spent the majority of the weekend with WM and Child W, visits which were also continuing into November 2018. Whilst this matter was addressed at a Core Group on the 30/10/18, and arrangements made to refer the case to a Legal Gateway Meeting, there was a significant delay in progressing this. This was due to the referral requiring further work and the Social Worker’s Manager taking a period of extended sickness absence. Consequently, the matter had not been actioned by the time that WM injured Child W, although the injury took place when WF was not at the family home. WM and WF were both seen as part of this review and whilst both parents differed in their accounts regarding who was responsible for the domestic abuse incidents, each blaming the other, the one area where they were agreed on was the need for WF to have had contact with Child W away from the family home. The relationship between WF and WM was very much characterised by a dynamic of co-dependency which both parents found difficult to break away from. In that respect the plan did not consider the impact of the separation of WF and WM, which neither parent was able to adhere to. 5.5.5 The incident at the end of October 2018 was not referred to the EDS, which was a significant omission, given that all three children were subject to Child Protection Plans and the absence of appropriate oversight in the Contact Centre has already been referred to. 45 5.5.6 The length of time between the incident at the end of August 2018 and the date of the ICPC on the 24/9/18 is significant, as there was no safety plan for Child W during those 4 weeks. Learning Opportunity ● That the time between the conclusions of Section 47 Enquiries and the date of an ICPC is critical for formulating a safety plan. ● That the effectiveness of the Child Protection Plan will depend on the clear roles and responsibilities of support services. ● That significant breaches in a Child Protection Plan will require a timely and robust response which incur the minimum of delay. ● That having qualified social work oversight as part of the Contact Centre arrangements is a critical feature of safe and effective decision making. ● That alternative arrangements for contact between WF and Child W may have lessened the impact of a co-dependent dynamic in the relationship between WF and WM. 5.6 Key Line of Enquiry 6 To what extent was the risk of abusive head trauma in the mind set of professionals 5.6.1 Abusive Head Trauma (AHT), often referred to as Shaken Baby Syndrome results in serious injuries which often present in a constellation, including intracranial injuries, retinal haemorrhaging, long bone fractures and spinal fractures which can led to brain damage, blindness, learning disabilities and death. Research suggests that two years after injury, 25.5% of babies with AHT will have died and 40% will have significant disabilities. UK studies indicate that it affects approximately 24 of every 100,000 babies admitted to hospital each year and that 1 in 9 mothers have shaken their babies 46 and 2 in 9 have felt like doing so. Critically, an inability to cope with a crying baby is one of the key reason for carers losing control and shaking their baby. It has also been noted from previous Serious Case and Learning Reviews that AHT features more in 2nd, 3rd and 4th babies (Learning from Case Reviews, 2018) 5.6.2 The multi-agency partnership has implemented a national programme known as ICON, based on the study of AHT prevention programmes in the USA and Canada, learning and research. This is a multi-agency co-ordinated programme comprising a series of touch points which reinforce a simple evidence based 4 point message which makes up the ICON acronym. ● Infant crying is normal and it will stop (I) ● Comfort methods can sometimes soothe the baby and the crying will stop (C) ● It’s ok to walk away if you have checked that the baby is safe and the crying will stop (O). ● Never, ever shake or hurt a baby (N). 5.6.3 Research suggests that some carers lose control when a baby’s crying becomes too much and may go on to shake the baby with serious consequences. Apart from preventing AHT most adults who have ever cared for a baby appreciate some advice about how to comfort a crying baby and how to cope when it goes on for a long time. The key to the ICON approach is that the message is simple, consistent and is reinforced by different professionals at key points. 5.6.4 The Manchester ICON Steering Group was set up in April 2018 and the South Manchester Pilot commenced in May 2018, concluding on the 31st August 2018. A city wide implementation has been taking place in 2019 and all Midwives and Health Visitors are currently receiving brief training on the ICON model. Whilst the pilot has been focused on health touch points, it is clear that this is a universal health message and as such, all partnership organisations working with families need to adopt the approach. 47 5.6.5 Information provided to this review suggested that the possibility of AHT was not present in the mind set of professionals and practitioners across the multi-agency partnership. The review could not find any evidence from any agency that this possibility was given consideration. The GP reported that “this did not cross her mind once, WM was always immaculate and well turned out and this was mirrored in her children who were also well turned out”. The GP reported that WM always appeared to have her children’s interests at heart and had been seen by the GP two weeks prior to the incident, who noted that her anxiety had lessened and that medication was no longer required. There was no information that suggested Child W was causing WM undue stress and the Health Visitor reported that the relationship between WM and Child W was “thriving”. Information from the Child Protection Conference Chair indicated that WM appeared engaged during the Conference and appeared to understand the reasons for the Conference and agreed with the recommendations, including that WF was not to visit the family home. 5.6.6 These factors will have mitigated against professionals considering the possibility of AHT, despite Child W’s age and vulnerability, the presence of domestic abuse, substance misuse, poor mental health, parental resistance, erratic behaviour and insufficient support systems for the family. The lack of any referral onto EDS by the Contact Centre is particularly concerning, given Child W’s age, the level of domestic violence, previous history and importantly that Child W was subject to a Child Protection Plan. Learning Opportunity ● That the possibility of AHT is always considered in cases where there are very young babies and children and domestic abuse is present 48 ● That AHT is currently not sufficiently profiled across the safeguarding partnership. ● That the ICON Model as a helpful and informative approach for parents and carers can be profiled on a city wide basis. An invigorated approach to the education of professionals and the public will reduce the risk of fatal and non-fatal injuries 6. Recommendations 6.1 This review has evidenced that whilst there are structures to support an efficient and collaborative response to domestic abuse in Manchester, there were a number of deficits in the timeliness and rigour of interventions with the family. 6.2 There are five particular points in the critical pathway of intervention that deviated from the systems and procedures in place. Firstly, that the incidents in July 2018 did not trigger a co-ordinated Section 47 Enquiry where previous history, particularly the number of referrals, re-referrals and previous assessments were considered. Secondly, that the Child Protection Plan, whilst strong in some respects, was not appropriately categorised, did not reference support service responsibility and did not address the issues of parental resistance. Thirdly, that the high gravity domestic abuse incident which occurred in October 2018 was not referred onto the EDS by the Contact Centre, despite Child W being subject to a Child Protection Plan. Fourthly, that the breach in the Child Protection Plan which took place did not result in a timely and robust response to ensure that Child W remained safe. Fifthly. That there was a significant delay in actioning the Legal Gateway Meeting, following the incident 49 on the 31st October 2018, and which had still not taken place by the time that Child W was injured in mid-November 2018. 6.3 Key Recommendations 1. For all Child in Need and Child Protection planning to routinely consider; ● The longitudinal family history with and levels of engagement with the agency ● Chronologies that identify the impact on the child ● Comprehensive agency involvement, particularly adult mental health and GPs ● An evidence based analysis of what is known to agencies that excludes an over reliance on self-reporting ● Addresses domestic abuse from a gender neutral perspective ● The strengths and significance of the importance of wider family ● Contingency planning and responsiveness, particularly where there are breaches in a Child Protection Plan 2. Safety planning to be routinely in place between the conclusion of any Section 47 investigations and a subsequent ICPC 3. That planning and interventions are informed by a conceptual model of change, particularly when working with families struggling with inter related mental health issues, alcohol or substance misuse. 4. That a trauma informed approach to planning and interventions is embedded into practice, particularly where Adverse Experiences in childhood (ACEs) have been identified. 5. That the use of Motivational Interviewing (MI), incorporating a “Signs of Safety” approach is embedded in thinking and practice. 50 6. That the ICON approach is embedded across the partnership and informs advice, guidance, thinking and practice. 7. That the role of the IDVA is promoted in all responses to domestic abuse |
NC046984 | Death of a 4-month-old girl in September 2013 whilst sleeping in her parents' bed. The Inquest concluded there was no evidence that drugs caused or contributed to the death and the medical cause was recorded as unascertained. Parents were convicted of Child Cruelty and received a six month custodial sentence suspended for two years. Family had been referred to children's services by health professionals and the police due to concerns around parental substance misuse and the behaviour of the two eldest siblings. Initial assessments were undertaken, but did not result in any child protection intervention. Mother had a history of: non-engagement with professionals, substance misuse and a violent relationship with the father of her first three children. The role the mother's new partner, the father of Baby E, played in her children's lives had not been assessed by professionals. Identifies findings, including: failure to engage effectively with fathers or significant males; concerns not given high enough priority; professionals were too parent-focused and wishes of older children were not considered; lack of multi-agency collaboration and risk assessment tools; and conflicting professional views about the impact of illegal substances on parenting capacity. Sets out key findings using a systems model based typology. Sets out issues for the Local Safeguarding Board to consider in light of these findings.
| Title: Serious case review: Baby E: overview. LSCB: Sunderland Safeguarding Children Board Author: Linda Richardson and Jan Grey Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. - 1 - Serious Case Review Baby E (The SSCB has used a pseudonym to protect the identity of the child and family) Publication Date: 6 September 2016 - 2 - Contents Page No 1. Decision to hold a Serious Case Review (SCR) 3 2. The approach we used 3 3. Scope and Terms of Reference 4 4. The Family’s Perspective 4 5. The Family as known to Agencies 4 6. Areas of Significant Practice (ASP) 6 ASP 1: Children’s Services: Response to Referrals from other Agencies 7 ASP 2: School’s response to concerns about the children 9 ASP 3: The use of the Common Assessment Framework (CAF) 10 ASP 4: Multi-Agency Partnership and Collaborative Practice 11 ASP 5: Failure to challenge and escalate concerns 13 ASP 6: Managerial Oversight and Supervision 15 7. Agency Learning 16 8. The Findings 17 9. Summary 25 Appendix 1 The SCR Review Team 26 Appendix 2 Roles and Responsibilities in the SCR Process 28 Appendix 3 Methodological Limitations 30 Appendix 4 Agency Learning Reports 32 Appendix 5 How has the learning from this SCR improved practice? 36 - 3 - 1 Decision to hold a Serious Case Review (SCR) 1.1 Baby E was born in May 2013 at 37 weeks plus 1 day and died in September, aged 4 months. The family had been known to agencies for several years. Professional concerns included parental substance misuse, poor school attendance and the behaviour of the two eldest children, but these concerns had never culminated in the children being subject to Child Protection or Child in Need Plans, although ‘child in need’ services had been offered to the family. 1.2 A Case Review Sub-Committee of Sunderland Safeguarding Children Board (SSCB) held a scoping meeting on 26 September 2013 and agreed that the circumstances surrounding the death of Baby E met the criteria for holding a SCR.1 The Independent Chair of SSCB endorsed the recommendation on 2 October 2013. The reason for the delay in the completion of this SCR is an issue, which should be addressed by SSCB, but it appears that the volume of work in respect of other SCRs being undertaken was a contributory factor. Publication of the SCR has been delayed due to criminal proceedings in respect of the parents of Baby E and the inquest into Baby E’s death. 1.3 The decision to hold this SCR was also influenced by the similarities between this case and other reviews relating to the death and injuries of babies under the age of one year in Sunderland. The SSCB Chair therefore directed that this review should not only consider the learning and recommendation from previous SCRs but also should pay special attention to the findings and recommendations from Baby A and Child C, the most recent SCRs, and consider any similarities between the reviews. 2 The approach we used 2.1 It was agreed that the review be undertaken using a different approach to that which the Board had used previously and which was prescribed in statutory guidance 2010. Whilst the review was to consider individual practice, the SSCB Chair wanted to adopt a ’systems methodology’, an approach that recognised that the actions and decisions of practitioners occur through a chain of events and the interaction of a number of factors, many of which are beyond the control of the individuals involved. This review therefore was undertaken using an approach that provides a theory and method for better understanding why good and poor practice occurs, so effective supports and solutions can be more easily identified. 2.2 Senior managers from key agencies who had worked with the family or were working with the family at the time of Baby E’s death were asked to join a Review Team which met on four occasions during the SCR process. Membership of the Review Team is attached in Appendix 1. 1Regulation 5 of the Local Safeguarding Children Boards (SSCB) Regulations 2006 requires SSCBs to undertake reviews of serious cases in specified circumstances and to ‘advise the Authority and their Board partners on lessons to be learned’. A SCR is one where: ‘a) abuse or neglect of a Child is known or suspected: and b) either – (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the Authority, their Board partners or other relevant persons have worked together to safeguard the child.’ - 4 - 3 Scope and Terms of Reference 3.1 Taking a systems approach encourages reviewers to begin with an open enquiry rather than a pre-determined set of questions from terms of reference. This uses the evidence to lead into exploration of the key issues. Key lines of inquiry for this review quickly emerged in relation to assessments and thresholds, early intervention, the role of the Common Assessment Framework (CAF)2, child protection referrals and hospital discharges for vulnerable babies when it was known parents misused substances. 3.2 This review looks at events that took place between March 2012, shortly before the birth of Sibling 3 and Baby E’s death in September 2013. 4 The Family’s Perspective 4.1 It would appear that LC and JR separated sometime in 2013. A number of attempts were made to contact both parents inviting them to contribute to this review but neither parent responded to these requests or to the correspondence sent to their individual addresses. The absence of their views in this report sadly limits the scope of this review. 4.2 The Maternal Grandmother (MGM) did however contribute to this review. She met with two representatives from SSCB and offered a very helpful perspective. During the discussion the grandparent’s commitment to their grandchildren and to their daughter was clearly evident. MGM described the children as ‘lively’ and those they were a ‘happy loving family’ with lots of hugging and lots of fighting”. 4.3 MGM offered regular support to her daughter and grandchildren but was not aware that there were concerns about the family and she was not aware of the involvement of Children’s Services until after their involvement ended. Maternal Grandparents have found the agencies involved to be very helpful although she reported that the children had been allocated 5 different social workers since moving to live with them. 5 The Family as known to Agencies 5.1 The Family3 Mother LC 32 years Sibling 1 8 years Sibling 2 7 years Sibling 3 13 months Father GB to above children 34 years 2 The Common Assessment Framework (CAF) is a process for gathering and recording information about a child for whom a practitioner has concerns in a standard format, identifying the needs of the child and how the needs can be met. 3Names, dates of birth and some family details have been changed to preserve anonymity. The ages given are the ages at the time of Baby E’s death. - 5 - Baby E b. May 2013 d. September 2013 Father JR to Baby E 24 years Maternal Grandmother (MGM) Maternal Grandfather (MGF) 5.2 GB has a history of ongoing medical issues including mental ill health and alcohol and drug dependency. He has also a series of convictions for violent offences. Children’s Services records indicate the couple separated in 2007 as a result of physical assaults on LC, but GB appears to have remained in contact with LC and has had some contact with his children. 5.3 Between 2007 and 2012, the children received variable care from their parents; their lives were affected by exposure to their father’s depressive episodes and severe mental health problems and they heard and witnessed violent outbursts. Throughout this period, Police, Probation and the Community Midwife all contacted, or made referrals to Children’s Services to highlight their concerns about the children in the family. In response to these, two Initial Assessments were undertaken by Children’s Services between 2008 and 2011 but these did not lead to any support or intervention. 5.4 During 2012, there were three significant missed opportunities where purposeful interventions could have positively impacted upon the lives of these children. In March 2012, a Midwife made a referral to Children’s Services expressing concerns about LC’s drug use during her 3rd pregnancy and referring to GB’s recent discharge from hospital. The response to this referral by Children’s Services however gave insufficient weight to the risk factors and explored the possibility of a CAF, missing an opportunity to undertake an Initial Assessment. At the end of the Summer Term 2012, despite the children attending school with bruises and conflicting stories about how they were sustained and with previous evidence of neglectful care (hungry and poorly clad in cold weather), no discussions were held with partner agencies and no referral was made to Children’s Services by school staff. This was also a missed opportunity to initiate more assertive interventions with the parents. In August 2012, the two older children were involved in the deliberate death of a kitten. Police sent a notification to Children’s Services who undertook an Initial Assessment and gathered information from agencies who knew the family. Whilst there were different views about the way the family was functioning, the assessment concluded in October 2012, with a plan to offer a family support package. A referral was subsequently made to the Common Assessment Framework (CAF) Panel but no work with the family took place. After several weeks delay, the CAF Panel referred it back to Children’s Services as they determined that the family’s needs met the threshold for a higher level of intervention. The children were subsequently made subject to child in need status. 5.5 Between October 2012 and May 2013, work with the family was uncoordinated and piecemeal. Communication between agencies was contradictory and confusing and without any child in need plan or multi-agency meetings, the children continued to experience poor quality care within their family and concerns continued to be raised by individual frontline staff from different agencies. Attempts by professionals to engage with LC were largely unsuccessful. LC did not often respond to requests to meet with school or health colleagues but when this did happen, records indicate she was vocal, co-operative and willing to talk about how best she could meet the needs of her children. Subsequent attempts however to follow up on plans or appointments were usually thwarted by LC - 6 - failing to follow these through or offering various explanations/justifications for her non-engagement. 5.6 However, no professionals escalated their concerns to their safeguarding leads or questioned why no multi-agency meetings were taking place. Towards the end of this period, school staff, the Health Visitor and Social Worker, having liaised by telephone, concluded that the children no longer met the thresholds for ‘Child in Need’ and were best supported using the CAF framework. 5.7 Baby E was born three weeks premature in May 2013. Concerns were again raised by the hospital Midwife in another referral to Children’s Services in relation to LC falling asleep when feeding the baby and needing to be prompted to initiate these feeds. Despite the continuing concerns around the use of drugs, LC and Baby E were discharged without a pre-discharge meeting but an Initial Assessment was undertaken two weeks later. No further action was taken by Children’s Services following this visit as home conditions were considered to be satisfactory and LC said she was not taking drugs and she and her [new] partner only drank alcohol on special occasions. LC said she was well supported by family members. 5.8 Baby E died in September 2013. The Inquest concluded that there was no evidence that drugs caused or contributed to the death of Baby E, but the baby was co-sleeping. The Coroner’s view was that, more likely than not, that the primary cause of death was the child sleeping in the parents bed. He recorded the medical cause of death as unascertained. Her parents were convicted of Child Cruelty and received a six month custodial sentence suspended for two years. 6 Areas of Significant Practice (ASP) 6.1 The narrative above provides a clear indication of an absence of assertive interventions with LC and her children to ensure the children’s welfare was properly considered. Whilst none of the concerns directly led to Baby E’s death the absence of proactive, co-ordinated, system wide action contributed to Baby E and her siblings continued neglect. This section looks back at the actions and decisions of professionals working with Baby E’s family and explores ‘why’ these professionals acted as they did. The ‘why’ questions are important as they helped the Review Team understand what systems were in place at that time to support good practice or make poor practice more likely. 6.2 From studying key documents and listening to the views and experiences of front line practitioners involved in this SCR process, the Review Team identified six areas of significance for Sunderland agencies. These are listed below and are explained in more detail in later sections • ASP 1: Children’s Services: Response to referrals from other Agencies • ASP 2: School’s response to concerns about the children • ASP 3: The use of CAF • ASP 4: Multi-Agency Partnerships and Collaborative Practice • ASP 5: Failure to question or challenge decisions taken by Children’s Services • ASP 6: Managerial Oversight and Supervision - 7 - 6.3 ASP 1: Children’s Services: Response to Referrals and Initial Assessments According to agency records, five referrals were made to Children’s Services between March 2012 and September 2013, one from Police, and four by Health professionals. The Police sent a Child Concern Notification (September 2012) to Children’s Services after Sibling 1 and Sibling 2 were found to have been directly involved in the death of a kitten. Referrals made by Health Professionals, (March, November 2012 and April, May 2013) were as a result of knowing the history of the family, LC not keeping medical appointments and continuing to take drugs through the pregnancies of Sibling 3 and Baby E. In response to these referrals, two Initial Assessments were undertaken, neither of which assessed the children as being at risk of significant harm or as meeting the Child in Need threshold. 6.3.1 How Children’s Services responded to referrals is significant. The pattern of referrals indicates the family were perceived by Children’s Services as having ‘low level’ needs and consequently the wider issues around risks in relation to substance misuse, domestic violence and mental health were never fully explored, or the Sunderland threshold model applied to inform decision making. 6.3.2 Concerns had been raised several times over a five-year period about domestic violence in the home, drug and alcohol abuse and the significant mental illness of GB, the father of the eldest siblings. Domestic violence, parental drug misuse and mental health problems are factors which are well known to adversely impact on children’s outcomes. Despite the past history of domestic violence and LC’s known drug use, when it was known she was pregnant in 2011 and 2012, there were no Pre-Birth Assessments undertaken despite concerns being raised by Midwives who were aware of LC’s history. 6.3.3 In response to the five referrals made by the Police and Midwives during March 2012 and September 2013, the period under review, only two led to Initial Assessments but neither of these involved discussions or consultation with the referring agencies, or with the Substance Misuse Midwife who had known LC throughout her three previous pregnancies. Nor were the GPs for LC or JR contacted for additional information. 6.3.4 The four referrals from the Midwives were made following single agency assessments, which took into account past history and what was currently known about the family. The Early Warning Tool was used by the Health Visiting Service to analyse current risk and the ‘high’ scores led to the referrals to Children’s Services. It is not however a requirement that these single agency assessment tools are forwarded with referrals and this possibly restricts opportunities for Social Workers to understand the importance of concerns from a health perspective. 6.3.5 The first Initial Assessment in September 2012 sought information from the School Nurse, the Health Visitor and the Head Teacher, none of who had expressed any concerns prior to the killing of the kitten. The Social Worker considered that the family were in need of support services, but as LC refused to engage with the ‘Child in Need’ process, it was decided the needs of the children could best be met by the CAF process. There is however little to suggest that LC was willing or motivated to engage in this process but nevertheless the notion of a CAF partnership was presented by Children’s Services as a viable means of support to the family. The Initial Assessment clearly highlights concern about attachment issues and confirmed that Mother uses cannabis ‘when the - 8 - children are in bed’. In conversation with Social Worker 1 she advised that many families in the area are known to use cannabis and that in itself was not a significant concern. 6.3.6 The Initial Assessment was updated a few weeks later. LC informed the Social Worker that she was 10 weeks pregnant but she would not disclose the name of the father. This information did not change the Social Worker’s assessment. They concluded that Children’s Services intervention was not necessary. In the practitioner’s meeting held as part of the SCR process, the view was expressed by Social Worker 1 that ‘compared to some of the other referrals, these children did not particularly stand out’. CAF was seen as an appropriate way to meet their needs. 6.3.7 The referral to the CAF Panel went ahead but without any reference to LC’s pregnancy. Even without this additional information, the CAF Panel returned the referral indicating the needs of the family were considered too high for CAF work. Although this prompted the children to be reassessed as ‘Children in Need’, in effect no additional services were offered and the family were ‘closed’ several weeks later. The reasons given in conversations and in the practitioner meetings were that, according to the school, the children’s behaviour had ‘settled down’ and the phrase ‘low level’ concerns was again used to explain why the involvement of Children’s Services was no longer needed. The children’s involvement in the killing of an animal was described as ‘no longer of any concern’ although there are no records which offer a rationale for this statement. 6.3.8 There was no action taken by Children’s Services in relation to the referrals made by the Community Midwife in November 2012, and April 2013, but the Team Manager in Children’s Services did agree to an Initial Assessment in May 2013 following a referral from the Midwife on the Labour Ward when LC had given birth to Baby E. This referral did not however prompt a pre-discharge meeting as might have been expected. An Initial Assessment took place two weeks after LC had returned home with Baby E. The assessment concluded that home conditions were satisfactory; LC said she was not using drugs and neither she nor JR drank alcohol except on special occasions. There was no consultation with the referring Midwife on the Labour Ward or with the Substance Misuse Midwife. The assessment relies heavily on self-reporting by LC in respect of her drug misuse and that of her current partner. The impact of this is that other known professionals who would have pertinent information about the family were not contacted and therefore the decision was made based on limited and missing information. It is possible that in viewing this family, as one with ‘low level’ needs, only information, which confirmed that view, was sought. Research suggests that professionals do have a tendency to maintain intuitive beliefs even in the light of contradictory evidence. However, the existence of multi-agency processes, the Threshold Model and other tools are designed to minimise the possibility of this happening. 6.3.9 School staff were asked to contribute to the Initial Assessment in September 2012 but not to the later assessment in May 2013. Given that Sibling 1 and 2 both attended school, this was poor practice. 6.3.10 The role JR played in the lives of the children was not assessed despite Children’s Services records, which note that the Health Visitor, in discussions with Team Manager, in April 2013 was advised that it ‘had been agreed that JR would oversee the care of Baby E due to Mum’s cannabis use’. The Health Visitor however has no recollection of this discussion and it is not documented in Health records. - 9 - 6.3.11 There were clear frustrations expressed by health colleagues during the review process that the risks posed to unborn and newly born babies (i.e. Sibling 3 and Baby E) were not adequately assessed or well understood by their colleagues in Children’s Services. The Vulnerable Babies Protocol was not followed despite it being known that LC was pregnant with Sibling 3 and again with Baby E despite the concerns highlighted by the Midwives. 6.3.12 Approximately half of all SCRs are in relation to babies less than one year of age, underlining the importance of effective universal services provision for young children e.g. Health Visitors and early-years services. As in previous studies domestic violence, substance misuse, mental health problems and neglect were frequent factors in the families’ backgrounds, and it is the combination of these factors which is particularly ‘toxic ‘. 6.3.13 It is worthy of note that in single agency records, there are references being made to ‘referrals’ to Children’s Services, whilst in Children’s Services records, those same ‘referrals’ are recorded as ‘contacts’ by Children’s Services. There was no common language and understanding between professionals as to what constitutes a referral, what is determined as a contact and how professionals should challenge any of these applications if they are not in agreement. The Review Team were informed that this has subsequently been addressed in Sunderland. 6.4 ASP 2: School’s response to concerns about the children School staff reported concerns about the children’s behaviour and describe an incident where Sibling 1 had claimed to have teeth knocked out by Sibling 2. This was backed up by bruises to body and eyes. School had concerns about the children being hungry, poor school attendance and lack of engagement with LC, yet there were no safeguarding records held in School. The children were described as ‘not standing out’. 6.4.1 The Review Team considered that this was an area of significant practice as school staff were well placed to observe at first-hand how these children presented and would have been able to monitor any changes in behaviours. There were no safeguarding records in respect of Sibling 1 or Sibling 2, yet notes held by a Teacher documented several concerns; the dead kitten; bruising to eyes and thighs of Sibling 2; 4 month old baby with nose bleed after falling from bed after being placed there by Sibling 1; the children often arriving late to school and being hungry. None of these individual concerns were referred to Children’s Services and neither do they appear to have been discussed with LC. Significantly, the concerns were not brought to the attention of the Designated Person in school4 nor brought to the School Nurse’s attention. It is clear that staff were not aware of their safeguarding responsibilities and procedures and in this respect, there was a concerning lack of safeguarding leadership in the school. 6.4.2 It is equally concerning that school had no records which related to historical information, the mental health of the older children’s Father and the domestic violence the children must have witnessed. Nor were there any records on school files about the Initial Assessments that had been undertaken in respect of the children. The Review Team gained the impression that school was not well informed about this family, yet the school health records contained a wealth of historical information, which highlighted intermittent involvement from Children’s Services throughout the 4 This person has responsibility for dealing with and responding to safeguarding concerns in school. - 10 - older children’s pre-school years. This information was not discussed, shared or accessed despite the concerns highlighted in the teacher records. 6.4.3 It is perhaps significant that the School Attendance Officer could not remember these children and neither could he recall a conversation with the Social Worker as part of an Initial Assessment in September 2012 or access any records in relation to that conversation. Given his name was on the documentation, he agreed that such a conversation must have taken place, but he could not remember the children or what information he may have shared with the Social Worker. According to school records, education professionals could not engage LC apart from one attendance at a ‘Barrier Meeting’ in October 2012, set up to try and help improve the children’s school attendance. The minutes from that meeting could not be located. 6.4.4 School had evidence of poor school attendance, children being hungry and inappropriately dressed but none of these, together with the reported injuries were seen in the context of neglect. Due to the absence of any records it is impossible to state how, when and if these children were being supported and how Teachers and other school staff would have been able to identify and recognise the impact of cumulative concerns. 6.4.5 The School Nurse provided information to the Social Worker in the Initial Assessment undertaken in September 2012. Information was shared about A&E admissions for minor injuries, health appointments and Mother’s drug misuse. However, the school health records do not include any references to injuries or bruising to Sibling 2 or being seen for nursing/medical assessments or make any reference to discussion with school staff in relation to these. 6.5 ASP 3: The use of CAF Children’s Services continued to persevere with CAF as a means of engagement despite historical and current evidence that LC was neither willing nor motivated to engage in this process. This left the children vulnerable as they continued to live in an environment in which quality of care remained largely unassessed. 6.5.1 The Common Assessment is intended to provide a framework to help practitioners who work with children and families and/or young people to assess children and young people’s needs for earlier and more effective services, develop a common understanding of those needs and how to work together to meet them. This practice was deemed significant because the Review Team considered that the Initial Assessment undertaken in September 2012 was not sufficiently robust and yet CAF continued to be considered as a viable alternative to intervention by Children’s Services despite evidence that LC was unlikely to engage with that process. 6.5.2 It is unclear to what extent the issue of CAF was actually discussed with LC. The Review Team gained the impression that this was not discussed by the Social Worker in any depth and was seen as almost a conciliatory action on the part of both the worker and the parent. According to records made available to the Review Team, the Initial Assessment, which began in September, was updated in October when it became apparent that LC was 10 weeks pregnant and a referral was made, on the advice of the Team Manager to the CAF Panel in November 2012. This referral was not however accepted as the needs of the family were considered by the CAF Panel to be ‘too high’ for the CAF process. - 11 - 6.5.3 CAF is a holistic assessment of a child’s needs for services. It is a process for recognising signs that a child may have unmet needs that universal services cannot meet. It is also a process for identifying and involving other agencies that may be able to support the child and/or undertake specialist assessment. Central to its development is the principle that it is child/young person centred, holistic and can be shared across professionals as appropriate. There is no evidence that any work was undertaken at any time with the older children, or any work even considered, despite significant concerns about their behaviour and, given the older siblings involvement in the death of a kitten, any possible risks to the baby within the family. 6.5.4 The view of the CAF Panel in November 2012, that the needs of the children met the threshold for Children’s Services intervention was accepted by Children’s Services without challenge and the three siblings, according to records held by Children’s Services, were ‘progressed to a Child in Need Plan’. The Review Team have however been unable to locate a Child in Need Plan for any of these children and it is doubtful that any such Plans were established. No multi-agency meetings took place and the family were ‘closed’ to Children’s Services three months later despite the knowledge that LC was again pregnant. Social Work records indicate that the family would best be served through the CAF process – a decision which is difficult to comprehend given the views of the CAF Panel in November 2012 and the lack of any evidence to suggest that LC and JR would contribute to that process. 6.6 ASP 4: Multi Agency Partnerships and Collaborative Practice Despite the concerns highlighted by Police, school staff and several health professionals no multi-agency meetings ever took place in respect of these children and whilst information may have been gathered, it was not shared in a purposeful way. There were no attempts by any agency to set up multi–agency meetings with LC or to establish a professional’s meeting to share concerns and pool information. 6.6.1 Whilst the lead agency for undertaking Initial Assessments is Children’s Services, that agency does need to rely on partner agencies to provide much of the information, which underpins assessments. In this case there was a pattern of minimal contact between agencies from the outset, and that which did occur tended to be telephone contacts seeking information rather than creating opportunities for multi-agency working. Concerns were seen in isolation and were too readily seen as ‘low level’ but had information been pooled from other agencies, patterns of disengagement with services and the impact of parental resistance to professional intervention may have been more readily identified. 6.6.2 Listening to the professionals who knew this family, the absence of any multi-agency work became clear and this potentially weakened the identification of needs and risks in this family. Each professional involved in, or with the family, appeared to be working from a single agency perspective and concerns or incidents were channelled through referrals or contacts with Children’s Services. None of the agencies involved sought to initiate a CAF themselves but each looked to Children’s Services to take action. 6.6.3 Talking to frontline practitioners, it is clear that that Children’s Services continues to be viewed as the key agency for co-ordinating work around safeguarding children. Consequently, a sense of frustration was evident when the response of Children’s Services to concerns was slow or non-existent or when there was difficulty in understanding why certain decisions had been taken. The - 12 - responsibility of all professionals from every service to act assertively was neither well understood or well demonstrated. 6.6.4 Thresholds to access services from Children’s Services appeared to the Review Team to be high, even where there was evidence of domestic violence, [albeit historical] mental ill health and drug and alcohol addiction. The response by Children’s Services was low key. However, what became very evident from feedback from professionals and from records is that where the children in this family were concerned, each referral or contact was viewed in isolation, with each agency having its’ own information and own perspective about the risks to the children. 6.6.5 Decisions were taken by Children’s Services that thresholds for services or intervention were not met. This was a matter of professional judgement which given the information gathered from LC, the school and the Health Visitor could be seen to be a reasonable judgement. However, the documents seen by the Review Team and information gathered from the conversations with practitioners suggest a lack of professional curiosity on the part of the Social Workers about what was happening in this family. The local ‘Threshold Model’ for decision making was not applied and too much reliance placed on LC’s self-reporting that all was fine. The information about the house conditions contained in Children’s Services records contrasts sharply with what the Police found when they were called to the home after Baby E’s death. The unwillingness to explore in any detail the extent of drug taking in the home and the impact this had on parental capacity also left all the children vulnerable. 6.6.6 Successive analyses of SCRs warn that the presence of significant males in families is often overlooked by professionals. Although JR was not believed to be living in the family, he was nevertheless a significant adult in the lives of these children and although he appears to have been regarded as a supportive, and compared to LC’s previous partner, a caring partner, he remained an unassessed risk. 6.6.7 There is a sense in this case that when the Initial Assessments were undertaken, the Social Workers looked for reassurance that all was well for these children and this is what they found. It is important that professionals are mindful of the dangers of making assumptions and using intuition as the only basis on which to make judgements. Research5 advises that it is a human tendency to seek only the information that we ‘wish to find’, and confirms the dangers of a tendency to ‘stick to what we think we know’ and carry on with the plans without question or challenge. Opportunities to reflect on and explore thinking and conclusions were not discussed with colleagues from other agencies or it transpires, in supervision. 6.6.8 Brandon et al6 consider the importance of analysing rather than simply identifying what is known about a family’s history and warns without such an analysis there is a risk of falling into the trap of what is referred to as the ‘start again syndrome’. There is evidence that each report/referral to Children’s Services was seen in isolation from past concerns and this was clearly present. 6.6.9 It is clear from records that the hospital Midwife had concerns about LC’s ability to offer appropriate care to her newly born Baby E and she shared these concerns with the Team Manager in Children’s 5 Fish, Sheila, Munro, Eileen and Bairstow, Sue (2008) Learning together to safeguard children: developing a multi-agency systems approach for case reviews. 6 Understanding Serious Case Reviews and their Impact – A biennial Analysis of Serious Case Reviews 2005-2007. - 13 - Services. These concerns did not lead to a decision to hold a pre-discharge meeting but resulted in mother and baby going home and an Initial Assessment being undertaken two weeks later, which led to no further action. The experience and expertise of health partners, especially in relation to Midwifery Services was simply not recognised by Children’s Services. The tension between the two agencies was evident at times in the practitioner meetings as was a clear and distinct difference of professional views about taking drugs, specifically cannabis and the impact this could have on unborn babies and a parent’s ability to offer good enough care for children in the family. Regrettably concerns were not then escalated to senior managers. 6.6.10 Whilst agencies may demonstrate a theoretical commitment to multi-agency working this was not borne out in this case by a practical approach to safeguarding. The Housing Provider Manager was completely unaware that there were concerns about this family and considered that had they been so notified, they may have been able to offer support. In effect, records indicate that his staff had seen Baby E on a number occasions and the baby appeared clean and well dressed. There were no concerns about this family’s tenancy. 6.6.11 The safeguarding sector is emerging from a very procedurally driven era marked by a requirement to ‘follow the rules’ and there was a view clearly expressed in this and other SCRs in Sunderland that professionals cannot meet [as a group] unless they have parental consent. Professional meetings that do not involve family members did not feature in Working Together to Safeguard Children (2010) and it was, common to assume that they are not allowed. 6.6.12 However, such a course of action is perfectly legitimate and would have been useful to professionals in this case. Had a meeting taken place with the School Nurse, the Health Visitor and the Midwives for example, it is possible that through the sharing of information, and joint decision-making, a more effective multi-agency and co-ordinated approach to work with this family would have occurred. Working in conditions of uncertainty and risk without legitimate forums for professionals across agencies to come together to share, reflect and make sense of what is going on in the lives of families they are trying to help leaves professionals isolated and highlights a vulnerability in multi-agency systems trying to safeguard and protect children. 6.7 ASP 5: Failure to challenge and escalate concerns The view that this was a family who did not meet the threshold for Children’s Services intervention was accepted too readily by some frontline practitioners who did not challenge decisions taken by Social Workers/Team Managers or escalate their concerns through their own line managers or safeguarding teams. 6.8 There is a sense in this SCR that only professionals in the Midwifery Service were concerned about the risks to children born into this family. It was these concerns that prompted the four referrals made to Children’s Services in 2012 and 2013 in relation to LC’s pregnancies. 6.8.1 The Unborn Baby Procedures clearly state that a multi-disciplinary pre-birth assessment must always be undertaken where7 • The mother is failing to take up ante-natal care …… 7 Extracts from Sunderland Unborn Baby Procedures. - 14 - • Where alcohol or substance abuse is thought to be affecting the health of the expected baby….. 6.8.2 Clearly these procedures were not followed when LC was pregnant with Sibling 3 and with Baby E although the above criteria were clearly met. There were however no challenges or queries by health professionals as to why these procedures had not been followed. The view was expressed by some health professionals that decisions made about children by Children’s Services often seemed to be more influenced by the views held by Social Workers and Team Managers than by research, specialist knowledge and shared multi-agency concerns. Nevertheless, the decisions taken in respect of the children in this family and the rationale for those decisions were not challenged and/or escalated to senior managers in the respective agencies. It is significant that concerns about procedures not being followed or the perceived failure of Social Work professionals to grasp the significance of parents who continue with drug misuse, were not discussed or shared with the Named Midwife for Safeguarding. 6.8.3 In conversations with the Social Worker who undertook the Initial Assessment in September 2012, she advised the Review Team that she believed that there should have been a further assessment, but her views were overruled by her Team Manager who directed her to make a referral to the CAF Panel. The Social Worker advised she felt unable to challenge this decision; she was newly qualified and had joined the team only recently. She considered her Team Manager had more experience to make these judgments and she was not confident enough to challenge this decision. 6.8.4 In the practitioners’ meetings the discussions highlighted a divergence of views between Social Workers and health professionals about the use of cannabis and the impact on families. In a previous SCR in Sunderland, Social Workers were acutely concerned about a mother’s use of heroin and the impact on children in the family. These concerns however, were not replicated with LC who self-reported regular use of cannabis. The issue of professional understanding and recognition of the impact of different substances on parenting capacity is an issue, which requires further exploration by SSCB. 6.8.5 The Midwives did not robustly challenge the decisions taken by Children’s Services, although there were many opportunities to do so: following the decisions taken after the Initial Assessments; failing to liaise with key professionals; failure to follow pre-birth assessments and discharge of vulnerable babies procedures; the de-escalation from ‘Child in Need’ after only several weeks and without any consultation with key professionals. In the meetings with Practitioners, it became evident that the health professionals had not discussed their concerns with their Safeguarding Leads and whilst they would not be expected to highlight each and every case, there were significant risk factors in this family to trigger further discussions. 6.8.6 It was acknowledged when Midwives have any Child Protection concerns, regardless of whether these are shared by Children’s Services, they should be brought to the attention of the Named Midwife for Safeguarding so support and advice can be offered. It was also suggested that it was not uncommon for some professionals to hold the view that Social Workers ‘must know best’ so they could rest assured that their concerns had been appropriately shared and properly addressed. This made challenges far less likely. - 15 - 6.9 ASP 6 Managerial Oversight and Supervision Besides supporting frontline staff, managers have a duty to monitor the functioning of the organisation and to check that responsibilities are being met. There is evidence in this case review that supervisory processes were not robust and the practice of frontline workers was not fully supported or challenged. Management oversight of practice and systems was weak possibly as a result of the family being assessed as incurring only ‘low level’ concerns. 6.9.1 High quality reflective supervision is central to providing good support for professionals working with families with complex needs. There is a wealth of research and literature to assist managers to develop high quality supervision across agencies8; the best supervision offers both managerial oversight and constructive challenge to practitioners, using evidence based research to help the practitioner decide what sort of support is required for individual families. 6.9.2 Supervision and managerial oversight for all key practitioners should identify poor practice and examples where short cuts are taken to manage organisational demands. This case review revealed that there were several instances where safeguarding procedures were not followed and where the very systems intended to highlight vulnerable families were ineffective. For the health professionals, supervisory practices were not robust either in terms of supporting the practitioners or challenging practitioners when they were not persistent in following up concerns. It was however pointed out that if issues/family concerns were not raised in supervision, managers would be unaware of these. This highlights the importance of clear guidance about risk indicators in families which if present, should always be discussed in supervision or with safeguarding leads. 6.9.3 Some aspects of frontline practice should have been addressed through supervision in Children’s Services; especially given Social Worker 1 was new to the team and was recently qualified. In the conversations held with the Team Manager, it was pointed out that pressure of work meant that it was not always possible to audit every assessment, or check that historical and concerns had been addressed. The Team Manager could not recall if she knew that LC was pregnant when the ‘case’ was closed in February 2013 but added that the volume of work restricted the amount of time she could spend on monitoring assessments and closure of cases. In addition there were several new members of staff joining the team and it was not possible to give the level of supervision that many of the workers needed. This was also the reason given as to why there were no supervision notes for Social Worker 1 or 2, although the Team Manager was clear that supervision had taken place. 6.9.4 The Team Manager advised that she was aware of the Unborn Baby Procedures and that these procedures would have been discussed at every supervision with staff. 6.9.5 Two other factors were considered significant; one was the frequent change of managers through restructuring and sickness levels and another factor related to the way in cases were ‘block’9 transferred between teams allowing important details about vulnerable children to be easily overlooked. 8Staff Supervision in Social care,” Tony Morrison, 3rd edition and “The Impact of Supervision on Child protection practice –a study of Process and Outcome” 2003.Jane Wonnacot; Effective supervision in social work and social care, Professor John Carpenter and Caroline Webb SCIE Briefing 2012. 9 ‘Block’ transferring of cases was a shortcut process in which cases were transferred between teams by a list of cases on an email. - 16 - 6.9.6 What became clear to the Review Team was that whilst the practice of supervision varies across agencies, there was an absence of managerial oversight in all key agencies, which made it easier for frontline practitioners to work in isolation and from a single agency perspective. This contributed to a start again syndrome whereby assessments of each individual incident always started from the beginning and the potential cumulative harm to the children was never assessed. The ongoing concerns held by Midwives about the impact of drug misuse on unborn and newly born babies, a finding identified in other reviews - was not escalated to senior managers in partner agencies or robustly raised with SSCB. 6.10 Context in which professionals were working Practitioners were clearly working under a great deal of pressure, both in respect of competing demands for time, and the fact that thresholds for intervention were high. The practitioners in the review process spoke about the impact of both, commenting that high caseloads could easily encourage professionals to focus more on their own individual responsibilities because multi-agency working can appear to take more time and maintenance. 6.10.1 Information from the Practitioners Group and the Review Team suggests that in this Local Authority like others, there are diminishing budgets and competing priorities. Research by Brandon et al (2008)10 suggests that these factors along with pressures of work result in a tendency to raise thresholds for access to services as a way of rationing responses. Moreover, the acceptance of referrals for further intervention can be affected by the ‘speed practices’ and short cuts to manage and deflect referrals that develop when referral levels are high, especially when Local Authorities have tight timescales. This was clearly evident when, in response to referrals in June 2011, March 2012 and September 2012, LC was asked to come into the office to discuss the concerns before a decision was taken about the next course of action. 6.10.2 This view of ‘rationing responses’ was endorsed by many of the practitioners who contributed to this review and especially from colleagues in health settings. There continue to be misunderstandings around roles, responsibilities and thresholds and these challenges are compounded by the growing number of families referred for services in this Local Authority. 7 Agency learning and actions taken11 7.1 All the agencies involved in this SCR completed Agency Learning Reports (see Appendix 4). The information contained in these reports highlight that the individuals who contributed to the process either as a member of the Review Team or the Practitioners Group were able to identify personal learning. 10 Brandon, M et al:(2008)Analysing Child Deaths and Serious Injury through Abuse and Neglect: What Can We Learn? A biennial analysis of serious case reviews 2003-2005. Research Report DCSF-RR023. University of East Anglia. 11All agencies in the SCR completed a Learning and Reflection report, which are to be found in Appendix 4. This section encompasses information from these reports and from comments in the Practitioner’s meetings. - 17 - 7.2 Not all of the reports identified in detail, how this learning would be transferred to wider practice within individual agencies. Where necessary, the Lead Reviewers have identified or clarified additional actions that should be undertaken and which should be monitored by SSCB. 7.3 The pathway for interventions in relation to services for the family of Baby E was determined by a range of key points and decisions. The significant issues are identified below and are linked to previous case reviews in Sunderland. 8 The Findings 8.1 The Review Team identified seven findings or underlying patterns, which helped the team to understand why some practices happened in the way they did. Each of the findings is explained with a rationale, an indication of its impact on the wider systems in Sunderland and a series of questions designed to enable the Board to strengthen safeguarding by addressing the root causes underpinning the finding. 8.2 The findings fall into different typologies of systems issues, with a clear link between each of the findings and each of the typologies. This is not unusual, as it would be expected to find links between findings when adopting a whole systems approach. There are 7 findings for the Board to consider, these are: Patterns of Management of Systems 1. Managerial oversight is central to supporting critical thinking, challenge and good assessments in multi-agency work and this was not evident in this review. 2. Concerns, which appeared low-key and were not incident or crisis-driven, were not given high enough priority and this left the children, and especially Baby E vulnerable. Patterns of Professional-Family interaction 3. Professionals were too parent - focused. The lack of engagement with the older children meant their experiences, wishes and feelings were not fully considered. 4. Understanding the presence and role of males in families is critical to understanding family functioning and assessing risk. Patterns of Professional Bias 5. There are conflicting views between professionals about the impact of illegal substances on parenting capacity and the extent to which the use of cannabis increases the level of risk to children and unborn babies. Patterns in Multi-Agency work 6. There was a lack of robust multi-agency collaboration and challenge across agencies regarding decisions, plans and threshold. Patterns in the Use of Tools 7. Single agency risk assessment tools, where they exist, are neither recognised nor valued by other agencies and the absence of a multi-agency risk assessment tool made sharing information and assessing risk more difficult. This increased the risk of professional tensions. - 18 - Finding 1 _________ Managerial oversight is central to supporting critical thinking, challenge and good assessments in multi-agency work and this was not evident in this review. How was this manifest in this review? There is evidence that key frontline practitioners were not well supported by good quality reflective supervision. This case review revealed that there were two occasions when safeguarding procedures in respect of unborn babies were not followed and at least 4 occasions where assessments of children in this family failed to take place and/or did not meet expected standards in respect of robust analysis and multi-agency involvement. These issues were not discussed in supervision yet significant risk indicators were present. There was no managerial overview in respect of safeguarding practices in school and the absence of any robust recording systems left these, and possibly other, children vulnerable. What became clear to the Review Team was that whilst the practice of supervision varies, there was in this case, an absence of strong managerial oversight and challenge in key agencies and this made it easier for frontline practitioners to work in isolation and from a single agency perspective. This also made it less likely that concerns about decisions taken by Children’s Services practitioners would be challenged or escalated. Clearly, the impact of competing priorities and limited resources impact on services delivery but it must also be recognised that times of transition are periods which increase risk and require strong contingency plans from managers to ensure that vulnerable children do not slip through the gap. Is this an underlying issue in Sunderland or unique to this particular review? • This finding was recognised by the Practitioners and the Review Team as being an underlying issue in Sunderland and not unique to this particular review. • This finding replicates Finding 7, 8 and 11 in SCR Baby A and Child C, 2014 and Learning Lessons Review in 2012. Issues for the Board to consider 1. How is the Board assured that partner agencies support the provision of good quality and regular supervision even and especially through times of organisation change? 2. Is the Board aware of what systems are in place in partner agencies to monitor safeguarding practice and performance of frontline practitioners? 3. Can the Board be assured that systems are in place in each agency to ensure that families with vulnerable children and seemingly ‘low level’ concerns do not slip through the net? - 19 - Finding 2 ________ Concerns, which appeared ‘low-key’ and were not incident or crisis-driven, were not given high enough priority and this left the children, and especially Baby E vulnerable. How was this manifest in this review? There was a lack of clarity across agencies about thresholds, and limited understanding about the boundaries of family support and child protection. There was evidence that the children in this family had witnessed domestic violence, the parents misused drugs and the birth parents had at various times suffered with significant mental health problems. These factors, known as the toxic trio are well researched in terms of risk and poor outcomes for children and especially so for babies under the age of 1 year old. School did not make any referrals despite evidence of injuries and the worrying behaviours of the older children. Until (and even after) the incident with the killing of the kitten, concerns about children in this family were described as ‘low level’ and each of the five referrals made in the period under review were seen in isolation from each other. Consequently cumulative risks to the children remained unassessed. There was clear disagreement between professionals about the risk posed to these children and different views as to the extent to which LC was compliant in working with professionals to address their concerns. Is this an underlying issue in Sunderland or unique to this particular review? • This finding was recognised by the Practitioners and the Review Team as being an underlying issue in Sunderland and not unique to this particular review. • This finding replicates Finding 1 in SCR Baby A and Child C, 2014 and Learning Lessons Review in 2012. Issues for the Board to consider 1. Is the Board confident that frontline practitioners understand the risks to children associated with the ‘toxic trio’ and does the Board’s Multi-Agency Threshold document require amendments in the light of this finding? 2. Are there practice improvements that could be made to reduce risk for unborn babies where substance misuse or domestic violence in their families is known? 3. Are the procedures for instigating pre-discharge meetings for babies about whom there are concerns sufficiently robust and well understood by key practitioners? 4. Is the Board confident that professionals in all agencies fully understand the significance of missed medical appointments for pregnant women and children and are there processes in place to monitor when these occur, how often and what action to take when concerns about these arise? 5. Is there clarity about when parenting risk assessments should be undertaken and is it clear that these should include an assessment of parent’s capacity/willingness/motivation to change - 20 - Finding 3 Professionals were too parent - focused. The lack of engagement with the older children meant their experiences, wishes and feelings were not fully considered. How was this manifest in this review? There is little to suggest that any professional had spent time with the older children to find out more about their life at home despite past concerns about domestic violence and aggressive behaviour whilst in school. The lack of engagement with the children when it became known that they had killed a kitten is of some concern as is the view expressed by Social Worker 2 that the incident was ‘no longer of concern to Children’s Services’. Social Worker 1 had recorded concerns about the behaviour of Sibling 2 and had queried the extent of drug misuse by the parent but there was no follow up work proposed or undertaken. When the parent did not engage with the CAF process, the needs of these children appear to have been forgotten despite previous and very valid concerns. Children mistreating animals is not a new phenomenon, but the killing of a kitten by such young children should have led to further enquiries. There are few records, which pertain to Sibling 3 or to Baby E, and most references are taken from Health Visitor records. Is this an underlying issue in Sunderland or unique to this particular review? • This finding, of the children’s views and experiences not being fully considered, was recognised by the Practitioners and the Review Team, although were also aware of pockets of excellent practice. Issues for the Board to consider 1. How does the Board assure itself that where there are concerns about parenting the voices and experiences of children are actively sought? 2. Does the Board have a mechanism for quality assuring the extent to which the views and experiences of children are sought and recorded? 3. Is the Board confident that frontline practitioners understand what is meant by professional judgement and how to apply it? 4. How does the Board ensure frontline practitioners develop skills in engaging with non-compliant or resistant families? - 21 - Finding 4 _______ Understanding the presence and role of males in families is critical to understanding family functioning and assessing risk How was this manifest in this review? Serious case reviews have repeatedly highlighted failures by Social Workers to effectively engage Fathers or significant males in the family and this was clearly evident in this review. JR was clearly seen as a resource in this family, whilst the Father of the eldest children was considered a risk. However, neither male was considered or assessed in terms of their role and relationships with the children and this was poor practice. Is this an underlying issue in Sunderland or unique to this particular review? • This finding was recognised by the Practitioners and the Review Team as being an underlying issue in Sunderland and not unique to this particular review. Issues for the Board to consider 1. This is a significant issue, well evidenced and researched. How can the Board ensure that assessments and work with families and children fully engage significant males in the family in those processes? 2. Gender biases are pervasive in child welfare research and practice. Although these biases are to some extent well known, there continues to be a lack of information on Fathers and an overrepresentation of information on Mothers in case files and assessments, and thus the biases continue. How can the Board begin to tackle this issue? - 22 - Finding 5 _______ There are conflicting views between professionals about the impact of illegal substances on parenting capacity and the extent to which the use of cannabis increases level of risk to children and unborn babies. How was this manifest in this review? Community Midwives were concerned to learn from toxicology reports that LC was still taking cannabis and amphetamines during pregnancy despite her assertions to the contrary. Social Worker 1 noted that LC’s self-reported drug use was very probably understated but these facts alone did not lead to further enquiries as to how substance abuse by parents were impacting on LC’s parenting role and that of JR. In the Practitioners meetings there was considerable debate and disagreement between professionals about the use of cannabis and the extent to which it should be seen as a risk factor significant enough for Children’s Services intervention. Is this an underlying issue in Sunderland or unique to this particular review? • This finding was recognised by the Practitioners and the Review Team as being an underlying issue in Sunderland and not unique to this particular review. Issues for the Board to consider 1. Does the Board need to clarify its position and guidance in relation to Substance Misuse and the impact of different substances on parenting capacity? 2. Is there value in health and social care professionals exploring this issue in greater depth? 3. If the use of cannabis is as widespread in some areas as professionals indicate, how will the Board address this? - 23 - Finding 6 _______ There was a lack of robust multi-agency collaboration and challenge across agencies especially in relation to early help, decision-making and thresholds. How was this manifest in this Review? The absence of any multi-agency work with this family is striking, as too are the absences of any challenge about the decisions that were made. All agencies seemed to look to Children’s Services to take action and when they chose not to intervene, this decision appears to have been accepted without challenge. The emphasis of partnership working with parents seems to leave professionals believing that without parental consent, and/or Children’s Services involvement they cannot meet to share concerns unless the child protection thresholds are met. Is this an underlying issue in Sunderland or unique to this particular review? • This finding was recognised by the Practitioners and the Review Team as being an underlying issue in Sunderland and not unique to this particular review. • This finding replicates Finding 3 and 4 in SCR Baby A and Child C, 2014 and Learning Lessons Review in 2012. Issues for the Board to consider 1. Do all professionals in the safeguarding system fully understand their responsibilities in relation to CAF/Early Help 2. Are professionals able to articulate the benefits of Early Help to parents who may be resistant to engage? 3. How can management systems encourage recourse to multi-agency processes and purposeful professionals-only meetings in situations where the practitioners are ‘stuck’ in finding a way forward 4. There are benefits of providing multi-agency first line management workshops which reinforce the systems to support multi-agency working 5. That further work is undertaken with practitioners to gain a greater insight into the operational barriers/resistances to multi-agency working as a first step to addressing changing cultures 6. To what extent are professional challenges welcomed between professionals and between agencies? 7. Is escalation encouraged and are staff in all agencies supported as a means of resolving professional differences? - 24 - Finding 7 ________ Single agency risk assessment tools, where they exist, are neither recognised nor valued by other agencies and the absence of a multi-agency risk assessment tool made sharing information and assessing risk more difficult. This increased the risk of professional tensions. How was this manifest in this review? Whilst health colleagues use the Early Warning tool to inform their judgement about risk and vulnerability, this tool did not appear to be generally recognised by colleagues in Children’s Services. The Early Warning tool was used by Midwives when LC was pregnant with Sibling 3 and Baby E and this contributed to a decision to make a child protection referral. The absence of any multi-agency risk assessment at the time meant that the different elements of risk experienced by these children were not considered holistically and the cumulative impact was not recognised. The issue of how risk is defined, assessed and by whom is an issue, which was widely recognised by the practitioners and review team members. Is this an underlying issue in Sunderland or unique to this particular review? • This finding was recognised by the Practitioners and the Review Team as being an underlying issue in Sunderland and not unique to this particular review. • This finding replicates Finding 5 identified in SCR Baby A and Child C, 2014 and Learning Lessons Review in 2012. Issues for the Board to consider 1. Is the Board confident that across all agencies the Multi-Agency Threshold Guidance ensures there is a coordinated and unified approach to identifying concerns, assessing needs and measuring risks? 2. Are current assessment and referral procedures effective in taking a holistic approach to both current and historic safeguarding issues? 3. If single agency assessments are undertaken such as the Early Warning tool, can these be used more effectively to aid assessment and decision-making? - 25 - 9 Summary It is impossible to state whether the sad death of Baby E, aged 4 months was preventable. The family were advised by the Health Visitor about the risks of co-sleeping but the parents elected, as many do, to place the baby in their bed to sleep. The cause of death was unascertained meaning it was not possible to find an explanation as to why the baby died. However, the circumstances in which the baby was found after her death gave cause for concern and some difficult questions had to be asked of the professionals who knew the family. The views of the parents would have undoubtedly enriched this report. Just as it was not possible to predict the death of Baby E, neither is it possible to attribute the cause of death to any failings on the part of professionals who knew the family. The review has however highlighted the need for professionals to be persistent, curious and above all child-centred when pursuing concerns about the welfare of children. There are lessons to be learnt for all the agencies involved with this family. Arguably, had the concerns been more robustly assessed and the challenges to parents and professionals more dogged, with strong assertive interventions made to ensure the children’s welfare was promoted, several of the factors highlighted in this report may have emerged and the sharing of multi-agency information may have exposed the true vulnerability of the family’s circumstances. - 26 - Appendix 1 The Serious Case Review (SCR) Review Team Function To conduct, on behalf of the SSCB, the Serious Case Review, ensuring timely progression and taking responsibility for the production of the final SCR report presented to the Board at an agreed date. One or two lead reviewers, one of whom must be independent of any agency represented on the Review Team, will lead the work of the SCR Management Review Team. Membership of the SCR Review Team Membership will usually be senior representatives from the various agencies working with or known to the family. They must not have had any direct contact with the family or children or have held decision-making or supervisory role in relation to the frontline practitioners working with the family. Members of this Team will be expected to have the authority to hold their own agency to account to ensure that required reports/documents are made available and key staff supported to take an active role in the SCR process. Agencies represented on the Review Team were as follows: Linda Richardson Lead Reviewer Jan Grey Second Reviewer Lynne Thomas SSCB Business Manager Head of Safeguarding Sunderland CCG Lead Nurse Safeguarding ST NHS Foundation Trust Education Safeguarding Team Manager Sunderland City Council Lay Member SSCB Legal Representative Sunderland City Council Acting Detective Inspector Northumbria Police Lead Midwife City Hospitals Sunderland Head of Safeguarding Sunderland People Directorate Each member of that team was asked to identify the frontline practitioners from their agency who were known to, or had worked with, the family of Baby E. These practitioners formed the Practitioners Group and this group met on three occasions. The Practitioner’s Group consisted of: Operational Manager Children’s Services Operational Manager Children’s Services Social Worker Children’s Services Social Worker Children’s Services Deputy Head Teacher School Class Teacher x 2 Schools - 27 - Neighbourhood Managers x 2 Housing Providers Operations Manager Housing Provider Detective Constable Northumbria Police School Nurse STNHS Foundation Trust Midwife x 3 Maternity Services Health Visitor ST NHS Foundation Trust Responsibilities of members of the Review Team • Represent their agency • Understand the broad details of the case under review • Ensure that a very broad outline chronology is undertaken • Identify key frontline practitioners who were known to the family • Undertake tasks related to data collection and analysis • Take ownership of the contents of the final report in presenting findings to the SSCB Rationale: This SCR Review Team may well involve many of the same managers involved in the SSCB Learning and Improvement in Practice sub-committee, it’s function and purpose however, are different in that its’ work is solely to lead and work on a specific SCR. Members need to be clear about their responsibilities, as this model requires far greater involvement from senior managers than the previous prescriptive IMR type methodology. - 28 - Appendix 2 Roles and Responsibilities SSCB Chair • Confirms the decision to hold a SCR • Commissions on behalf of the Board, the Independent Reviewers • Agrees to the model used and holds agencies to account for their active involvement in the process • Ensures that there are sufficient resources in the SSCB Business Unit to support the SCR process • Ensure Board partners are kept well briefed about the SCR and its progress • Intervene where difficulties or barriers emerge from agencies SSCB Business Manager • Is familiar with the model used and acts as a source of information for all who are involved in the SCR process. This can be a stressful and anxiety-provoking experience for those unfamiliar with this type of approach • Ensures that all key parties are kept informed and there is formal sign up from all agencies involved in the SCR • Convenes all meetings and ensures that these are well documented and minuted • Works with and to the lead reviewers in terms of access to resources, data collection and contact with key individuals • Ensures that steady progress of the SCR is maintained • Keeps the SSCB Chair and the Board briefed about emerging issues and progress • Manages issues about any parallel processes • Acts as the key link between the SCR Review Team and the SSCB SCR Review Team Members will be expected to • Attend all meetings where possible – deputies are not encouraged • Collect documentation from own agency as and where required • Read and analyse relevant data • Undertake discussions with frontline staff from their own and other agencies if agreed and write up these ‘conversations’ • Support their own staff who are involved with SCR ensuring they receive full and appropriate support throughout the SCR process • Identify and facilitate changes within their organisation in response to any emerging practice or policy issues • Meet/communicate with the staff at the end of the SCR process to discuss agency and professional learning • Ensure that the required Learning and Reflection report is submitted for inclusion in the SCR final report • Ensure that information about SCR process is communicated throughout their agency to managers and frontline practitioners • Ensure required reports are submitted on time • Read and contribute to draft and final reports • Take responsibility for addressing any issues, which arise in their organisation in relation to the SCR, including any findings and recommendations Practitioners Group members will be expected to • Attend Practitioner Group meetings and/or - 29 - • Meet with two members of the Review team to discuss their views about working with the family and what factors helped and hindered your practice • Reflect on their own practice and that of their agency • Offer support and respectful challenge to other colleagues through their reflective and shared journey • Read and comment on any draft report circulated by the Review Team Lead Reviewers will • Offer leadership to the Review Team, chairing meetings and ensuring key tasks are identified and followed through • Work in partnership with Review team to ensure work is co-ordinated and progressed • Offer guidance and support to all individuals involved in the SCR process • Maintain a reflective log to ensure that lessons can be learnt for future use of this model • Produce draft reports for the Review Team, offering insights, analysis and challenge and take responsibility for the production of the final report on behalf of the team • Ensure they have supervisory and mentoring opportunities to provide scrutiny and challenge to their role as lead reviewers Rationale: The role of Business Manager is a vital one and it is essential that this individual understands the key part they play in supporting the SCR. Equally, others who are involved need to be clear about what is expected of them in this way of working. SSCBs may elect to appoint one lead reviewer to lead on the SCR and agree that the second lead reviewer can be an internal appointment from any of the agencies involved. It is important however to note that if this decision is taken, appropriate resources should be made available including external supervision for both reviewers. - 30 - Appendix 3 Methodological Comments and Limitations 1. The Review Team’s understanding of using the model initially created anxiety due to this being a new experience. Even with the benefit of the Review Team being provided a presentation of the model by the Lead Reviewers, concerns regarding elements of the process were expressed by some Review Team members. 2. There was clearly a good working knowledge of undertaking serious case reviews in the previous models prior to Working Together 2013. This, coupled with a Review Team that had worked together for a considerable period of time, led to nervousness about the changed process but also created opportunities for challenging some accepted practices. 3. The terminology used within the Model was different and this also impacted on the understanding of individual Review Team members and led to additional explanations of the process and guidance from the Business Manager. In future the Board will produce a SCR Information Pack for all those involved in the review process. This has already been developed as the Review Panel learnt lessons throughout the process. 4. Concerns about roles within the process became evident within Review Team meetings and a level of constant reassurance was required. The less prescriptive approach of this model allowed some flexibility within the Review but timescales weren’t sufficiently robust and this is an issue the Board will address in future reviews when using this approach. 5. The number of SCRs being undertaken in this Authority at the same time clearly impacted not only on timescales but also on the workload and availabilities of the Review Team. On occasions it also made it more difficult for the Review Team to separate one review from another due to the similar nature of the case. However, the lessons emerging from this Review corroborated those already identified and strengthened the messages for the Board. 6. The Model was amended part way through the process to include agencies producing a Learning and Reflection Report. This enhanced the process of learning from the case as the staff themselves were directly involved in identifying the learning from the case. However this had not been part of the original Model and was introduced when it became evident that the Board needed evidence that agencies had learnt lessons from their participation in the Review. Taking on board the Review Team’s feedback in future this needs to be explained much earlier especially regarding the sign off of these reports. 7. The Review Team have a better understanding of other agency’s learning through this very interactive practitioner/Review Team relationship. Some of the learning enabled individual agencies to better understand the role, function, and practice of their multi-agency partners in this case. It also challenged agency’s assumptions of one another roles and statutory responsibilities. The experience of undertaking conversations with frontline practitioners although time consuming was thought to be beneficial to the SCR process. 8. Feedback from frontline practitioners indicated that they thought the Practitioners Meetings, although not always comfortable, did help them better understand the role of their colleagues and made a - 31 - difference to their practice. They valued being involved as key practitioners in the SCR process and thought this approach was more inclusive and offered greater learning than previous models. 9. Overall, the experience was thought to be a positive one, but one which was not necessarily any less time consuming than previous approaches. - 32 - Appendix 4 Agency Learning Reports 1. City Hospitals Sunderland (CHS) Learning Points and Actions taken • Importance of recognising risk where parents have history of non-engagement with services and substance misuse • Need to challenge and escalate concerns when procedures are not followed or referrals are not acknowledged • When communication channels are not robust, children are vulnerable • Any agency can instigate multi-agency meetings if there are concerns (Reviewer’s comments) • MASH processes have improved communication • Being involved in a Serious Case Review is stressful • CHS guidelines have been updated to aid practice • Postnatal documentation now includes a section relating to discussions with parents around safe sleeping practices. The HV and MW pathway will be audited to ensure this process is followed • Midwives will now escalate cases to the Named Midwife for Safeguarding children regarding any complex issues or delayed feedback from Children’s Services. The HV and MW pathway will be audited to ensure this process is followed • Pre-discharge planning meetings are now required for all cases where there are Child Protection concerns • Safeguarding arrangements have been reviewed and are now more robust regarding babies in hospital who are transferred to the neonatal unit 2. South Tyneside NHS Foundation Trust (STNHSFT) Learning Points and Action taken: • Where vulnerabilities in pregnant women are identified, this should lead to early allocation and early intervention by Health Visitors. The HV and MW pathway will be regularly audited to ensure this process is followed • All pregnancies where vulnerabilities are identified will be discussed with the safeguarding advisors to provide support for professionals and to ensure adherence to SSCB Unborn Baby Procedures • The Early Warning Tool will be reviewed and it's use clarified for all front line professionals, including social workers. An audit of its use across Sunderland will be completed within 6 months of this review • The learning from this review will be shared and discussed with the School Nurse Operational Lead to support the development and use of the Early Warning Tool for School Nurses • The learning from this review will be shared with operational leads and frontline professionals to ensure the impact upon parenting capability is both recognised and considered when there are concerns regarding any substance misuse. This should be clearly documented following each health contact • Better communication between the community health team allows for increased flow of information. The GP Safeguarding team meeting provides the ideal conduit for this - 33 - information to be shared. Health Visitors and School Nurses will be encouraged to attend these meetings so information about vulnerable families can be shared • The Health Visiting service and the School Nursing Service are employed by STNHSFT. The learning from this case and the recommendations identified will be monitored by both STNHSFT Safeguarding Strategic Operational Group and the CCG Strategic Safeguarding Group 3. Learning for General Practitioners Learning Point and Action taken • Record Keeping: There were issues within both practices12 about “flagging” safeguarding concerns on the electronic records. “Flagging,” alerts every practitioner using the system to any concerns about, for example, Child Protection Plans, Toxic Trio and/or risks to staff visiting the home. In busy General Practice where there may be a number of GPs this is of paramount importance as individual GPs may not have met the patient previously Clear guidance on how to “flag” safeguarding concerns will be incorporated into the Safeguarding Children Primary Care Resource Pack which will be circulated to all GPs and Practice Managers in June 2014. Whilst this information was contained in a previous resource pack this has been reviewed and strengthened in the 2014 version • Analysis of Information: There was good evidence that the antenatal vulnerability assessments were received into the GP practice from the midwife and being scanned into LC’s record, but these were not analysed in the context of her already having children and consideration was not given to ‘flagging’ the records accordingly The importance of utilising historical information and assessments undertaken by other health professionals features in all Level 3 GP safeguarding children training. This training will be reviewed and the learning from this case highlighted. A briefing paper on the learning will also be produced and shared with all Practices • Communication with Midwives and Health Visitors: JR’s GP practice was not contacted by the midwife involved in LC’s care despite his name and date of birth being included on midwifery records. This information was also included in the child protection referral submitted by the midwife. The GP practice was not contacted by Children’s Services undertaking the Initial Assessments and the GP indicated that they would have shared the information known about his substance misuse • There has been an agreement that midwives will copy the antenatal vulnerability assessment to a father’s GP practice (if different to mother’s). Practices must ensure that this is scanned onto the father’s GP records and the system flagged accordingly. This needs to be incorporated into the Safeguarding Children Primary Care Resource Pack, which will be circulated to all GPs and Practice Managers in June 2014 and will be included in the briefing note to all Practices. City Hospital’s internal safeguarding policies and procedures will need to be reviewed to ensure this change to practice is incorporated here is no evidence of midwifery verbally sharing or updating LC’s GP Practice regarding the vulnerabilities identified during her antenatal and postnatal period. An audit of attendance at “vulnerable family “multi-disciplinary meetings within Primary Care must be undertaken across Midwifery, Health Visiting and Primary Care by the agency leads. 12 LC and JR were registered with different GPs. - 34 - Midwifery policies and procedures must be reviewed to ensure GPs are copied into any safeguarding children referrals and that attendance at such meetings should be seen as core business • Evidence Based Care: It is imperative that GPs undertake regular training in safeguarding children and can recognise the “Toxic Trio” and other factors that may impact on parenting capacity. The continued emergence of children not being brought to medical appointments in reviews emphasises the importance of GPs attending training on neglect and how it may present Both practices were not aware of the increased vulnerability of babies to Sudden Infant Death Syndrome when parents/carers adopt unsafe sleep practice. The training programme for GPs must be reviewed to ensure all of the learning from Baby E is highlighted and that all health professionals promote safe sleep practice to all parents/carers The Child Death Overview Panel is currently undertaking a review of the “Give Me Room To Breathe” campaign and any change to advice and new resources will be shared with all GPs in Sunderland • Systems and Processes: Both GP practices for JR and LC have been offered support from the CCG Safeguarding Children Team in reviewing their systems and processes in light of the learning identified from this review. The learning from this case review has already been shared with the 2 practices involved and will be shared across the city as the SCR progresses in a variety of training and awareness sessions. A briefing paper on the learning will also be provided to the GPs and Practice Managers in Sunderland • GPs are commissioned by NHS England, the learning from this case and ensuring the recommendations are implemented will be monitored by both the CCG and NHS England, via the CCG Strategic Safeguarding Group and the NHS England Safeguarding Forum • The Head of Safeguarding will share the recommendations and the Named GP for Safeguarding Children within the CCG in timescales as agreed by the Serious Case Review Panel 4. Children’s Services Learning Points and Action taken • Lack of shared understanding by staff in Children’s Services of thresholds across Early Intervention and Social Care • Importance of following Vulnerable Babies Protocol • Importance of assessments seeking and incorporating views of other professionals • Practice of transferring cases between social care teams needs review • Supervision and support to staff need to be consistent • Need to improve Induction programmes • Business processes need to support the Safeguarding system • A review of the Step Up/Step Down procedure to be carried out to ensure that this protocol is fit for purpose, widely understood and followed • Joint workshops on thresholds, preferably in localities, to be put in place • Refresher sessions re the Vulnerable Babies protocol to take place in team meetings across the 5 Child Protection Locality Teams and in the MASH • Follow up sessions after the Assessment Training being delivered in June 2014 to ensure that the learning from this training is embedded in practice • Implementation of the new Single Assessment to emphasise the importance of social workers routinely speaking to all other professionals involved when conducting assessments in order to inform their analysis • Transfer protocols to be reviewed and updated to be more specific re need for Transfer summary to be in place when cases are transferring between teams - 35 - • Each CP team should have 2 Senior Social workers (rather than 1 as at present), to assist with supervision. The Senior Social Workers need to have significantly reduced caseloads so that they have time to supervise staff • Review of induction for new staff joining the service, including those who are not newly qualified, and agency social work staff. Process for in-service induction/familiarisation for staff moving to new team/taking on new roles within Children’s safeguarding to be put in place • Multi-agency development sessions, where possible on a locality basis so that staff from different agencies working with children can get to know each other and forge more effective professional relationships • Audits of Contacts to ensure an email or “action job” is sent to the social worker and manager to inform them when new contacts are received on open cases 5. Gentoo – Housing Provider Learning Points and Action taken • There were potential opportunities for the staff to have explored vulnerability and support needs of the tenant and wider household. As there were no obvious presenting issues and as the family lived in general needs accommodation, this did not happen. Therefore consideration of a more general approach to assess vulnerability needs to be given • Vulnerability is currently referenced throughout various separate processes at Gentoo. We have dedicated Domestic Abuse and Safeguarding Policies as well as a Community Safety Strategy. However, we do not have a more generic vulnerability policy, therefore, as stated above, consideration needs to be given to developing a more generic policy and approach • It is frustrating for Gentoo staff to have learned that Children’s Services had historic involvement with the family, yet no one at Gentoo had been notified of this. We need to agree information sharing process and protocol with Children’s services so Gentoo are notified of cases such as this and can contribute to any family support plan • Any tenancy breach matter should alert housing staff to the possibility that there may be vulnerability issues or tenancy support needs. This is obviously more difficult when there are no obvious presenting vulnerability issues. Therefore, the matter of treating tenancy breaches as a vulnerability trigger needs to tie into the development of a more general vulnerability policy and approach • Develop generic vulnerability policy • Develop specific information sharing protocols with Children’s Services • Raise awareness of the learning points from the case with all front line housing staff • Train front line staff on the new vulnerability policy and approach which will include considering tenancy breach as a trigger • Carry out safeguarding refresher training to all front line staff 6. Children’s Services: Education • Safeguarding procedures have been revised and implemented • Roles and responsibilities in school have been clarified • The importance of recording concerns and sharing these with the Designated Person in school has been stressed. Importance of seeking feedback has also been highlighted • Staff will receive Safeguarding training as a matter of some urgency so they are clear about roles and responsibilities in relation to safeguarding children in their care • Children’s Services will ensure these lessons are disseminated across all schools - 36 - Appendix 5 How has the learning from this SCR improved practice? City Hospitals Sunderland (CHSFT) • To improve midwifery documentation, to include evidence of information giving regarding safe sleep IMPACT: Post-natal documentation has been updated and this provides a section to evidence discussion relating to safe sleep for midwives to complete. An audit was undertaken in July 2015 and June 2016 and this provided assurance around compliance to discussion around safe sleeping practices and pre-discharge planning meetings • To ensure child protection cases are managed well, Midwives to escalate any complex cases or delayed feedback from Children’s Services to named midwife IMPACT: Communication via emails, supervision and staff briefings to all midwives regarding this requirement which has led to an increase in discussion with midwives around complex cases with the named midwife for safeguarding. Vulnerable babies Interface meetings were established with CHSFT and Children’s Services in February 2015 to ensure effective communication and oversight of cases • Pre discharge planning meetings are to be held in all cases where there is an unborn child protection plan in place IMPACT: Communication via emails, supervision and staff briefings to all midwives regarding this requirement. Documentation was improved to support these meetings and an audit was undertaken which evidenced that processes were being followed. This audit was repeated in April 2016 and again this provided assurance that pre-discharge planning meetings were embedded in practice and that babies were being discharged safely from hospitals • Where parents require supervision, the birth arrangements are clear on the agreed provision including if babies require to be cared for in the Neonatal Intensive Care Unit (NICU) IMPACT: New birth arrangements were formulated which have clear plans for supervision. All of the recommendations from this review will be included within CHSFT safeguarding children training and supervision IMPACT: The training and supervision is having a positive effect upon staff awareness and understanding of safeguarding and serious case reviews, with the training evaluation demonstrating feedback. Assurance via the quarterly safeguarding dashboard South Tyneside NHS Foundation Trust (STNHSFT) • Improve communication between HV and MW services o All Health Visiting teams now have an ante-natal database to record patient information following receipt of ante-natal vulnerability (AVA) form from midwifery colleagues. Identification and Notification of vulnerable families via the AVA has led to early allocation and involvement of Named Health Visitor during earlier stages of pregnancy o On receipt of the AVA this is analysed by the Health Visitor in the context of what is already known about the family, enhancing sharing of information and multi-agency communication o Where vulnerability has been identified on the AVA, Health Visitors will undertake early contact and intervention with the family, contributing earlier to multi agency working o The Safeguarding team are notified on a monthly basis of AVA notifications received and the identified named health visitor. Improved communication between the safeguarding team and the health visiting service supports the provision of safeguarding advice during the pregnancy • Appropriate use of the HV and SNS Early Warning Tool EWT across STNHSFT o Health Visiting Child Health records now include both an Early Warning Tool, and a Workload intervention tool. Early identification of risk ensures families and children receive - 37 - specific support and intervention from the most appropriate health professional in a timely manner • All vulnerable UBB cases will be discussed by health professionals with the safeguarding advisors o Safeguarding Children Advisors now provide safeguarding supervision to all health visitors specifically with regard to Unborn Babies following identification of vulnerability on the AVA. Safeguarding supervision ensures SSCB and STNHSFT Safeguarding Unborn Baby Procedures are adhered o STNHSFT Safeguarding Team link with CHS midwifery lead to raise and discuss any concerns with the HV/MW Pathway both verbally and at a dedicated interface meeting. Enhanced communication across HV/MW ensures LSCB and STNHSFT Safeguarding Procedures regarding the Unborn Baby are adhered with • The impact upon parenting capabilities following the identification of the use of any substance should be considered at each health contact. This should be clearly documented within the child health records o A safeguarding training package Level 3 has been developed ‘Substance Misuse and the impact upon Children’. This training equips health professionals with the knowledge and skills regarding illegal substances, and the impact a parent’s reliance on illegal substances may have upon the child or children within the household. This supports health professionals with completion of health and risk assessments o New Health Visiting Child Health Records have been introduced 1st June 2016.Health Visitors are required with all families to discuss substance misuse at all contacts with the family as part of the overall health assessment. Early identification of reliance on substances leads to early support and specialist intervention for the family and earlier identification of potential risks posed to children • The GP Safeguarding practice meeting should be attended or information shared with regard to vulnerable families from community professionals o Each GP practice has a named Health Visitor to attend GP Safeguarding Practice Meetings. Vulnerable families are discussed at this meeting promoting effective communication and enabling primary care practitioners to share and analyse information to progress the most appropriate support and intervention for children and families Learning for General Practitioners (GPs) • All practices will clearly ‘flag’ children and families where there are safeguarding concerns o Both clinicians and administrative staff will be able to easily identify children and families at risk, which may influence provision of appointments, and indicate who is the best person to see that child or family o Such children and families will be easily identifiable in order to piece together information shared from other agencies, which will help identify further needs o This will enable practices and staff to take a “whole family” approach to safeguarding and ensure that the right service is offered at the right time • GPs to recognise the importance of analysing information received and shared by agencies in the context of what is already known about the family o GPs are in a strong position for collating information from multiple sources about patients. Through recording information received and applying this to what is already known GPs can piece together a much fuller picture of a family o GPs all hold regular multi-disciplinary meetings which are an ideal environment to discuss families and any information received about a family. This enables practices to consider the relevance of the information and apply that to supporting a child or family in a timely manner, by the most appropriate practitioner - 38 - • Midwives to send copies of antenatal vulnerability assessments to GP practice of the birth father of the unborn child, where the father is registered at a different practice, when safeguarding concerns are noted. GPs to recognise the importance of the father’s history as well as the mothers and to aim to avoid the possibility of the ‘invisible’ father o Where safeguarding concerns are raised by the midwife, a safeguarding referral will be made, and standard procedures for safeguarding referrals will be used to gather information on relevant family members in order to process the referral. o Where male patients disclose information of concern to the GP, and the GP is aware that they are, or are soon to be a father, this information will be taken into account and discussed with the patient, and safeguarding referrals made where appropriate o Where safeguarding concerns are raised by the midwife and the father is present at that appointment, the fathers GP will be informed of the concerns • Practices to regularly hold multi-disciplinary meetings including midwives to discuss cases of concern and more complex cases o All practices in Sunderland hold regular multi-disciplinary meetings, at varying frequency depending on the size of the practice. Midwives are invited to these meetings o This should improve communication between a range of practitioners and result in a shared understanding of the needs of families, agencies involved and result in more timely involvement of appropriate services to improve outcomes for children and young people. o Most practices have systems in place to collate information from midwives, should they be unable to attend meetings, thus sharing their information and enabling informed discussions at MDT meetings o An audit is conducted on an annual basis to identify any problems in meeting with relevant professionals and holding MDT meetings. This is then fed-back to appropriate lead professionals and processes are reviewed to resolve any problems and improve communication between agencies Children’s Services • Improve the understanding of thresholds across early Intervention and Social Care o The ‘Step Up and Step Down’ procedures were revised in 2014 and shared internally within Children Social Care & Early Help Services and with partner agencies o Threshold Workshops were delivered across the city to multi agency groups in November 2015 o Early Help activity is being closely monitored by the Improvement Board • Need to follow Vulnerable Babies Protocol o The Unborn Baby Protocol was revised in February 2016 and is awaiting a further review in the light of the introduction of the Single Assessment o Vulnerable Baby workshops have been delivered jointly by Health and Children’s Social Care • Importance of assessment incorporating views of other professionals o The Single Assessment was fully implemented in February 2016 which emphasises the importance for social workers to routinely speak to all other professionals when undertaking assessments, in order to inform their analysis o Risk tools were introduced in August 2015 – Bruce Thornton, supported by training events to all Children’s Social Care and Early Help staff • Transfer of cases between social care teams o The Transfer Protocol is currently under review in the light of the changes made to the structure of Children’s Social Care i.e. MASH moving to be an Integrated Contact and Referral team; Child’s Permanence Reports to be undertaken in the Locality Safeguarding Teams o Transfer summaries are required and this is built into the Practice Standards for Social Workers and monitored through the audit process - 39 - • Supervision and support to staff including induction o Supervision Policy revised and re launched – May 2015 o New recording pro-forma has been developed and under continuous review to reflect the new guidance o All supervisions are recorded on CCM and there is monthly reporting to the Improvement Board o Themed audit of supervision was carried out in January 2016 to assess quality with a further audit in August 16 • Continually work towards improving the working relationships with other professionals o This is an on-going endeavour and is best seen in some of the structural multi agency developments in Children’s Social Care ie the MASH and the Multi Agency Looked After Panel • Improve the business processes supporting the safeguarding system o The introduction of the Business Manager in each of the locality teams has significantly improved the business processes o Quality of information and data has improved o CCM version 29 has been implemented in the early part of 2016 and the introduction of Liquid logic is planned for June 2017 Gentoo – Housing Provider • There were potential opportunities for the staff to have further explored vulnerability and support needs of the tenant and wider household o Gentoo are in the process of developing a generic vulnerability policy o Training sessions have been held to ensure all relevant staff are clear about expectations around exploring vulnerability. Sessions took place in November and December 2014, January 2015 and May 2016 Impact The impact of this new approach will mean that any tenancy breach matter, regardless of how minor, will alert housing staff to the possibility that there may be vulnerability issues or tenancy support needs. • Gentoo were unaware that Children’s Services were involved with Baby E and her family. Information sharing protocols with Children’s Services to be developed Impact If Gentoo were made aware of all cases involving their tenants, we could be part of any improvement/support plan for the child/family. Our involvement with the family would be completely different to those where we are simply managing a general tenancy Children’s Services: Education • Safeguarding procedures have been revised and implemented: o Children’s Social Care Services have revised procedures for contact/referral to MASH; escalation routes where schools are not satisfied with how referrals are dealt with have been clarified; all referrals should now receive acknowledgement response • Roles and responsibilities in schools have been clarified: o Termly training for designated persons in schools refreshes and reinforces the approach to safeguarding in schools which is also covered in schools/academies Ofsted Inspection Framework o The importance of recording concerns and sharing these with the designated person in school has been stressed. Importance of seeking feedback has also been highlighted o Schools are now encouraged to seek acknowledgement/outcomes of referrals if these are not forthcoming - 40 - o Staff will receive safeguarding training as a matter of urgency so they are clear about roles and responsibilities in relation to safeguarding of children in their care o Designated person training, SSCB training, including social care/ health delivered training in relation to vulnerable babies o Children's Services will ensure these lessons are disseminated a cross all schools o Representative schools involvement in SSCB executive arrangements has led to improvements in dissemination of lessons in addition to termly training for designated safeguarding leads Sunderland Safeguarding Children Board • SSCB have developed and implemented a procedure and a prompt sheet identifying how staff can work effectively with parents who are resistant, hostile or unco-operative. This should have the impact of challenging the member of staff around whether parents are actually working with agencies to improve outcomes for their children. Consultation with frontline staff confirmed that these prompt sheets did have the required impact on staff • The SSCB used the Section 11 audit process for agencies to self-assess their internal learning and improvement processes. This included assessment around if the agency used learning from all reviews/audits to develop service deliver. The SSCB is planning to undertake a staff survey in Autumn 2016 to triangulate the findings with the Section 11 audit findings in 2016-2017. This will give the Board a more accurate overview of the impact of the extensive improvement work across the safeguarding system as a whole • The SSCB Unborn Baby procedures have been strengthened and a multi-agency audit of the instigation of pre-discharge meetings for babies (where appropriate) is to be undertaken in 2016-2017. This will measure the impact of the procedural changes focusing on both compliance and the quality of work undertaken • The SSCB Threshold Guidance has been strengthened as part of the development of the SSCB Early Help Strategy. Analysis of performance information has identified that these two frameworks have not significantly impacted to improve outcomes for children. The SSCB is therefore undertaking a further review of both documents, establishing a joint framework for dissemination of information as a mechanism to fully embed the changes in practice required. The impact this has will be measured through the planned multi-agency audits for 2016-2017 on referrals to Children’s Social Care, the robustness of the Step Up/Step Down procedures and the quality of early help where domestic violence is a risk to children • Whilst not a specific recommendation from this SCR, learning has highlighted the need to strengthen the SSCB so the SSCB has strengthened its approach to obtaining assurance about the safeguarding system in Sunderland and it’s partner agencies through: o Undertaking a Section 11 audit in 2015-2016 which evidenced compliance by partner agencies in respect of their staff supervision arrangements13 o The SSCB Chair is undertaking assurance work through requesting Board partners to provide assurance of their current safeguarding arrangements and their agency annual safeguarding report for 2015-2016. This will be one element contributing to strengthening the SSCB’s understanding of how effective the safeguarding system in Sunderland is o Refocusing on the behaviours, values etc, that the SSCB wants to be embedded into safeguarding practice in Sunderland 13 Section 11 of the Children Act 2004 places duties on a range of organisations and individuals to ensure their functions, and any services that they contract out to others, are discharged having regard to the need to safeguard and promote the welfare of children. This includes ensuring they have safe recruitment practices for individuals whom the organisation will permit to work regularly with children, including policies on when to obtain a criminal record check; appropriate supervision and support for staff, including undertaking safeguarding training. - 41 - • Implemented a learning and improvement monitor which is providing robust scrutiny and high challenge on the implementation of all recommendations from all SCRs the Board is undertaking |
NC047754 | Death of a 17-year-old boy of Ghanaian heritage in July 2015 in North London. "James" was found collapsed with a sheet tied around his neck. The Coroner recorded an "Open Verdict" on his death. James was a looked after child in semi-independent accommodation, following a breakdown in relationships with his family. He was known to the police and children's services in a number of local authorities. James had a history of: running away; violent and criminal behaviour; sporadic school attendance; non-engagement with services; drug misuse; self-reported mental health issues and suspected involvement in gangs. Issues identified include: looked after child (LAC) placements situated too close to areas where gangs operate; incomplete mental health assessments; insufficient work by professionals on understanding family dynamics and rebuilding family relationships and the absence of a positive action plans in response to concerns raised in LAC reviews. Examples of good practice include: James was listened to, efforts were made to engage him and he was supported regarding his court appearances. Uses a mixed methodology to identify factors that influenced how agencies and professionals worked together. Recommendations include: review safeguarding arrangements for children in custody and young people presenting as homeless; widen the remit of looked after children inspections nationally to include semi independent placements; embed a more robust record keeping and follow-up process for health assessments; assess the risk posed by any condition disclosed by a child or young person in custody to a forensic medical examiner and develop a matrix for identifying and escalating concerns about children in care.
| Title: James: serious case review: overview report. LSCB: Thurrock Local Safeguarding Children Board Author: David Byford Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 JAMES SERIOUS CASE REVIEW OVERVIEW REPORT Publication Date:- 1st December 2016 Independent LSCB Chair - David Peplow Independent Overview Author - David Byford A THURROCK LOCAL SAFEGUARDING CHILDREN BOARD COMMISSION 2 Contents CHAPTER 1 – INTRODUCTION ................................................................................................................ 4 CHAPTER 2 – INITIATION OF THE SERIOUS CASE REVIEW ..................................................................... 9 Period under Review and Terms of Reference ................................................................................... 9 Purpose of the Serious Case Review ................................................................................................... 9 Terms of Reference and Specific questions ........................................................................................ 9 Key Issues .......................................................................................................................................... 10 Scoping .............................................................................................................................................. 10 Membership and Conduct of the SCR Panel ..................................................................................... 10 Family ................................................................................................................................................ 11 Methodology ..................................................................................................................................... 11 Inhibitors to the process ................................................................................................................... 12 CHAPTER 3 – DETAILS OF THE INVESTIGATION INTO JAMES DEATH .................................................. 14 Details of Investigation ..................................................................................................................... 14 Post Mortem ..................................................................................................................................... 15 Coroner’s Inquest .............................................................................................................................. 15 Coroners Verdict ............................................................................................................................... 16 CHAPTER 4 - CHRONOLOGY OF KEY EVENTS WITHIN THE TERMS OF REFERENCE ............................ 20 Introduction ...................................................................................................................................... 20 Key Events ......................................................................................................................................... 20 CHAPTER 5 – ANALYSIS OF KEY EVENTS AND PROFESSIONAL PRACTICE ........................................... 33 Thurrock Children’s Social Care ........................................................................................................ 33 LAC Care Plans ............................................................................................................................... 34 LAC Reviews and the IRO .............................................................................................................. 34 Thurrock Children’s Commissioning and Service Transformation (CCST) .................................... 36 Key Social Workers ........................................................................................................................ 37 Personal Adviser ............................................................................................................................... 37 The Prince’s Trust .............................................................................................................................. 38 General Practitioner .......................................................................................................................... 38 Thurrock CCG (Health) ...................................................................................................................... 39 LAC Placements 1 – 2 and Compliance ............................................................................................. 40 Open Door Return Interview ............................................................................................................ 43 CAMHS (St Anne's Hospital) .............................................................................................................. 43 School 4 ............................................................................................................................................. 44 3 Hackney CSC ...................................................................................................................................... 45 Norfolk CSC ....................................................................................................................................... 45 POLICE ............................................................................................................................................... 45 Essex Police ................................................................................................................................... 45 Metropolitan Police Service .......................................................................................................... 46 Norfolk Constabulary .................................................................................................................... 46 Cambridgeshire Constabulary ....................................................................................................... 47 British Transport Police ................................................................................................................. 48 Hampshire Police .......................................................................................................................... 48 London Ambulance Service ............................................................................................................... 49 Missing Person Episodes ................................................................................................................... 49 Gang Culture, Drugs and Criminal Offending .................................................................................... 49 Home Office Initiative - Ending Gang and Youth Violence ............................................................... 51 Culture and Diversity ........................................................................................................................ 51 Voice of James .................................................................................................................................. 51 CHAPTER 6 FINDINGS – LESSONS LEARNT AND SUGGESTED RECOMMENDATIONS FOR THE CONSIDERATION OF THE THURROCK BOARD ..................................................................................... 59 CHAPTER 7 – CONCLUSIONS ................................................................................................................ 66 CHAPTER 8 – THURROCK LSCB INITIAL RESPONSE .............................................................................. 71 Appendix 1 - Biography ........................................................................................................................ 73 Appendix 2 - Bibliography .................................................................................................................... 74 Appendix 3 – Glossary of terms ........................................................................................................... 75 Appendix 4 - Recommendations .......................................................................................................... 77 Appendix 5 – Anonymised genogram…………………………………………………………………………………………..80 4 OVERVIEW REPORT CHAPTER 1 – INTRODUCTION 1. This Serious Case Review (SCR) was commissioned by Thurrock Local Safeguarding Children Board (TLSCB) following a notification of the death of James, a seventeen year old British male of Ghanaian heritage. He was a Thurrock Looked After Child (LAC). On 15th July 2015, James was found in his bedroom at his placement, a semi-independent accommodation in North London. He was discovered by two support workers attempting to wake him for a Youth Court appearance in Cambridge that morning. He was collapsed on the floor between his bed and his bedroom door, preventing access that was later gained by a London Ambulance Service (LAS) paramedic. He was found to have a bed sheet tied around his neck which was cut off by the paramedic. He was unresponsive and all emergency attempts to resuscitate him were made without success. James was pronounced dead at the scene by an Advance LAS paramedic at 9.46am. 2. James’ unexpected death took his family and professionals by surprise. There had been no previous information, concerns or threats made by him to suggest he had any suicidal ideation or to self-harm that could have stimulated an intervention. At the subsequent post mortem, the Home Office Pathologist gave the cause of death as by way of “Suspension.” The Coroner at James’ inquest recorded an “Open Verdict” with no other third party involvement in his death. 3. The SCR is an opportunity to understand James life and to address the questions posed by TLSCB within the Terms of Reference set for this review. Additionally it avails the chance to analyse his personal circumstances, relationship breakdown with both of his estranged parents, mental health considerations, escalating criminal offending, his involvement and interaction with services, key professionals and agencies that provided those services, to enable change. To learn from his story, may help prevent a similar occurrence happening to others. It is hoped that lessons can be learnt, by translating the findings at Chapter 6 of this Overview Report (OR), into recommended programmes of action that lead to sustainable improvements for the welfare and support of LAC. 4. Thurrock Local Authority, Thurrock Local Safeguarding Children Board, the Independent Chair of the Serious Case Review Panel, the Independent Overview Author (IOA) and multi-agency partners within the SCR process, express their sincere condolences to James’ family after his tragic death. Abstract of findings 5. TLSCB, Thurrock Children Social Care (CSC) and agency partners should feel reassured that the tragic outcome for James, whilst a Thurrock LAC was neither predictable nor preventable. This assertion is further discussed and explained within the conclusions at Chapter 7. The review has sought to identify any short comings in existing and recent practice and aims to suggest recommendations at Appendix 4, for improvement that are learning on the fringes of the review and not a contributable factor. Background 6. The family dynamics of James’ early life, particularly with his parents and his and their relationship breakdown, were not well documented by agencies prior to this serious case review. This information has been enhanced from the family meetings between James’ parents and the 5 Independent Overview Author (IOA) which were open and constructive. There were no criticisms expressed of professionals concerned in the support of their son while he was a LAC. Further details of the family is contained within the family involvement to this report and an anonymised genogram has been prepared at Appendix 5. 7. James was born in Hackney, to parents both of Ghanaian heritage. They lived together until they divorced in 2001. He went to live with his paternal grandfather, a successful business person and Civil Servant in Ghana for approximately two years, returning to live with his mother, in time to start his first day at school in Hackney. He was later brought up with his mother, step-father (who met in 2002) and a younger half-brother (who is now thirteen years of age). His father had two further relationships and has another son also aged thirteen years old. In his current relationship and second marriage, he has three daughters aged six years, three years and a six month old baby. 8. At the end of 2012, James went to live with his father in Thurrock, as his mother and step-father could not cope with his behaviour. They were concerned for him and the effect it was having on his half-brother. He had been given a stable and comfortable life, staying with his father at weekends in Essex. According to his mother, he suffered violent mood swings which led to a domestic incident where he picked up a knife and made threats. Metropolitan Police Officers (MPS) attended the home and diffused the situation. His mother and step-father believed his behaviour, was compounded by his regular cannabis use and possible affiliation with local gangs. 9. James was an intelligent young man who achieved good GCSE grades in Year 11 at School 4, which did not seem possible at first. He enrolled in the school after he initially went to reside with his father in the Thurrock area. On his first expected day of attendance in Year 10, he argued with his father and was reluctant to go to school. James then went missing but returned home later that day. Becoming a missing person became a persistent and concerning factor in his life which the father had to contend with. The father on most occasions reported his son missing as James continued to flout his father's home rules, usually returning to his unknown friends in Hackney. He at no time divulged details of his friends to Police, his family or practitioners. He either returned of his own accord, was found by MPS Police officers or turned up at Hackney Children Social Care (CSC) offices, which he did on two occasions. There were times when he was not reported missing by either parent due to their frustration, as they knew he would always return, but his missing episodes persisted. School 4 had concerns with CSC when seeking assistance to help challenge James’ missing person episodes. Referrals and contacts did not receive adequate responses. School 4 have now introduced a system to challenge non responses and to escalate concerns with CSC or other agencies, if the situation persists in the future. (See School 4 Agency IMR Recommendation at Appendix 4.) 10. In Year 10, his attendance at one point was as low as 30%. Eventually after several months of failing to attend school, he was removed from the school register with his education monitored by the Education Welfare Service (EWS). His father managed to speak with James and convinced him of the importance of gaining an education. With the help of the EWS, James enrolled back at School 4. His Year 10 attendance rose to 86% and in Year 11 he attained 98.8%. A Common Assessment Framework (CAF) was carried out and this period educationally, was successful. He achieved six GCSEs A* to C grade, sufficient to continue into further education but he declined to take up the option. 11. During this period, James also attended Shoreditch Police Station and Hackney CSC, presenting himself as homeless. These contacts are further critiqued in Chapter 5. As well as attempting to 6 address his regular, if not daily use of cannabis, practitioners continually made further attempts to advise him to keep away from gang culture, which he always denied any association with. 12. After he left school, James became (NEET), not in education, employment or training. In October 2014, he was allocated a support worker from the Thurrock Adolescent Team who remained James’ Personal Adviser when he transferred to the Careers Team, this maintained consistency for him. His Personal Adviser was the constant factor throughout James’ period as a LAC who endeavoured to stop him being NEET. He managed to enrol James on a Prince’s Trust twelve week course at Hackney College. James persistently failed to engage with the course, he was either always late or did not bother to turn up. 13. His father attempted to provide a home for James but he was constantly concerned with his son’s use of cannabis which he felt affected him mentally. Professionals suspected that he was dealing in drugs and this suspicion was not unfounded as he was previously arrested in 2014 at Great Yarmouth, Norfolk in unusual circumstances. James was discovered at the home of a middle aged woman whose address the local Police were searching and found him hiding in a wardrobe. Both were arrested for a small amount of drugs found on the premises. Subsequently Norfolk Constabulary took no further action. There was however possible safeguarding concerns between Norfolk CSC and Police, as James when bailed for further enquiries by Police, was given a travel warrant and allowed to travel home late at night, after an apparent agreement between the Social Worker and his father. He missed his train and the Norfolk Social Worker had to report him as a missing person. He was not found until the following month, staying at his maternal aunt’s home in South London. 14. There were a number of domestic incidents. James threatened his mother, as alluded to on one occasion and on several occasions he threatened his father and paternal uncle. Police attended on these occurrences, culminating in the last episode in December 2014 at his father’s home. James was temporarily taken to stay with his maternal aunt as a stop gap, as his father declined to take further care of him. On the 29th December 2014 James presented himself to Thurrock CSC as homeless due to the breakdown in his relationship with his family. Up until that time he had not actually been homeless. Nevertheless, due to the emerging situation, Thurrock CSC took immediate and appropriate steps. James became a LAC, accommodated under Section 20 of the Children Act 19891. Thurrock CSC carried out an assessment, instituted a statutory Care Plan and appointed an Independent Reviewing Officer (IRO) for his LAC Review meetings. He had an allocated key Social Worker, SW1, prior to this event and there is evidence between the three Social Workers James had whilst a LAC, that there was a smooth transition between them. 15. He was accommodated in a Semi-Independent Placement 1 in Haringey, a five bedroom house with four rooms allocated for residents aged 16 to 18 years of age. He was described by practitioners as a shy and withdrawn person who could lose his temper if provoked. Whilst in the placement he continued to go missing, predominately to the Hackney area, where his unknown friends were. He was suspected of smoking cannabis in his room and this and other concerns identified by his second Thurrock Social Worker (SW2) were escalated and challenged with support from Thurrock senior management. It was believed the placement did not know how to deal with him and were not compliant with reporting James missing, necessitating Thurrock CSC making a formal complaint to the Head Office of the company providing the placement. 1 Section 20, Children Act 1989 7 16. Whilst in Placement 1, after a meeting with The Prince’s Trust practitioners, they were concerned how James presented. (He was subsequently removed from the course for failing to engage.) They referred their concerns to Thurrock CSC who through SW2 and his key support worker at Placement 1, he was taken to his new GP surgery. The GP was concerned about his response to questions posed and also with his cannabis use and referred him to CAMHS. They did not accept the referral but suggested BUBIC, a local drug service, who in turn recommended Insight (Haringey) a drug and alcohol advocacy. Despite numerous attempts by Insight, he failed to engage with them and refused to attend meetings and they closed his case file. He continued to be withdrawn and kept to himself, spending hours alone in his room with the lights off and even taking light bulbs out, which the GP was alerted to. James did not associate with the three other residents in the placement. 17. He had an active Care Plan and the resources, support and advice offered to him is well documented for him to achieve and to take a better direction in life. Within Placement 1, his missing episodes continued with the time periods extending. It is now known that he was travelling to other parts of the country, believed to be for the purposes of criminality and suspected drug dealing. To keep James from being NEET his Personal Adviser helped him in preparing a Curriculum Vitae (CV), continued to look at employment and community projects such as garden maintenance, but James would not integrate with groups of people. He had a lack of interpersonal skills and would not consider any of these options. A music production course was identified at a college, as this was his only real interest, writing music and lyrics. Unfortunately it did not start until September 2015 and other alternatives where explored to bridge the long period until the course began, including the failed enrolment on The Prince’s Trust Course. 18. In May 2015, James went missing for several days and was seen by a witness, a member of the public in Cambridge, acting suspiciously in a known drug dealing area of the city. There were two burglaries that occurred between the 6th and 9th May 2015. He was stopped on the 9th May and was found in possession of the second burglary victims’ iPhone. The victim had used her “find my phone” iPhone app and called the Police to the location. James initially attempted to run off but was caught and had to be restrained. The witness who had seen him in the area over the preceding days believed he witnessed James going into bushes with “property.” When he came out he did not have the “property” on him. Police subsequently recovered stolen laptops from the bush from another burglary. He admitted to the arresting officers at the scene that he had drugs on him, twenty one individual packets containing heroin. He was arrested for possession with intent to supply drugs and the two burglaries which were linked. 19. It transpired that he had been a missing person since the 1st May 2015 but Placement 1 had not reported him missing to Police until the 4th May 2015. After his arrest, MPS officers attended Cambridge, when he was bailed for the further investigation of his case and for the analysis of the drugs, to escort him back to his placement. SW2 made a point to see him to discuss the arrest but James was not forthcoming. 20. The placement arranged and carried out assessments for 1) Child Sexual Exploitation (CSE) and 2) knife and gang crime. There was no concern regarding CSE and it was confirmed that he was not visiting inappropriate websites. He continued to deny any knowledge or association with gangs. There were still underlying concerns that he was becoming involved in crime but with no firm evidence that he was in association with gangs. He accepted to be interviewed on one occasion by Open Door, an independent service that interview children and young people when they return from periods of being reported missing. They were not convinced by his denial of gang affiliation. He was 8 living above his limited means, bringing home expensive takeaways and still able to pay for his regular cannabis habit which he said he had for three years. His parents confirmed that they did not give him extra money and they did not know how he paid for an iPhone that was seized by Cambridgeshire Police. 21. On 7th June 2015, he was stopped by Police in Portsmouth as he was acting suspiciously. His placement were unaware he was missing. When he returned, the staff said that he seemed stressed. Several days later on the 10th June, there was a violent argument between James and another resident who it was alleged he assaulted. James left the placement prior to the arrival of Police. The victim and the placement staff declined to assist Police, so there was no further action taken. 22. On the 15th June 2015, James threatened another resident at his placement with a knife. MPS Police Officers attended and arrested him. He was later charged with an offence of affray to attend a London Court on the 14th July 2015. His bail conditions were not to return to the placement or to have any contact with named persons at the premises. The Placement Director carried out an urgent Risk Assessment in consultation with a SW Manager of Thurrock CSC. There was an agreement to transfer him to the company’s Placement 2. James in communication with the Placement Director, stated that “my past is catching up with me.” James also admitted to her and shared with SW2, an acknowledgement of his drug dealing in Cambridgeshire and his concern with going to prison. 23. On 25th June 2015, he returned to Cambridge to answer his bail. On the authority of the Crown Prosecution Service (CPS), he was charged with the possession with intent to supply Class A controlled drugs and the handling of the stolen iPhone only. He was bailed to appear at a Cambridgeshire Youth Court on the 15th July 2015. There was insufficient evidence against James to charge him for the two initial allegations of burglary. 24. Arrangements were made for Placement 2 to support him at his impending Court appearances. He subsequently failed to appear at a London Magistrates Court on the 14th July and a warrant for failing to appear was later issued but too early to activate before the event that followed. It is recorded that his Placement 2 key worker was aware of the date and had informed SW2 of it previously. The reason why he failed to appear, has not been obtained from his placement, as the company are now in administration. The following morning of the 15th July at 8.30am, an escort from the company placement provider arrived at Placement 2 to take him to his Cambridge Court appearance, when James was found collapsed in his bedroom. He was subsequently pronounced dead by the LAS called to the scene. (See Chapter 3, Details of the Investigation into James Death.) 9 CHAPTER 2 – INITIATION OF THE SERIOUS CASE REVIEW 1. Following a recommendation from Thurrock Local Safeguarding Children Board SCR Sub-Group, the Independent LSCB Chair David Peplow, took the decision to commission a Serious Case Review on the 18th August 2015, as the circumstances met the criteria in accordance with Section 5 (2) (a) and (b) (I) LSCB Regulations 20062 and Working Together to Safeguard Children 20153 • “Abuse or neglect of a child or young person is known or suspected and • The child or young person has died or been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child or young person”. 2. Ofsted were notified of the decision to commission a SCR on the 13th October 2015 and the National Independent Serious Case Review Panel were informed by TLSCB of the review on the 18th November 2015. Additional time during the course of completing the review was requested and agreed. This was due to the complexity and number of agencies participating in the SCR, the parallel coronial process and the limited access to family and professionals required to be interviewed. Period under Review and Terms of Reference 3. The Terms of Reference (TOR) requested information from James tenth birthday, until the date of his death. This period assisted in understanding the background history and for learning from the review. Each agency were asked to complete a brief summary of their involvement with the family prior to the agreed timescales. Purpose of the Serious Case Review 4. The purpose of the Serious Case Review is to: • Establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children and young people. • Identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result and, • As a consequence, to improve inter-agency working and better safeguard and promote the welfare of children and young people. Terms of Reference and Specific questions 5. Terms of Reference and specific questions identified to be addressed by Agencies are: 1) The arrangements in relation to James plan as a LAC. How that was or was not connected with what was happening in his life? 2) How was he being supported in his Court appearances? 3) What link was being made in relation to his possible connection with drugs? 4) Was the possibility of James being involved in drug dealing being considered? 5) The knowledge of staff within the home. Were they aware of his past and current needs? 6) Was there YOS involvement and if not why? 7) The referral made to CAMHS, what was the rationale for the referral? 2 Local Safeguarding Children Board Regulations, 2006 Section 5 (2) (a) and (b) (i) 3 Working Together to Safeguard Children, 2015 10 8) What plans were in place in relation to supporting James from becoming NEET? 9) The referral to Insight, what was this for and was it appropriate? 10) The reporting of absence or missing persons – was the appropriate policies and procedures complied with? Key Issues 6. Key issues to consider 1) Did all agencies work together effectively to safeguard this young person? 2) Was the outcome preventable? 3) Were the safeguarding procedures followed appropriately? 4) Was the young person’s voice heard throughout agencies involvement? Scoping 7. The following Agencies were asked to provide a chronology and an Individual Management Report (IMR) or Summary Report where identified of their agencies involvement with James as follows: Agency Participation Metropolitan Police Service - IMR and chronology Insight (Haringey) - Not required CAMHS - No participation NELFT - IMR and chronology (Received August 2016) Youth Offender Service - Not required Placement Service Provider - IMR and chronology Courts - Not required Cambridgeshire Police - IMR and chronology Norfolk Police- Summary Report Thurrock CSC - IMR and chronology Haringey CSC - Not required Hackney CSC - Chronology GP - Report Hampshire Police re Portsmouth - chronology Education/School 4 - IMR and chronology Essex Police - IMR and chronology Thurrock CCG - IMR and chronology (Revised IMR received August 2016) British Transport Police – Summary Report National Probation Service – Not required 8. The Serious Case Review Panel (SCRP) met on eight occasions prior to the Final Overview Report being presented to the Thurrock Board for approval. The Independent Overview Author was invited to and attended all SCRP meetings from December 2015. The SCRP meeting dates were: 21st September 2015, 11th December 2015, 11th February 2016, 7th March 2016, 25th April 2016, 22nd June 2016, 15th July 2016 and 5th September 2016. Membership and Conduct of the SCR Panel 11 9. The Independent Chair for the SCR is Helen Gregory NELFT. Adviser to the SCR is Alan Cotgrove, Thurrock LSCB Manager and the Independent Overview Author, David Byford was appointed to carry out the SCR on the 17 November 2015. He has met all deadlines set by TLSCB. 10. Both Ms Gregory and Mr Byford have no operational involvement, connection or conflict of interest with the case of James. (See Appendix 1 for biographical summary for the Independent Chair and Overview Author.) 11. All Agency IMR and Report Authors have demonstrated their independence within their agency responses to the SCR. 12. The Serious Case Review Panel (SCRP) consisted of the Independent Chair, Independent Overview Author and the following Senior Representatives from agencies: • Thurrock LSCB Manager • Thurrock LSCB Project Officer • Thurrock Children’s Social Care • Thurrock LSCB Legal Adviser • Essex Police • Thurrock Clinical Commissioning Group • NELFT • Metropolitan Police • Deputy Principal Education Psychologist Family (An anonymised genogram is produced at Appendix 5). 13. Subject: James Other relevant family members Mother Father Step Brother Step Father Significant Others: Maternal Aunt Paternal Uncle Methodology 14. In carrying out this review the following methodology and approaches were made: • Liaison with Police, Thurrock CSC personal including CSC key Social Workers, Independent Reviewing Officer (IRO), Children’s Commissioning and Service Transformation and the CSC IMR Author. • Liaison with James’ parents and step father, coroner’s office, placement support workers and viewed coroner Police report and statements. 12 • Attended the Pre-Inquest and Inquest for James. • A desk top review of all Thurrock LAC procedures, Care Plans and LAC Review meetings and consideration of previous Thurrock SCR’s, Ofsted Inspections of Thurrock, 2012 and 2016 (see Chapter 5, paragraph 86) together with additional research of guidance material. • Analysis of agency submissions to the SCR and compliance with the Terms of Reference and statutory requirements. • A review of the Thurrock CSC complaint and escalation of Placement 1. • Interviews with family members and key practitioners. 15. Statutory guidance provided by the Department for Education4 requires serious case reviews to be conducted in a way which: • Recognises the complex circumstances in which professionals work together to safeguard children; • Seeks to understand precisely who did what and the underlying reasons that led to individuals and organisations to act as they did; • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • Is transparent about the way data was collected and analysed; and • Makes use of relevant research and case evidence to inform findings. 16. Thurrock Local Safeguarding Children Board (TLSCB) agreed a mixed methodology to understand professional practice contextually, to identify factors that influenced agency and professionals in the quality and nature of working together with James and his family. This was to utilise and analyse submissions to the review from Individual Agency Management Reports (IMR), agency chronologies, summary reports, key practitioners and family interviews. 17. The Independent Overview Author (IOA) identified at an early stage from the agency submissions, additional areas requiring further information to be provided and were requested from agencies. This additional information was predominately provided within the agencies final submissions. Significant case notes, documentation, policy and procedures, care plans, minutes of meetings, Police investigation reports particularly the report to the Coroner and the statements of witnesses directed to attend the formal inquest, were additionally obtained for direct analysis and comparison. Interviews of their agency key practitioners were carried out by IMR authors. Additional practitioners relevant to the review and the family were identified and interviewed by the IOA. Every effort has been made to ensure accuracy, openness, transparency, comprehensiveness and challenge of the information provided to the SCR process in completing this overview report. Inhibitors to the process 18. The following inhibitors to timeliness have impacted this review:- • Some agencies failed to meet the deadline for their submissions to the process. This necessitated an extension of the TLSCB timeline on several occasions with the commissioners actively chasing up individual agencies. • Feedback and comments of the IMR's and reports by the IOA, required additional analysis and information with the specified questions in the TOR not always being addressed. 4 Working Together to Safeguard Children, 2015 Chapter 4 13 Responses were slow and tightened the timescale for this author and TLSCB, requiring comment. • Further lines of enquiry were therein identified, necessitating other agencies to be invited to participate and key professionals to be interviewed for the purposes of completing the SCR. • The Coroner inquest processes delayed the interview with family and professionals, imperative to the SCR, as they were formal witnesses at the inquest into James’ death. • The TLSCB had three concurrent SCR's and other necessary commitments which effected administration of the review. During the review, they effectively recognised and recruited a new LSCB Administrative Assistant to alleviate and provide additional support. This was effective action by TLSCB and assisted the IOA by actively chasing outstanding responses. • The company that provided both semi-independent placements have gone into administration during the SCR process and follow up enquiries were not readily available. • A key placement support worker did not appear at the inquest and questions that the family and this serious case review wanted to know were not able to be asked. Attempts were made to make to contact but without success. 14 CHAPTER 3 – DETAILS OF THE INVESTIGATION INTO JAMES DEATH Details of Investigation Warning - The next section of this review contains details of the circumstances in which this young man was found, which some people may find upsetting. Thurrock LSCB considered this section and the contents very carefully. It was decided that it is an important part of the learning from this case to highlight just how quickly a person can be affected by the course of action which is described. 1. In the evening of Tuesday 14th July 2015, James was at his Semi-Independent Placement 2. It was a five bedroom house with a bedroom each for the four residents and another for staff who stayed overnight. He was seen by the support worker 1 who was on duty until the following day. He appeared in good humour and had eaten some food and went to bed at about 10.30pm. He was due to travel to Cambridge the following morning to attend a Youth Court to appear for the offence of Possession with intent to supply Class A controlled drugs and handling stolen property. 2. On the 15th July 2015, support worker 2 who did not know James and worked for the same company service provider at another location, attended Placement 2. He had been instructed to drive James to Cambridgeshire for his Court appearance. He should have arrived at 8am but due to heavy traffic arrived at 8.30 am. He had some difficulty getting into the premises. Eventually with the assistance of a telephone call to the resident support worker 1 from his Head Office, he was let in just before 9am. In her statement to Police the resident support worker said she made attempts to rouse James at 5.11 am, 6 and 7 am by knocking on his first floor bedroom. The only response received was on the first occasion, James did not say anything but she heard a thud sound on the bedroom door from inside. This was apparently a normal occurrence when staff knocked on the door and he did not want to get up. 3. Both support workers went to James bedroom, Support Worker 1’s statement said it was 8am but support worker 2, who later gave evidence at the inquest, said it was nearer 9am which was more likely. They did not get a response and managed to partially open the door (whether a key was used or it was open is not known as Support Worker 2 could not recall and this review has not been able to obtain a response from Support Worker 1.) They could not open the door fully, as James was collapsed behind it wedging the door closed. 4. An emergency call for an ambulance was logged by the LAS at 8.51 am. Paramedic 1, attended the scene at 8.56am. On his arrival, he was taken to James’ bedroom and was informed by the support workers that they could not get a response from James and could not open the door. The paramedic described the door as not locked and on pushing it, managed to get a glimpse of James wedged between the door and the bed. The door would not open beyond three inches. Fearing the worst, the paramedic called his control for Police and colleague backup. In the meantime, with the help of the support workers who assisted him, he pushed the door and eased through a tiny gap into the room. 5. Once inside he saw James, who lay in a lateral position, unresponsive and unconscious, tightly wedged between the door and the bed, with a white bed sheet tied around his neck. The paramedic pulled the bed away and dragged James to the centre of the room and cut loose the sheet wrapped around his neck. His airway was obstructed, he was not breathing and there was no palpable carotid pulse. He established a diagnosis of cardio respiratory arrest and instituted a full resuscitation attempt assisted by other LAS paramedics who subsequently attended. On the arrival of the “Advanced” paramedic, a surgical airway was established. Resuscitation attempts to revive James 15 were unsuccessful and at 9.46am James was pronounced dead at the scene by the “Advanced” paramedic. 6. Police Constable 1 from Wembley Police Station attended with other Police officers. He was present whist the paramedics were trying to resuscitate James. He described that James had a white sheet tied into a knot around his neck, with another knot in the sheet suggesting it had been tied around something else like the door handle. After James was declared dead at the scene, Police informed the staff of his death, Thurrock Children Social Care, the Coroners Officer, Scenes of Crimes Officer (SOCO) and the Criminal Investigation Department (CID), who having attended, agreed the death was non-suspicious, as there was no evidence of any third party intervention and no apparent injuries on his body. It was not known at the time if James had been in recent contact with Police for his outstanding Court case and his failing to appear the day before. As required, they notified the Directorate of Professional Services (DPS) who deemed the incident was not a death after Police contact. 7. The scene was photographed and searched. There were no mobiles phones discovered (Cambridgeshire Police had seized two previously.) The knotted sheet was taken possession of, as well as a blue exercise book which contained written rap song lyrics. The book was open at a page referring to dying and the end of life. The bedroom was untidy and a suitcase containing clothes and kitchen utensils was next to the unmade bed. There were no suspicious circumstances evident. 8. Copies of the LAS paramedic’s notes and details of his missed and upcoming Court date were obtained. Statements were taken from the two support workers, Director of the placement and from two of the other residents. Nothing untoward was noted by anybody to suggest James might want to harm himself. 9. PC 1 provided the serious case review, with a copy of the Police report and statements he prepared for and on behalf of the Coroner. In conversation with the IOA at the subsequent Pre-Inquest and Inquest (see below), he stated that Police were often called to the placement for residents going missing and various other matters. The officer prior to the inquest, travelled to Cambridge and took possession of James’ property that had been seized for possible evidence when he was arrested. The property seized included a Samsung mobile phone, a scroll tablet, oyster card, a sim card and Nike bag. At that time, they further retained his iPhone which because of the lack of a password could not be accessed. As Cambridgeshire Police had possession of his two mobile phones since his arrest, it is reasonable to suggest there was nothing relevant to James death on the devices. Post Mortem 10. On the 21st July 2015, a post mortem was carried out by Home Office Pathologist David Rouse, at a public mortuary. He confirmed that on examining James, there were no obvious signs of third party involvement other than the attempts to resuscitate by the LAS paramedics. He gave the cause of death as - 1a Suspension. The pathologist records in his statement to the Coroner when describing suspension, that death could be immediate or within seconds. The subsequent toxicology report confirmed there was no alcohol or drugs detected within James’ body at the time of his death. Coroner’s Inquest 11. The Coroner (details and location restricted) held a Pre-Inquest in March 2016 to determine the evidence and witnesses required to attend to give evidence at James inquest. Both parents attended 16 with the step-father. A decision was made that there would be no requirement to have a jury sworn and the date was fixed for the full Inquest. 12. In April 2016, the full inquest was held before the Coroner. Witnesses were called to give evidence in person and other witnesses had their Police statements read out in open Court. The parents and step-father were in attendance and were encouraged by the Coroner to ask questions of the witnesses. The support workers who found James collapsed in his room were called but only Support Worker 2 attended and gave evidence. The other support worker 1 did not attend. Questions therefore remained unanswered for the coroner and parents as to why she would try to wake him as early as recorded in her statement. Therefore the discrepancy in the times and whether a key was needed when Support Worker 1 and 2 together tried to open James’ bedroom door, was not known. The likelihood is that it was just before 9am, more consistent with the account of Support Worker 2 and the recorded time of the subsequent emergency call and LAS paramedic attendance. 13. The mother confirmed to the IOA, the notebook found in his room was in James’ own handwriting. The inquest discussed the notebook with the song lyrics that he had altered. The words could give the impression by the tone of the lyrics that he may have been in a low mood, but the Coroner‘s view was the notebook could not be determined a suicide note and that was accepted by the parents present. At the hearing Support Worker 2 disclosed to the IOA that he had left the placement company prior to them going into administration, as they were not paying him his wages. Coroners Verdict 14. The Coroner after the evidence at the inquest was heard, recorded James’s death as an Open Verdict. An open verdict means that the cause of death cannot be established and doubt remains as to how the deceased came to their death. In this case, the Coroner could not be sure that James intended to kill himself from the evidence available. Therefore he declared:- James died as a consequence of suspension. Finding of fact – On 15th July 2015 in his room at (address) James was found in between the bed in the room and the door with a bed sheet tied around his neck and having died. 15. The Department of Health (DoH), statistical update on suicide, January 2014 (revised)5 explains that open verdicts include cases where the evidence available to coroners is not sufficient to include that the death was suicide (beyond reasonable doubt) or an accident (on the balance of probability). They include those cases where there may be doubt about the deceased’s intentions as in James’ case. Family Involvement 16. What was known by professionals at the time of the serious case review? 17. The information known about the family dynamics was not extensive and is incorporated within Chapter 2, Background, as above. However a fuller understanding was obtained in the family interviews with the IOA, encompassed in the following paragraphs. 18. What other information was obtained within the family interview for the SCR? 19. The IOA met with James’s father, his mother and step-father to discuss James early years and his life in general, with the intent to obtain and understand the family dynamics and their views for the 5 Statistical update on suicide, January 2014 (revised), DoH, Health Improvement Analytical Team 17 serious case review. Significant was the fact they had not been previously asked to any extent, about either James or their own background history by professionals, as a review of agency submissions would seem to confirm. 20. The parents of James are both of Ghanaian heritage and met in 1995. They lived together in the Hackney area and James was born two years later. They married in 1999 and divorced in 2001 when his father moved out, initially in Hackney and latterly to the Thurrock area. When James was aged two or three years of age he was sent to live in Ghana with his paternal grandfather, a very successful civil servant. He lived there for approximately two years until he returned to live with his mother in Hackney, in order to start schooling at School 1. 21. His grandfather, father and mother believed in the importance of education, a priority instilled from both sides of his respective families. Their aim was to support James in order for him to academically achieve. James’ mother met her current husband, James’ step-father in 2002. Their son James’s half-brother, was born in 2003 and all four lived together as a family, with his mother and step-father marrying in 2006. James normally stayed with his father at weekends and this arrangement seemed to work. 22. In the meantime, his father had another relationship and in 2003 he had a son another half-brother to James. Both half-brothers are the same age (now 13 years of age). This relationship ended, but as he did with James, he actively remains to this day, part of his son’s life. In 2005 his father met another lady who he married in 2006. In 2008, she moved out to Barking as she found it difficult coping with James. Although estranged from his wife, he still has a relationship with her and they have three daughters now aged six years, three years and six months of age. James only really knew his elder half-sister, his younger half-sister was not born until after James had died. 23. Within the narrative of this review, the chronology of key events from School 4, suggested that when James went to live with his father, he was not always present but living in Barking, leaving James with his paternal uncle who also lived with them. In fact he was dividing his time between two families, as he was visiting and staying with his wife and other children. 24. His mother’s sister, James maternal aunt, resides in South London. James stayed with her for short durations as tension arose with his parents and during the missing person episodes in the latter period, shortly before he became a LAC. It was at her address that he went to in July 2014 after he went missing following his arrest in Great Yarmouth, Norfolk. The parents were aware of the arrest but were not fully aware of the circumstances. 25. There were four domestic incidents, one with his mother and three with his father where James would threaten everybody in the home. It culminated in the third and final incident at his father’s home in December 2014, when James threatened his father and paternal uncle. He was taken to his maternal aunt, whilst Thurrock CSC made arrangements to accommodate him. However she could not supply him with a permanent home as she had children herself to raise. His step-father later collected him and took him to Thurrock and left him with his paternal uncle prior to him becoming a Thurrock LAC. James told his step-father, he was happy that he was going to be a LAC, believing he could do what he wanted and not having to comply with family rules. 26. There was some consternation that Placement 1 was only a short bus ride away from his friends who, the family believed, were coercing and corrupting him. It is recorded that the father had raised the issue of a placement out of London away from temptation, in an effort to avoid him becoming evolved in drugs and criminality. It is not recorded however that both his mother and step-father also felt the same way. The voice of the family was not realistically listened to or taken into account 18 in relation to this concern. In communication with the IOA, the family believed that an attempt to hold a Family Group Conference (FGC) would have been a good idea where James could hear from his own parents, how his behaviour affected them. 27. When he was younger, both parents and his step-father said that James was a pleasant and intelligent young man. His mother and step-father took him on holiday to Canada and on another occasion to Dubai. He was described as a good boy. His behaviour began to change when he started secondary school education at School 3. They did not realise it the time, but he got involved with the wrong people, as he was described as gullible and impressionable. His mother who is a safeguarding nurse, now knows that the school had a problem with gangs. They always enquired of James, wanting to know where he was going and who he was seeing. James never divulged his movements or contacts to either parents or subsequently in any dealings with professionals. According to his father, he was secretive and this statement is evident. 28. His parents and step father believed he began to smoke cannabis when he was thirteen years old. His step-father, on one occasion had to drive around the streets, as James had not returned home from school after many hours. He was found with a group of youths and was the only one still in his school uniform. He knew that if he had gone home to change clothing after school he would have been questioned as to his movements by his parents. His unauthorised absences started to increase. His mother initially reported him to Police but as later happened with his father, became frustrated and did not always report him missing, knowing he would always return home. 29. As his behaviour at home with his mother became erratic (believed through his use of smoking cannabis and his associating with youths or gangs), all efforts and advice given by his parents to change his behaviour, were ignored. 30. When his step-father went away for work, his mother was at times “scared” of James as he could explode into a rage. He never harmed her but he could be a bit rough with his younger brother. On one occasion his mother saw that he had his “Twitter” account open. She observed an individual was attempting to communicate with James speaking “street language,” believing he was encouraging her son to use drugs. She challenged him on “Twitter” and the youth laughed off the approach. They wanted their son to get away from the area in order to break his connection with local youths, his smoking cannabis and the effect his behaviour was having on his sibling. They did not know how he was getting the money to feed his habit but strongly believed he was being used by others and probably concerned in drug dealing. His father agreed for him to move to his home and to start school in School 4. The concerns that followed at School 4 are analysed within Chapter 4 and 5 in more detail. 31. Culture was discussed and there were nothing significant to suggest culture and diversity was an issue. He did not like Thurrock because it was too far from his friends, but there was no cultural or diversity concerns. It was however culturally taboo in Ghanaian society to smoke even more so to smoke a drug like cannabis. It was also felt mental health may be a slight embarrassment but this did not stop them wanting him to get the help if needed. Both parents were of the view, he may have had a mental health problem that needed to be explored. James had a future and was given options as both parents had supported him and were prepared in the future to do so if circumstances changed. In a conversation with James, his father gave him options to return to Ghana, go to a paternal uncle in Miami or to consider property development with him in the future, if he changed his behaviour. The parents were aware that he had an interest in writing and producing music which his Personal Adviser had identified a suitable course for him to later attend. They disclosed he had managed to sell some of his work online. 19 32. His father spoke to him regularly but whilst at Placement 2 he had not managed to visit him. His mother did not visit him in either placement but had regular contact with him. She saw him twice before he died, since his arrest in Cambridge. The first occasion was one month before he died when he visited her at home. He kept receiving calls on a cheap throw away phone that he had and said “they won't leave me alone”. He had to take his phone battery out to stop the calls. This statement would support the conclusions at Chapter 7 that he was being pressurised by others. On the second and last occasion, two weeks before his death, James visited his mother and step-father and he was wearing a suit which they had never seen him in before. They assumed he was going to Court but the timing it is suggested, may have been him returning to Cambridge at the end of June 2015 when he was charged for the offences alleged against him. 33. His step-father received a phone call previously from James but he cannot exactly recall when. It was before his arrest. He stated James was in Cambridge and apparently “stuck,” asking for him to pay for a night in a hotel. He would not say why he was there and was told to return home. This would confirm that he had been to the area before. 34. The parents had no concern regarding the support provided to James by agencies and understood that he could be difficult and would not always engage with people. The mother was particularly complementary of his female support worker at Placement 1 (DM), SW2 keeping her up to date and the MPS when she had contact with them and when they went to Cambridge and returned James back to Placement 1. His father in a conversation with SW3 and the IRO the day before James died, discussed his case. He believed a custodial sentence for his outstanding Court cases may have been beneficial for him and an opportunity to learn the error of his ways. 35. In conclusion, both his half-brothers were not spoken to for this review, as they were being supported by their respective parents who did not want to unsettle them. The two meetings with the parents were open and rewarding. Even though there was no CAMHS mental health assessment or a FGC held, they believed he may not have wanted to engage in either case. 36. All three members of his family agreed with the consensus of opinion, he was being exploited to commit crime by others who were probably supplying him with cannabis to keep him involved. The parents in discussing the death, said it came as a total shock to them. They had no idea he had any inclination to take his own life. It was apparent to the IOA there was strong affection for James, with two homes available to him if he had only changed his behaviour. He was loved and is sorely missed. His mother summed up her feelings succinctly, “I loved him but I did not like what he became.” 20 CHAPTER 4 - CHRONOLOGY OF KEY EVENTS WITHIN THE TERMS OF REFERENCE Introduction This section highlights the chronological events in James life as it evolved, together with a brief commentary. It outlines the significant key events of James and of professional practice during the period under review. Information from Police state that James came into Police contact on approximately 33 occasions and the CSC IMR identified 27 missing person episodes including unauthorised absences, during the period under review. They are not fully replicated here. A fuller version has been provided to TLSCB for corporate memory. The analysis of these events are expanded in some circumstances within Chapter 5, Analysis of Practice and within Chapter 6, Findings. Key Events Date Event 2003 to 2009 Started School 1. Displayed disruptive behaviour in Year 6. 2009 James first became known to Hackney CSC. He commenced School 2. 2010 James attended School 2 until November 2010 2011 School 3, Year 8. He was disruptive in class. Mother states this was the period when he started to become involved with the wrong people at his school which had a gang problem. 2012 School 3, Year 9. James displayed disruptive behaviour and absences from school. He was twice placed in a seclusion room. November James was offered a place at School 4, Year 10 as James moved from his mother to his father’s home in Essex. November James was reported missing on his first day at school, a constant theme throughout the period under review. James was reported missing to Essex Police by his father. James refused to commence his first day at School 4. He returned home later. This was the start of his father struggling to get him into school and to stop him going missing. December School 4 contact Thurrock Initial Response Team (IRT) as James who was missing, was in 21 School 4 concerns regarding Thurrock IRT and Hackney IRT dispute about who should accept responsibility for James. Hackney and were concerned about his missing episodes. Both Thurrock and Hackney IRT’s declined to pick up his case. A Thurrock duty Social Worker told them Hackney should come back to them if they do not assist. The school spoke with Hackney IRT who stated that as James main residence was in Thurrock they should pick up the case. (School 4 Agency Recommendation.) December Thurrock CSC’s first contact with James James first became known to Thurrock CSC Adolescent Team whilst residing with his father. Limited background records showed he had been known to Hackney since 2009 with suspected gang affiliation. Thurrock and agency partners at the time confirmed there was no evidence of any gang association. 2013 January Domestic Incident with his mother. James had an argument with his mother within the family home. He picked up a knife. Police attended and upon investigation, no offences were alleged, highlighting anger issues. NFA. January James attendance at School 4 was poor recorded at 30.6% and his case referred to the Education Welfare Service (EWS). January James was removed from School 4 for poor attendance. James was then supported by the EWS who subsequently assisted James to return to education at School 4. (See entry for February below.) 10.02.13 Police Protection James attended Shoreditch Police Station seeking accommodation as his mother and stepfather would not let him stay in the family home. He was taken into Police Protection, accommodated by Hackney CSC and returned to his father after consultation with James the following day. As James was not a resident, Hackney CSC closed their case file. February Request by James father for him to be reinstated at School 4 which was agreed. Comment: This second opportunity was taken and his attendance improved significantly. 16.04.13 James attended Shoreditch Police station stating he had an earlier argument with his father but now had no way to get home to Essex. His mother and step-father were contacted but wanted nothing to do with him. He returned home and Essex Police attended his father’s home but he was not initially in. Recorded as NFA. 22 26.04.13 He first became known to NELFT and a record on their “SystmOne” computer database showed a request for his records was made to Child Health Records, South West Essex on this date. The records were not obtained until the 13.09.13. (NELFT Agency Recommendation 4.) 24.07.13 James registered as a new patient in the Thurrock area whilst residing with his father. James did not on any occasion attend his Thurrock GP surgery. (Thurrock CCG Agency Recommendation 1.) 24.08.13 MPS Police found James sleeping rough in Hackney and they returned him home to his paternal uncle. He was not reported missing. September James continued his education at School 4. According to the CSC IMR, James had plans to return to Hackney after his exams and stated that he sometimes sleeps on the street when he was living with his mother (this was not known by his mother). His Child Health records were received and reviewed by the School Nurse (SN) who recorded that there were no health or safeguarding concerns noted. 2014 17.01.14 James was spoken to at school by the SN regarding his immunisation status which he believed he had already received. He was requested to find his “red book” (hand held child health record) and the SN would contact the GP. There is no record to show this was followed up. (NELFT Agency Recommendation 3.) March Domestic Incident - James was arrested at his father’s home for affray to prevent a breach of the peace. SW1 from the Adolescent Team engaged. Essex Police attended the home address of the father regarding a Domestic Incident after he made an emergency call to say that James was threatening to stab him. James was arrested for Affray and to prevent a breach of the peace. The father later declined to press charges and no further action was taken. Thurrock CSC notified Police that they will be intervening due to James’ age. SW1 dealing. The SN was made aware but there is not a record of any follow up with either James or his parents noted. (NELFT Agency Recommendation 2.) March A tutor at School 4 was informed by a third party that James’ best friend in Hackney had been shot? He did not want his father to know and records he was supported by the 23 tutor. There was no other details recorded as to whether it was true and what support was offered. April James presented to Hackney CSC as homeless. Hackney CSC record James presented himself to them as homeless advising that his father had kicked him out of the house. The duty Social Worker contacted Thurrock. He was advised to attend the Civic Offices in Grays, Essex. 11.06.14 There were no further incidents noted by the School Health Team and he was discharged as he had left the school. 04.07.14 Thurrock Adolescent Team wrote to his GP requiring information about him as they were carrying out a Child and Family Assessment. (See entry below for outcome.) 23.07.14 James arrested in Norfolk. He was allowed to travel home alone with a travel warrant but missed his late night train. He was reported missing by the Norfolk CSC Social Worker dealing with the case at the time as he could not be found. He was located on the 13.08.14 at his maternal aunt’s house. James aged 16 years of age was arrested for suspected possession of drugs with a middle aged woman whose house was being searched in Great Yarmouth, Norfolk. Police identified he was a vulnerable young person and informed Norfolk CSC. There were safeguarding issues identified, (See Chapter 5 and the suggested TLSCB Overview Report Recommendation (10) for Norfolk Constabulary) regarding the quality of information recorded on the custody record for the safeguarding of children and young persons in their custody (TLSCB Overview Report Recommendation (11) for Norfolk CSC) as to their compliance to the Children’s Act 1989 and welfare of James. James’ Thurrock GP sent a letter to Thurrock Adolescent Team confirming they had not seen James in the surgery since his registration, from his records his immunisations were up to date and the GP was not aware of any concerns as to his welfare or the parent’s capacity to meet his needs. 30.07.14 Strategy Discussion (SD) held by Thurrock and Sec 47 Investigation commenced whilst James was still missing from home. A follow up SD was held a week later on the 05.08.14. It updated agency enquiries and actions, as he was still reported missing. He was active on twitter but he had blocked his father who did not have other contact details. 13.08.14 James had been missing from Cambridge and found at his maternal aunt’s home in South London. 24 26.08.14 Domestic incident at his father’s home. James’ father made an emergency call to Police over a Domestic Incident where James was threatening everyone in the house over an argument regarding food and concerns about his continual use of cannabis. Police attended and found the situation was calm and no evidence of drugs. Father agreed to take him to his maternal aunt. 23.09.14 James stopped in London by Police admitted to criminality to fund his drug habit (cannabis). He presented to Hackney CSC as homeless. James was stopped in North London by Police. He admitted to criminality to fund his drug habit. The search was negative and NFA was taken. The MPS IMR records that a Merlin PAC (come to notice form) should have been created for this encounter to share the information. This was an isolated incident and individual learning for the officer. He presented himself at a Hackney service centre as homeless, similar to a previous entry in April. A Hackney SW informed him they would need to speak to his parents and told him to charge his dead mobile phone and then return and supply the contact details for his parents. He was informed Hackney would not be housing him and advised him to contact Thurrock CSC. He did not return, his whereabouts were unknown and therefore no proactive work was undertaken by Hackney. The information was later shared with Thurrock CSC when they contacted Hackney CSC about James. October Adolescent Team key worker MF who later became his Personal Adviser allocated. Adolescent Team Key Worker MF, who later became his Personal Advisor began working with James. A relationship that was maintained throughout his time with Thurrock and covered his total period as a LAC. November A Child and Family Assessment was completed. Child/Young Person's Plan (part 2) completed. His father agreed to support him financially in order to enable him to enrol in college and to adhere to family boundaries. 11.12. 14 Domestic Incident at his father’s home. Domestic Incident. James threatened everyone in the house following an argument over food and his use of drugs. Police attended and found no evidence that he had taken drugs. His father took him to his maternal aunt’s as he declined to further care for him. 29.12.14 James was accommodated by Thurrock Local Authority as a LAC under the terms of Section 20 of the Children Act 1989. A 25 James was accommodated by Thurrock Local Authority in Placement 1, a spot purchase. It was confirmed that no additional commissioning checks were carried as to the suitability of the placement. Case allocated to SW1. Thurrock Child LAC Care Plan was completed and his first Looked After Health Assessment took place and accommodated in Placement 1 with SW1 allocated his key worker. His assessment recorded that he was using cannabis on a regular basis and was registered with The Princes Trust, a course to be overseen by his Personal Adviser, who was working with him to enrol on a music producer college course for the following September 2015 and to support him from being NEET. Comment: James presented himself to Thurrock CSC as homeless. In fact it was known that since the incident on the 11.12.14 at his father’s home, his father had made the decision that he could no longer care for him. After the incident he was taken temporarily to stay with his maternal aunt to diffuse the situation. James was later picked up from his maternal aunts by his step-father and returned to Thurrock. Until the time of his self-presentation he had not been homeless. As his family were declining any further care for him, Thurrock CSC treated him as homeless and accommodated him. 2015 13.01.15 Thurrock CSC completed a Child and Family Assessment, the review assessment stated that he was already subject to a CIN plan as he had been accommodated since December 2014 by Thurrock. NELFT LAC Team received notification Part A of the British Adoption and Fostering form (BAAF). NELFT emailed Placement 1 advising that his Initial Health Assessment (IHA) was due and that he was still registered with his Thurrock GP. Comment: James’ IHA was subject to continual concern and was chased up by professionals throughout his Care Plan and LAC Reviews until the GP confirmed in April 2015 that it had been carried out. This lack of record keeping and delay in notification has been addressed. (NELFT Agency Recommendation 4.) 16.01.15 James was registered at a Haringey GP Surgery. 26.01.15 First LAC Review (1 of 3) James First LAC Review. Health unmet target was to access mental health resources if needed. A DUST form to be provided by Personal Advisor to address how cannabis 26 affects him and to carry out a revised Personal Education Plan (PEP) every six months. He continued to explore an attendance for James at the music college in Hackney for him and to continue with The Princes Trust Course he had recently started. 28.01.15 A CSE Assessment was completed. There was no concern that he was a victim of CSE and his placement were satisfied that he was not accessing inappropriate websites. The Designated Nurse attended a Thurrock placement panel where it was reported there does not appear any reconciliation with his parents, he had settled into Placement 1, he was still smoking cannabis, a DUST test was completed and he had been referred to a local drug and alcohol service. The Provider LAC Nurse was advised. (Thurrock CCG Agency Recommendation 2.) 19.02.15 CSC IMR records that his Personal Adviser contacted Placement 1 as he was concerned about James smoking cannabis which seems to be effecting his daily functioning and concerns reported by The Prince’s Trust. He asked the key support workers to take him to his GP. 20.02.15 He was taken to his new GP, by staff from Placement 1 in confirmation, after The Princes Trust contacted Thurrock CSC regarding his strange behaviour displayed at a meeting to discuss his lack of engagement on the course. The GP referred him to CAMHS for a mental health assessment as a result of a high level of concern. 02.03.15 Case allocated to SW2. James allocated to senior practitioner, Social Worker 2 (SW2) who remained his allocated Key Social Worker until 11.06.15. March An MPS intelligence report names James within a gang member’s bail conditions (the gang member was affiliated to the ‘Hoxton’ gang.) This was an indirect link only. It was confirmed by the MPS that James was not known on any Gang Matrix. 11.03.15 A joint home visit conducted by SW2 at Placement 1 with his Personal Adviser. Police were at the premises as James was reportedly using threatening and abusive behaviour. He was apparently smoking cannabis in his room and a member of staff threw a bottle towards him to get his attention! The Police diffused the situation. SW2 and his Personal Adviser 27 spoke with him about his behaviour. NFA taken by Police. 13.04.15 LAC Review (2 of 3) held at Placement 1. LAC Review meeting held in Placement 1. SW2 invited both parents but neither parent attended. James was not happy with the meeting and walked out. Some practitioners had concern with the IRO management of the review and this was addressed. SW2 was chasing up the outcome of his initial health assessment (completed earlier in the year), CAMHS and contact with his GP. The IRO was concerned the two Placement 1 representatives had no report for the meeting and were not prepared. 17.04.15 SW2 spoke with James’ GP who confirmed CAMHS had refused their service to him. 22.04.15 An internal Placement Panel was held and reports that James’ father would consider taking care of him in the future when there was evidence he was not smoking cannabis. The Designated Nurse attended. It was recorded that James was having difficulties with his independence skills and stayed in his room for long periods and CAMHS had declined their services to him. He was also having an assessment by Insight and was receiving support from a local drugs service for his cannabis use. It was uncertain where he would live, post him attaining 18 years of age. The Provider LAC Nurse was advised. 26.04.15 Placement 1 reported him missing to Police and he returned later and was debriefed. Comment: - He was referred to Open Door to hold a return interview but James told SW2 he did not require one. 30.04.15 SW2 escalated concerns of Placement 1 not being compliant when reporting James missing. James was reported missing from Placement 1. He returned the following morning. SW2 escalated his concerns to Head of Children Social Care (CSC), his Team Manager and the Placements Quality Assurance Team Manager and the IRO, regarding the non-compliance by Placement 1 reporting James as a missing person to both EDT and Police. A formal complaint was made by Thurrock CSC to the Placement Providers. 01.05.15 SW2 carried out a LAC visit with a placement key worker and James who was argumentative and left. His bedroom was dirty and untidy. Several small empty plastics SW2 carried out a LAC visit with James and his key placement support worker. It was disclosed that he had a positive relationship with his paternal grandfather in Ghana. When he visited the UK and asked to see James he told his father that he “had things to do” and 28 bags were found that could have been used to hold cannabis. James was stopped at Cambridge Railway Station and given a fixed penalty notice for not having a ticket. had to go out. His grandfather returned to Ghana a few days later having not seen James. Later the same day, he had been seen at Cambridge railway station, travelling several times in the evening on short journeys. Railway staff stopped and gave James a fixed penalty ticket as he did not have a valid ticket. They stated that he has possession of two phones and “acts suspiciously in his mannerisms.” He had clearly left his placement and travelled to Cambridge. He was not reported missing until several days later by Placement 1. 04.05.15 James was belatedly reported missing by his Placement. He was in Cambridge. Placement 1 reported James missing to the MPS, he was last seen on the 01.05.15 at 1.30pm. He was later found having been arrested in Cambridge (see entry for 09.05.15). 05.05.15 Supervision and escalating by SW 2 to Head of CS. A complaint was made by Thurrock CSC about not being informed that he was missing on the 01.05.15. SW2 escalated to the Head of CSC, who gave advice, requesting to be kept informed. 09.05.15 Arrested in Cambridgeshire James had possession of the following property: • £1000 cash. • Two mobile phones and sim cards containing evidence of apparent sale and distribution of Class A drugs • Quantity of heroin (21 individual wraps. • Possession of a stolen mobile iPhone. He admitted he used cannabis that day. An iPhone was stolen from a burglary in Cambridge and later reported to Police. The victim located her mobile by using the “'Find my phone” app. The location was given to Police. James was eventually stopped, having tried to run off and had to be restrained. He had possession of the iPhone and admitted to the officers that he had a quantity of heroin in his possession. He was arrested for two linked burglaries and for the possession of Class A drugs with intent to supply. James had been seen by a member of the public who suspected James was attempting to sell drugs in a student area of the city. Cambridgeshire Police carried out welfare and safeguarding checks and found he was reported missing from Placement 1. He declined to answer any questions and was bailed to attend the Police station following further enquiries. He had £1000 cash and two mobiles of his own taken from him, an iPhone which he declined to disclose the password for and another phone and sim card that Police obtained intelligence from subsequently. MPS officers were notified and they attended Cambridgeshire and escorted him back to his placement. 29 Comment: - The drugs were later analysed and confirmed he had 21 wraps of Diamorphine (Heroin) with a street value of £250 to £350 as assessed by the Cambridge Expert Drug Witness. Open Door conducted their only return interview with him on 19.05.15 for these events. 13.05.15 SW2 visited the placement. James wanted to leave but was persuaded to stay and engage in discussion. He seemed friendly but did not want to be specific about his arrest other than he was caught for Class A drugs. He said he did not want contact with either of his parents and was willing to explore his education and college options. He said he had since cleaned his room and was aware that any more offending would be an aggravating factor in his current case in Cambridge. 15.05.15 James attended a GP appointment. There was no further concerns of delusional thoughts. 19.05.15 James attended a dental appointment and had his only Open Door return interview (See Chapter 5.) 27.05.15 James was reported missing from Placement 1. He was missing from 26.05.15 at 4pm and returned on 27.05.15 at 3.51am 28.05.15 Placement 1 again reported James missing late. Placement 1 reported James missing since 8.53am however the placement did not report him missing until he went missing again on the 02.06.15. SW2 notified his senior management team. June 15 Gang and knife assessment/Drug Risk Assessment completed. Placement 1 and Thurrock CSC had concerns that James was involved in organised gangs and possibly exploited by others involved in criminal activity. He had an assessment regarding his relationship with gangs and knife crime and a drug Risk Assessment due to his offending behaviour in his recent arrest concerning Class A drugs. He denied involvement with gangs and the effect drugs had on him. 02.06.15 Placement 1 reported James missing person since 01.06.15 at 2.44pm. He returned on his own accord on the 08.06.15, having been stopped in Portsmouth on the 07.06.15 (see following entry.) MPS IMR states that the placement were not aware he was missing. MPS officers attempted to debrief him on the 11.06.15 but he would not converse. 07.06.15 Hampshire Police notified the MPS that James was stopped by Police in Portsmouth, called 30 James was stopped in Portsmouth. to an incident between two youths one armed with a knife. James was stopped and searched and had no knife. His placement appeared unaware that he was missing. He was sent home by train to Placement 1 who says he returned stressed. This was noted by SW2 and reported within James’ third LAC Review. 08.06.15 James assaulted another young person at Placement 1. At Placement 1, James assaulted another resident by punching him repeatedly in the face. Police were called but he left before their arrival. The allegation was recorded that James may have approached another resident with a knife but this was not the case according to officers at the scene. The victim declined to proceed with the allegation and staff would not provide a statement as they were concerned that it would lead to increased tension in the home. The case was closed. 09.06.15 SW2 carried out a Strength and Difficulties Questionnaire (SDQ). James was deemed to have severe difficulties with a score of 27/40. The concerns were due to his criminal involvement, periods of absconding and not complying with current strategies to keep him safe and to his cannabis use. His case was transferred to the Through Care Team. Comment: - The SW in discussion with the IRO looked at the option of moving him to another unit to reduce the risk and break the chain of him associating with others involved in crime and exploitation. However events outlined below at Placement 1 required that he be immediately moved to Placement 2 following a risk assessment. (See TLSCB Overview Report Recommendations 7.) 10.06.15 James returned to Cambridge in answer to his bail. SW2 attended placement. James returned to Cambridge with a key worker from Placement 1. He was further bailed to a later date. SW2 attended and spoke with the Placement 1 staff as James had not returned with his support worker from Cambridge. He informed the placement that James’ case was being transferred to SW3 on the long term team. 11.06.15 Placement 1 reported James missing. He returned of his own accord the following day. James refused to speak to Police. SW2 was informed by a placement key worker by email confirming his bail conditions. He was in a positive mood and talked about a return to 31 Ghana. 15.06.15 James was arrested at Placement 1 for affray. He was charged to appear at Court on the 14.07.15 A Risk Assessment was carried out by the placement. He was transferred to Placement 2. James disclosed he was bi-polar to an FME, a condition not known to health professionals within his medical history. Police were called to Placement 1 by staff when James had an altercation with another resident. He was brandishing a 7 inch knife. James was arrested for affray. He was later charged with the offence of affray with conditions not to attend Placement 1 or to have any direct contact with two named persons at the placement. He was bailed to appear at a London Magistrates Court on the 14.07.15. This was the Court date he later failed to appear at the day before his death. Whilst James was in custody he was examined and disclosed to the FME that he was Bi-Polar. The comment was recorded in the detention and FME log. It does not appear that this information was shared. (TLSCB Overview Report Recommendation (9) for the MPS.) The Placement Director provided a full Risk Assessment the same day, as a mechanism to manage his criminal and behavioural activity. A decision was made to remove him to the same company’s LAC accommodation at Placement 2 after consultation with a SW manager. His move was not discussed at a placement panel meeting but was known and raised at James third LAC Review by the IRO. This issue and further placement commissioning failures were identified. (See TLSCB Overview Report Recommendations and Finding 2.) SW2 notified his father of the move, who was still of the opinion that James should be moved away from London. 20.06.15 His new Placement 2 reported him missing, he returned later the same day. 22.06.15 Care Planning meeting Care Planning meeting held and plan effective until 29.06.15 when his third LAC Review at Placement 2 was arranged for. Comment: - The CSC IMR chronology made comment that the placement at the LAC Review was deemed unsatisfactory. It in fact refers to Placement 1. The concerns were addressed by CSC senior management at the time and he was subsequently moved to Placement 2 due to the incident against another resident in Placement 1 on the 15.06.15. 25.06.15 James attended Cambridge with a placement support worker and charged to attend Court It appears from the CSC IMR that James was supported by placement support workers and returned to Cambridge Police station. He was charged with possession with intent to supply 32 on 15.07.15. a Class A drug and handling stolen goods (iPhone) on the advice of the CPS. He was bailed to appear at a Cambridgeshire Court on the 15.07.15. 29.06.15 LAC Review (3 of 3). James’ third and final LAC Review was carried out at Placement 2. He appeared happier and fully engaged at this meeting. SW2 who was no longer his key worker as James was transferred to SW3 on the Thurrock Long Term LAC team, attended to ensure continuity. The IRO noted his engagement with proceedings. James agreed to remain after the review to speak with SW3. The Placement Director confirmed talking to and supporting James with his current concerns. 11.07.15 Placement 2 reported James missing, he had informed staff he was going to see his mother. He returned of his own accord early that morning. (His mother states she last saw him two weeks before his death.) 14.07.15 James failed to appear at a London Magistrates Court for the offence of Affray. Father had a meeting with the IRO and SW3. James failed to appear (FTA) at Court and a warrant was issued. Thurrock CSC IMR states his Placement 2 support worker (RR) informed CSC of his bail conditions and records that he attended the Police station with him and Court. It has not been confirmed how he FTA, as the company are now in administration. On this day there was a meeting between the IRO, SW3 and James father to discuss the outcome of his LAC Review and the current situation facing James. The FTA was not known at this stage. 15.07.15 James was found collapsed in his bedroom, unresponsive to emergency resuscitation and was pronounced dead at 9.46am. See Chapter 3 Details of the Investigation into James Death. 33 CHAPTER 5 – ANALYSIS OF KEY EVENTS AND PROFESSIONAL PRACTICE 1. The key events in Chapter 4 above, together with the input from the agencies and practitioners participating in this review, are further analysed within this section. The Findings and Lessons to be learnt are outlined within Chapter 6 below, for the Thurrock Board to consider. Thurrock Children’s Social Care 2. Thurrock CSC involvement began when James came to live with his father in late 2013. A period with James going missing, repeatedly returning to the Hackney area and failing to attend school. His father struggled to cope with his son’s behaviour and cannabis habit and was allocated a key Social Worker from the Adolescent Team, SW1. 3. Prior to becoming a LAC, on the 23rd July 2014, Thurrock CSC were contacted by Norfolk CSC after James aged 16 years of age, was arrested in Great Yarmouth, Norfolk. He was bailed by Police for the offence of possession of a controlled drug for further investigation to Norfolk CSC. Norfolk and Thurrock CSC had a discussion as to who should have responsibility for James and whether to treat him as a homeless person. Both of James parents refused to accommodate him even though he was living with his father preceding this event and Norfolk CSC assumed responsibility. 4. This serious case review identified safeguarding issues for Norfolk Constabulary and CSC as James was allowed to travel home alone to his father’s home after he was persuaded by a Norfolk Social Worker to accept him. James missed his train and the Social Worker could not locate him and had to report him as a missing person. (This is discussed further within the analysis for Norfolk Constabulary and Norfolk CSC below.) Thurrock subsequently held a strategy and follow up meeting, carrying out a Section 47 Investigation, as James was a missing person until the 13th August 2014, when he was found at his maternal aunt’s and returned to his father. 5. There were three domestic incidents where his father had to call Police to the home address. The final incident in December 2014 was the reason why James became a Thurrock LAC after his father declined to care for him any longer. He was accommodated under Section 20 of the Children Act 1989 and provided with semi-independent accommodation at Placement 1. 6. The initial CSC IMR did not have sufficient detail regarding the LAC Reviews and the Independent Reviewing Officer (IRO) or the commissioning of the placements that were provided for James. In relation to the IRO it was known that she had a meeting with James’ father the day before he died. However the IRO was not available to the CSC IMR author due to being certificated sick until early March 2016. 7. The IMR author assisted the process and met with the IOA to analysis practice and helpfully discussed James’ case. What was evident, Thurrock CSC provided continuous support, resources and advice for James while he was a LAC that he often did not appreciate or accept. There were concerns when at Placement 1, with staff at the placement not always informing either the Emergency Duty Team (EDT) or the Police when he went missing. This was escalated with ample documentation showing that SW2 was in constant contact with senior management and the Head of Children Social Care (CSC) on numerous occasions. The Head of CSC personally supported and addressed the issues and outlined action that Placement 1 had to take to be compliant and to meet standards of care. The company through their Head Office, acknowledged the complaint, were supportive and increased their compliance. 34 8. The IOA also met with the Independent Reviewing Officer (IRO), the IRO’s supervisor, his Personal Adviser (PA) and SW2 to obtain the additional knowledge of practitioners who knew and worked closely with James. This proved beneficial, confirming views on James family interaction, the extent of the professional input provided to support him, his drug offending and criminality and pressures of his impending Court cases. It further confirmed the attempts made to develop an educational and independent pathway for him and the incomplete assessment of his possible mental health issues. The IRO confirmed that she and SW3 met with James’ father the day before his son’s death to discuss the recent June 2015 LAC Review meeting that he could not attend. LAC Care Plans 9. James’ LAC Care Plan was completed efficiently, with timely updates and covered the full period James was a LAC. (See Chapter 6 Findings.) His continuing Care Plan was to explore rehabilitation in the home. It states a Family Group Conference (FGC) to be explored. However there was never a FGC carried out. The plan was to support James towards living independently and applying for housing as soon as he was eligible. Comment: - There is evidence to support the open offer by his father to have James return home if he stopped smoking cannabis and followed house rules. It was also reiterated by his mother and step-father in the family interviews. (See also the comments within the entry for LAC Reviews below, regarding strategies to minimise future risk of repeated missing person episodes.) LAC Reviews and the IRO 10. Context: The context of Thurrock LAC Reviews and IRO’s during the period in James’ case, were obtained from the IRO Annual Report 2014 to 2015 as submitted to the Corporate Parenting Committee in September 20156. It confirms there were 283 children and young people in care at the end of 2014/2015 (71.6 per 10,000 of the population). Of the 671 reviews carried out, 640 were completed on time. This was a performance of 95.3% which compares favourably with the English and Statistical Neighbour data of 90.5% and 90.6% respectively. 11. LAC Reviews: There were three LAC Review meetings chaired by an IRO and are outlined within Chapter 4, the chronology of key events. His father was the main family contact with James’ three allocated key Social Workers and his Personal Adviser during his LAC period. His father did not attend any LAC Review but did attend one Placement Panel Meeting. SW2 made attempts to engage with his mother to attend the reviews and although she also did not attend, she was regularly updated by SW2 and James’ father. The ultimate goal was to prepare him for independent living with a prepared pathway plan, in the hope to reunite him with his family. Both parents as discussed above offered to have him back if he gave up his cannabis habit, changed his concerning behaviour and followed basic home rules. It was believed James’ case would have benefited from a FGC. Both parents in conversation with the IOA agreed it may have helped but were not convinced he would have necessarily engaged. Whether it would or would not have succeeded, we cannot answer, as there was no attempt to arrange a FGC. Comment: - Considering the objective was to build relationships with his parents in order for him to lead an independent life and to end being LAC, there should have been a concerted and documented attempt for professionals to understand more about the family dynamics, particularly with his mother and step-father. The reason for the breakdown in their relationship 6 Thurrock IRO Annual Report 2014 to 2015 submitted to the Corporate Parenting Committee (Sept 2016) 35 and the anxiousness the mother had regarding her son, needed to be understood in order to try to forge a relationship. There was no Family Group Conference called but in the interview with the IRO and her line manager it was said this would still have been an option and would have been acceptable to the parents. (TLSCB Overview Report Recommendation 8.) 12. In his second review in April 2015, James became noticeably upset and did not understand the process and the terminology used by professionals. He then left the meeting. It was reported that some professionals including SW2 were not impressed how the IRO managed the meeting however, there were no such concerns in his first and last LAC Reviews. His missing person episodes remained a concern and there were still issues about him smoking cannabis and associating with gangs. It was also discussed that he was possibly dealing drugs to fund his regular cannabis habit and the practitioners were challenging this. He was not fully engaging with The Princes Trust and drugs advocacies initially from BUBIC, a local Tottenham Drug Service working with young people identifying their drug use and effects of substances, recommended by CAMHS who in turn referred to Insight (Haringey). They were still awaiting the outcome of the GP referral to CAMHS and whether James’ Initial Health Assessment (IHA) was completed. The Designated Nurse for LAC reported that James had difficulty with independence skills and stayed in his room for long periods and Placement 1 confirmed he sat in his room with the bulbs taken out. SW2 raised his concerns about the chairing of the meeting to his Line Managers the following day and this was acknowledged by the IRO. There were no similar concerns in his third and final LAC Review. Comment: - It was confirmed that the IHA was completed. The GP was eventually spoken to after several attempts made by SW2 and confirmed the referral by the GP to CAMHS (St Anne’s Hospital) was declined. The reason why has not been ascertained by professionals during the course of this Serious Case Review, after requests by the IOA to obtain their rationale. 13. On the 29th June 2015, at James’ final LAC Review, both the IRO and SW2, agreed that James was readily engaging. At this meeting, James was actively involved in discussions and asked questions. Information discussed included his impending Court appearances and he stated he did not want to live with either parent. His father could not attend on this occasion and there was no meaningful engagement or participation by his mother of note whilst James was a LAC. 14. On 14th July 2015, there was a meeting between the IRO, SW3 and James’ father to discuss his LAC Review and the current position of his impending Court appearances. His father felt that in his opinion, it would be in the best interest of his son, that he received a custodial sentence as it would help him to stop using drugs and offending. He was of the view that people in Hackney were controlling him. He said that by December 2014 he was aware that he was dealing drugs but not witnessed it. He also believed James should have been given a placement in Essex away from temptation and this was the view of his mother and step-father. This does not seem to have been considered or explored by practitioners. Comment: - The view of the location of James’ placement by both parents (See Chapter 3 Family Contact), the issue of CAMHS declining their service, the referral to Drug and Alcohol Services which failed, his missing person episodes, escalating criminality, could other alternatives within his LAC Care Plan and Reviews, have been considered? (TLSCB Overview Report Recommendations 5 and 6.) 15. It was acknowledged by the IRO in the interview with the IOA that both a FGC and a Strategy Meeting could have been considered at an earlier period to address James’ criminality, his behaviour and pending Court cases. It is noted that this it would have been considered but events took a 36 drastic turn with James’ death shortly after the final LAC Review. (See Findings at Chapter 6 and suggested TLSCB Recommendations at Appendix 4.) 16. Thurrock CSC clearly provided noticeable support and numerous attempts were made to help and advise him. It was his own decision whether to engage or not. As alluded to, a Strategy Meeting could have been considered after his two arrests, to bring together the necessary agency professionals to consider options and initiatives to challenge and support James, looking at the wider issue of his criminal offending and whether he was being exploited to commit crime by others. 17. The DfE in 2014 issued the “Statutory guidance on children who run away or go missing from home or care.”7 This is a helpful flowchart showing the roles and responsibilities when a child goes missing from care and what should be considered. Thurrock CSC were compliant and readily challenged his placement when they failed to comply. These issues are subject to further comment within the Findings at Chapter 6 with suggested recommendations to cover both LAC Care Plans and LAC Reviews, to ensure that all aspects are captured and initiatives put in place to address increasing concerns and incomplete mental health issues for a LAC. (TLSCB Overview Report Recommendation 4 and 6.) Thurrock Children’s Commissioning and Service Transformation (CCST) 18. Context: Under the Guidance on the Provisions of Accommodation for Looked After Children 20108, the sufficiency duty requires Local Authorities to do more than just provide accommodation, they must also meet the needs of children. It should also take into consideration as in James’ case, the type of accommodation, the particular skills, expertise or characteristics of carers, provisions for care leavers and the availability of additional services to ensure the needs of vulnerable children are met. 19. It transpired that there were concerns with Placement 1, which necessitated a formal complaint. The same company provided both Placement 1 and 2 and it is now known these were “spot purchases”. It does not involve as much scrutiny and therefore when a spot purchase is made due to an urgency, a full Individual Placement Agreement (IPA) should be completed soon after agreeing to the placement. Unfortunately following extensive checks, no record could be found of an IPA being carried out and is a system failure. 20. The IOA carried out enquiries and revealed that financial checks would have showed that the company in July 2014 was subject to a “Winding Up” Petition by the Commissioners of HMRC. In August 2014 the company at Court, successfully challenged the petition and it was dismissed. This shows that there may have been some concerns that ultimately, we now know, ended in February 2016, with the company going into administration. There could be a perfectly valued reason why this situation occurred and if commissioning scrutiny had identified these facts, it could have been suitably considered and addressed. 21. In an interview with the IOA, the Strategic Lead and colleague of Thurrock CCST agreed to address the issue with the enhancement and requirement of more regular financial checks on service providers of LAC placements to increase scrutiny. In James’ case, the necessary checks were not carried out. They will now systemically complete the necessary financial checks as soon as practicable on spot purchases which are provided only in urgent placement cases and then reviewed 7 Statutory guidance on children who run away or go missing from home or care, DfE (2014) 8 Guidance on the Provisions of Accommodation for Looked After Children, 2010 37 annually. Whilst this will not be the whole picture it does give an indication of the financial stability of the provider. 22. The problem that CCST have is that currently when they spot purchase with new providers, there is not always enough time to undertake these checks prior to placing the LAC. However, they say they can follow up and complete the requirement as soon as possible. (See TLSCB Overview Report Recommendation 2.) Key Social Workers 23. There were three Senior Practitioners, Thurrock Social Workers (SW1, SW2 and SW3) allocated to James throughout his period as a LAC. SW2 and SW3 both attended the Coroner’s Inquest for James and SW2 was interviewed by the IOA. He displayed a knowledge and understanding of James. He described James as both shy and withdrawn but if persons pushed him he could have an aggressive side. He had a physical presence that some may have found intimidating but this was never an issue with either SW2 or his Personal Adviser. SW2 made seven visits to see him and was also in regular communication. He maintained detailed notes which were viewed and helpful for the review. He correctly challenged Placement 1 on how they were dealing with his care and support and the non-compliance of reporting James as a missing person. The escalation resulted in a formal complaint to the company placement provider supported by Thurrock CSC senior management and supervised by the Head of CSC. 24. In particular, on the 1st May 2015, SW2 visited James at his placement. He refused to supply details of friends who he was meeting or a girlfriend that was mentioned, if in fact one existed. Staff were aware that he always had money when he arrived back at the unit, together with “takeaway” food that he would not normally be able to afford as he only had a £53.70 weekly allowance. He appeared defensive and paranoid when asked questions about this, stating that he does not understand why people always ask him a lot of questions. After a short period he took his bag, a sign that he would not return until later that evening and left the placement. In fact he went direct to Cambridge where he was until he was arrested on the 9thMay 2015. 25. His room was observed and it was noticed there was a number of small plastic bags that could be used for containing cannabis. A subsequent appointment was made to have a blood test but he failed to attend and this does not appear to have been followed up. His room was disorganised with dirty dishes, paper and clothing strewn on the floor. The shower cubicle was unclean and blocked and it was pointed out that the new toilet seat was his fourth, the others were still in the room. Staff did not know why they kept being broken and concluded James would not allow staff into his room to clean. His Personal Adviser arrived and agreed to follow up and discuss the concerns within his contacts with him. Personal Adviser 26. James’ Personal Adviser was interviewed by the IOA who started work with James when he was on the Adolescent Team in October 2014. He continued contact with James when he was transferred to Thurrock Careers in early 2015. He confirmed James as initially shy and withdrawn with no eye contact, an opinion that SW2 also shared of him. James had an interest in music production but the course at a college suitable for him was not available until the following September 2015. To stop him becoming NEET, he helped James with his CV and there was an attempt to encourage James to find employment and attend other educational courses or consider community project ideas to work on. He was not interested and refused to consider these options. James was secured a twelve week 38 course with The Princes Trust at Hackney College in North London. James’ regular use of smoking cannabis was discussed with him as it was believed it was impacting on him coping with the course. It was evident from the interview with the Personal Adviser that he was conscientious and was trying to obtain the best for James’ future, a similar impression given by SW2, as both professionals coordinated well with each other over James’ case. The Prince’s Trust 27. This is a youth charity that helps young people aged thirteen to thirty years of age to get into employment, education and training. James was provided with a twelve week course during the start of 2015. He was supported by his Personal Adviser but James did not engage. On the 16th February 2015, due to his behaviour, he was spoken to by a Social Worker from The Prince’s Trust about his lack of engagement in the team, attendance, punctuality and participation towards the programme. James displayed strange behaviour, drawing reference to his eyes being bigger than normal and being able to see into the future. This worried the practitioner, so a private meeting with James and other practitioners was held on the 19th February to address these concerns and the issues they had with his involvement on the course. During the course of the meeting he consistently displayed, what can only be described as worrying behaviour. Additionally when he was informed he could go home, he made the comment that he needs to wait until the big hand on the clock gets to one; he then spent time looking at the clock on the wall, moving his eyes around in various directions, holding his chest and breathing in a controlled way. As the Practitioners left the room, he insisted on staying until he had completed his gestures. Due to this behaviour, The Prince’s Trust carried out a Risk Assessment and promptly shared their concerns with his Placement 1 Key Worker and his Personal Adviser. As James continued to fail to engage with The Prince’s Trust, he was removed from the course. General Practitioner 28. The following day the 20th February 2015, after the preceding disclosure from The Prince’s Trust, Thurrock CSC took immediate steps and requested that James be taken to his GP. This was his first visit to the surgery and he was spoken in depth by Doctor RE who was concerned with James presentation. He admitted regular use of cannabis and his behaviour to comments made in the consultation were concerning, therefore the GP referred James to CAMHS (St Anne’s Hospital). SW2 later telephoned the surgery and after several attempts he spoke to the GP who confirmed that CAMHS had declined to offer their service. James was being initially assessed by BUBIC a local drug advocacy which James felt he did not need. He was referred on, to receive support from Insight (Haringey), from a drug and alcohol dependency support service who would look at his drug habit. CAMHS reason for declining their service was not known to professionals and their rationale was requested for the purposes of this review but not obtained. 29. The GP referral to CAMHS records his symptoms and “odd delusions” are most likely due to his cannabis use, and may be affecting him, requesting a further assessment. It is believed that CAHMS may have taken this literally to refer him to a drug advocacy and did not take account of his presenting behaviour. This does not however answer the whole concern and therefore his mental health was not ever assessed effectively and should have been followed up within his LAC Care Plan and LAC Reviews, as it remained unresolved. James informed the GP he had been smoking cannabis for three years. The GP notes that it was his choice not to engage with people and does not find activities stimulating enough. He said he does not engage with SW1 or others around him as he does not believe there is anything wrong with him. He denied any visual or auditory hallucinations such as staying up at night. He was in denial that smoking cannabis for such a time had any effect on his physical or mental health. The GP tried to discourage him and an examination of James showed him 39 as of normal appearance with no suicidal ideation, intentions or plans. (TLSCB Overview Report Recommendation 5 and 6, also Thurrock CCG Recommendation 4 in Appendix 4.) 30. In March and April 2015 there was communication with both the allocated Key Worker from Insight (Haringey) and SW2. Insight confirmed that they tried working with James but after repeated attempts to make a visit or arrange a meeting with him, the Key Worker had to close the file as he would not engage and on the 15th May 2015 he attended and saw GP, Doctor NA. It records in his consultation that James went sightseeing to Cambridge where he was arrested for drugs and he felt unfortunate that he got caught. He discussed his Court case with the possibility of going to prison. His mood was positive, he admitted in the past to feeling paranoid but he stated he was no longer hearing voices and he was still using cannabis but denied using any other drugs. Thurrock CCG (Health) 31. The first contact with James was on 24th July 2013 when he registered as a new patient in West Thurrock. In 2014 it records information known by a Senior Practitioner at Thurrock Social Care Adolescent Team that they completed a Family Assessment. On 29th January 2015 his electronic records were transferred out to his new GP with his address now at LAC Placement 1. The Designated Nurse (DN) for LAC attended two Thurrock Placement Panel meetings and reported no conciliation with James and his family. It was reported he was settled in his placement, following rules but still smoking cannabis. His Personal Adviser completed a DUST Tool (Drug and Alcohol Assessment Form and referred him to the local Drug and Alcohol Services). The DUST tool is designed for two main purposes 1) To help professionals make decisions about how to respond to drug/alcohol use by a young person, and 2) To allow a professional team to create a profile and audit the prevalence of drug/alcohol use within their caseload. The initial IMR Author (see below) states this was an appropriate use of the tool in James' case. The DN attended his second Placement Panel and reported that James had difficulty with independence skills and stayed in his room for long periods, a fact also confirmed by Placement 1. 32. Due to a change in personnel at the latter stages of the SCR, another CCG representative joined the SCRP and made suggested changes to the previous CCG IMR and recommendations. The revised Thurrock CCG IMR was received in August 2016. The IMR was further considered by the IOA and incorporated within this Overview Report. It includes two recommendations shown within the Thurrock CCG Agency Recommendations at Appendix 4. Their findings take into account a recent “Care Quality Commission” inspection for implementation in November 2015. The recommendations were made to comply with practices with “The GP Patient Registration Standard Operating Principles for Primary Medical Care” in relation to a child being seen on registration with the practice. It is a contractual requirement that once registered, all patients must be invited to participate in a new patient check and neither registration nor clinical appointments should be delayed because of the unavailability of a new patient check appointment. This advice has been sent electronically to all GP practices in Thurrock and raised within the local GP Safeguarding Leads Forum. (Thurrock Agency Recommendation 1.) 33. Furthermore after James became accommodated, his records were transferred out of his Thurrock GP practice. Statutory Guidance promoting the Health of Looked after Children 2015 (DFE DOH) state that: GP records for LAC are maintained, updated and health records are quickly transferred, with no timescale given. A local Primary Care Resource Pack was developed in April 2015. The pack outlines Primary Care Teams statutory responsibilities. The guidance states that all patients including children should have a named GP at the practice where they are registered with additional guidance for LAC. It stipulates that practices should ensure timely access to a GP or other 40 health professionals and provide information on the health of the child, to inform other assessments. They should maintain a record of the Health Assessment and contribute to actions within the Health Care Plan to ensure best practice is achieved. The IMR further identified a need for the CCG to review governance and information sharing following attendance at Thurrock Placement Panel meetings. (Thurrock Agency Recommendation 2.) NELFT 34. James became known to NELFT in April 2013. The IMR identified delays in the statutory time-frames of his Initial Health Assessment (IHA). James was never seen by his GP whilst he resided in Thurrock. However when he became a LAC in December 2014 and placed out of borough, he was taken to a local GP for his IHA. It is noted that the outcome and record keeping in regards to the IHA was unsatisfactory. Regulation 7 of the Care Planning, Placement and Case Review (England) Regulations 20109 requires the LA that looks after the LAC, arranges for a registered Medical Practitioner to carry out an IHA. The request was timely within 20 days. There was no record to say the assessment took place and also no copy of the Health Assessment, but there were electronic records chasing up both the GP and Placement 1. Their IMR acknowledges the insufficient recording keeping and lack of information regarding his IHA. They have addressed the issue. (NELFT Agency Recommendation 4.) They also acknowledge that James’ immunisation (January 2014) as well as a domestic incident (April 2014) were not apparently followed up by the School Nurse at School 4. (NELFT Agency Recommendation 2 and 3.) Comment: - Their IMR suggested that Thurrock CSC should consider informing health professionals of the details of vulnerable young people in need of CIN Plans, to determine the level of service Universal Health Services can provide. It was also further suggested Thurrock CCG could possibly commission a programme for keeping young people from becoming NEET. NELFT Agency Recommendation 1 and 2.) These comments are learning on the fringes of this review and do not impact on the conclusions of this Overview Report as they will require further consideration outside the SCR process as to their feasibility. (See NELFT Agency Recommendations at Appendix 4.) Any learning, implementation or outcomes of these NELFT suggestions, should be reported for the information of the TLSCB Action Plan that follows and supports this Overview Report. LAC Placements 1 – 2 and Compliance 35. James was placed with the same company service provider for both placements that he resided in whilst a Thurrock LAC. The company provides semi-independent accommodation and is a supported housing project, housing young people in the community from the ages of 16 to 24 years of age. In James’ case, both placements were for young people aged 16 to 18 years of age only. The placements were “Spot Purchases” due to the initial urgency to find LAC commissioning services, and were recommended by other Local Authority LAC Commissioners, in a regional group that share information on placements. In this case, financial checks on these spot purchases were not carried out which are required when commissioning a full contract and an Individual Placement Agreement (IAP) was not completed and was a system failure. In February 2016 the company went into administration. (See Chapter 6, Finding 3 regarding associated issues and suggested TLSCB Overview Recommendations) for the Thurrock Board to consider. 36. Placement 1: James was housed in his first placement and allocated two Key Workers with 10 hours a week key work support, within a 24 hour staffed house. There were three other young people in residence at the time. The key work was commissioned by Thurrock CSC for the duration 9 Regulation 7 of the Care Planning. Placement and Case Review (England) Regulations 2010 41 of his placement, to look at independent living skills and to support James with his appointments with professionals. 37. Throughout his placement, he was continually going missing and there was concern with him smoking cannabis. His behaviour at his father’s home started to be displayed in his placement, with a number of incidents with other residents. He at times displayed challenging behaviour with knives and aggression towards other young people in the placement, as recorded in the key events above. In particular the incidents on the 8th June 2015 when James assaulted another resident who declined to press charges and on the 15th June, when he was arrested and subsequently charged with affray. This last incident culminated in the Placement Director carrying out a Risk Assessment and discussed with James his criminal offending and drug use. With the shared agreement of Thurrock CSC Social Work management, as his bail conditions to attend the London Court on the 14th July, stipulated that he should not attend Placement 1 or contact two named persons at the residence, he was moved to Placement 2, as a safeguarding necessity for others. 38. There had been concerns reported by SW2 who found the placement cleanliness unacceptable and queried whether the experience of some staff at the placement was suitable. Thurrock CSC also had cause to make a formal complaint whilst James was in Placement 1 as they were not appropriately informing both EDT and Police when he went missing. These failures were effectively challenged by Thurrock involving SW2, Senior Management and the Head of CSC. The placement responded to ensure compliance. 39. Placement 2: After James arrest for affray and after the Risk Assessment, James was transferred to the same company service providers Placement 2. It was a similar set up as Placement 1 with three other young people in residence. From an interview with SW2, it appears that this placement was in a better area but with less in the locality for him to do. James during this placement was transferred to SW3 as his case was transferred to the Long Term team. At the placement there were no significant concerns however, he went missing on a couple of occasions but only for short durations and returned of his own accord. 40. The Placement Director after he was moved to Placement 2 reported that since James returned from Portsmouth, he had been behaving strangely, agitated, annoyed and not his normal self. He agreed that he would not intimidate staff and other residents in future, as occurred with his arrest in his previous placement. Staff had overheard a conversation that when in Portsmouth, he was chased by an unknown male with a knife and possibly robbed. The Director informed her staff to keep an eye on James if there are any more changes in his behaviour. The Placement Director confirmed to Thurrock CSC that she had spoken to James and stated the following:- • Speaking about going to Cambridge he said that he had been visiting friends and that he had been dealing (drugs) as he wanted to earn money. He said he did not plan on doing this forever but wanted to earn some cash. He said he had a plan for the future but that he might go to jail due to the recent incident. • The people at the unit understood him and sometimes he feels that he has to wear a mask to hide who he really is but there are times that he feels he can talk to people. • He was also asked why he liked to sit in the dark and hence why he had taken out his light bulb? He said sometimes sitting in the dark is what he likes, he can think in the dark and when he feels good he likes the light. He made a comment that he thought he might be “mad”. He was told that when he is not happy with himself he becomes introverted and wants to be in the dark and be by himself. • He said he writes music and wanted a computer to further his interest and he was offered studio time but he said he was more interested in the writing than the singing. 42 • James agreed to keep his room tidy and clean but he will not allow staff into clean his room because he did not like people in his bedroom. 41. On the 14thJuly 2015 James failed to appear at Court to answer his charge of affray and the reason why and what support that was offered by the placement is not known. Attempted contact by the TLSCB with the placement provider company, to provide the answer since the company went into administration, has not been successful. That evening at the placement he appeared normal and communicated with the on duty Support Worker before he went to bed. There was never any concern or intimation from James that he would attempt to commit suicide or self-harm. On the 15th July 2015 at about 9am, James was found collapsed behind his bedroom door by two support workers who called the LAS and Police. He was later certified dead at the scene. (See Chapter 2 Details of the Investigation.) 42. Placement Compliance for LAC: There was some good work provided by his Key Workers at Placement 1, to address James’ missing person episodes and his regular use of cannabis which persisted. They took him to his GP appointments who, after concerns as to his presenting behaviour identified by professionals, referred him to CAMHS. His Key Support Worker DM consistently attempted to get James to engage but this was evidently difficult to achieve. Whilst at the placement he was supported in an effort to stop his offending, such as when he was arrested in Cambridge, outlined in Chapter 4 and discussed below. They supported him by taking him to Cambridgeshire to answer to his Police bail and when he was charged in June 2015. The placement updated his Social Worker by email on these occasions. The placement also attended all of James three LAC Review meetings. Significant comments made to questions posed by the Placement Director of the company in conversation with James in early June 2015 were captured. His voice and his concerns were heard and shared to Thurrock CSC, his SW and at the LAC Review meeting on 29th June 2015. 43. A Gangs and Knife Crime Risk Assessment was completed in June 2015. He did not talk about gangs, but the opinion was his behaviour was in keeping with gang culture in London and carrying knives. A drug Risk Assessment was also completed in the same month due to his offending behaviour in his recent arrests. Staff and other professionals were aware of the outstanding cases and offences concerning Class A drugs. As there was no CAMHS involvement they were not aware of his mental health without this input. The referral to CAMHS it is claimed, was made because of his change in behaviour, with more aggression shown and being withdrawn in the placement. They were also not aware of all his past issues but his father did disclose about James going missing previously while living at home. Comment: - The placement company provided an IMR for this SCR but the IOA required further information. This was not forthcoming as during the process of completing this review in February 2016 the company went into administration. In a discussion with the IOA at James’ Inquest, the support worker 2 (who came to take James to Court in Cambridge) stated he had left the company prior to it going into administration, because he was not getting paid. This statement together with the financial and company checks within the commissioning for LAC placements, identified a system failure as indicated previously and further addressed in the Findings at Chapter 6. Their suggested IMR recommendations were on examination, not recommendations but questions posed. TLSCB have a copy of the recommendations which due to the company no longer being viable, are no long relevant, as training issues for LAC placement staff are captured within the Thurrock CSC IMR and his incomplete mental health assessment is also addressed under the IRO and LAC Reviews above within this chapter. It is clear from the analysis that Placement 1 was not compliant with reporting James missing as indicated within Chapter 4, Key Events. This was 43 appropriately escalated and Thurrock CSC were right to challenge and complain to the placement company. Open Door Return Interview 44. Open Door administer a Missing Young People’s Service and offer return interviews. James only agreed to one return interview following his periods of being reported missing. On the 19th May 2015 (after his arrest in Cambridgeshire) he was interviewed. He stated he had been brought up most of his life in Hackney with his mother but lived with his father in Thurrock for the last one and a half years before he was accommodated. He did not see his father much and did not like to travel to Thurrock. He sees his mother occasionally when he goes to Hackney, where he tries to spend as much time as possible with friends, usually once a week. When asked about his family he said he had four half brothers and sisters but does not ever see them "because they are with his parents". He did not mind being at his placement but did not agree with all the rules. He had a weekly allowance but was not allowed all the money at once, he received it in intervals during the week. He confirmed he did not attend college and spent most days in bed watching TV and sleeping. (He woke up at 3pm for the interview.) 45. James stated he had ambitions to do an apprenticeship, possibly in music as he can play the piano. He did not want to talk about going missing. Eventually he confirmed that he went to Cambridge to "stay with friends" and he was sightseeing but laughed to himself at this comment. He was asked if he stayed at one friend’s house for the duration of the time he was missing? He said "No” and said "They are just friends". He said that it was not the first time he had been to Cambridge, he said he had been on lots of occasions before. (His step-father stated in telephone call from James that he was in Cambridge on one occasion.) He admitted that he was stopped by Police and arrested but denied he had any involvement in gangs. 46. Open Door Service made two recommendations, 1) Career advice and The Princes Trust, as he was keen to complete an apprenticeship, and 2) St Giles Trust SOS Gangs Project, a project that works specifically with young people at risk of gang involvement in London boroughs. Although James would not confirm this, the interviewer's suspicion was raised that he may have some involvement in a Hackney Gang. As previously stated he failed to engage with The Prince’s Trust course. CAMHS (St Anne's Hospital) 47. CAMHS declined the referral from the GP. BUBIC were suggested and appointed a SW to meet James and start an assessment and then referred on to Insight (Haringey). CAMHS at St Anne's Hospital sent a letter to the wrong address for Placement 1 who never received it. The placement requested in future all letters be addressed to the company to ensure that all correspondence was received and accounted for. This matter was addressed at the time. The concerns the GP outlined of James’ behaviour in the referral, citing as a possible consequence of his regular cannabis use, may suggest CAMHS took this as a reason, that he only had a drug problem and was depressed. This does not however answer the whole concern from the referral submitted by his GP. Therefore the possibility of his mental health was not ever effectively assessed and should have been followed up within his Care Plan and LAC Review with health professionals. (See the Findings at Chapter 6.) 48. Since November 2015, CAMHS, is now run by Southend, Essex and Thurrock (SET) NELFT and called the Emotional and Wellbeing Mental Health (EWMH Service), an early help service and a single point of entry, enabling direct intervention to receive and screen referrals. The service will have a long term aim of responding earlier to children’s needs to help prevent, reduce or delay the 44 need for more specialist interventions and is currently being rolled out. This may be beneficial for the future of SET but as many LAC are placed out of area will still require communication with other CAMHS in whose area the LAC is accommodated, therefore the recommendations suggested at Appendix 4, are still relevant. School 4 49. On 23 November 2012 James was offered a place at School 4. Straight away his father had challenges for him to attend as highlighted in Chapter 4 key events, who reported him missing after an argument to attend on his first day. The school appropriately informed the Child Protection Officer, Assistant Head and Student Achievement Leader (SAL) of his absences and were aware that he was moved from Hackney as he was getting involved with gangs. James continued to miss school, wanting to return to the Hackney area. On one occasion in December 2012 during his persistent missing person episodes, James had convinced his mother that his father mistreats him and said he tried to strangle him. Both his father and mother in conversation with the IOA stated that James was playing both parents off against one another in order that he could stay in the Hackney area, using it as an excuse to keep off school. The school made a referral to Thurrock CSC and it was recorded as NFA. James continued to live with his father, as his mother refused to allow him to stay with her. 50. His attendance remained poor, recorded in January 2013 at 30.6% and School 4 referred James to the Education Welfare Service (EWS). On the 8 February the school sent a letter to his parents for failure to attend school since December 2012 and informed them James was removed from the school roll. 51. On the 27th February 2013, his father contacted the EWS and asked if James could return to School 4. He was allowed in March 2013 to restart at the school. There were other concerns and on the 17th April the School Child Protection Officer met James at school as he was very late and it was mentioned about apparent arguments he had with his father and uncle. The SAL was informed by email and records a CAF Referral was carried out having listened to him. 52. On 11th September 2013, School 4, received a referral to the Child Protection Officer about concerns of parenting. It noted that his father lives with his girlfriend in Barking and visits the house once a week to bring food. His paternal uncle lived at home but leaves for work at 9-10pm and returns after James goes to school in the morning. It was recorded as NFA and not clarified further. Comment: - From the family interview the reason why his father continually went to Barking was to stay with his estranged second wife and at that time, his two young daughters. 53. In March 2014, a tutor was informed by a third party that James best friend in Hackney had been shot? He did not want his father to know. James was spoken to and offered bereavement support which he declined. It is not known whether this information was correct and was not elaborated on. 54. After James was accepted back into education in Year 10, he obtained 86% attendance. In Year 11 it rose to 98.8%. He left at School 4 with six GCSE's A* to C + grades including English and Maths. James had a careers interview and secured a place at South East Essex College but he did not take up the option. When he left Year 11 he was not NEET. 55. The IMR author made four recommendations. Only one recommendation is effective for the purposes of this review as the others have already been implemented. Their recommendation is regarding responses to referrals to an outside agency, as their IMR criticises social work allocation and involvement to tackle the issues surrounding James’ missing from home episodes. Their 45 Safeguarding Officer will now address the situation and if necessary, escalate the matter if no satisfactory response is received from referrals to other agencies. (School 4 Agency Recommendation at Appendix 4.) However in James’ case, no major referral was missed by School 4. Safeguarding procedures were followed and his voice was consistently heard even though, since April 2015 a more robust system to record student voice has been in place. The EWS and school intervention in Year 10 allowed James to settle well into Year 11, enabling him to go into further education if he so desired. Hackney CSC 56. The CSC provided a chronology of contacts with James. They did not supply a report or an IMR of the analysis of events regarding him presenting himself to Hackney CSC as homeless, on two occasions. The chronology duplicated entries which were identified. Comment: - A request was made by TLSCB to Hackney CSC to supply a report analysing their action taken and up to June 2016 this has not be supplied. The IOA has reviewed the chronology and cross referenced it with other submissions to the serious case review. There appears no significant concerns, but their view on the action taken, particularly when James presented for a second time on the 23rd September 2014, poses the question whether they should have offered more assistance to help him charge his phone battery to obtain his parents contact numbers? Consequently he left the Hackney Service Centre, his whereabouts were unknown and he did not later contact Hackney with the details. This information was later shared by Hackney CSC when Thurrock CSC contacted them for information on contacts with James. Norfolk CSC 57. Norfolk CSC have been asked as to their agencies safeguarding arrangements for James as he was presenting as homeless in their area. The circumstances of the events in July 2014 are detailed in the Norfolk Constabulary entry below, when James was arrested in Great Yarmouth, Norfolk and are not replicated here. Norfolk and Thurrock CSC had a discussion as to who should have responsibility for James and whether to treat him as a homeless person. At that time, James’ parents refused to accommodate him and he was living with his father preceding his arrest. It was agreed that Norfolk CSC assumed responsibility for him. There were safeguarding issues for Norfolk CSC, as James was allowed to travel home to his father’s home and he missed his late night train, causing the Norfolk SW who could not find him, to report him as a missing person. He was later located at his maternal aunt’s home in South London on the 13th August 2014 and the reason for their decision and action taken is not known. (TLSCB Overview Report Recommendation 11.) POLICE Essex Police 58. Contact first commenced in October 2012 when James was aged 14 and concluded in December 2014 after his 17th birthday. They dealt with him on numerous occasions when he resided with his father, mainly when he was reported missing, emergency calls by his father for domestic incidents in the home and in communication with the MPS when he was found missing in London. 59. The final contact was on 11th December 2014, when his father made another emergency call to Police, as James was threatening everyone in the house following an argument over food and regarding his use of drugs. Police found no weapons or evidence that drugs had been taken. There was no further action taken and it was agreed that he would be taken to his maternal aunt’s home in 46 South London. This was the final straw for his father that ultimately led to James becoming a Thurrock LAC. There was good communication and sharing of information between Essex Police and the MPS in their contacts with James. No recommendations were identified by the IMR Author which is acceptable. Metropolitan Police Service 60. James came to the notice of Police on thirty three occasions of which the MPS were concerned on twenty occasions. Of these, eleven related to him being reported missing between the period of January 2013 and July 2015. The common themes were disagreements with his parents, and failing to return to his placements. In all contacts between the MPS and James, referrals were appropriately made in relation to his missing person episodes. There were two incidents requiring further comment. On the first incident he was stopped in the street and admitted he committed crime to fund his cannabis habit which should have stimulated a referral by completing a Merlin (come to notice) for CSC. This was individual learning for the officer and secondly, when he was arrested in June 15 for affray at Placement 1, he mentioned to the Forensic Medical Examiner (FME) when examined in custody, that he was bi-polar. In all other aspects policies and procedures were complied with and information shared. It was confirmed that there were no identified links to James affiliation with gangs and he was not on the MPS Gang Matrix at that time. 61. In relation to the bi-polar comment, there is no record of this possible concern being shared with CSC either from the medical professional carrying out the examination nor whether it was recommended to the Police Custody Officer, to complete a Merlin report for onward sharing. It has been confirmed by the Chair of the SCR Panel, who carried out further enquiries, that there is no record of James being on any medication for bi-polar or anything health related. His history as given to his GP referred only to an allergic asthma, allergy to nuts and smoking cannabis. The MPS Safety Compliance Investigations Team state it would not be the responsibility of the FME, who will advise and complete the National Strategy for Police Information Systems (NSPIS) medical form, to raise concerns and it would be the responsibility of the Custody Officer to take any action. (TLSCB Overview Report Recommendation (9) for the MPS.) Norfolk Constabulary 62. Norfolk Constabulary submitted a report, requested by the IOA, due to a possible safeguarding issue between Police and Norfolk CSC Initial Response Team (IRT.) In July 2014 James was arrested in Great Yarmouth, Norfolk. Police were carrying out a search of a fifty year old women’s home where a small quantity of drugs (one wrap) was recovered at the scene. He was found hiding in a wardrobe. He declined to comment in interview but the women arrested with him alleged they met up a couple days previously and as he was homeless, she gave him somewhere to stay and had a “fling with him.” She said that the drugs were left by another person who visited her home. He was provided with an Appropriate Adult from the Norfolk Appropriate Adult Scheme, but declined to answer questions. He was bailed by Police for the offence of possession of a controlled drug. Norfolk and Thurrock CSC discussed who had the responsibility for James and whether to treat him as a homeless person, as both of James parents refused to accommodate him at that time. His father confirmed that his son had no family contacts in the area. James was bailed by Police but kept in the company of a PCSO and supervised while Norfolk CSC arranged accommodation. After further negotiation by the Social Worker dealing with James, his father agreed he could return home to him. James was furnished with a travel warrant and allowed to travel home alone. He missed his late night train, causing the Norfolk Social Worker, who could not find him, having to report him as a missing person to Police. 47 Comment: The custody record lacks information and shows that his bail was subsequently cancelled but no details are recorded why? It was presumably due to the lack of evidence of who possessed the drugs. The report further states that ongoing safeguarding concerns were satisfied but cannot comment on the ongoing arrangements by Norfolk CSC. It does not explain how he was handed over to Norfolk CSC who were initially looking to accommodate him overnight and how he missed his late train home. (TLSCB Overview Report Recommendation 10.) Cambridgeshire Constabulary 63. Between the 6th and 7th May 2015, a caretaker’s office in a residential block of apartments was burgled overnight with two laptops and a pair of Nike training shoes stolen. The following morning James was apparently seen in the street, by a witness, who saw him carrying property. He went into a bush and when he came out he did not have the property on him. The witness informed Police who recovered a laptop bag with two computers inside from the bushes from the burglary. He believed he saw James several times over the preceding days and suspected he was dealing drugs to individuals. Later that day there was a walk in burglary at Lucy Cavendish College, part of the Cambridge University campus between 7.30 and 9.30pm. Cash and an iPhone were stolen from an unattended locker room. There were no suspects seen or witnesses to the actual burglaries but the two crimes were later linked. 64. On the 9th May 2015, the loser of the lost iPhone used the “Find my iPhone” app, she tracked and reported the location to Police. James was approached by Police and ran off but was arrested after a short chase. He had to be subdued as he was resisting arrest. He was described as having the physical size of a much older person. Once detained, he immediately conceded that he had Heroin drugs on him. This was the only significant admission he made. At the scene, Police requested paramedics to attend, as James complained of being unwell. They examined him and found him fit, with no concerns for further medical care. Comment: - The area James was found in was frequented by drug users, this was not a familiar area with visitors to the city. 65. At the Police station, checks with the Police National Computer (PNC) showed he was a missing person from Placement 1 and in need of protection. James was interviewed by detectives in connection with his possession of drugs and a large quantity of cash found in his possession (£1000) and the burglaries. He was represented by an Appropriate Adult but declined to answer questions other than mentioning he had personally taken cannabis that day. 66. Cambridge Police notified Placement 1 and the MPS. James was bailed until the 10th June 2015 (later extended) to return to the Police station whilst forensic examination of the twenty one separate packets of drugs recovered in his Nike bag, and the investigation into the two burglaries continued. Property retained by Police was the cash, two mobile phones (an iPhone and a Samsung) together with a sim card for analysis of the contents. He was released into the care of MPS officers who attended Cambridge and escorted him back to Placement 1. 67. His bail was again varied for finalising enquiries until 25th June 2015 when he answered to his Police bail. He was further interviewed but declined to answer any questions. There was insufficient evidence in relation to the two burglaries however, the CPS gave authority to charge James with the offences of possession with intent to supply Class A controlled drugs and handling stolen property, the iPhone. He was released into the care of his placement support worker who had taken him to the Police station, to appear on 15th July 2015 at a Cambridgeshire Court. 48 Comment: - The drugs analysed confirmed he had Diamorphine (Heroin), with a street value of £250 to £350 as assessed by the Cambridge Expert Drug Witness. 68. Appropriate Risk Assessments were carried out by Cambridgeshire Police and they enquired into James’ welfare. The Police officer dealing with him failed to complete Form 101, a child and young person coming to notice form, a referral through their Multi Agency Safeguarding Hub (MASH). The officer did however, contact James’ father who declined to become involved. The officer through Police checks was aware he had come to notice of the MPS for potential 'gang related matters' and was regularly reported missing. James was given every opportunity to provide information. He did not give any indication of his relationship with any criminal gangs, individuals and there was no implied risk. He was reluctant to answer questions and it was not known who the drugs or cash belonged to or whether he was acting alone or on behalf of others, as the witness had seen him in the preceding days acting alone. Due to his age and following assessment whilst in custody, he was observed and placed in a CCTV cell to monitor his wellbeing which, was good practice by Cambridge Police. 69. Furthermore a Police Electronic Notification to YOS (PENY) on the point of charge is required within 24 hours and was not completed. This aspect was addressed by the IMR Reviewing Officer and it had no detrimental effect on the case. This omission slightly delayed any necessary notification, checks and input with the YOS team, PNC, crime files and other databases. These omissions are subject to their agency recommendations at Appendix 4 and did not impact on the outcome for this review. Comment: - The IMR reports that a credited Expert Drug Witness stated that Cambridge is on occasions, being used by street level dealers from the larger Metropolitan areas. Working outside their own area may indicate that they are less likely to be identified and risks reduced. It is believed that a number of street level dealers are coerced into this by organised crime groups. This was not known if this was the case for James but his actions mirror the findings in the Home Office, Ending Gang and Youth Violence programme from 2011 to 201510 and which is now subject to Home Office Guidance 2016 for Local Authorities. All the London areas frequented by James in this serious case review of Hackney, Haringey and Brent had joined the initiative in April 2012 and may have been a source for the IRO to consider when addressing James behaviour and concerns in his LAC Reviews. Thurrock implemented their own Ending Gang and Youth Violence, Local Assessment Process in February 2016 after James death. British Transport Police 70. On the 1st May 2015, James was noticed at Cambridge railway station. He was not seen by Police but BTP records confirm that ticket inspectors gave him a fixed penalty notice for not having a ticket. He had been seen to frequent the station for several journeys of short duration and had been in possession of two mobile phones, which we now know were subsequently seized by Police. Hampshire Police 71. James was seen on the 7th June 2015 by Police officers in Portsmouth. He was stopped and questioned as to his demeanour and a record was made. Police were originally called to a male making threats to another male with a knife. James matched the description of one of the males involved but no knife was found on him. They record that he was “acting strange” and were more concerned for his welfare. He was sent home by train to Placement 1. 10 Ending Gangs and Youth Violence programme, Home Office (2011 to 2015) 49 Comment: The Police officer having concern for welfare should have considered a safeguarding referral and it has been confirmed that their Child or Young Person at Risk form (CYPR) was not completed. This has been noted by the Hampshire Constabulary, Serious Case Reviewer and is learning for the officer which, is acceptable in the circumstances as the stop was recorded correctly for later accountability and the information was available to this review. London Ambulance Service 72. The witnesses statements were obtained from four paramedics, compiled for James inquest who attended James on the 15th July 2015. There was no learning identified from the LAS report for this serious case review. Their account and actions taken by them is detailed within Chapter 3 above under Details of the investigation into James death. Missing Person Episodes 73 James was reported missing or had unauthorised absences on approximately 27 occasions. There were several episodes as detailed in Chapter 4 that showed he was found by Police in London and not reported missing by his parents. In another case he was found sleeping rough by MPS Police officers who returned him to his father's home in Essex. On each occasion the agreement of both James and his father to return home was obtained. There was acceptable compliance to policy and procedures between Police notably the MPS and Essex with the respective Local Authorities Thurrock, Hackney and Haringey CSC’s. It was also ascertained that Placement 1 had failed to report him missing and had no idea he was missing when he was discovered and sent home from Portsmouth or when he went missing to Cambridge on 1st May 2015 and was not reported missing by Placement 1 until the 4th May. This failure was challenged by SW2 and necessitated a formal complaint from Thurrock CSC. 74. Overall, his missing person episodes were actively pursued and attempts to hold return interviews as required were frustrated by James. He only agreed to have one interview with the Open Door service, commissioned to carry out return reviews. Police debriefs of James when available, were recorded as soon as practicable but met with unwillingness from James, who did not divulge anything of note as to his actions and whereabouts, whilst he was missing. James missing persons episodes are further discussed as above, within Care Plans and LAC Reviews, as there is a need for both processes to address and include strategies to minimise LAC persistently going missing and is discussed in the Findings at Chapter 6 and Conclusions in Chapter 7. Gang Culture, Drugs and Criminal Offending 75. As part of the Home Office Gang and Youth Violence programme, Thurrock Local Authority developed a “Gang and Youth Violence” Local Assessment Process (LAP)11, Thurrock (Feb 2016), and is expanded below. (See Ending Gang and Youth Violence in the proceeding category.) This is post the death of James but addresses the associating issues that impact on the Thurrock area, identifying amongst other matters, gang members coming into the area from London. However in James’ case, there is no evidence that he was an affiliate of any gang and certainly not in Thurrock. His actions and the subsequent recorded events, makes it reasonable to assume that he had gang knowledge and connections, but any association for James would have been in the Hackney area of London. 76. James was travelling to other areas that drugs were known to be sold or easily able to be obtained. Information from the Cambridge Expert Drug Witness statement, confirm that drug 11 Gang and Youth Violence Local Assessment Process (LAP) Thurrock (February 2016) 50 dealers from metropolitan areas like London, attend the area that James was frequenting, for the purpose of supplying drugs. Similarly also it could be said, when in July 2014, he was arrested in Norfolk. In that incident there was a local gang association but James was not known and in June 2015 when he was located in Portsmouth. James always denied he was in a gang, insisting his friends, who he never identified or spoke about, were not gang members. Both the IOA, his parents and professionals spoken to for the purposes of this review, are not convinced with his denial. 77. SW2 on one occasion saw two alleged friends waiting outside his placement and he seemed to be in a hurry and anxious to get away. Consequently SW2 received an email from the Placement 1 Head Office wanting it on record that James was seen at the placement with another former resident (possibly one of the two observed by SW2) who they had concerns with previously with a lifestyle of drugs. This could have been a form of an insurance policy for the placement as they were aware of the attendance of SW2. It was noted but not explored further but adds circumstantially to the conclusions below and within Chapter 7. 78. It is a reasonable assumption to suggest he was funded by other persons and sent to these targeted areas outside London, to deal in drugs. Furthermore, when he got back from Portsmouth, he was reported as stressed and not his usual self. He was overheard in his placement to say that he ran away from an unknown male with a knife when he was there. It is possible that this other person may have tried to or even managed to steal property from him, attacked for working on another dealers “patch” or seen as a vulnerable or an easy target. We will never be able to ascertain what really happened and this cannot be answered within this serious case review. However, such an incident did take place, as the response from Hampshire Police confirms they were called to an incident between two males, one with a knife. On stopping James, he did not have a knife or any illegal substances on his person. He may have been the victim on this occasion and not the aggressor. 79. Furthermore when arrested by Cambridge Police, they confiscated his drugs (street value between £250 and £350) and £1000 cash and had retained his two mobiles and sim card. Was he being exploited and did he owe a debt to pay these drugs and cash back to others? We can only surmise, but this is highly likely. Another scenario to consider is that at the time of his death, a search of his bedroom found no cannabis or other drugs. Furthermore his toxicology report showed that there was no alcohol or drugs found in his body. As a consequence he may not have been obtaining his cannabis, a persistent habit for his last three years. Was he keeping away from others because he owed the seized drugs and money? In support of this observation, in the family interview, it was disclosed that after his arrest in Cambridge, he visited his mother. He had a cheap throw away mobile phone and persons kept texting and phoning him (it is not known where this phone is!) He said to his mother “they will not leave me alone,” he then took his battery out to prevent further interference. 80. James’ father stated on several occasions that he wanted Thurrock CSC to move him to a placement well away from London and this is recorded. What was not apparent, was that his mother and step-father also shared the same view. They were concerned when he was first placed in Placement 1, as he was only a short bus ride away from the people they believed were coercing and controlling him into dealing drugs. It is a consensus of opinion, that gang members were probably paying him and supplying his cannabis for personal use to keep him involved and therefore exploited him to commit crime. The parents view to move him away from London, appears not to have been reasonably considered and is addressed under Finding 2 in Chapter 6 and within the family interviews with the IOA in Chapter 3. (TLSCB Overview Report Recommendation 4.) 51 Home Office Initiative - Ending Gang and Youth Violence 81. The Home Office (HO) funded Ending Gang Violence and Youth Violence (EGYV) programme January 201612 and is guidance and an approach to tackling gang related violence and exploitation. Priorities for 2015/2016 and onwards are:- 1) Tackle county lines – the exploitation of vulnerable people by a hard core of gang members to sell drugs. 2) Protect vulnerable locations – places where vulnerable young people can be targeted, including pupil referral units and residential children’s care homes. 3) Reduce violence and knife crime – including improving the way national and local partners use tools and power (extending gang injunctions, HO, with the Ministry of Justice (MOJ) to develop a national approach to information sharing and provide consistent reliable access to data etc.) 4) Safeguarding gang-associated women and girls, including strengthening local practices. 5) Promote early intervention – using evidence from the Early Intervention Foundation (EIF) to identify and support vulnerable children and young people (including identifying mental health problems). The EIF is a home office funded initiatives to identify risk and protective factors. The HO is working with the Department of Health and other agencies to work closely with other initiatives. 6) Promote meaningful alternatives to such as education, training and employment. Comment: - This guidance stimulated Thurrock’s Local Assessment Process in February 2016 as alluded to previously. It has been put in place since James death but is learning for the future. James case meets five of the six points in the above criterion, except point 4. LAC Care Plans and Reviews therefore should identify at an early stage and apply the EGYV and Thurrock’s Local Assessment Programme guidance, to help identify trends and take appropriate action. (See TLSCB Overview Report Recommendation 4.) Culture and Diversity 82. Culture and diversity was not an issue identified within this serious case review. It was discussed within the family interviews with the IOA and is included under family involvement within this report. Voice of James 83. There is substantial information that James voice was consistently heard and listened to by professionals. He was able to determine himself what he wanted to do and what he wanted to say. This aspect is also addressed within the key questions set within the terms of reference in Chapter 2 and below. OFSTED 2016 84. During the SCR James process, Ofsted carried out an inspection of Thurrock Council and published their findings in April 201613. It was an inspection of services for children in need of help and protection, children looked after and care leavers, looking also at the leadership, management and governance. Ofsted’s overall assessment was they were all “Requiring improvement”. They also 12 Ending Gang Violence and Youth Violence programme, Home Office (January 2016) 13 Ofsted Inspection of Thurrock Local Authority (April 2016) 52 reviewed the effectiveness of the Local Safeguarding Board and gave it an overall grade of “Good.” The previous Ofsted inspection in 2012 gave the local authority a grade of “Good.” 85. Reference is made to the Ofsted 2016 Executive Summary and the issues identified requiring improvement, in comparison to the findings within this serious case review, as follows:- • Assessment and planning for children. The assessment and planning for James was evident and efficiently put in place when he became a LAC. • Securing a secure and stable workforce. TLSCB recognised the need to employ an additional administrative serious case review assistant to support SCR’s and this greatly assisted the IOA in this review. • Supervision and oversight. Supervision was displayed by Thurrock CSC who addressed the serious concern of the non-compliance of Placement 1 not correctly reporting James as a missing person. This was challenged with appropriate escalation through senior managers to the Head of CSC who took positive action to ensure compliance. An issue that does however require more supervision oversight is the LAC Review and IRO process which this overview report has identified and addressed within the findings in Chapter 6 and within suggested TLSCB Overview Report Recommendation 7. • Children looked after do not receive a consistently good service/too many become looked after in an emergency. James received more than adequate support and this is documented within this narrative. He was accommodated in an emergency due to a domestic incident when his family declined to accept further responsibility to care for him and the local authority took appropriate action in his case. • Children living outside the borough away from communities, family and friends. This has also been identified and addressed within the findings in Chapter 6. In James’ case, keeping him away from his friends who were suspected to be coercing him to commit crime would have been a better option for him. • Personal education plans. James Education Plan was consistently being monitored by his Personal Advisor. He would not readily engage, accept any of the advice or support offered to him. • Performance management and quality assurance. Suggested TLSCB Overview Report Recommendation 7, identified in the findings in Chapter 6 would assist IRO’s in the early intervention of escalating concerns for LAC that can be monitored and reflected in their annual report. Furthermore TLSCB Overview Report Recommendations 5 and 6, for Thurrock CSC, NELFT and NHS Thurrock CCG would allow quality assurance to be monitored in relation to the outcomes of mental health assessments and other assessments of children and young people. • Consideration of trends from return interviews. James would only agree to one return interview with Open Door and all other attempts including approaches from Police to debrief him received a negative or non-committal response. 86. In conclusion, the sixteen Ofsted Local Authority recommendations for Thurrock should be read in conjunction with the findings in this SCR, particularly their Recommendation 15 - to ensure that children and families’ views and feedback are used well to shape service developments. This review identified that the views of James parents did not receive adequate consideration which a FGC may have assisted in achieving. 87. Regarding FGC’s, Ofsted identified that they were not being fully realised and is also a finding in this review. The emotional, wellbeing and mental health refers to the new SET procedures but as identified in this SCR, this would not be the whole picture, as so many LAC are accommodated 53 outside the area. This would require the constant vigilance of other service providers to ensure that they are meeting the needs of the Thurrock LAC. 88. In relation to leadership management and guidance, Ofsted states that commissioning arrangements are robust. This review has identified however systemic failings for commissioning of 16 plus Semi-Independent placements at a local and national level (see Findings 1 and 2.) The findings would suggest the proposed national TLSCB Overview Report Recommendation 1 for the inspection of Semi- Independent accommodation for LAC, needs serious consideration for implementation, as there is a noticeable gap in the inspection for vulnerable children and young people, in this type of accommodation. Specified Questions and Key Issues from the Terms of Reference 89. The following specified questions and key issues to consider, were identified within the Terms of Reference to be addressed by Agency IMR’s or Summary Reports in their submissions. Not all agencies adhered to the request but the responses were able to be elicited from agencies submissions. Specified Questions: 90. The arrangements in relation to James plan as a LAC. How that was or was not connected with what was happening in his life? There was reasonable assurance and corporate warnings within James’ Care Plan identifying that he had a cannabis habit, a propensity to go missing from his placements, a suspicion of drug dealing, a possible gang affiliation, escalating criminal offending and concerning behaviour which stimulated a GP referral to CAMHS at St Anne’s Hospital who cover the area Placement 1 was located in. Initiatives and numerous attempts were made to address these mounting issues which James either refused or failed to engage with. His arrests in Placement 1 for affray and in Cambridge for possession with intent to supply controlled drugs, should have triggered an emergency Strategy Meeting of key professionals to discuss all available options. He was facing a possible custodial sentence and the level of concern in the June LAC Review should have stimulated some positive action plan to be considered. The fact that this was not completed, did not impact or contribute to a lack intervention on the events that followed, as there was no inclination given by James that he contemplated self-harming, known to either family or professionals. The outcome, whether such action would have been successful, cannot be determined or whether James would have complied, but in other LAC cases, this may have a positive effect for the safeguarding and welfare of children and young people. 91. How was he being supported in his Court appearances? Information regarding his attendance at the London Court on the 14th July 2015 for affray has not been confirmed due to the company now being in administration. His support worker in Placement 2 stated to SW2 that he knew of James Court date and was being supported. TLSCB enquiries with the company have not determined the answer who was attending with James to Court on this day, if he was escorted and how he failed to appear? James was being supported for his Court appearance at a Cambridgeshire Court on the 15th July 2015. A key worker from the service provider’s other placement attended Placement 2 on the morning of the hearing. He was to collect James and drive him to his Court appearance in Cambridgeshire, when he and the resident support worker found James collapsed behind his bedroom door. 54 92. What link was being made in relation to his possible connection with drugs? It was identified and commented in his Care Plans and within his LAC Reviews regarding his connection with drugs. He had a regular habit of smoking cannabis. He was continually going missing from his placements and was found in other parts of the country and suspected of dealing in drugs. His three Social Workers and his Personal Adviser addressed these concerns with concerted efforts to stop his misuse throughout his term of being a LAC. There were additional attempts by his GP and an Insight (Haringey) drug worker, who he failed to engage with, to address his habit. He freely admitted smoking cannabis which in itself, brings him into the contact of the street dealing of drugs. Even though he was suspected of dealing in Class A drugs (see below), there is no evidence to say that he ever used these harder drugs. The fact that James regularly used cannabis was believed from the period when he was living with his mother in Hackney, when he was at School 3. 93. Was the possibility of James being involved in drug dealing being considered? This must be read in conjunction with the aforesaid question. There is clear evidence that James was regularly dealing in drugs. Professionals and his father suspected that he was dealing in drugs and the events that subsequently occurred would seem to confirm this. He himself alluded to the fact about supplying drugs to others, in comments made to professionals, particularly to his key practitioner SW2 and the Placement Director, after he was charged in Cambridge with the serious allegation of the possession of a controlled drug with intent to supply. When moving around the counties of Norfolk, Cambridgeshire and Hampshire and in situations that suggested possession of drugs and drug dealing, he was in areas where he had no connections. These are highlighted concerns that are a national issue along “County Lines”. The Home Office, Ending Gang and Youth Violence programme, identified criminality of people moving between areas to deal in drugs and other crime related matters, exploiting vulnerable persons, manipulated by gang members to deal on their behalf. Confirmation to some degree was when he was arrested and charged for possession with intent to supply heroin in Cambridgeshire where he had a quantity of heroin and £1000 in cash in his possession. Would he have been indebted to pay the loss back and was this a worry playing on his mind? What must be remembered, he was never convicted of dealing in drugs but it is a reasonable assumption to make? Furthermore his allowance was such that he would not have the finances to purchase his own cannabis and other drugs to be able to deal and travel to other areas outside London for several days at a time. This practice would need funding, with other third party involvement. 94. The knowledge of staff within the home. Were they aware of his past and current needs? His Care Plan and the LAC Reviews make it clear what was expected of staff within his placements. It would appear from information supplied by SW2 that they did not always know how to cope with him. One Placement 1 key worker repeatedly attempted to challenge his drug use and supported him in going to see his GP. James’ mother and father acknowledged that she was trying to support their son but he would not listen, had his own agenda and persistently ignored advice not to go missing. James would not comply and his room was noted to be unclean as he would not allow staff in his room to clean. SW2 had concerns that Placement 1 were not reporting him missing appropriately, this was challenged and escalated. Thurrock CSC made a formal complaint which the company provider accepted and ensured improvements. When James allegedly assaulted another resident in Placement 1, who did not wish to pursue charges against him, placement staff also 55 declined to assist Police so as not to aggravate the situation. However, a short while later he was arrested in the placement for affray aftMPDirector carried out a Risk Assessment and had James moved to their other semi-independent accommodation in Placement 2 and as previously stated, this decision was made in consultation with a Thurrock SW Manager. While at Placement 2, SW2 felt this was a better environment for him. 95. Was there YOS involvement and if not why? There was no involvement with YOS other than after his arrests when SW2 was in contact with the local YOS to discuss his Cambridgeshire and Placement 1 arrests. In the two separate charges of crime that James was facing and due to attend Court for, the YOS were not at that early stage of Court proceedings, involved with James. 96. The referral made to CAMHS, what was the rationale for the referral? The IOA has not received a rationale from CAMHS at St Anne’s Hospital for declining their service to James. This aspect is also discussed above. 97. What plans were in place in relation to supporting James from becoming NEET? In February 2013 he was referred to the Young People Hackney Service due to being NEET (not in education, employment or training.) Thurrock allocated him a Personal Adviser who maintained contact and a relationship throughout James’ period as a LAC. This overview report outlines within this chapter, the attempts made with James to prevent him becoming NEET. There was constant support and advice offered to James, but he persistently failed to engage or accept any suggestions, support or take reasonable advice. 98. The referral to Insight, what was this for and was it appropriate? The referral to Insight (Haringey) a local drug and alcohol advocacy was appropriate, particularly as CAMHS were not accepting his referral. Despite attempts by his Placement 1 key worker, SW2 and the allocated Insight drugs worker, James failed to attend meetings or engage and Insight closed James’ case. 99. The reporting of absence or missing persons – was the appropriate policies and procedures complied with? From within the responses to the review from the Police (Essex, MPS, Norfolk, Cambridgeshire and Hampshire Police Services) and from information provided by Thurrock and Hackney CSC, displays evidence there was significant sharing of information between the agencies, with missing person policies and procedures followed. However Placement 1 consistently failed to comply with the reporting of James missing person episodes. They either failed to notify the Emergency Duty Team (EDT) or Police or both. There are recorded details that they were unaware when he was stopped in Portsmouth that he was missing. When he was missing and subsequently found in Cambridgeshire, the Placement had last seen him on the 1st May 2015 but did not report him missing to Police until the 4th May 2015. The SW2 and Thurrock CSC appropriately challenged the placement and made a formal complaint which the placement company acknowledged. Essex Police use the COMPACT computer system to manage missing persons with automatic notification to local authorities. This allows effective information sharing between agencies. There 56 was good communication with the MPS when dealing with James’s persistent missing person episodes. Key Issues to consider 1) Did all agencies work together effectively to safeguard this young person? There is clear evidence that agencies consistently worked effectively to safeguard James. He had numerous missing person episodes that were effectively shared, with a few exceptions that are detailed within Chapter 4 and 5, none of which impacted on James welfare and his safeguarding. However Placement 1 failed to consistently and in a timely manner, report James missing. As previously stated, this was effectively challenged by Thurrock CSC and was escalated to the Head of CSC and the Placement Director implemented compliance. The Princes Trust identified worrying behaviour that James was displaying which was promptly reported to Placement 1 and Thurrock CSC, who acted quickly and ensured placement staff took James to his GP. The GP made an onward referral to CAMHS who declined their service to James. There has been no rationale why they made this decision and this has been requested for the purposes of this serious case review, with no response seen by the IOA and this is addressed within the narrative above. In 2014 when he was arrested in Norfolk, there were safeguarding concerns. A discussion was held between Norfolk and Thurrock IRT over who had responsibility for James reported as homeless, as he resided with his father in Thurrock prior to his arrest. Thurrock declined and asked Norfolk to accommodate him. Later his father agreed with the Norfolk CSC Social Worker dealing with James that he could return home. He was given a travel warrant by Police at the request of Norfolk CSC but missed his train. He was then reported missing by the Social Worker. He was missing for about two weeks before being found safe. James presented himself homeless at Hackney CSC on two occasions. This serious case review has not received any analysis of their agencies contacts with James as to the appropriateness of their actions. Cambridgeshire Constabulary IMR identified omissions when James was arrested. Their Form 101 referral was not completed to share information but they carried out all necessary child protection safeguarding checks and identified that he was missing from London. Also their local YOS should have been notified via their PENY system at the point of charge. This was not completed but would have been addressed when James attended Court on the first occasion. There was however good liaison with the MPS who travelled to Cambridgeshire and escorted him back to Placement 1. The MPS IMR reported in September 2014 that James was stopped in London and stated he committed crime for his drug habit, information that should have been referred by submitting a MERLIN come to notice form to Hackney CSC. This was individual learning for the Police officer. Furthermore when he was arrested in June 2015 for affray he was examined by an FME and stated he was bi-polar. This is addressed within Findings at Chapter 6 and subject to (TLSCB Overview Report Recommendation 9.) School 4 IMR found that in their contacts with CSC’s they did not return calls and have made a recommendation to follow up and address this issue. A CAF was completed. However the School Nurse should have followed up in January 2014, James’ immunisation history and in 57 April 2014 with him and his parents following a domestic incident at his father’s home. There is no record confirming that either was carried out. (See NELFT Agency Recommendations 2 and 3.) It was also apparent that there was a lack of information and records of when and if his Initial Health Assessment was carried out. Repeated requests were made to his GP and professionals discussed the outstanding information and outcome within in his second LAC Review. This issue of record keeping and timeliness has been addressed. (See NELFT Agency Recommendation 4.) The Thurrock CCG IMR identified the need to incorporate guidance within training at GP Forums and Level 3 Safeguarding Training in relation to new contractual requirements for all new registered patients. (See Chapter 5, Para 32/33 for full details, Thurrock CCG Agency Recommendation 1.) His LAC Care Plan and LAC Review were fully aware of James evolving concerns and reported actions to address them. DfE 2014 Statutory guidance on children who run away or go missing from home or care,14 identifies the responsibilities of the Local Authority that care plans should include a strategy to minimise future risk of repeated missing episode and IRO’s informed to address these in statutory reviews. His missing person episodes were allowing him the opportunity to become involved in criminality and early action even before he was eventually arrested for offences should have been considered by both processes and within supervision. Whether this would have been successful with James non-engagement should not deflect from complying with guidelines, particularly after his arrest, to call an urgent strategy meeting with all the agencies involved, to discuss his case and for the future, incorporating Thurrock’s LAP 2016 for Ending Gang and Youth Violence guidance. No issues outlined above within this question, impacted on the final outcome for James, as his fatal action was not suspected or anticipated by any person. 2) Was the outcome preventable? The outcome for James death was, on the information provided, not preventable and came as a total surprise to family and professionals. He did not display any previous behaviour or intimated that he would either commit suicide or self-harm. This aspect is further discussed at the conclusions at Chapter 7 of this report. As the Thurrock CSC IMR states, James was showing elements of change to his behaviour the month before his death but there would have been no connection with him harming himself. On his second GP visit there was no concern of suicidal ideation or self-harming evident. In his third and final LAC Review in June 2015, it records the harm probability remains high, as he continues to use drugs, is reported missing regularly and is involved in gangs. As suggested in the Thurrock CSC IMR, the harm probability was linked to his lifestyle and not to self-harming which is a reasonable assumption and the IRO’s account would agree with this. 3) Were the safeguarding procedures followed appropriately? Safeguarding procedures were generally followed as alluded to but this should be read in conjunction within Chapter 5, the analysis of practitioners practice and 1) above which also discusses safeguarding for James and concerns by Thurrock CSC making a formal complaint 14 Statutory guidance on children who run away or go missing from home or care, DfE 2014 58 to Placement 1 for non-compliance of missing persons procedures. Their IMR considered that the strategy meeting after James went missing from Norfolk should have been held earlier and was not held immediately however, it was held whilst he was still reported missing and a follow up meeting was carried out prior to him being found safe at his maternal aunts home. It was felt that James should not have been allowed to travel home late at night and a suggested recommendation for Norfolk CSC has been made. (TLSCB Overview Report Recommendation (11) and under Chapter 5 Analysis.) 4) Was the young person’s voice heard throughout agencies involvement? There is significant information that shows James’ voice was consistently heard and listened to. He often wanted to be left alone and did not like to be asked too many questions. In his Personal Education Plan he was able to identify the career he wanted to do in close association with his Personal Adviser and Social Workers. The chronology of key events at Chapter 4 outlines the contacts that he had with professionals, particularly whilst a LAC. His voice was heard in all contacts with agencies and practitioners. Although described as shy and withdrawn, he displayed an aptitude to communicate when he wanted to. The fact that he would decide when to engage and when to communicate is not through the fault of his family or professionals. It is not known whether his regular use of cannabis impacted on his decision making and communication ability, as his mental health, as this review identifies, was not properly assessed. Other attempts to address his drug misuse were unsuccessful as he declined to engage with professionals attempting to provide a service to him. (See TLSCB Overview Report Recommendations 5 and 6.) The advice, support supplied and offered by agencies is well documented and it is a reasonable assumption to say he was listened to by professionals from the information supplied to this SCR. This view is evidentially displayed in meetings with SW2, his Personal Adviser, the IRO within his LAC Reviews, within education, his only Open Door interview, two GP appointments and the Placement Director, this list is not however exhaustive. 59 CHAPTER 6 FINDINGS – LESSONS LEARNT AND SUGGESTED RECOMMENDATIONS FOR THE CONSIDERATION OF THE THURROCK BOARD This chapter outlines the findings identified from the analysis of professionals practice. They are produced for the consideration of the Thurrock Board to identify and implement any learning from this serious case review. There is an expectation from the National Panel of Independent Experts for Serious Case Reviews that overview reports should have recommendations that are concise and smart. Therefore the Findings contain suggested TLSCB Overview Report Recommendations and are forwarded for the assistance to the Thurrock Board to consider for implementation: FINDING 1 – INSPECTION OF LAC PLACEMENTS. Does the Thurrock Board agree there is a need for Ofsted to carry out inspections of LAC semi-independent LAC placements? What is the issue? Childrens homes are subject to an Ofsted inspection. There is however, a natural gap in the inspection process, as semi-independent LAC placements are not currently inspected by Ofsted. The Thurrock Ofsted 2016 inspection stated commissioning was robust contrary to the findings found in this review. (See also Finding 2 below.) What should be considered? This serious case review highlights the need for a national inspection of all LAC including semi-independent placements. Local Authorities overall aim is to supply a stable and safe environment, in order to support and develop a pathway for children and young people to succeed and thrive independently. Children and young people aged 16 to 18 years, accommodated in a semi-independent placement are as vulnerable as any other LAC. The issues within this review shows the complexity and the requirement to ensure that the commissioning of the right placement, for the right LAC is essential and requires consistent monitoring of standards. It is suggested Thurrock Local Safeguarding Children Board consider the following recommendation, as there is a strong case to warrant such action and is further evidenced in Finding 2. Thurrock LSCB Overview Report National Recommendation (1) for Inspection of LAC Placements. It is recommended that the Department for Education consider the wider remit for Looked after Children inspections to include:- • The implementation of Ofsted inspections for all LAC provisions, regardless of the type of placement provided. • An inspection to monitor the commissioning and compliance, checks by the Local Authority as to the suitability of the placement, experience of placement staff and financial checks made as to the stability of the Company and Board of Directors, providing the service provision. • An opportunity for DfE and Ofsted enhancing support for Local Authorities, with the consideration of developing a national directory of suitable LAC service provider companies and directors in the industry. 60 FINDING 2 – COMMISSIONING. Are the Thurrock Local Safeguarding Children Board satisfied? 1) With the system improvement this review has provisionally implemented in consultation, for financial stability checks for spot purchases with Thurrock’s Children Commissioning and Service Transformation (CCST) for LAC placements? 2) Whether the current Thurrock commissioning strategy of LAC arrangements are safe? 3) Whether the regional Local Authorities commissioning services who work with Thurrock to identify suitable LAC Placements, should be shared up to date, relevant information of LAC placements? 4) Should the Thurrock Gang and Youth Violence, Local Assessment Process (2016), capture within the commissioning process for LAC placements, additional Gang and Youth Violence information to ensure Thurrock LAC involved or vulnerable to exploitation are not accommodated within significant Gang areas of concern? What happened? James resided in two Thurrock LAC placements provided by the same company. However, Thurrock CCST in communication with the IOA, stated that the company were spot purchases. The company was recommended by other Local Authorities in the regional group that Thurrock CCST interact with to agree, share and recommend suitable placements. Information obtained during the course of this review raised concerns namely, Police being regularly called to the placements, a complaint made to the placement provider by Thurrock CSC regarding failure to comply with the reporting of missing persons, a former employee who confirmed that he was not being paid and had since left the company and finally in February 2016, while participating in this SCR, the company and its placement properties were put into administration. Routine financial checks in July and August 2014 would have shown that the company may have been in some financial difficulties. Regular checks as to the financial stability of companies were not carried out which could have stimulated further scrutiny. The Company may have perfectly valid reasons for going into administration and there is no criticism. It is not developed further within this Serious Case Review and is eluded to merely show that there was a system failure within commissioning. Thurrock CCST financial scrutiny of spot purchases will now be completed. They do not always have the time due to the urgency of finding a placement but insist checks will be carried out as soon as possible and then reviewed annually. In this case there was no contract or Individual Placement Agreement completed, the placements remained spot purchases and were a system failure. What should be considered? (1 to 3 above) the new proposal will capture all spot purchases but are the Thurrock Local Safeguarding Children Board satisfied with the arrangement, support and supervision of the placement of LAC to provide a supportive and stable environment for Thurrock’s LAC. (4 above) the Thurrock Local Assessment Process 2016 for Gangs and Youth Violence should ensure that sufficient checks are carried out as to the suitability of the location of a proposed placement. Particularly where vulnerable LAC liable to exploitation or association with gangs, are to be placed, to include contact with other area LAP’s and Local Authority MASH’s and Integrated Gang Teams. (See also Thurrock CCG Recommendation 4 and comments at Appendix 4), regarding commissioning cases where a service is declined by an out of area provider, cases should be discussed at the Joint Funding panel so that the case can be escalated to specialist commissioners and funded as per the Responsible Commissioners guidance if indicated. The following suggested recommendations are completed for the decision of the Thurrock Board: - Thurrock LSCB Overview Report Recommendation (2) for Thurrock Children Social Care. 61 It is recommended that Thurrock CSC require, Thurrock Children’s Commissioning and Service Transformation, to carry out a review of the supervision of commissioned contracts and spot purchases of LAC placements to ensure the continued stability of the accommodation for Looked After Children. Thurrock LSCB Overview Report Recommendation (3) for Thurrock Children Social Care. It is recommended that Thurrock CSC require, Thurrock Children’s Commissioning and Service Transformation, to share relevant information of concerns obtained from financial checks and scrutiny of their LAC placement service providers, with other regional Local Authority commissioning services, to ensure that only appropriate and viable contracts are awarded. Thurrock LSCB Overview Report Recommendation (4) for Thurrock Children Social Care. It is recommended that Thurrock CSC review the Thurrock Gang and Youth Violence Local Authority Process 2016, to include commissioning checks to the suitability of the location of LAC Placements, to ensure that vulnerable children and young people are not placed in an area of significant gang and youth violence. FINDING 3 – MENTAL HEALTH AND OTHER ASSESSMENTS. Are the Thurrock Local Safeguarding Children Board satisfied that outcomes for LAC who are referred for a mental health and other assessments, are followed through to a recorded and acceptable conclusion? What happened? 1) James’ concerning behaviour was evident in February 2015 when it was known he was regularly using cannabis and referred for a Mental Health Assessment. His GP referred him to CAMHS who declined their service and who referred his case onto a drug and alcohol service. Needless to say, his mental health concerns were never effectively assessed. There was no notable delusional concerns apparent to the same extent in the latter months, but his criminal offending and anger issues in the placement started to escalate. Ironically when James’ room was searched on his death, there were no drugs found and toxicology results confirmed he had no drugs or alcohol in his body. 2) His Social Worker carried out a Strength and Difficulties Questionnaire (SDQ). James was deemed to have severe difficulties with a score of 27/40 as outlined in the chronology at page 30. The outcome of the SDQ was discussed by the Social Worker with the IRO. They were considering the option to move him to another area to reduce the risk and break the chain of him associating with others involved in crime and likely exploitation. He was however subsequently moved, not because of the SDQ outcome, but due to the assault incident concerning another resident in Placement 1 when he was transferred to his second placement. What should be considered? 1) The GP referral to CAMHS St Anne’s Hospital, records that his behaviour noted was possibly connected to his regular use of cannabis, CAMHS possibly believed that a referral to a drug and alcohol service, was more acceptable. No consideration was made to look at the wider picture and is part of the service they advertise. Therefore no Mental Health Assessment was carried out. The rationale for CAMHS decision was never received for this serious case review or resolved within his Care Plan or LAC Reviews, so remained an unresolved Mental Health Assessment. It was not 62 however seen as an issue at his inquest and in his GP appointment in May 2015, where he did not show such concerns. 2) Where a concern is identified within a SDQ that a LAC has severe difficulties, there needs to be a robust system in place, with a clear support pathway identified, to address the concerns. Comment: To compliment these findings, NELFT Agency Recommendation 3 addresses the need to follow up the outcome of LAC’s immunisations, ensuring they are up to date. NELFT further identified NELFT Agency Recommendation 4, the requirement to embed a more robust record keeping and follow up process, in terms of health assessments and delays noted within this SCR, particularly for LAC placed out of the Borough, due to the added vulnerabilities they may encounter. The following suggested recommendations are submitted for the decision of the Thurrock Board: - Thurrock LSCB Overview Report Recommendation (5) for Thurrock Children Social Care and NELFT. It is recommended that Thurrock LSCB require Thurrock Children Social Care and NELFT, review LAC Care Plans and LAC Reviews, to ensure outstanding Mental Health assessments are notified and if required, escalated to the Thurrock Clinical Commissioning Group or appropriate partner agencies, in order that outstanding assessments are followed up and completed to a satisfactory standard, with the rationale recorded. Thurrock LSCB Overview Report Recommendation (6) for Thurrock Clinical Commissioning Group. It is recommended that Thurrock LSCB request NHS Thurrock Clinical Commissioning Group under the Responsible Commissioners Arrangement, to escalate and provide support when notified by partner agencies, where a health practitioner makes a mental health referral for children and young people, which remains outstanding. This is in order to obtain a satisfactory outcome for the patient, with the rationale of the decisions recorded on the patients’ health file by the provider organisation. Thurrock LSCB Overview Report Recommendation (7) for Thurrock Children Social Care, NHS Thurrock Clinical Commissioning Group and NELFT. It is recommended that Thurrock LSCB require Thurrock Children Social Care, NHS Thurrock Clinical Commissioning Group and NELFT, to ensure that when a Strength and Difficulties Questionnaire (SDQ) identifies that a LAC has been assessed with severe difficulties, there is a robust system in place to track these high risk cases with appropriate intervention levels and effective pathways established and applied, to address the concerns in support of the LAC. FINDING 4 – EARLY RECOGNITION OF CONCERNS. Does the Thurrock Local Safeguarding Children Board believe there should be a process of an early recognition of concerns by supervisors and Independent Reviewing Officers, in addressing escalating issues for LAC and of action to be identified and taken to address these safeguarding concerns? What happened? Within James LAC Care Plans and within his three LAC Reviews it was clear that issues were escalating with recorded actions allocated, however there was not a joined up approach. There was a goal for James to return home, although there was interaction with his father, there was no relevant contact with his mother by practitioners. Professional concerns of his many missing person episodes, his cannabis use, travelling to other parts of the country and possibly concerned in 63 the supply of drugs, his anger and possible mental health issues, non-engagement with practitioners, being NEET and his father requesting James be placed within a placement in Essex prior to his third LAC review, were all evident. What should be considered? Section 20 of the Children Act 1989 (Accommodation15) stresses that the views not only of the subject but those of the parents should and have been taken into consideration and a Family Group Conference would have been a sensible forum for this. There is a need for the consideration of holding an early FGC if there are relationship problems and a strategy meeting to discuss increasing criminal offending with the relevant agencies and to listen to the voice of both the subject and family. In conversation with the IRO and her manager, these suggestions in James’ case regarding a FGC, would have been considered for future meetings and agreed with the IOA that there is a need to be able to recognise the evolving issues for the LAC earlier with multi-agency involvement. There is also a need to establish a robust system to effectively monitor the distribution of LAC minutes, to ensure that the information, actions and the outcomes are satisfactory completed by appropriate agency professionals. A consideration of the DfE 2014 Statutory Guidance on children who run away or go missing from home or care,16 should have been followed to assist functioning. The following suggested recommendation is completed for the decision of the Thurrock Board: - Thurrock LSCB Overview Report Recommendation (8) for Thurrock Children Social Care. It is recommended that Thurrock CSC ensure that supervisors and LAC Independent Reviewing Officers (IRO), develop a matrix for the early identification of escalating concerns with LAC and of action taken to address those concerns. This should include an effective system to monitor and distribute LAC minutes to appropriate key practitioners to guarantee that any actions identified are satisfactorily completed. Any interventions can be reflected within the IRO Annual Report for monitoring purposes. FINDING 5 – SHARING OF INFORMATION. Does the Thurrock Board believe that relevant medical disclosures made to a Forensic Medical Examiner by children and young people arrested in Police custody are sufficiently captured and relevant safeguarding information shared with children social care? What happened? When James was in custody at a Haringey Borough Police Station, he was examined by a Forensic Medical Examiner and James stated he was bi-polar. This was recorded in the detention and FME log. There is no record of this information being shared with CSC either from the medical professional carrying out the examination or whether it was recommended to the custody officer to complete a Merlin report for onward sharing. It has been confirmed by the Chair of the SCR who carried out further enquiries, that there is no record of James being on any medication for bi-polar or anything health related. The only history given to the GP was a part history of allergic asthma, allergy to nuts and smoking cannabis. The MPS Safety Compliance Investigation team state that there is no responsibility of FME’s to inform partners, they complete the National Strategy for Police Information Systems (NSPIS) medical form, it is then for the custody officer to take whatever action is necessary. 15 Section 20 of the Children Act 1989 (Accommodation) DfE 16 Statutory guidance on children who run away or going missing from home or care, DfE (2014) 64 What should be considered? The FME has a responsibility to bring to the attention of Police the medical history disclosed and how it can be determined, if the person does or does not have a particular illness and recorded in the custody detention and FME log. The Police need to remind custody officers to be aware of these situations, to ensure relevant information is shared after a consultation with the FME making the entry. This aspect is further discussed within Chapter 7 Conclusions, Paragraph 14, as there may be learning on the fringes of this review that can be developed. The following suggested recommendation is completed for the decision of the Thurrock Board: - Thurrock LSCB Overview Report Recommendation (9) for the MPS It is recommended that the Metropolitan Police Service remind custody officers, that any apparent condition or vulnerabilities disclosed to a Forensic Medical Examiner (FME) by a child or young person in custody, must be risk assessed. If this highlights any risks or concerns, this should be referred to appropriate agency partners by the investigating officer upon the completion of a MERLIN. FINDING 6 – SAFEGUARDING CONCERNS FOR CHILDREN AND YOUNG PERSONS PRESENTING HOMELESS IN ANOTHER AREA. Are the Thurrock Local Safeguarding Children Board satisfied with? 1) The arrangements and the quality of the recording within Norfolk Constabulary custody records of children and young people are sufficient for safeguarding and accountability? 2) The welfare arrangements by Norfolk Children’s Social Care, for a homeless child and young people were satisfactory in providing support and safeguarding the welfare? What happened? Norfolk Constabulary. James was arrested in their area for an offence of possession of a controlled drug. The standard of the information supplied from Norfolk Constabulary regarding arrested children and young people appears to be unsatisfactory. In James arrest and release on bail, it does not detail sufficient information to exactly know or record the outcome for James. He was apparently watched by a PCSO while Norfolk CSC arranged accommodation for him and then supplied with a travel warrant. It was reliant on the memory of officers, not ideal for accountability. It did not give the rationale as to why the case was subsequently recorded as no further action. The presumption is there was insufficient evidence against him. What should be considered? There is a need to record all safeguarding arrangements. It should detail how a travel warrant was issued and on whose advice. It should record details of the officers involved and their pocket books details. Records need to capture any agreement with Norfolk CSC as to the onward safeguarding arrangement for a vulnerable young person, as James was allowed to travel home alone. What happened? Norfolk CSC. James presented as homeless to the CSC after his arrest and released on bail from Police custody. His father initially would not allow him home and he became the responsibility of Norfolk CSC. Subsequently the Norfolk Social Worker in contact with his father agreed he could return to him and was provided with a travel warrant. He was allowed to travel 65 home, unaccompanied late at night and he missed his train. The Social Worker reported him missing as he could not be found. He remained missing for a significant period. What should be considered? The CSC should have followed good practice under the Children Act 1989 and accommodated him for an assessment and not allow him to travel home alone late at night. This is a safeguarding issue and the welfare of the young person was not thoroughly considered and resulted in a vulnerable person going missing. The following suggested recommendations are submitted for the decision of the Thurrock Board: - Thurrock LSCB Overview Report Recommendation (10) for Norfolk Constabulary It is recommended that Norfolk Constabulary review their custody safeguarding arrangements for the detention and supervision of children and young people within their care. This is to ensure that Police records accurately record all safeguarding arrangements and action agreed with Children Social Care for the outcome and welfare of children and young people within their custody. Thurrock LSCB Overview Report Recommendation (11) for Norfolk Children Social Care. It is recommended that Norfolk Children Social Care, review their compliance to the Children Act 1989 for children and young people presenting as homeless in their area, as to their safeguarding and welfare arrangements for vulnerable children and young people. 66 CHAPTER 7 – CONCLUSIONS Predictability 1. James death was not predictable. There had been extensive professional interaction with him and contact with his family in the latter period of his life. The findings and learning identified for agencies, were on the fringes of the review and did not affect or contribute to the final tragic outcome of events. Preventability 2. Professionals on all available knowledge and information, could not have foreseen or were able to prevent the outcome of James’ death. There were no previous concerns or behaviour known to family or practitioners to contemplate that James would take his own life or commit self-harm, even within the last few hours before he was found collapsed in his bedroom at his placement. Conclusions 3. Recognition of the efforts of key practitioners to support James. The fact that there is some learning identified and addressed within the agency and suggested overview report recommendations, should not detract from the enormous amount of professional involvement, resources and hard work provided to support this young person. Overall, services and support was constantly provided for James. 4. James’ engagement with professionals and family. He was a troubled adolescent who consistently failed to engage with the services offered to support him and this has been acknowledged by his parents to the IOA. Whether his persistent use of cannabis had any effect on his decision making cannot be determined within this review, as there was no satisfactory Mental Health Assessment carried out and is subject to comment and recommendations within this Overview Report. It is the view of the IOA that James did on occasions engage with professionals and family members, in particular after his arrests and when he was spoken to at length by the Placement Director, which was positive. However, James did not consistently engage with professionals. There is clear evidence provided to this SCR that supports this assumption. He only engaged with one return interview with Open Door and declined other attempts. Important information and follow up conversations with him after he returned from his missing person episodes, requiring to know his movements and whether he was being exploited, were declined by James or he was non-committal. He attended his three LAC Reviews at his placement but left on one occasion as he was not happy. He attended the dentist on one occasion and his GP on two occasions but had to be escorted to his appointments to ensure he attended. This view is also supported by information provided to this SCR from BUBIC, Insight, Princes Trust, Social Workers, his Personal Adviser, placement support workers and police. Overwhelmingly, he did not fully engage and his reasoning is not known to this review. 5. James was always determined to return to Hackney which his father believed was detrimental to his son. His non-engagement with Insight (Haringey) after his referral to CAMHS was declined, attempted to assess whether his behaviour was due to his drug habit or for other reasons. As CAMHS did not carry out any mental health assessment, whether it would have had a different outcome is pure speculation. It was likely he would not readily have engaged and in the opinion of his mother, that is a realistic assumption. There is no evidence to suggest these factors effected or impacted anyway on the subsequent death of James. 67 6. Analysis was evidenced by examining the interaction and support James had with key professionals obtained from interviews with practitioners and through agency submissions to the review. His father states he could be secretive and would not listen to the good advice from professionals and family and this view was supported in the family interview with James’ mother and step-father. The father was the main family member supporting the practitioners to help him while he was a LAC and would often become frustrated with his sons intolerance to reason. He made it clear that he would have allowed his son to live with him, if he gave up his cannabis habit which he personally believed, was affecting him mentally and to follow behavioural guidelines in the home. His father had also discussed options for him to go to Ghana or to a paternal uncle in the USA. There was even talk about jointly become involved with property development, utilising the equity from a small property the father had. 7. There were repeated attempts by Thurrock CSC in particular from SW2, his Personal Adviser and key workers in his placement to get him to refrain from the use of cannabis and are well recorded. James who could be shy and withdrawn, could also be determined and would not engage, a consistent factor. He was an intelligent young man, which his educational GCSE examination results show, but he had his own mind, as can be expected of a young adolescent seventeen year old. 8. There is nothing known that confirms he was affiliated to any gang, as he was not on any Police gang matrix. It can be assumed however, that his criminal offending showed the signs to suggest that he had some form of gang association. He was spending more money than his weekly allowance supplied to him at intervals through the week by his placement. There was also the need to feed his cannabis habit suggesting he was supplying drugs to get the finances which his parents and practitioners suspected but never witnessed. 9. Exploitation. It appears that there were external factors that may have influenced his decisions. It is likely that he was used or enticed by others who had a financial hold on him, to the extent that he could have been exploited to commit crime. On one occasion when SW2 attended Placement 1, he saw two males waiting outside the premises whose disposition and flagrant display of gold and jewellery had a noticeable effect on James who appeared anxious. James it is known, visited other parts of the country often for several days at a time. His method was that of a young person coerced to travel to other areas along “County Lines” by gangs or others in order to commit crime. He attended areas frequented by other young people and in Cambridge he was in an area known for drugs dealing where he had no contacts, in circumstances that implies he was supplying drugs. This suggests others were supplying him with the necessary funds, illegal drugs and directing him to targeted areas to supply drugs to others. 10. This is a national problem acknowledged by the Home Office in their Ending Gang and Youth Violence (EGYV) programme which began in 2011. They recently promoted “Ending Gang Violence and Exploitation a Practitioners Guidance for Local Assessment Process (LAP) 201617. As a result, Thurrock have issued their own Gang and Youth Violence LAP (February 2016). Under Chapter 6 Findings, of the overview report, it is suggested that further identification of suitable LAC placements, for those particularly vulnerable to gang association, is made for the safeguarding and welfare of LAC. 11. Opportunities to intervene prior to James death. We do not know what was on James mind or whether he really meant to harm himself when he placed the bed sheet around his neck. What is 1717 Ending Gang Exploitation and Violence a Practitioner Guidance for Local Assessment Process, Home Office 2016 68 clear, neither family nor professionals who knew or worked with him, had heard him speak about taking his own life or to self-harm. As previously mentioned, it came as a surprise to everybody. Even though he struggled in his relationships with his parents, they still miss him and cannot understand why it happened. There was therefore, no possibility or prior knowledge to be able to intervene, to stop the dangerous action that he carried out. As the HO Pathologist records, when describing suspension, death could be immediate or within seconds. 12. Alternatives to consider for the future All 32 London Boroughs have a MASH and have signed up to run regular multi-agency Integrated Gangs Team meetings (not all London Boroughs have a gang team.) If there are issues of Gang and Youth Violence, this is an additional forum if the concern relates to Thurrock. A Thurrock practitioner could attend, discuss, share and capture information to promote a wider understanding. (This is only a suggestion to support the Thurrock’s Local Assessment Process.) If in future a LAC persistently goes missing in a London placement, consideration should be made to contact the appropriate local borough MPS Missing Person Coordinator for advice or support, as it is their role to look at ways to prevent children and young people from going missing and to respond effectively to minimise the harm associated with missing person episodes. 13. Conclusions. The Overview Report’s analysis of events for the review, was obtained from the contributions from within individual Agency IMR’s, summary and other ancillary reports submitted to the review, including the participation and views of the family. Within Thurrock Serious Case Review Panel meetings, the IOA presented to the SCR Panel the findings and themes for discussion and challenge, identified in compiling the review, in order for the panel to critically examine the circumstances that lead to the tragic death of James. Where improvements and changes to policy and procedures were needed, if not already implemented, agencies made recommendations for lessons to be learnt, to challenge any shortfall. (See suggested Agency Recommendations at Appendix 4 below.) 14. Learning on the fringes of this review. The issues below were identified and raised within Agency IMR’s and within SCR Panel meetings. It is suggested they should be addressed outside the processes of this SCR, to establish whether there are further lessons to be learnt. • Thurrock Health Services. The bipolar comment James made whilst in custody, has been addressed within the Metropolitan Police TLSCB Overview Report Recommendation (9). However, Thurrock Health Services providers, should consider with NHS England whether there is a wider learning of the requirement for FME’s to also share this information and not as present, a required police responsibility, as this review has established. • Police - National Police Chiefs Council (NPCC). The TLSCB Overview Report Recommendation for the MPS discussed above, will allow Multi Agency Safeguarding Hubs (MASH) established throughout the MPS area, to be notified by the completion of a MERLIN (Come to Notice form.) This allows the information of a reported or established medical condition of a young person in custody to be risk assessed, with an opportunity to stimulate effective communication, ensuring relevant information is appropriately shared. However not all Police Forces have the same facility and practice. It is the view of this SCR, outside of the process, that there should be a dialogue with the NPCC for them to consider the wider implications and requirement to review police practice nationally in this respect. The need to seriously consider this suggestion is further supported (but not expanded upon within this report) by Thurrock LSCB. They have another current serious case review (SCR Harry) with similar concerns in relation to the sharing of information by police of a young person in custody with a medical condition. This could be an opportunity for the NPCC to support all Police Forces by creating clear procedural guidelines to address any evident risk or concern. 69 • NELFT. Their IMR Recommendations highlighted that Thurrock CSC could inform health professionals of the details of vulnerable young people in need of CIN Plans, to determine the level of Universal Health Services to be provided and also further suggested Thurrock CCG, consider commissioning a programme for keeping young people from becoming NEET. (See NELFT Agency Recommendations 1 and 2.) • Education. Two issues regarding EWS and within Education were recently highlighted and could be considered. They are suggestions only which do not impact upon the findings of this SCR. The first issue was when James was apparently taken off School 4’s roll for extremely poor attendance. With the assistance of the EWS, James was successfully reinstated back on the school role and went on to achieve good GCSE results and noticeably improved attendance. There is a requirement that a pupil should not be taken off a school roll until the forwarding school is known. • The second issue relates to when James finished Year 11. He was offered a place in further education, an option he decided not to take up. It is not known what arrangements were made for onward planning to keep him from being NEET. What is known however, is that James became a Child in Need in the October 2014, a very short period after he could have commenced his further education? At that juncture, Thurrock CSC appointed him a Personal Adviser who attempted to work with him, to stop him being NEET. A recent follow up with the Careers Team confirmed that tracking letters were sent and his case would have been picked up during the term, whether or not he was a CIN. The SCRP Education Representative with Thurrock EWS may wish to consider these comments further as to the continuity and tracking of such cases and decide whether there may be lessons to be learnt for the future. Comment: The comments above, are learning on the fringes of this review and do not impact on the Overview Report conclusions. Further consideration as to their feasibility and application is required and are suggested to stimulate further discussion. Any learning, implementation or outcomes should be reported to the TLSCB for inclusion into the TLSCB Action Plan that follows and supports this Overview Report. 15. No family member or professional knew any of James’ friends or associates. He did not mix with other residents in his placements, remaining withdrawn and kept to himself, normally in his room. He was secretive and would not divulge any information readily. As he reportedly stated himself, he did not like being asked questions. James was at an age where he could make his own decisions but even though he was in a semi-independent placement, reasonable boundaries were set, which he repeatedly tested either by going missing or with his unauthorised absences and his behaviour towards others. It appeared to SW2 that Placement 2 was a better environment and both he, his Personal Adviser and the IRO were hopeful for his future, that makes his unexpected death the more difficult to accept. 16. This review can only surmise the pressures on him after he had a large quantity of drugs and cash taken from him on his arrest in Cambridgeshire, as to what additional worries he may have had? We will never know and James was of the disposition that he would not disclose any information. In discussions post his arrest in Cambridge with professionals, he stated “my past is catching up with me.” However James was aware of the support available to him, but he chose not take up any option of help and this SCR cannot answer the reason why. 17. With this serious matter outstanding, together with him failing to appear at Court for his affray charge, his fragmented relationship with his parents, the possibility of others putting pressures on him, how cannabis was affecting him, whether he had any mental health issues, the possibility of going to prison and any other unknown concern, is not insignificant. We cannot determine with any degree of certainty the reason why he carried out the action that ultimately lead to his death. In 70 reiteration, his death was unexpected and a total surprise to his family and professionals that knew and worked with him. 18. The Coroner recorded an Open Verdict because he could not, with any degree of certainty, be sure that James intended to take his own life. The Coroners judgement carries significant weight, supported by the details within the Home Office Pathologist Report on the effect of death by suspension, as to whether James’ death was preventable or predictable which, this serious case review believes it was not. Learning for agencies, as previously stated, are on the fringes and did not impact on James’ death. 19. This independent overview report is submitted to Thurrock Local Safeguarding Children Board for the Thurrock Board to consider the Findings at Chapter 6 and the recommendations at Appendix 4 of this report. The aim is to capture any lessons to be learnt and to ensure effective change is implemented to safeguard the welfare of children and young people. 71 CHAPTER 8 – THURROCK LSCB INITIAL RESPONSE Response to Serious Case Review James from the Chair of Thurrock LSCB James’s death was both unexpected and shocking to his family and professionals who worked with him. When the circumstances were referred to me I felt it was really important that we understand more about his life and to see if there were lessons that could improve how the partnership of agencies work to keep our young people safe. Thurrock LSCB will make sure that all agencies have put in place effective responses that ensure that learning from this review does improve the way professionals keep children and young people safe in the future. It is clear that the findings show a number of positive areas where effective multi-agency working took place alongside missed opportunities and a need to revisit some procedures. This review identified that it was not possible to have predicted the tragic death of James. It has enabled professionals to look at their actions to see if there was anything that could be done in future to further improve working between agencies in particular for children who are Looked After where the risks of gang influences and criminal activity may be involved. The findings and issues for consideration from the review have been endorsed by those agencies involved who have already begun to make changes based on the review's findings. James parents have also been involved during the process and contributed to the review outcomes which have been shared with them. Detailed learning plans are being undertaken by individual agencies in response to the findings and the questions posed to the Board by the Review Author. The Board through its Serious Case Review (SCR) Sub Group will monitor the review and the progress of these plans on both a short and long term basis. Thurrock LSCB undertakes: • To oversee the implementation of single agency learning plans arising from this review and reflect on progress in the Annual Report. • In overseeing the implementation, the LSCB will establish timescales for action to be taken, agree success criteria and assess the impact of the actions. • The SCR Sub Group of the LSCB will actively monitor progress on actions from the agencies by requiring updates quarterly. • That all the findings from the Serious Case Review are assessed by the LSCB Training Sub Group to ensure multi-agency programmes commissioned by the LSCB reflect the learning. • All agencies that had involvement with this SCR have been asked to ensure their practitioners have been given feedback from the review prior to the publication of the final report. • At the point of publication, to ensure that the wider workforce is aware of the learning, the LSCB will also publish a SCR booklet. This will set out the key findings from the review, and also offer links to further advice and guidance should practitioners need it. 72 • A quarterly summary on progress on actions will be provided to the Full Board. • Learning from this SCR will be incorporated into LSCB ‘Learning from Review Sessions’ delivered as part of the Learning and Improvement Framework. • Thurrock LSCB will require partner agencies, as part of single agency Quality Assurance (QA) procedures, to undertake case file audit which incorporates a review of the findings identified. • Thurrock LSCB Audit Sub Group will receive from single agencies ‘quality assurance audit reports’ which will provide findings from audit activity and detail of remedial actions implemented in response to any findings. This Serious Case Review will be published on the Thurrock LSCB and NSPCC website to enable other Safeguarding Boards and Agencies to take any learning from the review. Dave Peplow Independent Chair 73 Appendix 1 - Biography The Independent Chair, Helen Gregory is a Named Nurse for Safeguarding Children with NELFT NHS Foundation Trust. She has been a registered nurse for 30 years, and has specialised in Safeguarding Children since 2010. Helen holds a BSc (Hons), Specialist Community Public Health Nursing degree and a PG certificate in Safeguarding Children. The Independent Overview Author, David Byford is a Safeguarding Expert and Managing Director of his own Safeguarding Consultancy. He retired in September 2014 after 40 years within the Metropolitan Police Service (MPS) including over 25 years’ experience in Child Protection. He was a Senior Investigating Officer responsible for investigating serious crimes against children and young persons. In 2003 with a colleague, he developed the SCR process for the MPS. After retirement as a serving Police officer (2006), he was again employed by the MPS as a Senior Review Officer, responsible for the MPS SCR responses for all 32 London Boroughs. He has acted as an adviser on SCR’s to the MPS, Association of Chief Police Officers (ACPO) now The National Police Chiefs Council (NPCC), Police nationally, local authorities, independent schools and LSCB’s. He has carried out national sensitive and bespoke reviews, including for the Attorney General and the Director of Public Prosecutions on expert witnesses. In 2010 he conducted an ACPO National Review for CEOP’s on SCR’s for the Police service. He has completed the DfE sponsored training “Improving the Quality of SCR’s” and invited to participate in the DfE funded NSPCC and SCIE led “ Learning into Practice Project (LiPP) for improving SCR’s (2016) to look at quality markers for Lead Reviewers. David is on the Association of Independent LSCB Chairs, National Directory as an SCR Lead Reviewer/Author. Acknowledgements The Independent Overview Author would like to take the opportunity to thank the family for their personal contribution to the serious case review. The review also could not have been completed without the valued assistance of the Thurrock Local Safeguarding Children Board’s administration support and the assistance of the TLSCB Manager, the SCR Chair and panel members. 74 Appendix 2 - Bibliography Care Quality Commission (2010) Guidance about compliance: Essential standards of quality and safety. What providers should do to comply with the section 20 regulations of the Health and Social Care Act 2008, London: CQC. Children and Families Act, 2014. Children’s Act 1989, 2004 (DfE). Ending Gang and Youth Violence, Local Assessment Programme, Thurrock (February 2016). Ending Gang and Youth Violence programme Annual Reports, Home Office 2011 to 2015. Ending Gang Exploitation and Violence, Practitioners Guidance for Local Assessment Process, Home Office, 2016. Hale, D and Viner, R (2012).Policy responses to multiple risk behaviours in adolescents. Journal of Public Health 34 (i11-i19). Information sharing to tackle violence: Audit of progress. The Department of Health initiative how A&E departments and community safety partnerships (CSPs) share non-confidential information to tackle violent crime. Keeping Children Safe in Education 2014, Department of Education. Ofsted inspection of Thurrock Safeguarding and looked after children inspection. (June 2012 and April 2016.) Munro, E (2011) the Munro Review of Child Protection: Final Report. A child-centred system London: DFE. National Panel of Independent Experts for Serious Case Reviews, 1st Report (July 2014) and the 2nd Report, (November 2015). Statistical update on suicide, Department of Health (January 2014). The Law Lords decision R(G) v Southwark LBS (May 2009) in relation to duty on councils to accommodate 16 and 17 year olds under Sec 20 of the Children Act 1989. Thurrock Serious Case Reviews – Julia and Megan. Thurrock Children and Young People Plan, 2015 – 2016, Thurrock Children and Young People Partnership. Working Together to Safeguarding Children (DfE 2006, 2010, 2013 and 2015) Chapter 4. 75 Appendix 3 – Glossary of terms AST Adolescent Services Team EIF Early Intervention Foundation (HO) BUBIC Tottenham Drug Service EDT Emergency Duty Team BTP British Transport Police EGYV Ending Gang and Youth Violence CAF Common Assessment Framework EWS Education Welfare Service CAMHS Child Adolescent Mental Health Service FGC Family Group Conference CCG Clinical Commissioning Group FME Forensic Medical Examiner CCST Children’s Commissioning Service FTA Failure to Attend CID Criminal Investigation Department Form 101 Police referral form COMPACT Essex Police computer system GP General Practitioner CSC Children Social Care HMRC Her Majesty Revenue & Customs CSE Child Sexual Exploitation HO Home Office CYPR Child or Young Person at Risk IHA Initial Health Assessment DfE Department of Education IMR Individual Management Report DN Designated Nurse IPA Individual Placement Agreement DoH Department of Health IOA Independent Overview Author DPS Directorate of Professional Services Insight (Haringey) Drugs Advocacy 76 IRO Independent Reviewing Officer NSPIS National Strategy for Police Information Systems IRT Initial Response Team Ofsted Office for Standards in Education, Children’s Services and Skills. LAC Looked After Children OR Overview Report LAC PLACEMENT 1 Same company. Details known TLSCB PA Personal Adviser LAC PLACEMENT 2 Same company. Details known TLSCB PEP Personal Education Plan LAP Local Assessment Process PENY Cambridgeshire Police electronic notification system LAS London Ambulance Service PNC Police National Computer London Court Known to TLSCB SAL Student Achievement Leader MASH Multi Agency Safeguarding Hub School 1 Known to TLSCB Merlin MPS come to notice form School 2 Known to TLSCB MOJ Ministry of Justice School 3 Known to TLSCB MPS Metropolitan Police Service School 4 Known to TLSCB NEET Not in education, employment or training SCR Serious Case Review NELFT North East London Foundation Trust SCRP Serious Case Review Panel NFA No further action SD Strategy Discussion NHS National Health Service SET Southend, Essex and Thurrock NPCC National Police Chiefs Council SN School Nurse SDQ Strengths and Difficulties Questionnaire TOR Terms of reference SOCO Scenes of Crime Officer TLSCB Thurrock Local Safeguarding Children Board SW Social Worker YOS Youth Offender Service 77 Appendix 4 - Recommendations Listed below are the suggested TLSCB Overview Report Recommendations, together with individual agencies recommendations, from Individual Management Reports and Summary Reports that have been reviewed and quality assured within their respective agencies. All agency recommendations have been considered and accepted after consultation by the IOA and the SCR Panel. The measurability, action taken by the agencies and timeliness for the completion of all recommendations are contained within the TLSCB’s Action plan that will accompany this overview report. The suggested overview report recommendations are for The Thurrock Board to consider together with the Individual Agencies Recommendations for their determination as follows:- Suggested TLSCB Overview Report Recommendations: Thurrock LSCB Overview Report National Recommendation (1) for Inspection of LAC Placements. It is recommended that the Department for Education consider the wider remit for Looked after Children inspections to include:- • The implementation of Ofsted inspections for all LAC provisions, regardless of the type of placement provided. • An inspection to monitor the commissioning and compliance, checks by the local authority as to the suitability of the placement, experience of placement staff and financial checks made as to the stability of the company and board of directors, providing the service provision. • An opportunity for DfE and Ofsted enhancing support for local authorities, with the consideration of developing a national directory of suitable LAC service provider companies and directors in the industry. Thurrock LSCB Overview Report Recommendation (2) for Thurrock Children Social Care. It is recommended that Thurrock LSCB require, Thurrock Children’s Commissioning and Service Transformation, to carry out a review of the supervision of commissioned contracts and spot purchases of LAC placements to ensure the continued stability of the accommodation for Looked After Children. Thurrock LSCB Overview Report Recommendation (3) for Thurrock Children Social Care. It is recommended that Thurrock LSCB require, Thurrock Children’s Commissioning and Service Transformation, to share relevant information of concerns obtained from financial checks and scrutiny of their LAC placement service providers, with other regional local authority commissioning services, to ensure that only appropriate and viable contracts are awarded. Thurrock LSCB Overview Report Recommendation (4) for Thurrock Children Social Care. It is recommended that Thurrock Children Social Care review the Thurrock Gang and Youth Violence, Local Authority Process, 2016 to include commissioning checks to the suitability of the location of LAC Placements to ensure that vulnerable children and young people are not placed in an area of significant gang and youth violence. Thurrock LSCB Overview Report Recommendation (5) for Thurrock Children Social Care and NELFT. 78 It is recommended that Thurrock LSCB require Thurrock Children Social Care and NELFT, review LAC Care Plans and LAC Reviews, to ensure outstanding Mental Health assessments are notified and if required, escalated to the Thurrock Clinical Commissioning Group or appropriate partner agencies, in order that outstanding assessments are followed up and completed to a satisfactory standard, with the rationale recorded. Thurrock LSCB Overview Report Recommendation (6) for Thurrock Clinical Commissioning Group. It is recommended that Thurrock LSCB request NHS Thurrock Clinical Commissioning Group under the Responsible Commissioners Arrangement, to escalate and provide support when notified by partner agencies, where a health practitioner makes a mental health referral for children and young people, which remains outstanding. This is in order to obtain a satisfactory outcome for the patient, with the rationale of the decisions recorded on the patients’ health file by the provider organisation. Thurrock LSCB Overview Report Recommendation (7) for Thurrock Children Social Care, NHS Thurrock Clinical Commissioning Group and NELFT. It is recommended that Thurrock LSCB require Thurrock Children Social Care, NHS Thurrock Clinical Commissioning Group and NELFT, to ensure that when a Strength and Difficulties Questionnaire (SDQ) identifies that a LAC has been assessed with severe difficulties, there is a robust system in place to track these high risk cases with appropriate intervention levels and effective pathways established and applied, to address the concerns in support of the LAC. Thurrock LSCB Overview Report Recommendation (8) for Thurrock Children Social Care. It is recommended that Thurrock CSC ensure that supervisors and LAC Independent Reviewing Officers (IRO), develop a matrix for the early identification of escalating concerns with LAC and of action taken to address those concerns. This should include an effective system to monitor and distribute LAC minutes to appropriate key practitioners to guarantee that any actions identified are satisfactorily completed. Any interventions can be reflected within the IRO annual report for monitoring purposes. Thurrock LSCB Overview Report Recommendation (9) for the MPS It is recommended that the Metropolitan Police Service remind custody officers, that any apparent condition or vulnerabilities disclosed to a Forensic Medical Examiner (FME) by a child or young person in custody, must be risk assessed. If this highlights any risks or concerns, this should be referred to appropriate agency partners by the investigating officer upon the completion of a MERLIN. Thurrock LSCB Overview Report Recommendation (10) for Norfolk Constabulary It is recommended that Norfolk Constabulary review their custody safeguarding arrangements for the detention and supervision of children and young people within their care. This is to ensure that Police records accurately record all safeguarding arrangements and action agreed with Children Social Care for the outcome and welfare of children and young people within their custody. Thurrock LSCB Overview Report Recommendation (11) for Norfolk Children Social Care. It is recommended that Norfolk Children Social Care, review their compliance to the Children Act 1989 for children and young people presenting as homeless in their area, as to their safeguarding and welfare arrangements for vulnerable children and young people. 79 Agency IMR Recommendations: The following are individual agencies own recommendations as supplied in their agency IMR’s and reports. Cambridge Constabulary At the time of his arrest the reporting/arresting officer should have completed Form101 (Child at Risk) referral. However safeguarding checks were carried out and it was noted that James was a missing person from London and liaised with the MPS who after he was released on bail attended and escorted him back to his placement. Recommendation 1: Further guidance is proposed to be circulated to all operational staff for compliance of completing Form 101 Child at Risk referral Forms. Recommendation 2: For all custody officers to be canvassed to identify the training needs and awareness of their safeguarding responsibilities and implement any training accordingly. The IMR also suggested two local aspirational recommendations which do not impact on this SCR and are not included. School 4 The school did not always receive a response to referrals made to other agencies. Recommendation 1: If the Academy makes a referral to an outside agency and does not receive a response, the Safeguarding Officer will intervene with a letter of concern to the relevant agency and their immediate line manager, sent with a date of an expected response. Thurrock Clinical Commissioning Group Recommendations comply with practices with “The GP Patient Registration Standard Operating Principles for Primary Medical Care” in relation to a child being seen on registration with the practice. These recommendations were subject to a late change. Recommendation 1: Thurrock Clinical Commissioning Group should ensure that GP practices comply with the Guidance on Patient Registration, Standard Operating Principles for Primary Medical Care (NHSE 2015) and to incorporate guidance within training at GP Forums and Level 3 Safeguarding Training. Recommendation 2: Thurrock Clinical Commissioning Group should review governance and information sharing following attendance at Thurrock Placement Panel meetings. Thurrock Children Social Care Recommendation 1: Thurrock Children Social Care commissioning, to ensure that the LAC Placement needs of the child and young people are specified and placement staff have the requisite skills. Recommendation 2: Thurrock LSCB Learning and Development Group to arrange training to support workers to identify: • Risk of self-harm. • Substance misuse. • Gang activity. 80 • Identifying and managing risk. • Adolescent neglect including using the adolescent tool. NELFT Recommendation 1: NELFT should ensure that Universal Health Services receive information from Children’s Social Care in relation to children and young people subject to a Child In Need Plan to enable the appropriate level of service to be offered. Comment: - This suggested recommendation is learning on the fringes of this review and is raised within the Conclusions in Chapter 7. Recommendation 2: NELFT should ensure that School Nurses follow up incidents of domestic violence against children and young people, particularly where the young person is out of school and NEET. (Not in Education, Employment or Training.) Comment: - The NELFT IMR further suggested that consideration be given by Thurrock CCG to commission a service for young people aged 16 to 18 years of age who are NEET. (Not in Education, Employment or Training.) It is the view of this SCR that this is learning on the fringes. It can be further considered outside the process, when considering the TLSCB Action Plan that will follow this Overview Report. (See Chapter 7 Conclusions for Learning on the fringes of the review.) Recommendation 3: NELFT should ensure that where there is uncertainty around a child and young person’s immunisation status, Health Practitioners should actively follow up and confirm whether the immunisation has been received and ensure that the child, young person and parent/carer are aware. Recommendation 4: NELFT should ensure that the NELFT Looked After Children (LAC) Team embed a robust record keeping and follow-up process in terms of health assessments and any delays reported to the Designated Nurse for LAC and the Local Authority, with specific attention and monitoring applied to the vulnerability of LAC, placed out of the area. 81 Appendix 5 – Family Tree |
NC52352 | Death of a 16-month-old child in December 2017. Child LO died due to an airway obstruction whilst sleeping unsupervised in an unsafe environment. Learning includes: seeing where babies and young children sleep (day and night) can improve assessment of safe sleeping environments and provide an opportunity for professional advice; local authorities should be aware of local holiday parks and ensure that the winter rules are adhered to; professionals need to be curious about why a mother and child is living in a holiday caravan and provide relevant advice and support to address any accommodation issues; the courts should share safeguarding concerns with front line staff; the midwifery electronic record and health visitor child health record should include full details of previous children by a mother or father, and new family members; parents are more likely to disclose their vulnerabilities if they know and trust the professional involved; multi-agency safeguarding hubs should share concerns with health professionals; better links between health visiting and nursery provision would promote better assessment and support through Early help; recognising and addressing domestic abuse early has a beneficial impact on children and family life. Recommendations include improved arrangements for: multi-agency working and information sharing; standards of domestic abuse processes; ensuring safe sleeping arrangements for babies and young children are involved; reduce the risk of children and families living in holiday park accommodation during the cold winter months.
| Title: Serious case review: overview report: Child LO. LSCB: Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership Author: Kathy Webster Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review Overview Report Child LO Author: Kathy Webster Date: December 2020 Publication Date: 5th October 2021 Contents Item Page Introduction 1 Methodology 1 Family Composition and Context 3 Circumstances and significant events (05/08/16 till 19/12/17) 3 Analysis of practice and organisational learning 6 • Unsafe sleeping arrangements for babies and toddlers 7 • Early Years multiagency working and information sharing 11 • Multiagency response to Domestic Abuse. 16 Practice Issues 21 Good Practice 22 Conclusion 22 Recommendations 23 References 24 Statement of Reviewer Independence 25 1 Introduction This serious case review (SCR) was commissioned by the Independent Chair of Lancashire Safeguarding Children Board (LSCB) on 06/02/18. This decision was made following discussions at the LSCB Serious Case Review Sub Group and advice from the National Serious Case Review Panel that the criteria had been met for a serious case review to be commissioned in line with Working Together 2015. During the course of this SCR, the legal statutory guidance for local safeguarding children arrangements has been revised resulting in the deregulation of Lancashire Safeguarding Children Board and the development of a new partnership in line with Working Together to Safeguarding Children (DfE 2018). The newly formed, Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership (CSAP) will be responsible for considering the learning from this SCR and for implementing any agreed recommendations suggested. The catalyst for this review was that a 16-month-old child, who will be known as Child LO, had died and initial findings were that this was due to airway obstruction whilst being left unsupervised within an unsafe sleeping environment. A full and thorough criminal investigation commenced in relation to concerns of neglect, which concluded that there was insufficient evidence to support a prosecution. A Coronal inquiry is awaited. At the time that Child LO sadly died, the family were not known to Children Social Care but were in receipt of local universal primary health care services and private nursery provision. The key learning themes identified in this review include; unsafe sleeping arrangements for babies and toddlers; early years multiagency working and information sharing and multiagency response to domestic abuse. Methodology The methodology for this review was carried out using the systems model approach to learning outlined in the Child Practice Review process provided by “Protecting Children in Wales Guidance for Arranging Multiagency Practice Reviews” (Welsh Government 2012). The overall purpose of the SCR model was to consider what happened in this case and explore why services were delivered as they were. Also, to consider how practice can be improved through changes in the system to improve outcomes for children. The process involved a Review Panel of representatives made up of senior managers and safeguarding leads who were from the organisations involved in providing services for the child and family. The role of the review panel was to provide relevant information and analysis of their organisation’s involvement in order to capture service/practice issues and to agree the key learning themes and actions required for multiagency practice improvement. 2 A Terms of Reference was produced by the Panel which provided a number of key lines of enquiry. Main key lines of enquiry 1) Determine whether decisions and actions in the case comply with the policies and procedures of the local services and the CSAP 2) Examine the effectiveness of information sharing and working relationships between agencies 3) Examine inter-agency working and service provision, including quality of assessments for the child and the parenting capacity of all carers within the child’s family. 4) Explore the response to risk factors within the family and consider the use of early help processes and their effectiveness. 5) Examine to what extent safe sleep advise and support was provided to the family. 6) Determine the extent to which professionals identified substance misuse (including alcohol) and domestic abuse and the level of support offered to support the family. 7) Establish any learning from the SCR in order to inform future practice development and improve outcomes for children. There was good attendance at the panel meetings and participants were knowledgeable about their own areas and safeguarding arrangements. They were keen to submit and consider learning issues and to provide support for staff attending the practitioner event. A composite timeline which included all agency interactions between 19/12/16 till 19/12/17 was scrutinised by both Review Panel and by the practitioners themselves at a Practitioner Learning Event to identify the key themes of learning. The practitioner learning event was held to bring together those practitioners who were involved with the child and family and had personal experience of the family dynamics and care provided. The role of the practitioner event was to identify frontline challenges, good practice, consider why things happened as they did and to identify any gaps in the system. The practitioners who attended the practitioner learning event were open, honest, articulate and had a good grasp of the issues identified within the review. Family involvement in the reviewing process is often key to understanding the nature of services provided to individual families. This provides an understanding of how helpful practitioners / services were perceived by family members on a day to day basis. Unfortunately, mother in this case has declined an offer for her involvement in the review process which has been respected and father has not been contactable. The Reviewer had access to a number of documents as follows: • Referral for Serious Case Review Group minutes • Joint multiagency timeline of significant events/analysis • Minutes of the Strategy Meeting following Child LO death 3 • All Pan-Lancashire Policies and guidelines were easily available via Lancashire Safeguarding Children Board website. Research evidence and national statutory guidance was considered and used throughout this review. Family composition and context at the time of the child’s death. The child and all family members were white British. Child LO Was a happy smiley toddler who loved cuddles and was meeting developmental milestones. Child LO was attending nursery 1 afternoon per week where the child enjoyed playing with toys and other children. During Child LO’s life the child lived at 3 different addresses and attended 3 different nurseries. Her parents had split by the time the child was 1 year old. Half Sibling Age 2 years. Same father different mother. Half sibling was subject to private law proceedings on behalf of father. Ex-partner was in contention to proceedings because of the risk she felt father posed to her child. Mother Age 24 years. Child LO was mothers first baby. She was living with Child LO’s father following pregnancy, birth and first year. Shortly after ending the relationship she alleged that domestic abuse was a feature in their relationship. Mother was in employment on and off during the timeline. Father Age 23 years. Father had another child from a previous relationship from which he was estranged. He was trying to gain access with the child through court proceedings, but his ex-partner was contesting this due to concerns over drug taking and domestic abuse. Father had a violent criminal background which was unknown to those working with Child LO. Mother’s Partner Age 22 years. Mother’s partner came into Child LOs life shortly after father moved out. The new partner was living in a rented caravan and mother and Child LO moved in with him leaving a furnished flat which had been the family home. Maternal Grandmother Mother was supported by the maternal grandmother. She cared for Child LO when mother was at work and did some washing and ironing for her. She was seen on occasions taking or collecting Child LO from nursery. Circumstances and significant events (05/08/16 – 19/12/17) Information outside the timeframe. Mother first presented with an unplanned pregnancy at 15 weeks gestation. This was classed as a late booking and was said to be due to failed contraception, which is not uncommon. Mother attended all antenatal appointments with no safeguarding concerns were noted by agencies during the pregnancy, labour or the birth. 4 Early in the pregnancy, Father attended the Children Centre to arrange a free solicitor appointment about access to his previous child then age 2, from which he was estranged. A private law application was received by the Children and Family Court Advisory and Support Service (CAFCASS) on behalf of father who was wanting to spend time with his estranged daughter. This was being contested by his ex-partner who alleged that he was unsafe on the ground that she experienced domestic abuse when they were in a relationship and he had taken money from her without permission. She also alleged that he was a drug user and dealer and was concerned about fathers’ criminal associates. Routine police and children social care checks were carried out at the time. Children social care found no information relating to the estranged child on their record keeping system. August – December 2016 (Child LO new-born – 4 months) Child LO was born with fathers’ private law application ongoing. There were no complications or safeguarding concerns during the midwifery post-natal period. Shortly after birth, the court made an order which noted concerns regarding historical domestic abuse and drug use. Father was requested to have drug tests but he responded that he could not afford the tests because he had just had a new baby. In view of this, the court were not able to support unsupervised contact between father and the estranged child until drug tests could prove he was no longer taking drugs. Supervised contact was ordered and information sent to CAFCASS who uploaded the information on their system. During this time period the Health Visitor visited the home (flat) on day 13 following the birth. Child LO was seen with both parents. There were a further 7 visits to the family with one visit resulting in no access because the family were not at home and another contact for treatment of nappy area and oral Thrush. No safeguarding concerns were identified and the child and family were assessed as requiring “universal” level services from the Health Visitor. January – August 2017 In April Child LO (8 months) started nursery (1). Child LO was on role for 2 months with mother arranging to pay on a weekly basis. Nursery staff never met father and mother would pick up and drop off. Child LO was happy and settled in nursery and enjoyed books. Mother used the nursery App to monitor progress. There was one episode of Child LO having a sore nappy area spreading into her thighs for which mother was advised to see the GP. The nursery manager spoke to mother about nursery payment arrears after which Child LO was abruptly removed from nursery without notice. June – Child LO parents split. Professionals unaware. In June Child LO (10 months) started nursery (2). Child LO was on for 2 months and registered for full day sessions on Tuesdays and Thursdays each week. Child LO only attended 4 out of the 8 sessions she was allocated to attend. The staff member working at nursery 2 had previously worked at nursery 1 so remembered the child from there. Mother told the manager she left nursery (1) due to changing jobs. On Child LO’s first day the child 5 appeared grubby and had a dirty nappy and nappy area soreness. Father collected Child LO on one occasion telling staff he did not know why Child LO had not attended nursery on the days planned. Nursery payment arrears started to appear and following a discussion with mother Child LO was taken out of nursery without notice. During August and just after Child LO (12 months old) left nursery (2) there were 2 Health Visitor home visits to undertake the 1-year development assessment, but the family were not home. A couple of days later a further planned visit was made with mother and Child LO and mother reported that she had split up from Child LO father and was living alone with family support. There were no health or developmental concerns identified during the 1-year assessment. Late in August father made a child protection referral to Children Social Care MASH (Multi Agency Safeguarding Team) and to the Police about concerns he had about Child LO being left unattended for short periods and neglectful home conditions. During this time a further contact was made to MASH by a family friend raising concern about mother drinking alcohol daily and that she had distanced herself from friends and family. Following on from this mother attended the police station to report that she had allegedly experienced domestic abuse (assault) during their past relationship and was currently experiencing harassment by father. Mother was in a new relationship and wanted the harassment to stop. A PVP (Protecting Vulnerable People) notification was shared with other agencies in relation to this. Police visited the home for a child welfare check and MASH was informed there were no safeguarding concerns. MASH made a number of attempts to contact mother which failed and resulted in a letter being sent to mother with offer of support and the case was closed. Father contacted the Health Visitor about concerns that Child LO mother was drinking alcohol regularly whilst caring for their child. The Health Visitor gave assurance that if children social care did not accept the referral, she would carry out a home visit. September – December 2017 The Health Visitor received the PVP ( 2 weeks later) and an opportunistic visit took place with mother and Child LO. Mother confirmed she was going to live with her new partner and disclosed that father has been harassing her about contact with Child LO. Mother did not want to give consent to contact with father because he allegedly used drugs and had been abusive to her. The following day father contacted the Health Visitor requesting contact with Child LO. The Health Visitor recommended mother to seek legal advice. Later in September Child LO registered at nursery (3). Child LO was on roll for 3 months. Child LO attended 9 out of 12 sessions available. It was reported to nursery that father had no legal access to Child LO and was not allowed contact. Mothers new partner was listed as step-father. Child LO attended one half day session every week and was waiting for extra sessions. 6 Early in October there was a planned Health Visitor visit to the new partners address which was a static caravan (1) on a holiday park. Child LO was sleeping on the sofa covered with a blanket. Mother stated she had sought legal advice about contact with father. Mother reported that the concerns raised about her drinking were malicious. During the rest of October and November Child LO attended nursery (3) where there were no concerns about Child LO’s appearance or presentation. There was a discussion with mother about nursery fees needing to be paid when Child LO did not attend. Nursery identified that finances were a problem and payment of arrears to the nursery became an issue. Child LO had a viral upper respiratory infection early in November for which the child was appropriately taken to see the GP. The day before Child LO died the child attended nursery and had appeared thirsty but was otherwise, happy and well. Incident A 999 call was made at 11.42 hrs. Child LO was said to be unresponsive and not breathing. The child had been found face down wrapped up in a duvet. The story given was that the child had been placed to sleep the previous night and seen again at around 01.00 hrs. The child had been heard to cry or chatter at around 07.00 hrs but this had not been responded to by the mother or partner. The child was found by mothers’ partner just prior to the ambulance being called. Basic life support was commenced by a neighbour who had been passing by the caravan and this was continued by the ambulance crew once they arrived. Child LO was transferred to the local hospital Emergency Department where the child was confirmed dead at 12.45 hrs. Concerns about the sleeping arrangements and home conditions soon emerged. Child LO had been sleeping on a mattress on the floor of a small room which had an overturned table with the feet towards the door preventing Child LO from getting out of the area. There was an adult duvet and child blanket for cover but no sheets. The room was said to have mouldy patches on the walls and condensation was present. Rat droppings were found in the corner of the room. The living area of the caravan was found to be in a poor state and smelled of smoke and only part of the caravan could be used because the bedrooms were being used to store the private belongings of the owner. The caravan was felt to be colder on the inside than the temperature was on the outside and there was very little heating available in the home for the time of year. Following relevant investigations, the child was found to have died due to airway obstruction whilst being left unsupervised within an unsafe sleeping environment. 7 Analysis of practice and organisational learning There were three main learning themes which emerged during the reviewing process as follows: • Unsafe sleeping arrangements for babies and toddlers • Early Years multiagency working and information sharing • Multiagency response to Domestic Abuse. Unsafe sleeping arrangements for babies and toddlers Safer Sleep Guidance There are clear national guidelines for safe sleeping arrangements for infants which are widely available and promoted on the NHS website, National Institute for Health and Care Excellence (NICE) and Lullaby Trust. The guidance is clear that practitioners such as Midwives and Health Visitors have a responsibility to inform new parents of the guidelines and to provide advice on safe sleeping arrangements. This advice should be routinely provided antenatally and throughout the first few weeks of life, with a reminder at each contact. Antenatal home visits and early engagement with parents about safe sleep is essential to enable them make safe choices for their babies. Seeing where babies sleep enables front line professionals such as Midwives and Health Visitors to directly assess sleeping arrangements for babies and this activity can usefully provide an opportunity to discuss safe sleep environments and to emphasise the narrative about the dangers of parental alcohol and drugs during the day and before bedtime. The adequacy and safety of the cot and other equipment can also be assessed and discussed at this point. In this case, it was apparent that the Midwives and Health Visitors had given appropriate safe sleep advise but none had asked to see where Child LO was sleeping during the day and night as would have been expected in accordance with the LSCB “Safer Sleep” guidance. This was because the guidance for professionals to see where baby sleeps had not been fully implemented in all areas and with all teams. The consequence of this was that the Child LO sleeping arrangements were never fully assessed and the opportunity to reinforce the safety messages to the parents about the importance of maintaining a safe sleeping environment was lost. Following a recently published (November 2019) local Serious Case Review which was commissioned by Lancashire Safeguarding Children Board on behalf of subject Child LR, which related to a child death featuring sudden unexpected infant death (SUDI), further work is being progressed locally to update and fully implement the “Pan-Lancashire Safer Sleeping Guidance for Children”. Recommendations from the Child LR SCR included the further strengthening of the guidance to promote the requirement for professionals to see where babies sleep and to develop and 8 implement an individualised safer sleep assessment to help parents understand the risks of SUDIs particularly around the dangers of co-sleeping following drug and alcohol use and to promote safer sleeping environments. Practice learning Seeing where babies sleep (day and night) can improve the level of assessment of safety of the cot and baby equipment in use and provide an opportunity for a conversation to provide professional advice about safe sleep environments and promote the message about not co-sleeping with a baby on the evening following drinking any amount of alcohol and/or recreational (and some prescribed) drugs. The reviewer enthusiastically supports the view that direct observation and assessment of infant sleeping environments is an important factor in promoting the reduction of SUDI deaths. This review further highlights a need for new work to be undertaken to consider sleeping environments for toddlers, particularly those who have recently moved into a new address. In this case, it is known that Child LO was last seen by a Health Visitor around two months before the child died. On that the occasion the child and mother had just moved into a static caravan (1) with mothers’ new partner and the child was seen sleeping on the sofa appropriately dressed and covered by a blanket. There was no discussion around sleeping arrangements or access to a cot or toddler bed. Whilst this conversation would have been useful at the time and would have given an opportunity to discuss relevant toddler bedroom safety. It is important to add that the family moved into another caravan (2) (unseen by the Health Visitor) as the winter became colder. Apparently, during this move the travel cot used for Child LO was broken and the family did not have the resource for a new cot/toddler bed for the child. This led to a “make-shift bed” being provided as previously discussed. Prevention of accidental deaths The Royal Society for the Prevention of Accidents (RoSPA) have recognised that at least one child under-5 is killed in an accident in the home every week. They suggest that the majority of these deaths are preventable by taking a number of safety measures. Child Accident Prevention Trust also agree and go on to state that asphyxia is the third most common cause of accidental child death in the UK. They explain that babies and young children who are not being supervised can easily get into situations that they do not have the experience or strength to get out of and this can lead suffocation. We are not yet fully aware of what happened to Child LO or how the child died because this is the role of the Coroner. However, we do know the child was found in unsafe sleeping conditions and therefore, an expansion of the local Safer Sleep Guidance would be of benefit to raise awareness of the risks of toddler deaths and to promote bedroom safety. 9 Seeing were children sleep at all routine Health Visitor visits including the 9-12month stage of child development assessment, in line with the Healthy Child Programme, this is the time when children may be sleeping in their own room and parents are thinking about the next steps following their child sleeping in a cot. Then seeing the child’s sleeping environment again at the 2-year visit, where the child may be in a child bed or parents are thinking about moving to a bed. A further safer sleep check could also be added to the “transfer in” visit when families are new to the area/accommodation and the status of the child’s sleeping arrangements are unknown. More sleeping environment safety checks accompanied by professionals advise may help reduce the number of under 5-year deaths both locally and nationally. Practice learning Seeing where babies and young children (pre-school) sleep is an important measure for assessing safe sleeping environments and for identifying the needs of children and families. Although this may be additional work as part of the Healthy Child Programme the benefits of this activity could have the potential to reduce infant and under 5 years mortality rates and could also increase the potential for identifying children and families requiring Early Help support. Local Child Death Data The reviewer contacted the local Child Death Overview Panel for data relating to children over 12 months and under 4 years deaths in the bedroom in the area. The local data is as follows; April 2017 – April 2018 – 1 death - inappropriate sleeping situation at 16 months April 2018 – April 2019 – 2 deaths - sleeping in own bed at 16 months - found in toy box at 13 months April 2019 – Dec 2019 - 2 deaths - sleeping in own cot at 17 months - in bed on holiday abroad at 2 years Whilst the number of child deaths under 4 years appear to be low there is still a need for greater awareness raising and assessment of toddler sleeping arrangements in the home. Every child death is a tragedy and as previously stated, the evidence demonstrates that these deaths can be prevented. Practice leaning – The more practitioners talk to parents about home safety issues and the need to provide a safe sleeping/bedroom environment for babies and toddlers the more informed parents will become about the choices they make to keep their children safe with the potential to reduce infant and pre-school mortality rates. 10 Parental supervision The lack of parental supervision of the child during the morning was a potential concern. Child LO was apparently seen during the night-time at around 22.00 hrs and 01.00 hrs, possibly reflective of the child’s and adult’s bedtimes. It is known that the parents were drinking alcohol on the night of the incident which may have reduced their availability to supervise and support the child. Child LO was heard making a noise at around 07.15am but the child was not attended to. Mother explained later to the police that this was because she was trying to get the child to settle without adult attention. Child LO was eventually attended to at around 11.00hrs by mothers’ partner. The duvet in use was found to be wrapped around the child possibly compromising the child’s breathing and this may have resulted in the child’s tragic death. There may be a lesson here for other parents. Young children will normally awake early after a full night sleep usually because they have had enough sleep, or they are hungry and uncomfortable because they have a full nappy. Leaving young children to their own devises at this point of the day serves the child no good purpose. When left to their own devices young children will try to do things themselves but without the strength or experience to get out of trouble as previously mentioned. This can potentially lead to untoward circumstances as found with Child LO. Practice learning It is may be not possible to supervise babies and children all of the time. It is therefore, important that babies and young children are placed in cots/child beds specifically designed to maintain their safety and with bedding suitable for their age group. Professionals need to feel confident in asking to seeing where babies and children sleep and in discussing and advising on safe sleep environments. Professionals in this case were not aware of Child LO’s inappropriate sleeping arrangements. Professionals at the practitioner learning event stated that had they been aware of the situation, help in obtaining a cot or an age appropriate child bed would have been forthcoming through the local Children Centre. Inappropriate living accommodation Another area of concern for consideration was the use of a static caravan situated on a holiday park during cold winter months. A number of holiday park websites identify that holiday parks cannot legally be lived in all year round. By definition a park is not allowed to be used as a permanent address. It is a legal requirement to own or rent a residential home in addition to renting a caravan. This may explain one of the reasons why mother chose not to give up the flat. The vast majority of holiday parks shut down and are not permitted to be occupied for at least 6 weeks during winter. Most static caravans are not designed for residential use. It is clear from police accounts that the cold temperature on the outside of the caravan was warmer than the inside. Child LO would have experienced very cold temperatures during the 11 night and early morning and it is not yet known if this too was a contributing factor in the death. Practice learning District councils should be aware of the activities of Holiday Parks in their area and should take steps to ensure that the winter rules about renting accommodation is adhered to. Professionals need to be more curious about why a mother and child is living in a holiday caravan and provide relevant advice and support to address any accommodation issues. Early Years multiagency working and information sharing Whilst the child’s sleeping environment was a key issue in this case, the reviewer has identified a number of areas where information sharing and multiagency working could be strengthened. It may not have been clear to professionals that Child LO was sleeping in an unsafe environment but there were clues that mother was faced with situations which were more likely to have required the need for Early Help assessment and support. Those clues included, - fathers need for supervised contact with a previous child, - poor living conditions, - debt of unpaid fees and intermittent severe nappy rash seen at nursery - domestic abuse allegations following split from father. Fathers supervised contact with a previous child Early in pregnancy father was trying to gain access to a previous child via the court. His previous partner (mother of the child) had objected to this because she felt he was not safe to have unsupervised contact with her 2-year-old child. Police checks became available for the court shortly after Child LO’s birth which identified a number of police contacts and allegations including: • Money taken from previous partners bank account without permission • A number of domestic abuse incidents reported to Police at the time • Threatened friends • Regular use of cocaine • Debts and drug dealing • Verbally and physically violent and was prosecuted for assault and had a Restraining Order in place. Whilst this information was effectively gathered and used in court to protect the 2-year-old subject child, professionals were unable to fully utilised this information to consider the risk to Child LO and mother. 12 Father shared information with the court that he was living with a new partner who had just given birth to a baby. Therefore, the court was aware that he was living with another child who was not being considered for supervision in the same way as the subject child brought before them. The Family Court Advisor contacted Children Social Care to establish whether father’s new partner and baby were known to them. The Family Court Advisor provided the full names of father and mother, but only had baby’s first name and no surname. Presumably, this would have been either fathers or mothers’ surname. In this case it was actually fathers’ surname. Children Social Care advised that the baby was not known to them and because there was no known address Children Social Care could not take the matter any further. The Family Court Advisor was told that at such a young age the baby would have a Health Visitor who would raise concerns with Children Social Care if there were any. The reality was that there was enough information to be passed on to the local 0-19 service who could have quite easily checked their NHS systems to match the child’s name and find the address in order to inform the Health Visitor of the concerns raised about father. The Health Visitor did not know about father’s history until after the child died. At the time of this this review the MASH team did not have NHS representation readily available in their team. Now that the MASH has a full complement of staff including health staff, there may be an opportunity to consider how this type of information can progress through the MASH system to ensure that front line health professionals are informed of risk factors within the families they are working with on a need to know basis. It is best practice for concerns about non-subject children who are mentioned within the court processes to be shared with other professionals who are working with the child and family in order to safeguard the child. Had information about concerns regarding father been shared with the Health Visitor working with the child and family, this may have led to further assessment by the Health Visitor and possibly an Early Help assessment being completed to support the child and family. With no apparent means of sharing information any further, CAFCASS and Court appropriately closed the case with arrangements for father to see his estranged child under supervised contact every other Saturday. There appeared adequate protection for the 2-year old child but none for a new born baby who may have been at greater risk. Practice learning – Local safeguarding arrangements should include a pathway of how relevant safeguarding concerns about children and families are shared from the Courts down to individual front line staff working with children on a “need to know basis”. This would allow front line staff such as Health Visitor to make a better assessment of the needs of children and families. The consequence of not sharing information with the Midwife, GP or Health Visitor were that they were not aware of father’s past history and his involvement with the police and the courts. Given his past violent behaviour against women those working with the family 13 should have been informed for their own safety as well as the safety of the mother and child. Record Keeping It has been found that whilst Midwifery have a system to record demographic details about fathers and any previous children, Health Visiting records do not lend themselves to asking relevant questions about past children and the father’s access to them. Father was actively going to court to gain access to his first child at the time the Midwife and Health Visitor were visiting and they may have been told the information by the parents if they had asked for it. There appeared to be a lack of professional curiosity and detail about the family circumstances and therefore, nothing recorded in the child’s health record which would identify any need to consider Early Help. Practice learning – Previous children by a mother or father should be routinely recorded in both the Midwifery electronic record and Health Visitor child health record and should include any previous child’s name, date of birth, current address and access arrangements. This would clarify the historical family context and enable further assessment of concern where this exist. It is known, that parents do not always tell professionals what they need to know because they choose to hide vulnerability factors which may heighten the level of professional intervention. Whilst this may be the case, professionals should not presume that parents are not going to give information when asked in the relevant setting. Parents are more likely to disclose their vulnerabilities if they know and trust the professional involved. Poor living conditions Practitioners at the learning event stated that although the flat was sparse it appeared warm and tidy and that they had “seen much worse”. There appeared to be no professional curiosity about the family’s lack of possessions and as previously stated, the Health Visitor did not ask to see where baby sleeps and therefore, the state of other parts of the property were not seen. Further to this, there was no antenatal visit by either Midwife or Health Visitor and therefore, no understanding of how prepared the couple were to cope with a new baby and no opportunity to assess the state of the home prior to Child LO’s discharge from hospital following birth. At the time of mother’s pregnancy, routine antenatal home visits were not being carried out by Midwives because they did not have the capacity to do so unless for safeguarding concerns of mother or child. Health Visitors were expected to provide a home visit at around 28 weeks of pregnancy as part of the “universal” health visiting programme but this did not occur. The reason for this is not known. 14 During the hospital admission for the birth and the postnatal period the Midwifery service had no concerns about the family and there was nothing in the Midwifery record about the state of the home which may have been an omission. Home environments and family circumstances are vital information for all professionals including Midwives, working with children and families in order to consider and recognise vulnerabilities which may require Early Help and support. The Health Visitor too did not record the appearance of the home conditions and assessed the family needing “universal” level services which is the lowest level of service provision available. However, the Health Visitor did go on to provide a number of additional visits outside the “universal” programme because she felt mother was in need of extra support although, this did not convert to a “universal plus” level of service which would have been expected. It was not clear why these visits took place with no rational recorded in the child health record. Child LO’s (then 13 months) sleeping arrangements were not seen at the flat until the police carried out a welfare check following allegations from father that mother’s new partner was dealing drugs from the property (the flat) and there was a pit bull type dog present in the home. Father reported that he thought the home was squalid and that there were machetes on the premises. The police at the learning event reflected that the flat living area had nothing but a couple of sofas. There was a separate room for Child LO with a toddler bed with mattress and suitable bedding. This was not an enclosed type cot/bed and no concerns were identified at this point. The dog was shut in the kitchen. Given the child’s stage of development (13 months) an enclosed type cot would have been advisable. Based on this assessment, which the police shared with children social care based at the Multi Agency Safeguarding Hub (MASH), there was no further assessment and no further concerns raised by father. Information about fathers contact with MASH was not shared with the Health Visitor as would have been expected. Apparently, at the time father’s concerns were reported, MASH was in the early stages of implementation and since that time changes in the way that MASH have been amended and now the Health Visitor would be informed via the health team based with MASH. This sharing of information is essential in enabling Health Visitors to monitor and assess the any concerns posed to pre-school children. Following the decision for no further action MASH tried to contact mother to offer support following father’s contact but they did not manage to engage her and the case was closed. It is positive that the police and MASH shared information about the conditions at the home, but the reviewer wonders whether the police assessment would have been as child focused as that of a Health Visitor or children social care worker who have training in child development and parenting. Agencies may presume that when a Health Visitor is involved with a child that they are being well monitored with little for other agencies to do. However, Health Visitors are totally 15 reliant on information being shared with them in order that they are able to make an assessment about a child in order for them to make an assessment of their wellbeing. Health Visitors follow the Health Child Programme which may mean that for a child receiving “universal” level service the child is not seen by them between 9 – 12 months to 2-2.5 years. This is a long time in the life of the child and at a time when children are developing rapidly and are at their most vulnerable. Practice learning Multiagency working and information sharing are key to keeping children safe from harm. MASH arrangements should include contacting relevant health professionals working with the child and family to share information where there are raised concerns by others in the best interest of the child. The day after father’s claim about the state of the flat, mother then went to the police to disclosed that there had been domestic abuse in their relationship and that father was continuing to hassle her. Issues around domestic abuse will be covered later in this report. Finally, mother left the flat with Child LO to move into a static caravan with her new partner and to get away from the hassle of father. Debt of unpaid fees and intermittent severe nappy rash seen at nursery. Child LO attended 3 different nurseries’ starting at the age of 8 months, 10 months and 12 months, staying in each of the first 2 nurseries until a conversation is had with mother about unpaid fees, after which the child was taken out of nursery and the fees remain unpaid. There was no information shared with the Health Visitor about nursery attendance and not all nurseries included the name and contact details of the Health Visitor on their records. Most early years settings locally do ask for this basic information as standard when completing initial registration paperwork as part of 'getting to know you'. Nursery settings develop their own format for recording information they feel they require. Nursery 3 did routinely capture the Health Visitor information although there had been no need for communication at the time. The reviewer is of the view that there may be an omission in routine information gathering, information sharing and communication in some nurseries. Early years services such as nurseries and Health Visiting need to be more joined up in relation to the health and development of children. Information sharing agreements and parental consent should be in place to link up nurseries more closely together to ensure that nurseries can contact each other about children who move from one nursery to another. During the time period of this review Lancashire did not appear to have a published an Early Years strategy to reflect how nurseries and other agencies should work together to provide a “safety net” for children. However, there was a Child Poverty Strategy (2014) which appeared to be out of date. 16 Since that time a new document called “The Early Years of Life” (2020-2023) has been published. This is “a strategy to ensure children, young people and families are safe, health and achieve their full potential in Lancashire”. The document is robust and fully comprehensive and advocates information sharing, “Good and effective partnership working between practitioners and with parents and/or carers so that information can be shared and additional support identified and provided at the earliest opportunity” (page 4). It may be useful to consider how this goal translates in the more practical sense at practitioner level. The reviewer is of the view that nurseries should be linked to the child’s Health Visitor to ensure that any issues arising for children in the nurseries care are shared. The Health Visitor is well placed to address low level concern with the family. Issues such as unpaid fees can be linked to poverty or other family stressors which may need to be explored further and supported. Another area where the nursery could have made better use of the Health Visitor was when the child had nappy rash. Instead of recommending seeing the GP the Health Visitor would have been well placed to treat the nappy rash and would have been able to use the episode of care as part of the holistic assessment. Practice learning –The Health Visitor can only work additionally with families where there is a need to do so. Health Visitors require relevant information from other agencies to enable them to engage families at the correct level of intervention in order to safeguard children and to promote their wellbeing. Better links between Health Visiting and Nursery provision would promote better assessment and better support through Early Help. The reviewer is aware that Lancashire is in the process of working with its partners to improve Early Help working arrangements. There has been a robust consultation and engagement process taking place in the area which should support and improve multiagency working where there are low level concerns. Multiagency response to Domestic Abuse. The crime survey national statists for England and Wales ending March 2018 has identified that 7.9% women and 4.2% men were subject to domestic abuse. It should be remembered that these are reported figures and that many more will experience domestic abuse for several years without telling anyone. There is a Pan-Lancashire Domestic Abuse Strategy update February 2017 with a clear action plan for future improvements. Lancashire Local Authority document is available on the website which was updated in November 2018. This document is titled Domestic Abuse – Intelligence Assessment. The document identifies the national statistics, improving police response and use of Domestic Abuse Protection Orders (DVPO). Lancashire Safeguarding Adult Board and Domestic Abuse Strategic Board Guidance (November 2018) is easily available on the Lancashire Safeguarding Children Board website. 17 It is a fully comprehensive and addresses all areas of domestic abuse. The guidance advocates the use of SafeLives risk checklist and identifies best practice around use of safe enquiries both topics of which would have been useful information to professionals working with Child LO and family. It is of note that there is little information available around the impact of domestic abuse on children contained within any of these documents. NSPCC (November 2013) “Domestic abuse: learning from case reviews” suggests that professionals need to engage more with men living in the family home, whilst also making sure they see the mother alone. Professionals need to keep in mind the impact on the children living with domestic abuse. Published case reviews had highlighted that professionals sometimes struggle to keep their focus on the child when working with parental domestic abuse because the parent’s relationship problems can end up overshadowing those of their children. Information sharing Whilst it was clear that father had been the perpetrator of domestic abuse with a previous partner which had resulted in a prosecution and Restraining Order it was not known that there was any domestic abuse between Child LO’s parents until the child was 13 months. An assessment of the child’s lived experience did not take place as it should once domestic abuse was disclosed. The GP, Midwives and Health Visitors working closely with the child and family were not aware of father’s past history of domestic abuse and were therefore, not able to factor these concerns into the care plans provided by the health services during the antenatal and postnatal period. There is an intention to improve multiagency information sharing via the local MASH safeguarding arrangements. This should improve relevant information being shared to relevant staff working with children and their families. Routine enquiry “Routine enquiry” is supported by the Royal College of Midwives, Royal College of Nursing, Royal College of Psychiatrists and the National Institute for Health and Care Excellence (NICE) public health guidance, ‘Domestic violence and abuse: multi-agency working’ (NICE 2014). Routine enquiry involves asking all women (when alone) at assessment about abuse regardless of whether there are any indicators or suspicions of abuse. It was established in maternity, sexual health, health visiting, substance misuse and mental health settings. This was due to the disproportionate number of women accessing these services who have experience of abuse. The aim of routine enquiry is to recognise the nature domestic abuse and to provide support through relevant local services. 18 Throughout pregnancy and the first year of Child LO’s life neither the Midwife or the Health Visitor asked any routine enquiry questions around domestic abuse. This was partly because father was present at several of the visits and when mother was alone the opportunity to ask relevant questions was not taken as would have been expected. At the time of the review period the Midwives had not yet fully implemented the routine enquiry programme into their care pathways. Health Visitors were expected to ask the questions, but unfortunately this did not occur. It is not clear why professionals were not using the routine enquiry which is commonly used in most other areas. More work needs to be considered to ensure that routine enquiry is normalised into every day practice locally and professionals need the skills to feel confident about asking questions about personal relationships and domestic abuse. Mother told the Health Visitor at the 1-year assessment that she had split from her partner (father of Child LO). There was no record or questioning about why or what happened in the relationship and no enquiry about how they were now. Research shows that domestic abuse often gets worse after a split in the relationship and since mother was now living alone with her child it would have been sensible to use routine enquiry to check that there were no welfare concerns. Practice learning - “Routine enquiry” is an essential part of antenatal, postnatal and follow on care. Recognising and addressing domestic abuse early has a beneficial impact on children and family life. Early help assessment enables professionals to identify risk factors and provide relevant support through multiagency care planning. Assessment of risk in domestic abuse Mother did not disclose domestic abuse until the day after father made a referral to MASH about his concerns for his daughter. Mother made a call to the Police about harassment and the call handler recorded that mother had said that her ex-partner had made a threat to kill. Often threats to kill can be said in the heat of the moment as a throw away comment. The definition of the offence of Threats to Kill is that: A person who without lawful excuse makes to another a threat, intending that, that other would fear it would be carried out, to kill that other or a third person. Following on from the police call, three days later, mother attended the police station and was interviewed to make a statement in support of her claim. She disclosed that she had suffered an historical physical assault, and now father was phoning and texting abuse. There was no repeated allegation of the threat to kill by mother at Police interview and nothing was said by mother to suggest that she was afraid of father. Mother did not want to prosecute father she just wanted him to stop hassling her. Father was hassling mother following the split because ongoing contact issues with Child LO, which was said to be going through Court for contact arrangements, although the reviewer has seen no evidence of this. 19 The Police raised a Standard Risk PVP in response to the allegations as a whole and shared with MASH, IDVA, Probation and Health. Father was seen by the Police Officer who had spoken to mother and was told not to hassle mother again and to seek legal advice for contact with Child LO. The Police Officer created a Crime Report for Assault (historic) to comply with Crime Recording Standards. There was no Harassment Warning Notice to support the Police verbal warning to father and no further action taken. Police Information Notices (PIN) were still being used by Lancashire Constabulary at the time the allegations were being made. PINs are warnings which the police may issues where there are allegations of harassment. These notices (sometimes called Harassment Warning Notices or Early Harassment Notices) are not covered by legislation and do not in themselves constitute any kind of formal legal action. PIN’s stopped being used by Lancashire Constabulary in November 2018 as a result of a joint inspection by Her Majesty's Inspectorate of Constabulary (HMIC) and Her Majesty’s Crown Prosecution Service Inspectorate (HMCPSI) into local area response to harassment and stalking which took place in July 2017. The inspection recommended that PIN’s were stopped to make way for more thorough investigation to better assess and manage the risk of victims and to prosecute more perpetrators. Mother went on to make a further telephone complaint to the police on the same day as making her statement at the police station. This resulted in an additional Standard Risk PVP being shared with MASH and other agencies. MASH responded to concerns raised by the PVP and father by gaining reassurance from the police following a child welfare check at the flat and as previously stated, MASH did try to contact mother to offer support around domestic abuse. MASH made a number of attempts to contact mother and after 5 days sent a letter to mother to offer support if required. Practice Learning Best practice would be that MASH should ensure that were there are concerns about domestic abuse whereby a mother with pre-school children cannot be contacted, MASH should inform the Health Visitor to enable an assessment of the child’s health and development in relation to considering the negative impact of domestic abuse. Further to this, father made a separate telephone call to the Health Visitor about concerns that mother was drinking alcohol daily whilst caring for Child LO. He reported that hygiene in the flat was poor and that relationships between them was not good. He told the Health Visitor that he had made a referral to MASH and the Health Visitor reassured father that she would carry out a visit at the home if children social care did not accept the referral. The Health Visitor was unaware of the allegations of domestic abuse at this point. No checks with children social care were made about the situation and a home visit did not take place in response to the contact from father. 20 SafeLives checklist The purpose of the SafeLives checklist is to give a consistent and simple tool for practitioners who work with adult victims of domestic abuse in order to help them identify those who are at high risk of harm and whose cases should be referred to a Multi-Agency Risk Assessment Conference (MARAC) meeting in order to manage their risk. When someone is experiencing domestic abuse, it’s vital to make an accurate and fast assessment of the danger they're in, so they can get the right help as quickly as possible. In this case, 2 weeks after fathers call, the Health Visitor received a standard PVP from the police identifying that mother was getting abusive texts from father. No immediate action was taken in response to this. Expected practice would be for the Health Visitor to contact mother and enquire about the PVP and ascertain if a SafeLives assessment was needed. A home visit at this point would have been advisable in order to consider fathers concerns alongside the information provided in the PVP. The following month the Health Visitor talked to mother at an opportunistic home visit. Mother shared that she was going to live with her new partner and that father wanted contact with Child LO but she was reluctant because he takes drugs and was abusive to her. There was an opportunity to complete a SafeLives checklist about the nature of the domestic abuse at this point. It would be best practice to fully record all information given about the nature and type of abuse and to consider safety planning. Assessing risk at the point of disclosure assists in appropriate interventions and risk management. At the following visit Mother was appropriately advised by the Health Visitor to seek legal advice about concerns around child contact. The Health Visitor did not check out fathers claim that he had spoken to children social care about concerns for Child LO and did not check on any further children social care involvement. The Health Visitor noted that Child LO was seen to be appropriately dress and strapped in a pushchair. Mother raised concern about Child LO’s behaviour which had recently become more challenging and an appointment was made for the following week to review this. The Health Visitor appointment took place as planned at a static caravan (1) which was the home of mother’s new partner. Mother stated she had sought legal advice about fathers request for contact which was ongoing. The Health Visitor did not take the opportunity to obtain details about the new partner or consider the role he would take in Child LOs care. The nature of the child’s declining behaviour was not ascertained as would have been expected. Practice learning – When circumstances change for children and families it is important to clearly record demographic information about new people entering the family. Gathering information about adults living with children is essential to keep children safe and promoting their wellbeing. 21 Domestic abuse is a common occurrence when working with children and families. Professionals need to be well trained and confident in all aspects of domestic abuse work and have a good understanding of the impact that domestic abuse can have on the health, development and wellbeing of children. Practice Issues A practice issue is an area of practice which has already been addressed locally but needs to be reviewed and considered in the individual agencies involved. • Record Keeping is an essential part of assessment and care delivery. All providers of services for preschool children should keep accurate demographic details of adults living with children. Any change in circumstance should be noted and new information included. • Midwifery and Health Visiting should review their records to additionally include; 1) Information about previous children to include names, dob, address and contact arrangements. (Midwifery already have this in place) 2) Evidence of Routine Enquiry about domestic abuse. 3) Home conditions and living arrangements 4) Evidence that baby sleep environments have been seen and safer sleep assessment conducted in line with new Pan Lancashire Safer Sleep guidance. • Nurseries should review their records to additionally include: 1) Details of previous nursery attended 2) Name and contact of child’s Health Visitor 3) Consent to share information with Health Visitors and other professionals working with the child and family. 4) Details of child’s father and any father figures including any changes including when and why. • Antenatal visits –Midwives do not have the capacity to carry out home visits locally. Health Visitors are expected to carry out a home visit through at around 28 weeks of pregnancy. This did not occur in this case. A review of how service monitoring is being conducted should be reviewed to ensure that the commissioner is alerted to gaps in service provision. • MASH should always discuss safeguarding concerns with both police and health before making a threshold decision. This statutory requirement has been in place since Working Together 2015. New MASH pathways have been implemented to improve threshold discussions and to share information to promote child welfare when the threshold for children social care intervention has not been reached. • SafeLives checklist should be further implemented into all professionals practice when working with adults suffering domestic abuse. • CAFCASS and childrens social care have reviewed their information sharing processes to take account of risks to children linked to private law proceedings. • Child Focus – all training and polices should include the importance of maintaining a child focus. 22 Good practice There was a number of good practice examples recognised across the time period of this review as follows: • Health Visitor made an opportunistic visit to Child LOs family home following concerns being raised by father and the PVP. • Police Officer welfare check was of the flat was of good quality and with good understanding about Child LOs sleeping environment which was satisfactory at the time. • Communication between Police and Children Social care was good and well documented. Conclusion This SCR provides learning from the tragic death of a 16-month-old child who died in an unsafe sleeping environment. A Coronal inquiry is planned for the near future. Although this SCR has been significantly delayed due to a Police criminal investigation, a number of identified improvements in practice have already been addressed. There remains a number of issues which have been identified and warrant the consideration of Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership (CSAP) who are now responsible for safeguarding children in the local area. This review should be shared to promote learning across the safeguarding partnership. 23 Recommendations The following recommendations are for the consideration of CSAP as follows: Recommendation 1 CSAP should ensure that the updated Pan-Lancashire Multiagency Guidance on Safer Sleeping includes clear instruction on when and how safe sleep assessments are conducted in line with Child LR Review and expand the scope of the guidance to include children under 5 years. Intended outcome – To improve the safety of sleeping environments for preschool children to reduce the incidence of possible accidental death. Recommendation 2 CSAP should request assurance from Lancashire Public Health that the new Early Years Strategy 2020-2023 is being fully implemented particularly around information sharing. Intended outcome – To promote the improvement of local multi-agency working and information sharing around pre-school children. Recommendation 3 CSAP should review and further implement the Lancashire Domestic Abuse Guidance to include: a) more focus on the impact of domestic abuse on children; b) ensure use of routine enquiry during pregnancy and beyond; and c) improve use of SafeLives check list when working with domestic abuse disclosure. Intended outcome – To improve standards of domestic abuse processes locally. Recommendation 4 CSAP should ensure that the new Multi-Agency Early Help arrangements are robustly implemented and front-line professionals fully understand their role and responsibilities in identifying vulnerable families. Intended outcome – To improve Early Help work with children and their families. Recommendation 5 CSAP should request written assurance from the District Councils in their area, that work is being progressed to enforce winter closure of Holiday Parks in line with the expected regulation. Intended outcome – To reduce the risk of children and families living in holiday park accommodation during the cold winter months. 24 References Working Together to Safeguard Children (HM Government 2015 & updated 2018) https://www.bing.com/search?q=working+together+to+safeguard+children+2015&qs=HS&pq=working+together+to+safeguard+children+201&sk=HS1&sc=8-42&cvid=FDF5E39011164A21B6DB63BFA7915B25&FORM=QBRE&sp=2 Protecting Children in Wales – Guidance for Arrangements for Multiagency Child Practice Reviews (Welsh Government 2012) https://gweddill.gov.wales/docs/dhss/publications/121221guidanceen.pdf New Learning from serious case reviews: a two-year report for 2009 – 2011. London. DfE. Brandon. M. et. Al. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/184053/DFE-RR226_Report.pdf Domestic abuse: learning from case reviews (2013). London. NSPCC. https://learning.nspcc.org.uk/research-resources/learning-from-case-reviews/domestic-abuse/ Domestic violence and abuse (NICE 2016) https://www.nice.org.uk/guidance/qs116/resources/domestic-violence-and-abuse-pdf-75545301469381 Health Child Programme: Pregnancy and the First 5 Years or Life. (Gov UK 2009) https://www.gov.uk/government/publications/healthy-child-programme-pregnancy-and-the-first-5-years-of-life Royal Society for the Prevention of Accidents (RoSPA) https://www.rospa.com/ Child Accident Prevention Trust https://www.capt.org.uk/suffocation-prevention SafeLives DASH risk checklist https://www.bing.com/search?q=safelives+checklist&form=EDGEAR&qs=HS&cvid=ead20418bf2f44e08cdc9b1b23e2f8d4&cc=GB&setlang=en-GB&elv=AY3%21uAY7tbNNZGZ2yiGNjfMr5%21hUnjRCdF7BNLMfsOJLfWywyHD0qIgfdutElqJbwx8uPAzkpnXNmH04VSor4Qo6oKh0tlykjYlxt96IdOL0&plvar=0 Co-Sleeping with your baby – The Lullaby Trust (2019) https://www.lullabytrust.org.uk/safer-sleep-advice/co-sleeping/ Reduce the risk of sudden infant death syndrome (SIDs) (NHS 2019) https://www.nhs.uk/conditions/pregnancy-and-baby/reducing-risk-cot-death/ 25 Statement of Reviewer Independence The reviewer, Kathy Webster is independent of the case and of Lancashire Safeguarding Children Board and its partner agencies. Prior to my involvement with this Serious Case Review; • I have not been directly concerned with the child or any of the family members or professions involved with the child, or have I given any professionals advice on this case at any time. • I have no immediate line management of the practitioners involved. • I have appropriate recognised qualifications, knowledge and experience and training to undertake this review. • The review has been conducted appropriately and with rigours analysis and evaluation of the issues as set out in the Terms of Reference. Kathy Webster – Independent Reviewer |
NC50693 | Significant neglect and sexual abuse of three children over a 15-year-period, resulting in care proceedings for the youngest and middle child in 2017. Referrals were first made to children's social care in 2003 regarding neglect; formal investigations of sexual abuse began with a disclosure by the oldest child in 2017. Parents had been offered help from multiple agencies over a number of years which they declined. History of poor school attendance and missed health appointments. The youngest child has a diagnosed learning need and behaved in ways that were indicative of sexual abuse; this was not fully investigated as the mother did not to give consent for the child to be interviewed. The older two children also made allegations of sexual abuse that were not investigated fully. Ethnicity or nationality of Family A is not stated. Key issues and learning focus on: the long-term impact of chronic neglect; vulnerabilities of children with additional needs; safeguarding practice in the schools; school attendance; engagement of parents presenting as hostile; and professional differences. Recommendations include: frontline practitioners working with children and families from all agencies should be trained to work with families who display aggressive and evasive behaviour; child protection supervision for all cases where children are the subjects of Child Protection Plans or Child in Need plans must be a priority for all agencies; family support advisors should keep professional records of their involvement with families.
| Title: Serious case review: in respect of: Family ‘A’ (sexual abuse and neglect of three children). LSCB: Somerset Safeguarding Children Board Author: Mark Dalton Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. SERIOUS CASE REVIEW In respect of: Family ‘A’ (Sexual abuse and neglect of three children) CONFIDENTIAL 2 Table of Contents 1. Reason for the Review ...................................................................................................................... 3 2. The Review Process ......................................................................................................................... 3 3. Defining Neglect and Sexual Abuse ................................................................................................ 5 Understanding Neglect ........................................................................................................................... 5 Sexual Abuse ........................................................................................................................................... 6 4. Learning from the case ................................................................................................................... 7 The Long-term Impact of Chronic Neglect .......................................................................................... 7 Vulnerabilities of children with additional needs ............................................................................... 8 Safeguarding in Schools ...................................................................................................................... 9 School Attendance ............................................................................................................................ 11 Failure to engage the family ............................................................................................................. 12 Concern about missed opportunities and drift ................................................................................. 13 Failure to use procedures ................................................................................................................. 15 a) Child Protection Plan ................................................................................................................. 15 b) Legal Process ............................................................................................................................. 15 Resolving professional differences ................................................................................................... 18 Information sharing and professional relationships ......................................................................... 20 Sexual Abuse ..................................................................................................................................... 22 5. Findings ......................................................................................................................................... 23 Recommendations ................................................................................................................................ 24 CONFIDENTIAL 3 1. Reason for the Review 1.1 The subjects of this review are three children who have suffered significant harm as a consequence of chronic neglect and sexual abuse. There are records of neglect from Children’s Social Care, schools, police and health agencies that span the last 15 years since referrals were first made to Children’s Social Care in 2003. The formal investigation of allegations of sexual abuse is more recent and began with a disclosure by the oldest child in 2017. 1.2 Care proceedings in 2017 resulted in Supervision Orders being made in respect of the youngest and middle children. 1.3 The impact of abuse on the children will be considered thematically. The review will consider the physical and emotional impact of living with neglect, and the cumulative impact of poor and neglectful parenting. 1.4 The investigation of sexual abuse is a key theme and will also be analysed as part of this review. 1.5 The review will consider the response from all the agencies who knew the family, collectively and individually. 2. The Review Process 2.1 The Chair of Somerset Safeguarding Children Board initiated this Serious Case Review at the conclusion of a multi-agency practice review held in 2017. The information shared at the practice review indicated that the threshold for a Serious Case Review as defined in section 4 of Working Together 2015 had been met.1 2.2 The Serious Case Review process commenced in August 2017; terms of reference were agreed, and management reports requested from the following agencies: Somerset County Council (Children’s Social Care) Avon and Somerset Constabulary Somerset County Council, Legal Services Somerset Clinical Commissioning Group Youth Offending Team Somerset Housing Association Somerset County Council (Education Welfare Service) Primary school 1 Working Together 2015 p75 CONFIDENTIAL 4 Secondary schools x 4 College of Further Education Somerset Partnership NHS Foundation Trust District Hospital NHS Foundation Trust Somerset County Council (Getset Services) 2.3 Agencies were asked to review all relevant records relating to the children and the family from the first Child Protection Plan of Autumn 2012 until the granting of Supervision Orders in Spring 2017 (the older sibling moved out of the family home in spring 2016). 2.4 The learning and information from the multi-agency practice review meeting held in 2017 was also considered, along with the direct experience of numerous practitioners who had worked with family members. 2.5 One of the children agreed to speak to the lead reviewer to discuss their perception of the help that was offered to them and their family. The focus of this conversation was their experience of professional support and included positive experiences as well as negative ones. 2.6 The report author is Mark Dalton, an independent social worker with experience in conducting Serious Case Reviews. Anonymisation 2.7 The subjects of this review are potentially identifiable from descriptions of their circumstances; therefore, this review will seek to protect their identities by referring to them by their place in the family. 2.8 Specific information which would identify individual family members will be limited in this report to enable its full publication. To protect the children’s identities, specific incidents will not be discussed but presented as themes. The Parents 2.9 The parents are a married couple, both local to the area. The extended family of one of the parents lived close by and they were occasionally involved in the care of the children. The mother was recognised as the dominant partner in the relationship and the one with whom professionals had the most contact. The mother had often been hostile and aggressive towards professionals and did not want any interference in how she chose to raise her children. CONFIDENTIAL 5 2.10 The husband has a more passive personality; for most of the period considered by this review he was in full time employment working long hours, which meant he inevitably had less contact with professionals. All the professional contact with him indicated that he shared his wife's view of professional involvement but would often take the line of least resistance rather than direct confrontation. 2.11 There is a history of all family members becoming involved in anti-social incidents in their community, sometimes resulting in altercations with neighbours and damage to property. 2.12 Both parents were psychologically assessed as part of the Care Proceedings and the assessment concluded that the parents were unable to make and sustain positive change, irrespective of support offered to them over a period of fourteen years. 2.13 The family had been the subject of multi-agency concerns for over ten years before the period under review. They have struggled as parents in meeting the needs of their children at all ages. 2.14 Any professional assessment should be cautious about labelling parents as "difficult", "hostile" or "hard to help". This report will highlight the failure to understand the children's perspective and their lived experience. However, it can be equally said that there was no professional perspective of the parents’ views and the reasons for their resentment and rejection of professional involvement. 3. Defining Neglect and Sexual Abuse Understanding Neglect 3.1 There are frequently problems for agencies in identifying and defining neglect where it exists alongside other forms of abuse. By itself, neglect comprises acts of omission and commission and the issue may be further complicated as a parent may be doing all they possibly can to provide safe and consistent parenting but are still seen as neglectful if the care is not of a sufficient standard. 3.2 Working Together to Safeguard Children (2015) defines neglect as follows: CONFIDENTIAL 6 Neglect: The persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to: • provide adequate food, clothing and shelter (including exclusion from home or abandonment); • protect a child from physical and emotional harm or danger; • ensure adequate supervision (including the use of inadequate care-givers); or • ensure access to appropriate medical care or treatment. 3.3 It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs. 3.4 The analysis of neglect used in this review is based upon the framework used in “Missed opportunities: indicators of neglect – what is ignored, why, and what is to be done”, published in November 2014.2 This report recognises that it can be difficult to recognise the indicators of neglect and when the threshold for proactive action has been reached. The report argues for making decisions based on the observable impact on the child being neglected. Professionals also need to recognise the long-term consequences for children of living in a neglectful environment. 3.5 A recent (2018) joint report by Ofsted, the Care Quality Commission and the police and probation inspectorates3 considered findings from joint targeted inspections of multi-agency responses to older children who are experiencing neglect, and notes that neglect of older children can go “unseen” and this group “may also be skilled at hiding the impact of neglect”. Neglect may present differently in older children and agencies may respond to the symptoms of neglect rather than the cause. Sexual Abuse 3.6 Sexual abuse is defined as forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, 2 Missed Opportunities: indicators of neglect – what is ignored, why, and what can be done? Brandon et al, DfE 2014 3 Growing up neglected: a multi-agency response to older children Ofsted, CQC et al, July 2018 CONFIDENTIAL 7 whether or not the child is aware of what is happening. The activities may involve physical contact, including assault by penetration (for example, rape or oral sex) or non-penetrative acts such as masturbation, kissing, rubbing and touching outside of clothing. They may also include non-contact activities, such as involving children in looking at, or in the production of, sexual images, watching sexual activities, encouraging children to behave in sexually inappropriate ways, or grooming a child in preparation for abuse (including via the internet). Sexual abuse is not solely perpetrated by adult males. Women can also commit acts of sexual abuse, as can other children.4 3.7 The final sentence of the statutory definition is of particular relevance in this case because one of the disclosures of sexual abuse in the family was a disclosure of sexual relationship between a male child and an adult female (this concept was first introduced into Working Together in 2010). This abuse occurred when the child was still below the legal age of consent and therefore should have been investigated as sexual abuse. 4. Learning from the case The Long-term Impact of Chronic Neglect 4.1 Neglect is the most common form of child maltreatment in the UK, it is also the most difficult for professionals to effectively engage with and produce long-lasting and sustained change in the family environment. In this case, the impact of neglect was evident in the physical standards in the home, anti-social behaviour in the community, poor school attendance, behavioural issues when the children were in school, failed healthcare appointments, and exposure to sexual abuse, parental violence and parental drug taking. 4.2 Neglect is a social construct: “clinical” neglect does not exist; for diagnostic purposes neglect is more helpfully considered as existing as a syndrome, where it is defined as a condition characterised by a set of associated symptoms. There are clusters of behaviours, patterns of interaction and presentations which are strong indicators that children have suffered parental neglect. 4.3 There are several assessment tools in common use in social work and health settings to help quantify the extent and impact of neglect.5 With this family, it would seem that the parents’ own problems and the fraught relationship with 4 Working Together to Safeguard Children 2015 p93 5 Examples include the Graded Care Profile and versions of the Neglect Identification and Management Tool. CONFIDENTIAL 8 professionals dominated the interactions between the family and agencies trying to work with them. 4.4 Chronic neglect can be more damaging than other forms of maltreatment because its impact is the most far-reaching and difficult to overcome. Neglect in the early years will also have consequences for later mental health and social functioning of the individual. The interpersonal and social problems demonstrated by the children may all be consequences of the psychological impact of neglect. 4.5 Given the history with this family, it is appropriate to question whether relative standards were also applied, and professionals tolerated a higher level of neglect of these children because of having low expectations of the parents. 4.6 In evaluating the information provided to this review there was a great deal of tangible and demonstrable evidence of the impact of parental neglect on the health and behaviour of the children. Parental attitudes towards professionals may partially account for the lack of a coordinated response but this was primarily the result of poor planning, a lack of analysis and a failure to coordinate interventions with the family. 4.7 The indicators of neglect were apparent to all professionals in this case and measurable evidence was available that the neglect experienced by the children was causing significant harm to their health, education and social development. This threshold was met in the Care Proceedings in spring 2017, although the evidence provided by the management reviews is that this threshold had already been met at the Child Protection Case Conference in 2012 and may well have been met much earlier. 4.8 It should not be forgotten that neglect can also be investigated as a crime, although this is a relatively unusual response and seen as a last resort. Given the lack of progress and serious nature of some of the incidents and because of the cumulative impact of neglect on the children, treating it as a criminal offence should have been considered in this case. Vulnerabilities of children with additional needs 4.9 The youngest child has a diagnosed learning need and attended a Special School from Year 6. The observations and records kept by the school are the best indicator of the lack of progress in addressing issues of neglect and sexualised behaviour. As a result of the youngest child’s intellectual limitations, CONFIDENTIAL 9 they required consistent parental oversight to keep them safe. Despite several agreements and undertakings by the parents that they would comply with safety plans there was no noticeable improvement in the youngest child's presentation or behaviour. 4.10 Research shows that children with disabilities are up to six times more likely to be abused than other children6. The reasons for this may include a reluctance to believe the disabled child, minimisation of the impact of the abuse on the child; or mistakenly attributing indicators of abuse to a child's impairment. Additional factors such as the disabled child’s inability to resist abuse or ask for help are also important. 4.11 The youngest child in this family had behaved in ways which were strongly indicative of exposure to sexually abusive behaviour. An allegation of extra familial sexual abuse was investigated in 2012. The Police liaised with the school and obtained relevant information about the youngest child’s level of functioning, which assisted them in preparing for a video interview. However, the mother would not give permission for her child to be interviewed. A further disclosure of alleged sexual abuse by an adult male was reported by the mother in 2013, who described that her child had an inappropriate interest in sex. The information was shared with Children’s Social Care, but this allegation was never investigated. This was an oversight and has subsequently been addressed by the Police. 4.12 There are two clear issues in this case: firstly, the lack of thorough investigation when allegations of sexual abuse were made; these seem to be the result of the parents refusing consent for the youngest child to be interviewed. Secondly, there is the accumulation of evidence strongly indicating that the youngest child had been either sexually abused, exposed to inappropriate sexual material or witnessed sexual abuse as a third party. The concerns from the primary school, Police intelligence reports and direct experience from the professionals involved with the family needed to be brought together through a Section 47 strategy discussion. In this instance, despite the multi-professional concerns, a Strategy Discussion was not initiated. Safeguarding in Schools 4.13 This review has raised a number of concerns about safeguarding practice in several of the schools attended by children. It is clear that schools were aware of the issues of neglect and the home life of the children. There are concerns about how these were recorded and monitored and how these concerns were addressed and escalated to Children’s Social Care. For example, one of 6 ‘We have the right to be safe’ Protecting disabled children from abuse NSPCC 2014 p8 CONFIDENTIAL 10 the primary schools kept daily notes on the youngest child for a period of four years. The entries are unsigned but describe concerning sexualised behaviour and neglect and include a sexually explicit drawing by the youngest child. This drawing alone should have been referred to Children’s Social Care. The reports written by the school for core groups and Child Protection Conferences did not include the details they had recorded on a daily basis. 4.14 The safeguarding arrangements at the primary school were not compliant with statutory guidance. The role of Designated Safeguarding Lead was held by an administrator and not a senior member of the school. This is contrary to Keeping Children Safe regulations.7 This case is a very good example why the Designated Safeguarding Lead needs a background in education and child development and has the authority to challenge other agencies and escalate concerns. 4.15 Schools and education services such as Parent/Family Support Advisers (PFSA) and the Education Welfare Service (EWS) had important roles in contributing to the assessment of risk and addressing the concerns about these children. Through the course of this review it has become apparent that there are differences between what schools had reported to Children’s Social Care and what they recorded on a day to day basis. 4.16 The Parent/Family Support Advisor (PFSA) was involved with the family for three years. Given the nature of the long-standing concerns and the fact that the children were subject of Child Protection Plans for a significant time during this period, the lack of formal recordkeeping is a cause for concern. The PFSA attended some safeguarding meetings, including Child Protection Conferences, but should also have kept case records of their ongoing involvement. 4.17 Many of the communications (emails and phone calls) sent by schools and the EWS did not appear in the Children’s Social Care chronology. The emails were often just reporting concerns to the social worker, but with no subsequent follow up or agreement as to how quickly this would happen. This failure contributed to the case drifting. Despite the frustration by the schools and EWS that the case was at times without an allocated social worker or any formal review of the case, no formal complaint or escalation was recorded. 4.18 There are some positive examples of safeguarding practice and diversion within the schools attended by these children, in particular the oldest child’s 7 Keeping Children Safe in Education. Statutory Guidance for Schools and Colleges p59. Revised guidance has been issued and will commence on 3rd September 2018 the role of the designated safeguarding lead is explained on page 18 of the new guidance. CONFIDENTIAL 11 secondary school and college offered additional support and access to counselling. The middle child also reported a more positive experience of their second secondary school because bullying was effectively dealt with and they felt safe. 4.19 Confronting parents who could be intimidating and aggressive was acknowledged as a risk by some schools. Failure to challenge the parents may also have reduced still further the children's attendance. The primary and special schools chose to support the children's attendance by providing changes of clothes and toiletries to address some of the issues arising from the neglect of the children’s basic needs. The schools have also noted that the level of attendance would have been significantly lower if they had not also assisted in getting the children to school in the morning. School Attendance 4.20 Poor school attendance was a long-standing issue for all the children. The primary schools and the Education Welfare Service had attempted to engage the parents to improve school attendance but none of these efforts had been successful. 4.21 The first prosecution for school non-attendance in relation to the older child occurred just after they had commenced secondary school. Due to the on-going poor attendance the local authority had obtained an Education Supervision Order in respect of the middle child two years later. The middle child attributes some of their poor attendance as being the result of bullying, which they believe was not addressed by the school. The Education Supervision Order was discharged, because it was having no impact on attendance. 4.22 A second prosecution for the same issue in respect of both the middle and youngest children was made 18 months after the discharge of the Education Supervision Order. The parents pleaded guilty and were given Community Sentences. The Probation Report noted that the mother felt unable to cope with the middle child and that the younger child’s poor attendance was due to medical issues. The father felt unable to help in getting the children to school because he had to work 4.23 Poor attendance by both the younger children continued to be an issue and, 6 months later the parents were prosecuted and fined a third and final time. 4.24 The parents were prosecuted three times for the non-attendance of their children at school over a four-year period. Prosecuting the parents had no CONFIDENTIAL 12 effect on the level of attendance and did little other than demonstrate the impotence of the statutory services and leave the parents to blame their children for the problem. Failure to engage the family 4.25 Both parents, but particularly the mother, presented as hostile, evasive and resentful of attempts by professionals to intervene on behalf of the children. The children’s mother had her own health problems which impacted on her ability to parent the children. 4.26 The father avoided professional contact as far as possible and did not seem to professionals to play a proactive role in parenting the children. On the occasions he met with professionals he appeared conciliatory and cooperative but was not motivated to work with them. 4.27 The collective professional experience of working with the family is that they resented outside involvement, at best tolerated this and at worst were aggressive and obstructive. The level of this sustained hostility is outside the normal range of experience for most workers. At different times, attempts were made to effectively engage the cooperation of the parents with the provision of material support; however, this did not produce any sustained improvements in the quality of the relationship. 4.28 The ability of professionals from Children’s Social Care to establish effective working relationships with the children and their parents appears to have been hindered due to the number of different workers involved with the family. Whilst it is inevitable that professionals will move on from time to time, for part of the period under review Somerset was having a particular problem recruiting permanent members of social work staff. Between 2012 and 2015, the management of the children’s case was overseen by 9 different team managers and 6 allocated social workers. It is quite likely that some of the inertia evident in this case can be attributed to the case being allocated to short-term locum social workers who were not in post long enough to build a working relationship with the children or their parents. It is notable that some of the schools – where staffing was more stable – felt they were able to build productive relationships with the older children and were able to have a positive impact on their behaviour. 4.29 Children’s Social Care were not the only agency which experienced significant changes of staff. The Education Welfare Service also had 5 education attendance/welfare officers and 5 managers allocated to the case during the period under review. In addition, the EWS restructured, which may CONFIDENTIAL 13 also have contributed to: (a) the relevant information about the case not being available to the allocated workers or (b) the information having been made available but not being pursued effectively. 4.30 Further, numerous referrals were made to different agencies attempting to work with individual children with a limited role. Given the family's antipathy to accepting help this made it relatively easy for them to avoid appointments and manipulate the network of professionals, particularly when the case was reallocated to a new worker. 4.31 Workers have felt compromised between doing their best to maintain a working relationship with the parents, which at least allows them some access to the children, and challenging the quality of parenting, which almost inevitably led to confrontation and access to the children being denied. In terms of learned experience, the parents have "learned" that professionals will eventually back down, and whatever consequences are threatened, ultimately nothing changes. Concern about missed opportunities and drift 4.32 Arguably, the key moment in the period under review was the failure to follow through on the recommendation from the Initial Child Protection Conference in autumn 2012 to initiate legal proceedings if the Child Protection Plan failed. At this point, Children’s Social Care and other agencies already had ample experience of seeking to engage the parents (given that concerns were first raised nearly a decade earlier), and it is in the light of this previous negative experience that the decision was taken to seek a legal remedy after a relatively short time. 4.33 The fact that the plan was only given a month is instructive; given what is known about the nature and causes of neglect, and the difficulty in changing parental behaviour, the decision to give the family one month to demonstrate a commitment to change suggests firstly, that agencies recognised the seriousness of the situation and secondly, they were not prepared to give the family time to obfuscate and delay. 4.34 However, despite these good intentions, there was a failure to act on the Child Protection Contingency Plan, which cannot be explained away by changes in personnel or through a lack of supervision. Fundamentally, all agencies would appear to have failed in their responsibilities to effectively safeguard and protect these children. CONFIDENTIAL 14 4.35 The second significant missed opportunity was the decision not to seek Care Orders when proceedings were before the Court; when the children had reached adolescence. It is a cause for concern that the local authority continued with its plan for Supervision Orders against the advice of all other agencies, including the Chair of the Child Protection Conference and the CAFCASS Children’s Guardian. There were also statements from the Court which indicated that the Judge had reservations about this plan and gave the local authority every opportunity to reconsider. Ultimately, the Court, as the final arbiter in the decision-making process, was assured that the plan presented by Children’s Social Care was of a sufficiently robust nature to meet the needs of the children. 4.36 Regardless of how “robust” a plan is, it is only effective if it is followed and implemented as agreed. Unfortunately, in this case the agreed plan was not adhered to by the family, but this did not result in any further action from Children’s Social Care to take steps to safeguard the children. 4.37 There are practical difficulties in removing older children, where there is a strong bond with their parent and an understandable fear and anxiety about being compelled to live elsewhere. It was clear that the middle sibling did not want to leave their parents and this view had to be considered. Furthermore, there would have been the distinct possibility that they would “vote with their feet” and run away from any placement. 8 4.38 The same argument could not be made for their younger sibling who had a significant developmental delay and other health problems. The local authority reported to the Court that they had difficulty identifying an appropriate placement for a planned move and could not find anywhere suitable. 4.39 Identifying a suitable placement for children with challenging behaviour and specific needs is extremely difficult (as has partially been demonstrated by the failure of the respite care arrangements for the youngest sibling). However, as the case was before the Court, Children’s Social Care should also have considered the potential harm of making an unplanned placement, which would have resulted if the Judge had been swayed by the argument of the Children's Guardian and made a Care Order. 8 “Professionals across all agencies must challenge any notion of older children being described as ‘choosing a lifestyle’. They must challenge the idea that because a child appears resilient this means they do not need help. …. choices older neglected children appear to be making are often their way of trying to cope in an unsafe world but in fact put them at more risk. “ Growing up neglected: a multi-agency response to older children. P29 CONFIDENTIAL 15 Failure to use procedures a) Child Protection Plan 4.36 The rationale for ending the Child Protection Plan, despite the evidence that circumstances at home had not improved, is unclear - it is described as a "unanimous" decision, but given the disquiet from School, School Nursing and Health and the demonstrable lack of progress, it is hard to understand why they would have agreed to this course of action. The social worker’s supervision record from earlier that year also states that "the CP plan has been in place for almost 2½ years with little change to the lives of the children". 4.37 However, the GP notes recorded: “Somerset County Council Children's Services Conference Record....'it was a unanimous view of this conference that [the children] should no longer be subjects of a Child Protection Plan. But they will continue to be supported as Children in Need as the above plan still needs to be progressed & monitored”. While the decision seems to have been recorded as “unanimous”, this is incorrect and the school and PFSA are clear that they did not agree with this decision. 4.38 This was clearly an overoptimistic decision apparently, based on assurances from the parents that they would work with professionals under Child in Need arrangements. It is unfortunately a common error in neglect cases to focus on arrangements with parents and overlook the everyday experiences of the children. 4.39 At this time, the Signs of Safety approach had been recently introduced into Somerset and was used in Child Protection Conferences to give clear, concrete examples of changes which needed to occur in order to reduce risk. The principle of Signs of Safety is that it uses everyday language with practical examples of what needs to change. The current level of risk is then given a score out of ten, with examples of what would need to change to improve that score. Despite its simplicity, Signs of Safety is a subtle tool and only works effectively if it begins with an honest multi-agency appraisal of current difficulties. This does not appear to have happened in this case. b) Legal Process 4.40 Some of the legal decisions in this case were made before the current process known as the Public Law Outline was in place. The Public Law Outline was applicable for decisions from summer 2014 onwards, but prior to that there was CONFIDENTIAL 16 still a system in place for consulting on legal decisions which would have considered historical concerns. 4.41 The lack of transparency regarding the legal decision making is a matter of concern: firstly, not convening a legal planning meeting following the failure to implement the contingency plan agreed at the Initial Child Protection Conference; secondly, the in-house “legal planning meeting” held without any professional legal advice. 4.42 By the time these proceedings were before the Court, Children’s Social Care faced a dilemma of where to place two adolescent siblings with a high level of need, who clearly stated that they wished to remain with their parents. It proved impossible to find suitable carers close enough to enable links with school and family to be maintained. 4.43 Therefore, the task was to balance the potentially negative impact of moving out of area and disrupting family links against the potential benefits of providing the experience of a secure foster placement. Children’s Social Care would also have been conscious that children in care do not always thrive and there are well-known risks in placing adolescent children against their wishes. There is no evidence that the local authority explained its dilemma to partner agencies which led to further frustration and breakdown in the professional relationships. 4.44 It would seem that Children’s Social Care was the only agency who believed that leaving the children at home was the best course of action. It is a common response when cases of neglect finally come before the Court that collectively everyone wishes that their predecessors had commenced proceedings earlier. 4.45 The view of the Children’s’ Guardian was that Care Orders were the only option which safeguarded the children, gave them some hope of addressing the physical and psychological damage they had suffered, and enabled them to take advantage of school and education. The Children’s Guardian reluctantly supported the local authority’s plan as there were no identified carers. 4.46 Disagreement over the decision not to seek Care Orders has been an important feature of this review. It would be wrong to portray the disagreement as an argument between the relative merits of Care Orders versus Supervision Orders. The original intention of the local authority was to apply for Care Orders and place the children with parents under the Placement with Parents Regulations.9 The local authority's argument was that Care Orders gave them parental responsibility and sufficient authority to override parental objections 9 In exceptional circumstances the law allows for a Child subject of a Care Order to be placed with their parents – see Placement of a Child in Care with Parents CONFIDENTIAL 17 about the care of the children. By the final day of the Court Hearing the local authority had also identified a respite carer for the youngest child who would look after them every weekend. 4.47 The Care Proceedings were subject to numerous delays, some of which were the result of the parents’ refusal to engage in the process. Given their track record and previous relationships with the local authority, this was to be expected. However, significant delay was also caused by the local authority’s lack of organisation and failure to complete tasks to agreed timescales. There are numerous examples of this, such as the failure of Adult Social Care to allocate the request for a Carer Assessment on the parents until a fortnight before it was scheduled to be filed. Children’s Social Care also failed to file reports on time and equivocated in the decision whether to seek Care Orders or Supervision Orders in respect of the children. 4.48 As part of the Court proceedings, a schedule of expectations specifying the actions the parents must take to support the plan was drawn up by Children’s Social Care. This document forms a contract between parents and Children’s Social Care and explicitly states, in unambiguous detail, actions the parent should undertake to improve the health and school attendance of their two youngest children. The schedule of expectations was originally agreed and revised to take into account changed circumstances when Supervision Orders were finally granted. The schedule of expectations was not legally binding, but the Court would consider failure to comply as evidence in further proceedings. 4.49 Unfortunately, the schedule of expectations proved to be ineffective and did not lead to the hoped-for changes in the parents’ behaviour. It could be argued that the failure to follow through the plan and return to Court if the parents failed to comply has been additionally counter-productive because it had demonstrated the local authority's unwillingness to confront the parents’ lack of cooperation. Listening to the Children 4.50 The voice of the child is an important concept in child protection as well as all other areas of social work with children.10 There is a balance to be struck 10 Ofsted (2011) The voice of the Child: learning lessons from serious case reviews: A thematic report of Ofsted’s evaluation of serious case reviews from 1st April to 30th September 2010. This report noted that the children were only able to speak about their experiences once they had been removed from their home environment. Ofsted claimed that this underlined the importance of providing a safe and trusting environment, away from carers, for children to be able to speak about concerns. CONFIDENTIAL 18 between respecting the wishes of the child and protecting them from the possibility of future harm where the child chooses an unsafe or dangerous environment. 4.51 The child of the family who contributed to this review stated that they felt that the social workers were there for her parents and did not remember any one to one conversations with social workers when they visited the home. They also remembered that the social workers changed without explanation or saying goodbye. At risk of stating the obvious, these simple steps of proper introductions, handover and farewell show respect and courtesy and may also lead to building a working relationship with a child. 4.52 In this case, despite long-standing professional concerns about the quality of parenting and dangers within the home, the children, when given the choice, unsurprisingly opted for remaining at home. This was to be expected, but nonetheless did not negate the professional responsibility to explore alternative care and the conclusions could have been different for each child. It should be noted that the Children’s Guardian discussed the prospect of foster care with both children and believed that, with the right introduction, the younger child was open to the idea and it could have been explored further if the local authority had been able to identify suitable carers. 4.53 A further practice issue is raised by the response to the male child’s disclosure of his sexual abuse by an adult female. Following the initial enquiries with the family and the identification of the likely suspect, the decision was taken not to proceed with this as a criminal investigation despite a clear allegation that a sexual offence against a child had been committed. Given the strength of the evidence, the decision not to investigate further is unusual and contrary to Police guidance. The decision poses the question about whether there was an unconscious bias because the victim was a male and the perpetrator an adult female, or whether the identity and history of the victim played a part in the decision not to take further action.11 Resolving professional differences 4.54 On several occasions there was significant disagreement in the professional network; the failure to seek legal advice following the lack of progress of the Child Protection Plan, the decision to seek revocation of the Education Supervision Order and the lack of strategy meetings following the disclosures of sexual abuse are examples where there was significant disagreement about the management of the case by Children’s Social Care from other agencies. 11 During 2017/18 Avon and Somerset Police have invested in training to raise awareness of conscious and unconscious bias. Equality Report 2017 CONFIDENTIAL 19 4.55 The ‘unanimous’ decision that the Child Protection Plan should be ended because there was agreement that the aims had been achieved is questionable. It would have been the wrong decision to end the Child Protection Plan because it was ineffective, but at least this would have been an honest reflection of reality. 4.56 The Child Protection Conference Chair (hereafter referred to as the CP Chair) responsible for chairing the Initial Child Protection Conference and subsequent Review Child Protection Conference was in a position to challenge the analysis by Children’s Social Care that the children should no longer be subject of Child Protection Plans. The CP Chair could also have challenged the conduct and effectiveness of partner agencies involved in the case. 4.57 The CP Chair has a statutory responsibility to raise concerns where children are placed at risk, and whilst concerns were raised these were not proactively followed up. This case raises concerns about the relative status of CP Chairs in relation to Team Managers, and whether their concerns are taken on board. It would appear that in this case the concerns of the CP Chair were too readily dismissed, and they were told they had no authority over “operational” decisions. However, it was the responsibility of the CP Chair to escalate their concerns and it is unclear why this did not occur. 4.58 Other agencies, in particular the school attended by the youngest child and the school nurse, seem to have become jaded by their experience of referring concerns to Children’s Social Care, with no apparent effect. As discussed earlier, there is evidence that the school nurse sought to escalate her concerns through her line management; however, this did not materially affect how Children’s Social Care managed the case. 4.59 The Somerset Safeguarding Children Board website includes a protocol for resolving professional differences12 which could have been used formally to raise these concerns with Children’s Social Care and if necessary escalate to senior management. This protocol was revised in late 2016 (it was previously known as the Escalation Process) and is clearer and more robust than the previous version. 4.60 There is an overall reluctance to use these procedures for a number of possible reasons; this is not a problem unique to Somerset and is a common finding of Serious Case Reviews. It may be that professionals are concerned about making an implied criticism of the professional standards of colleagues, fellow 12 Resolving Professional Differences Protocol CONFIDENTIAL 20 feeling in working with a difficult and unrewarding case, an understanding of resource implications and fearing a negative non-productive outcome. 4.61 It should be reiterated that safeguarding is a multi-agency responsibility and expressing dissatisfaction in the management of the case by Children’s Social Care is not an adequate professional response from any agency to the continued neglect of these children. Working Together (2015) and the Children Act (2004) place an equal duty on partner agencies to safeguard children and therefore agencies have a responsibility to escalate concerns until there is a satisfactory resolution. Information Sharing and Professional Relationships 4.62 There were clearly problems in sharing information in this case that were not simply the issue of failure to recognise the significance of information and pass it on. At times it would seem there were so many ongoing concerns that repeated themselves so frequently that some agencies, such as the primary school, simply recorded information (much of which was very relevant in terms of evidence of neglect) but did not pass this on regularly to Children’s Social Care or include it in statutory reviews and case conferences. 4.63 The lack of consistency within Children’s Social Care is an important factor in this dynamic. There were times when there was no allocated Social Worker, or Core Group meetings and passing information to a duty officer would not have seemed useful as these were pre-existing concerns which were well known to Children’s Social Care as an agency. It is also the case that some agencies were wary of an aggressive response from parents if they raised concerns with Children’s Social Care. 4.64 In child protection, a key relationship is between Children’s Social Care and the Police. The Police Management Report records regular sharing of information with Children’s Social Care and several strategy discussions. However, the report also notes that passing on information without concerns being analysed does not lead to proactive safeguarding action. The Police also failed to escalate their concerns about the family and it would seem they failed to link separate callouts to the family home and build a picture of chronic neglect. 4.65 Experience has shown on countless occasions that there is no substitute for face-to-face discussion to share concerns and analyse risks. This is particularly true of intractable cases which need face-to-face interaction to overcome the tendency to accumulate information without analysing it. 4.66 The review has revealed some very specific information sharing issues within schools; however, it would be prudent to consider these lessons across all agencies. The initial recording of concerns needs to be in objective and CONFIDENTIAL 21 quantifiable language. All records need to be signed and dated, including the date they are shared with colleagues or other agencies. These reports need to be kept securely in the individual child’s record and transferred between schools when the child moves. This applies equally to school records and those kept by other school-based services such as Parent/Family Support Advisors. 4.67 Contemporaneous records can be powerful evidence if they are recorded professionally. These concerns should also be reflected in case conference or other reports to provide an honest analysis of the level of risk. 4.68 Working with this family had a debilitating effect on the professional system; they displayed a high level of need and a high level of aggression simultaneously. Paradoxically, they would complain equally of a lack of support and of interference in their family. Professionals were wary of contacting the family with bad news and became used to being abused and intimidated. The failure to effect any change in the family with an apparent lack of consequence also led to some professionals behaving in a way where they were disempowered and deskilled. 4.69 There is no evidence in any of the reports of collaborative working to support colleagues who were being intimidated. In a case such as this one we would hope to see recommendations for joint visiting, support from managers and supervisors and discussions about strategies to reduce the risk to individual workers. Visiting the family at home in a relatively isolated rural community – sometimes outside office working hours and alone was an intimidating prospect. This needs to be recognised as difficult and challenging work and managers from all agencies have a responsibility to support their staff. 4.70 Early in the period under review, at the Initial Child Protection Conference, the Police representative noted that working with the family would require a strong team of professionals who were able to support each other and stick to agreed plans. It is possible that staffing problems within Children’s Social Care created a decision-making vacuum, and consequently the agencies lost the focus on the need to exchange information effectively. This multi-agency approach should have been the modus operandi of the Core Group; as such it would be expected in the absence of an allocated social worker monthly meetings would have continued to be held and chaired by a representative of one of the other agencies involved with the children. 4.71 It is also apparent that some agencies which could potentially have played an important part in working with the family were not integrated into the professional network. The Housing Association appears to have had little engagement in the concerns about material standards in the home (until later on in the period under review when concerns centred on reducing the number of animals kept in the premises), but instead had a narrow focus on anti-social behaviour and rent arrears. Similarly, the Education Welfare Service seems to have been focused on attendance issues rather than underlying problems. CONFIDENTIAL 22 Exchange of information was sporadic with little evidence of inter-agency dialogue. Sexual Abuse 4.72 Sexual abuse is a category of abuse in its own right and not always a symptom of neglect. It is an unusual feature of this case that the very obvious signs of sexual abuse were not more fully investigated by agencies. A more usual response is for concerns about sexual abuse to overwhelm other pre-existing concerns of neglect. 4.73 The youngest child had shown signs of sexually reactive behaviour and had possibly re-enacted their own experiences of being abused. Although they did not make a disclosure, they attempted to engage in sexual activity and initiated sexual contact with other adults and children. 4.74 The two older children discussed in this review have both made disclosures of sexual abuse that were not investigated at the time of the disclosure. The parents did not support further investigation; however, given the seriousness of the alleged crimes this should not have prevented an investigation taking place. There is no record of a Strategy Discussion or further action following an allegation of rape by one of the children. 4.75 The allegation of a sexual relationship between a twenty-five year old and one of the children led to a strategy discussion and a joint Police and Children’s Social Care ‘section 47’ investigation. However, the investigation was not progressed and discontinued after two weeks because the family refused to engage with the Police. 4.76 The differing responses to the allegations of different types of sexual abuse is striking; the allegations made by one of the children of sexual abuse by an adult female, were not considered as a possible case of child sexual exploitation (although the circumstances of the case would have fitted with the Barnardo’s model of child sexual exploitation in use at the time13). The challenge to all agencies is whether the potential for males to be victims of child sexual exploitation is recognised and responded to with equal seriousness as female victims. 4.77 It is significant that the oldest child did not disclose the sexual abuse by an uncle until they had moved out of the family home. Research shows that 13 Working with children who are the victims or at risk of sexual exploitation p12. This report suggests different models of child sexual exploitation, one of which is the Boyfriend/girlfriend model where the child is groomed into a "relationship" and believes their abuser to be their boyfriend or girlfriend. CONFIDENTIAL 23 young people often need to feel safe before they disclose. The oldest child eventually disclosed to a worker from the Youth Offending Team in the context of work on healthy sexual relationships. The Youth Offending Team worker played a crucial role in supporting the oldest child in making a disclosure to the Police. This illustrates the need for emotional support for the victims of sexual abuse; in this case it was available because the child was already engaged in the service, and support may not have been so readily available if the child had not had this pre-existing relationship. 5. Findings 5.1 The unavoidable conclusion of this review is that the significant neglect experienced by these children should have been identified earlier and the local authority should have used its statutory powers to safeguard them and promote their welfare. 5.2 In addition, they have been the victims of sexual abuse which does not appear to have been properly investigated. Equally the therapeutic needs of the children were not assessed. It is too early to ascertain whether this level of maltreatment will have long-term impact into their adult years, but research would indicate that there is a strong possibility they will develop further mental health and social problems as they become older.14 5.3 Children’s Social Care had a number of opportunities to intervene and safeguard the children. The failure to act decisively may be partially explained by staffing problems within Children’s Social Care. However, Children’s Social Care is not solely responsible for the apparent breakdown in interagency working; all agencies share this responsibility. 5.4 A further significant factor has been the implacable hostility of the parents to help from any agency, and their ability to keep professionals at arm's length. 5.5 The management reports from Police, Schools, Community Health, Education Welfare Service and the Independent Reviewing Service portray a consistent picture of failed parental engagement and no consistent evidence that the concerns about the children's welfare were being successfully addressed. 5.6 Schools and colleges attempted to address the obvious needs of the children on a day-to-day basis - sometimes providing food, or changes of clothing for the children where necessary and contacting the family directly to confront attendance issues. 5.7 The failure to address the safeguarding needs of these children was systemic and all agencies share some responsibility for the failure to act. While some 14 Missed Opportunities: indicators of Neglect DfE 2014 p9. CONFIDENTIAL 24 concerns were passed on, the failure to improve the home conditions remained apparent and all agencies, therefore, had a duty to escalate their concerns within their own line management structure and the wider safeguarding system. 5.8 In summary, these issues were the same as those first noticed over a decade earlier, the manifestations of the problems had slightly altered as the children had grown up but remain fundamentally the same. The only change was in the process of growing up in a culture of Neglect; the cumulative impact on the children was that they became more difficult to work with as they mirrored their parents’ antagonistic and anti-social behaviour; their vulnerability to sexual abuse and exploitation increased, and health and social problems became more evident. Recommendations 1. Somerset Safeguarding Children Board should develop a comprehensive training programme on identifying and working with Neglect and make this available on a multi-agency basis to all frontline practitioners and their managers. 2. Somerset Safeguarding Children Board should review the response to the recognition and response to sexual abuse from all agencies. The Police and Children’s Social Care should ensure that their practice regarding the investigation is compliant with the South West Child Protection Procedures.15 3. Frontline practitioners working with children and families from all agencies should be trained to work with families who display aggressive and evasive behaviour. 4. Somerset Safeguarding Children Board should seek assurance that Child Protection Chairs are sufficiently supported to fulfil their statutory responsibilities including challenge to all agencies when Child Protection Plans fail to protect children; and that appropriate measures are in place to document where challenges have arisen such that these can be monitored and reported to the SSCB. 5. Somerset Safeguarding Children Board should ensure that Child Protection Plans are routinely and effectively audited to confirm that they address the risks identified. 15 Child Sexual Abuse in the Family Environment CONFIDENTIAL 25 6. Somerset Safeguarding Children Board should seek assurance that all schools are compliant with the legal requirement that the Designated Safeguarding Lead in every school is a senior member of the teaching staff. 7. The Resolving Professional Differences Protocol should be relaunched and embedded across all partner agencies. 8. Child protection supervision for all cases where children are the subjects of Child Protection Plans or Child in Need plans must be a priority for all agencies. 9. The inability to resource Child Protection Plans, either through lack of staff or other resources, should be escalated within agencies’ own line management structures or through use of the Resolving Professional Differences Protocol. 10. Parent/Family Support Advisers should keep professional records of their involvement with families. Schools should include information from these records in reports to Child Protection Case Conferences and share information with other agencies. |
NC52289 | Death of an 8-month-old girl in July 2020 after becoming submerged in the bath whilst unsupervised by her parents. Mia was treated in hospital intensive care until her death three weeks later. Learning focuses on: considering risks for a blended family of several households; identifying and responding to neglect; sex offenders spending time within a family home; whether COVID-19 restrictions affected the single or multi-agency response. Recommendations focus on: emphasising the importance of documenting how a child is presenting and the interaction between the child and parent or carer to better understand the child's lived experience; the importance of understanding the lived experience of children in blended families, particularly when they are visiting or staying in different households within the blended family; situational risks such as house moves and temporary housing; the many forms coercive control can take in intimate and familial relationships; a robust process for information sharing between partner agencies when sex offenders are suspected of presenting a risk of sexual harm to children; work to support women who have been exploited by sex offenders should consider a range of scenarios in which women may become vulnerable to exploitation in the future.
| Title: Local child safeguarding practice review: overview report: Mia. LSCB: Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership Author: David Mellor Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Local Child Safeguarding Practice Review Overview Report Mia Author: David Mellor Date: 21st July 2021 Publication Date: 5th October 2021 2 Contents 1. Introduction Page 3 2. Terms of Reference and Methodology Page 3 3. Brief Summary of the Case Page 5 4. Views of mother, father, mother 2, father 2 and Callum Page 6 5. Analysis Page 11 6. List of Recommendations Page 27 3 1.0 Introduction 1.1 The purpose of this Local Child Safeguarding Practice Review (LCSPR) is to identify learning with which to improve practice from how partner agencies in a Council within the Children’s Safeguarding Assurance Partnership (CSAP) area worked individually and collectively to safeguard five siblings from harm. The siblings ranged in age from 8 months to 16 years and resided in two households. One of the children also spent time in a third household. Mia (not her real name) was the youngest of the siblings and died after becoming submerged in the bath whilst unsupervised by her parents. At the time of Mia’s death, her and her sibling’s exposure to the risk of sexual harm from her parent’s connection with a registered sex offender was being assessed by children’s social care. 1.2 CSAP decided to review this case following the death of Mia. CSAP anticipated learning from the response of partner agencies to concerns which began to emerge about the children, from the strength of the interface between safeguarding children arrangements and the management of risks presented by registered sex offenders and the extent to which members of a blended family who reside in different households are seen by professionals as members of the same family. A Panel of managers was established to oversee this LCSPR, chaired by the Designated Nurse from the Clinical Commissioning Group for the local area. CSAP commissioned David Mellor, a retired chief officer of police with nine years’ experience of conducting statutory reviews and no connection to local services to be the lead reviewer. 2.0 Terms of Reference and Methodology 2.1 The period covered by the review is from 1st January 2018 until 11th August 2020. Significant events which took place prior to 1st January 2018 have also been considered. 2.2 The key lines of enquiry for the review are: 1. How effective was safeguarding children practice when considering safeguarding risks for a blended family which included three households. This should include: • Professional’s responses to the voice of the children about their lived experience whilst spending time within the different households • Professional curiosity around the dynamics between the households and adults living in, and visiting, the family home of IPG • Acknowledging and understanding the reasons why father’s older children were reluctant to have contact with him. 2. How effective was safeguarding practice in identifying and responding to Neglect? This should include: • Professional’s recognition and response to Neglect indicators 4 • Understanding parent’s unmet needs and how this impacted on parenting capacity and their ability to prioritise their children’s needs and safety • Professional’s understanding of roles and responsibilities and additional early help services that may have been offered 3. How effective was safeguarding practice around Domestic Abuse: This should include: • Professional’s responses to disclosures made by mother around relationship difficulties and understanding the links to coercive and controlling behaviours • Understanding the lived experience of father’s older children who witnessed domestic abuse in their parent’s relationship and how this may manifest in father’s new relationship. • The Multi-agency response to reported incidents of Domestic abuse 4. How effective was safeguarding practice around sex offenders spending time within the family home? This should include: • Professional’s response to the risk of sexual abuse of the children living in and visiting the household • Safeguarding assessments that considered the risk of child sexual abuse (CSA), parenting capacity and parenting ability to protect the children from the risk of CSA • Assessments that fully demonstrate the lived experience of all the individual children living in and visiting the household • Information sharing and child safeguarding procedures for sex offender management within Police and Probation services, including when geographical borders are crossed by the sex offender • Effectiveness of the partnership response, including Child in Need planning, to mother’s earlier relationship with registered sex offender 1? (June to September 2017) Were assessments sufficient to ensure mother’s learning needs and understanding from this work translated into her capacity and commitment to protect her children from sexual abuse? 5. Did the restrictions imposed as a result of the Covid-19 pandemic have any effect on the single or multi-agency response to this case? 2.3 Agencies which had relevant contact with the family provided chronologies of that contact. A practitioner learning event was arranged to inform this review, which was attended by the following agencies: • Teaching Hospitals NHS Foundation Trust (Health Visitor, CAMHS and School Nurse) • Children’s Psychological Service. • Council’s Children’s Social Care Service. • GP Practice 1 and 2 • Schools attended by Callum, Connor and Adam. • National Probation Service 5 Lancashire Constabulary’s Management of Sexual Offenders and Violent Offenders (MOSOVO) team was unable to attend but contributed to the LCSPR through a subsequent interview with the lead reviewer. 2.4 The lead reviewer was also provided with any documents requested. 2.5 Mia’s parents (‘father’ and ‘mother’) have contributed to this review as have ‘father’s’ former partner - ‘mother 2’ and her partner - ‘father 2’. The eldest of the five children with which this review is concerned – ‘Callum’ – has also contributed. The views of the family are recorded in Section 4 of this report. 2.6 Further information on the process followed by the Children’s Safeguarding Assurance Partnership in deciding how LCSPRs should be conducted can be found at https://www.proceduresonline.com/resources/sgp/p_child_sg_review.html 3.0 Brief summary of the case 3.1 At the time of the incident in July 2020, in which eight months old Mia nearly drowned in the bath in the family home and which led to her death three weeks later, the family composition across three households was as follows: 3.2 Mia’s mother and father lived with her, her elder sister Emma aged 22 months and Adam aged 10 years who was mother’s son from a previous relationship. Mother and father had lived together for over two and a half years. 3.3 Father also had two children from an earlier relationship – Callum aged sixteen and Connor, who was ten years old. Callum and Connor lived with their mother - who will be referred to as mother 2 in this report – and her partner (father 2). There was considerable conflict between father and mother 2. Callum had a very troubled relationship with father and rarely saw him. Connor had regular contact with father and mother and stayed over at their house but this was also a conflicted relationship. Father fathered six children - Callum, Connor, Emma, Mia and two children who died prior to the death of Mia. 3.4 Mother’s son Adam also had contact with his birth father (father 3). 3.5 In June 2017 sex offender 1 targeted a number of families in the Council area in order to have unsupervised contact with children. Mother was groomed by sex offender 1 who had overnight contact with her son Adam - then 7 years old. Children’s social care completed a child and family assessment (CAFA) and a child in need (CIN) plan was implemented to safeguard Adam. The plan was closed after mother demonstrated the ability to protect Adam in future. 3.6 By January 2018 father and mother were in a relationship and mother was pregnant with Emma. 3.7 In May 2018 father was successful in obtaining a Family Court direction that Callum and Connor should spend time with him every weekend. The following month children’s social care became 6 involved after Connor – then 8 years old – disclosed that father had injured his foot with a ‘recklessly thrown’ cigarette. By this time Callum was refusing to spend time with his father. Connor was referred to CAMHS during this period as a result of ‘behavioural concerns’. There was a considerable delay in the referral being received by CAMHS and after they referred him to Children’s Psychological Services, the latter service was unable to offer him any intervention for over a year. 3.8 Emma was born in September 2018 and Mia was born in November 2019. However, mother and father’s relationship had begun to deteriorate and their relationship ended in December 2019 but they continued to live together in the family home, primarily for financial and childcare purposes. 3.9 Mother began a relationship with sex offender 2 during the spring of 2020. In mother’s contribution to this review, she denied having an intimate relationship with sex offender 2. Sex offender 2 is a prolific non-compliant sex offender who has targeted multiple women and who may present a risk of sexual abuse to their children. He is also a serial perpetrator of domestic abuse within intimate relationships. Sex offender 2 was also a business partner of father for a time and spent time in mother and father’s family home during which it is alleged that he sexually abused Connor whilst the child was staying in the household. There was at least one missed opportunity for agencies to become aware of the involvement of sex offender 2 with mother and father, before a referral from another local authority area disclosed his contact with a number of children in the council area including Connor, Adam, Emma and Mia. 3.10 Children’s social care were in the process of completing a CAFA after Connor alleged that he and Adam had been sexually touched by sex offender 2 when Mia was found face down in the bath in which she had been left unattended with Emma by her parents for a number of minutes. Mia was treated in hospital intensive care until her death three weeks later. 4.0 Views of mother, father, mother 2, father 2 and Callum 4.1 Mother and father contributed to the review on the understanding that they would not be asked about the events which led to Mia being found submerged in the bath in the family home given that the criminal investigation into Mia’s death had not yet concluded. Mother and father had read a late draft of this LCSPR report prior to contributing to the report. They were spoken to separately. 4.2 Father said he and mother had been let down by services, principally by them ‘not listening to a word they said’. He didn’t elaborate on this comment. 4.3 He said that he disagreed with most of the LCSPR report, adding that it was ‘mostly malicious’ and that he perceived the report as a ‘vendetta’ against him. The late draft of the report father had read included the comments from mother 2, father 2 and Callum. Father said that mother 2 had been making false allegations against him for the past three years. He said she had done this because he had stopped making child maintenance payments for Callum and Connor. He said he had stopped making these payments because the money was being spent on father 2’s alcohol consumption and not on his sons. He said he had contacted the Child Maintenance Service and explained why he had stopped making the payments and they had told him that what he had done was correct. 7 4.4 He said he had only ever put his son Connor first and that his son had always enjoyed being with him. He went on to say that if Connor’s mental health was ‘so bad’ then professionals should ask themselves what was going on in mother 2’s home? 4.5 He claimed that Connor’s cigarette burn had not been taken any further because it wasn’t clear whether it had happened whilst Connor was in his care or whilst the child was in the care of mother 2. Father then slightly contradicted himself by saying that everything that mother 2 said was accepted as the truth but that what fathers say ‘doesn’t matter’. 4.6 Turning to sex offender 2, father said that when he and mother found out the full truth, they stopped contact straight away. He acknowledged that he had searched the internet for information about sex offender 2 but claimed that all he could find was something from ‘ages ago’ about sex offender 2 meeting ‘a girl in a pub’. Father said that Connor was only in sex offender 2’s company once – when they drove to another town to collect a car – and he (father) was with Connor all the time. 4.7 Father said he didn’t believe Connor’s disclosure of sexual abuse by sex offender 2 and said that mother 2 had put words in his mouth. Father said that he knew this didn’t happen because Connor was always in his (father’s) care ‘100%’ of the time during which his son visited or stayed at his and mother’s house. He went on to say that whenever Connor visited or came to stay he would always arrange for his mother (Connor’s paternal grandmother) to be present so that he (father) had got a witness in case mother 2 made any allegations about his care of Connor. Father added that the best thing he ever did was stop contact with Connor as he no longer had to worry about ‘what allegations were coming next’. 4.8 Father said he very much appreciated the support he was receiving from the same paediatric bereavement counsellor who had supported him following the sudden death of another of his children. 4.9 Mother said that she had read the LCSPR report. She said that she wanted to make it clear that she was never in a relationship with either sex offender 1 or sex offender 2. She went on to say that the LCSPR report suggested that ‘loads of work’ had been done with her after her involvement with sex offender 1, when in fact she said she had met ‘the woman’ three times. She said that the independent social worker who recently assessed her for the care proceedings in respect of Adam and Emma had told her that three meetings were not enough, and she (mother) agreed. Mother acknowledged that she couldn’t remember much about the work done with her in 2017 but said that she felt that it didn’t leave her with a ‘great’ understanding of how sex offenders work and what to look out for. She said that if she had had a better understanding she would never have let sex offender 2 into her home. 4.10 Mother said that ‘no-one had told them anything’ about sex offender 2 in the beginning. She said that he informed them that he was on the sex offender register because he had ‘met a girl’ who was only 15. He said that he had admitted that he had done wrong and she (mother) thought ‘no worries’ - at least he’d admitted it. Mother went on to say that, looking back, she should have been 8 a little ‘wiser’ and ‘put a bit more effort into looking into’ sex offender 2. She said that woman B stayed at her house so that sex offender 2 could ‘see his little boy’. (Woman B was a vulnerable care leaver who had given birth to sex offender 2’s baby in late January 2020). However, mother said that she eventually had enough of this arrangement as she (mother) ended up doing all the cooking and cleaning. Mother claimed that sex offender 2 – who she referred to by a shortened and familiar version of his first name – had never touched any of her children because she would ‘never allow it’. 4.11 Mother said that it became ‘too much’ to have Connor stay with her and father each weekend, and that they had stopped this arrangement because he was ‘kicking off’, causing arguments ‘for the sake of it’ and threatening to hurt Adam and Emma. Mother said that Connor had not stayed overnight with her and father since December 2019. She went on to say that he continued to visit their house until late February 2020 and that the only time he had met sex offender 2 was when he and father had accompanied sex offender 2 to another town to collect a car. 4.12 Mother said that Connor had been ‘prone to lie’ in order to be ‘the centre of attention’ and if sex offender 2 had abused him, mother said that she would have expected Connor to disclose this at the time and not ‘months and months down the line’. 4.13 Mother said that she felt let down by the health visitor for Emma and Mia. She said that the health visitor had said her house was dirty and cluttered. Mother said she accepted that it was always cluttered but never dirty. She said she was also unhappy that the health visitor had said that Emma was left alone in the room in which the dryer was situated – in which potentially dangerous machinery was stored. Mother rejected this, saying that Emma helped her put clothes in and take them out the dryer. Therefore Emma had become familiar with the operation of the dryer but that this did not mean she was ever allowed to go into the room with the dryer on her own. 4.14 Mother acknowledged that father could be ‘slightly controlling’. She also said that mother 2 had kept taking father to court because she ‘liked to cause dramas’. Mother also accused mother 2 of ‘putting hate in her kids’. 4.15 Overall, mother felt that she had been honest throughout but that now everyone was trying ‘to kick her when she was down’. 4.16 Mother 2, father 2 and Callum contributed to the review via a telephone conversation with the lead reviewer. 4.17 After she left him in 2017, mother 2 said that father rang children’s services constantly to raise concerns about her and her partner’s parenting of Callum and Connor and children’s services followed them all up. She contrasted this with the response to her calls to children’s services, the NSPCC and the police to raise concerns about how father treated Connor and she felt that no-one followed up or helped the family in any way other than the referrals for support for Connor’s mental health. The contrast which mother 2 highlights here may indicate a tendency for professionals to focus on mothers as the primary providers of care to children and underplay a father’s parenting responsibilities. 9 4.18 She said that she and her partner felt that it would take something serious happening before services took their concerns seriously. In the event, they felt it took Connor’s disclosure of sexual abuse and the death of Mia before services began to appreciate the harm children in the care of father could come to. Mother 2 said that when these events took place, the attitude of children’s services towards her and her partner ‘suddenly’ changed and they wanted mother 2 to help them out. 4.19 Mother 2 felt that the concerns she expressed on behalf of her sons weren’t listened to by children’s services or the Family Court Judges. Callum also felt that he and his brother had not been listened to by children’s social care, the Court and CAFCASS. 4.20 After mother 2 and father’s relationship ended, mother 2 said that Callum didn’t want to see father whilst Connor wanted to see him but didn’t want to stay overnight with him. 4.21 Whilst staying with mother and father, mother 2 said that Connor suffered a cigarette burn from a cigarette thrown towards him by father, had an ashtray thrown at him which fortunately did not hit him but ‘smashed into pieces’ and caught scabies* from sleeping in dirty hotel beds. She said that father was managing hotels at the time and he and mother would move from one hotel to another. They would sleep in the flat provided for the manager but the children would often sleep in guest rooms. She said that Connor and Adam often shared a guest bedroom and the doors were not locked so it was possible for other people staying in the hotel to gain access. *The only reference to scabies in the chronologies submitted to this review relates to a GP attendance in July 2020 although Connor was taken to the GP in June 2018 with a skin rash suspected to have been caused by insect bites, which could have been seen as an indicator of parental neglect. 4.22 Mother 2 said that she stopped contact between Connor and father in 2018 and again in 2019 because the child was always ‘in a state’ when he returned home. She went on to say that she finally put a stop to Connor staying with his father in March 2020, after Connor told her that when he was out with his father, he felt like jumping out of the car and running away. Mother 2 said that she didn’t know at the time but this was around the time that Connor had allegedly been sexually abused. 4.23 Mother 2 said that Callum last saw father at Christmas 2018 when she had to collect her sons after father and mother tried to force Callum – who was 14 – to drink alcohol. Callum said that father and mother had both been drinking and they continuously tried to persuade him to drink alcohol. He refused because he didn’t want to but added that he was also conscious that there were younger children in the care of father and mother, including 3 month old Emma so he felt that someone needed to be sober and responsible. However, he said that father and mother simply wouldn’t take ‘no’ for an answer and kept pushing alcohol towards him and applying ever greater pressure. He said that mother 2 picked him up and he resolved never to stay with father again. 4.24 Callum said that, prior to that, he had felt forced to go and spend time with father and said that he ‘absolutely hated it’. He said that he was old enough to make sure that he went as infrequently as 10 possible but Connor was younger and didn’t have any choice. He reiterated that he and Connor spent quite a lot of time staying in the hotels his father was managing. They would stay in very small rooms and he said that he would be expected to clean the room before they went into it. He said that the hotels and the homes father and mother lived in were very unclean and their homes were an ‘absolute mess’ because, in his view they didn’t care. From the time he lived with father, before father and mother 2 split up, he knew what father was like, everywhere was a mess, father’s stuff was everywhere in every room – car parts, DJ equipment and loose tools including very heavy tools. 4.25 Callum went on to say that he had now cut father out of his life and changed his surname from that of his fathers. He said that he just didn’t want to be around him because father’s priority was always what he was doing, he couldn’t care less about anyone else, he was always drunk, always ‘kicking off’, being controlling and manipulative and he would leave his kids with anyone. Callum added that this was the way his father had been as long as he could remember. 4.26 Reflecting on her life with father, mother 2 said that he was violent towards her at times but was continually verbally abusive calling her a ‘slag’ and a ‘slapper’. She said that she was never allowed money or a bank card and that father wouldn’t leave her any cigarettes when he went out. She said he would also hide the car keys so that she couldn’t drive anywhere unaccompanied. Mother 2 said that father was verbally abusive to the children as well, calling them ‘thick’, ‘stupid’ and saying that ‘they would never be any better’ and just ‘bringing them down’ every day. She said that he also used to hit them. 4.27 She said that she eventually found the strength to leave him, adding that she keep everything secret and found another house ‘behind his back’. She said her mother helped her to move out. 4.28 Callum supported mother 2’s account of her relationship with father. He said that father never let mother 2 go out with friends and when she went to college, he accused her of ‘sleeping around’. He said that father never let mother 2 go out with money and that he would always have to go with her to spend the money himself. He recalled helping father when he was DJing and feeling he had no choice. He said father would always say that he would give him money for helping him, but never did. Callum said that father never allowed him to go out with friends but added that he never wanted to invite friends over to his house anyway because he didn’t want them to see what it was like. 4.29 Mother 2 said that since he had not had to have contact with father, Connor was ‘like a different child’ and his only worry was that he might be forced to see father and mother again. He also had expressed a wish to change his surname. 4.30 Father 2 largely confirmed what mother 2 and Callum had said. In father 2’s opinion, father ‘emotionally tortured’ Callum and Connor including threatening to kidnap them and to break into mother 2’s house and take all their things including the TV and playstation. Father 2 said that Connor still slept with his bedroom light on and with the bedroom door open because of these threats from his father. Father 2 said that father told Connor to ‘play up’ at home and he would reward him for it. 11 4.31 It is clear that considerable conflict has developed between father and mother and mother 2. In their contributions to this review they have provided accounts which contradict each other. However, mother 2 and Callum provided fuller accounts which were more consistent with the information recorded by agencies. Father’s contribution to the review was very brief and strained credulity at times, particularly his claim that children’s social care were unable to determine whether the cigarette burn to Connor took place at father’s home or mother 2’s home and his assertion that the Child Maintenance Service had approved of his refusal to pay child maintenance for Callum and Connor. 5.0 Analysis 5.1 In this section of the report each key line of enquiry will be addressed. 1. The effectiveness of safeguarding practice when considering safeguarding risks for a blended family which included three households, including: (a) professional’s responses to the voice of the children about their lived experience whilst spending time within the different households (b) professional curiosity around the dynamics between the households and adults living in, and visiting, the family home of Mia (c) Acknowledging and understanding the reasons why father’s older children were reluctant to have contact with him. 5.2 Professionals appear to have gained the greatest insight into the lived experience of Connor. His time in mother and father’s household seems to have been uncomfortable for him and punctuated by periods when either he did not visit, or his visits were curtailed for a time. Father went to a great deal of effort to have his right to contact with Connor upheld but Connor felt that father didn’t show much interest in him when he visited and there is the suspicion that father exerted his rights to contact with Connor to send a message to mother 2 that she wasn’t free of his controlling behaviour. Connor may also have experienced pressure from mother 2, who attributed his outbursts of anger in the home he shared with her and father 2 to his adverse relationship with father. Mother didn’t appreciate Connor’s presence and Adam appeared to resent the arguments which ensued between mother and father when Connor visited. Additionally, after Connor presented with ‘behavioural issues’ Connor was left without emotional wellbeing/mental health support for in excess two years despite a referral to CAMHS and then an onward referral to Children’s Psychological Services. 5.3 Adam may have been exposed to poor home conditions and drug dealing from the family home as a young child living with mother and father 3, although these anonymous concerns were not substantiated by children’s social care. He was twice exposed to risk from registered sex offenders who groomed mother and had access to him at the age of 7 – when fairly intensive support was provided to him over a three month period - and at the age of 10. It is not known whether the support provided to Adam when he was first exposed to the risk of sexual harm may have helped him to keep safe from sex offender 2 when the latter began visiting the family home. These two episodes may also have shaken his trust in adults who came into his life. Adam’s school was 12 represented at the practitioner learning event and noted that he had not shared any concerns in school and questioned whether he had normalised high risk situations to the point that his school was unable to pick up on them. 5.4 Otherwise Adam does not appear to have been particularly visible to professionals. Mother and father appear to have sometimes relied upon him to supervise Emma and Mia at bath times which was inappropriate given his young age. Adam’s relationship with Connor, who was the same age as him, appears to have been conflicted. For two children of the same age, there appears to have been much less contact between Adam and his GP practice than Conner which may reflect, in part, a different approach to seeking support for their children by the respective parents. 5.5 Emma was the first child of mother and father’s relationship, but that relationship was under strain by the time of her birth. It seems likely that she became accustomed to either witnessing arguments between her parents or experiencing tension between them. It is unclear how emotionally available mother was for Emma - and later Mia - given her largely self-managed depression. Mother worked night shifts in a nursing home and so she may have been sleep deprived when caring for the child. In theory father was often Emma’s primary carer although mother commented to the health visitor on the lack of support he gave her. Emma experienced a number of house moves, requiring her to adapt to changing environments which were often cluttered and sometimes dangerous. By the time of Mia’s birth, mother and father’s relationship was practically over and so Mia seems unlikely to have experienced parental harmony during her short life. Both she and Emma will have become accustomed to other adults visiting and staying in the house including sex offender 2 and a woman (Woman B) and a baby fathered by sex offender 2 who were known to another Local Authority Children Social Care Service due to their ongoing association with sex offender 2. It seems unlikely that hers and her sister’s needs were afforded sufficient priority by her parents or the visiting adults. Mother and father used Cannabis which may have affected their parenting capacity, including on the evening when Mia became submerged in the bath. The sudden disappearance of her younger sister from her life may have been traumatic for Emma, particularly as mother and father initially blamed her for Mia freeing herself from the seat in which she had been placed in the bath. Achieving any greater insight into the lived experience of Mia and Emma has been limited by the minimal records kept of their presentation by the professionals who came into contact with them, although it is accepted that the professionals who saw Mia and Emma were primarily providing them with a universal service. Recommendation 1 That CSAP reminds professionals of the importance of documenting how a child is presenting and the interaction between the child and parent/carer in order to better understand the child’s lived experience. 5.6 Callum stopped visiting his father but lack of physical proximity to his father seems unlikely to have insulated him from the effects of the continuing conflict between mother 2 and father and Connor’s unenviable position somewhere in the midst of these arguments. Callum was coming to terms with his sexuality, an issue on which he does not seem to have been supported by father. What may have lay beneath Callum’s self-harming and what were described as ‘suicidal’ social media 13 post (s) is suggested by the information Callum has shared with this CSPR (Paragraphs 4.24, 4.25 and 4.28) 5.7 The increase in blended families reflect profound societal changes. The Census counts ‘stepfamilies’ – defined in the 2011 census as ‘couple families’ including at least one stepchild. Stepfamilies accounted for 4.5% (717,000) of all families in England and Wales in 2011 (1). It is assumed that mother and father’s family would be classed as a ‘stepfamily’ for census purposes as Adam would be classed as a ‘stepchild’ of father. Questions 1a and 1b focus on the need for professional curiosity to understand the dynamics between the households of a blended family including understanding the lived experience of the children whilst spending time within different households. The practitioner learning event arranged to inform this CSPR brought together professionals who had knowledge of one or more of the children but were less aware of the lived experience of the same children when they were visiting or staying in different households in the same blended family. Professionals were sometimes unaware of the composition of the blended family and the potential impact that events which took place in one household had on other households in the same blended families. Feedback from the professionals who attended the learning event suggested that this was a key area of learning for them. Recommendation 2 That when CSAP disseminates the learning from this case, the opportunity is taken to emphasise the importance of understanding the lived experience of children in blended families, particularly when they are visiting or staying in different households within the blended family. 5.8 Understanding the lived experience of children within blended families depends to an extent on ‘professional curiosity’, but in order for professionals to be able to be curious, systems need to be in place which support professionals to observe children’s links with more than the household in which they are resident. In the case of children’s social care, their Record System MOSAIC has children’s demographic pages which have a ‘relationships’ section which presents links to extended family members outside of the family home (children’s extended family & social networks), previous child deaths which children’s social care have been informed of and other non-household and non-family members and associations, in this case sex offender 2. By clicking onto sex offender 2’s demographic page, his relationships section presents the other women and children he is known to have had associations with together with children’s social care involvement with the individual respective children. Also the Children and Family Assessment template includes guidance notes advising the professional conducting the assessment to consider the child’s family and social networks. This template was revised and implemented March 2020 and a total of 379 Children’s Services staff have received training from the Principal Social Worker and a member of their Systems Team over the past twelve months. 5.9 However, the Contact and Referral form completed by children’s social care when concerns first arose about the risk presented to mother and father’s children by sex offender 2 showed an incorrect address for Emma and Mia’s address was documented to be ‘unknown’. This suggests that systems for gathering or possibly updating address details for children – following the January 2020 14 house move (Emma) or following her birth (Mia) – may be less than fool proof. Incorrect address information could create confusion over precisely who the child is living with. 5.10 Mother, Adam, Emma and Mia were registered with a different GP practice to father who remained registered with the same GP as Callum, Connor and mother 2. The fact that father did not register with mother’s GP practice reflects his personal choice. However, this review has been advised that father’s GP practice did not link him with Callum and Connor, which is concerning given that their surnames had been the same (although Callum informed this review that he has since changed his surname to further distance himself from father). This CSPR has been advised that GP practices automatically link a mother with her children but that there is not an equivalent automatic approach in respect of fathers. 5.11 The CSPR Panel also felt that school admission systems could be enhanced to gain a better understanding of additional significant adults in a child’s life together with details of half-siblings and step-siblings. These and other proposals form single sector recommendations for Education which are shown in Appendix A to this report. Recommendation 3 That CSAP request all partner agencies to review their information systems in order to consider what changes may be necessary to facilitate professional focus on children in blended families who may move between households or may be affected by events which take place in a household in which they do not normally reside. 2. The effectiveness of safeguarding practice in identifying and responding to neglect, including (a) professional’s recognition and response to neglect indicators (b) understanding parent’s unmet needs and how these impacted on parenting capacity and their ability to prioritise their children’s needs and safety (c) professional’s understanding of roles and responsibilities and additional early help services that may have been offered 5.12 Neglect may involve a parent or carer failing to • provide adequate food, clothing or shelter (including exclusion from home or abandonment) • protect a child from physical and emotional harm or danger • ensure adequate supervision (including the use of inadequate caregivers) • ensure access to appropriate medical care or treatment It may also include neglect of, or unresponsiveness to, a child’s basis emotional needs (2). 5.13 The circumstances of Mia’s near drowning, which led to her subsequent death, indicate a failure to protect from danger and a lack of adequate supervision. Allowing sex offender 2 to spend time in their home and have unsupervised access to their children, was also a failure to protect by father and mother which will be addressed later in this report. 15 5.14 However, indications of parental neglect arose prior to the incident which led to the death of Mia, in particular the dangers faced primarily by Emma as a mobile child following the house move in January 2020, given the health visitor’s concerns about the storage of heavy tools, metal ladders and other equipment in the dining room. In his contribution to the CSPR Callum described father’s homes as an ‘absolute mess’ with his father’s stuff ‘everywhere in every room’, including car parts, DJ equipment and loose tools including very heavy tools (Paragraph 4.24). Additionally, the Rapid Review of this case, which preceded this CSPR stated that whilst she was being treated in hospital following the near drowning incident, nursing staff found a drawing pin in Mia’s nappy. It was thought that she ingested this prior to the incident and it was suggested that other foreign objects were in her stomach, although that had yet to be positively confirmed. Although the health visitor was told by mother that Emma was not allowed to go into that room, she had good reason to doubt mother’s honesty on this point. There could have been greater professional challenge at this time. 5.15 There could also have been greater curiosity about the sleeping arrangements for new born Mia who was sleeping in a Moses basket in the lounge with her parents. It was unclear why the baby was sleeping in the lounge with parents in a detached house. 5.16 Mother and father moved house on more than one occasion during Emma and Mia’s lives, including the January 2020 house move. Father also managed a number of hotels which appeared to necessitate frequent moves from one hotel to another. There may have been opportunities for professionals in contact with the family to have explored their living arrangements during this period. House moves and temporary housing are amongst the factors identified as ‘situational risks’ which can lead to unsafe sleeping environments for infants in the National Child Safeguarding Practice Review Panel’s review ‘Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm’ (3). Recommendation 4 That CSAP ensures that ‘situational risks’ such as house moves and temporary housing are highlighted in the local response to the learning about sudden unexpected deaths in infancy highlighted by the National Child Safeguarding Practice review’s report. 5.17 After mother gave birth to Emma in Autumn 2018, indications of mild depression were noted by the health visitor. Mother saw her GP in January 2019 and said she was feeling depressed for which she was prescribed antidepressants. It is understood that mother’s prescription of antidepressants was short-lived, probably because of her pregnancy with Mia. Her GP also referred her the single point of access for mental health services in April 2019. However, the single point of access has no record of receiving any such referral. 5.18 By October 2019 the health visitor noted that mother was ‘self-managing’ her mental health although difficulties in her relationship with father over his infidelity, the lack of support he gave her and arguments arising from Connor’s visits, were causing her stress. When the health visitor saw mother the following month (November 2019) mother said that she was feeling ‘overwhelmed’ which the health visitor did not feel was unusual for a new mother. She disclosed that her relationship with father remained ‘difficult’. When she saw mother in late December 2019, mother 16 agreed to complete the PHQ-9 Depression Questionnaire which disclosed severe depression. Mother was described as tearful and wanting to end her relationship with father but being unable to do so as ‘neither of them had anywhere to go’. The health visitor referred mother to Supporting Minds – which offers brief psychological treatment for depression and anxiety disorders – but that service has no record of mother ever accessing the service. When the health visitor later asked mother if she had made contact with Supporting Minds, she said that she hadn’t. It appears that Supporting Minds rang mother, did not receive a reply and she did not return the call. 5.19 It is possible that father may have had unaddressed mental health issues. He was reported to have attempted to take his own life by throwing himself into the sea four months after the death of one of his children with mother 2 in 2008. It is now known that father received bereavement support at that time. In June 2020 father is also said to have left the home he shared with mother in a ‘suicidal state’ after an argument with mother, before later being found safe and well at the sea front by the police. His GP practice was represented at the practitioner learning event and they suggested that father’s statements about self-harming could also be seen as manipulation. He was never referred to mental health services. 5.20 Mother and father may have benefitted from the offer of Early Help following the birth of Mia in November 2019. Their needs appeared to largely correspond to the ‘Level 2 – Universal Plus’ level of need - set out in ‘Working Well with Children and Families in Lancashire’ - at which the offer of Early Help should be considered in that they appeared to require extra help to meet the specific emotional needs of mother, to respond to the short term crisis occasioned by the breakdown in mother and father’s relationship and to improve their parenting. Had mother and father consented this would have led to an early help assessment which could have helped to support the family and increase the visibility of the range of issues affecting the family, and the wider blended family including father’s controlling and coercive behaviour towards mother, mother 2 and Connor. Recommendation 5 That CSAP seek assurance that the principles of ‘Working Well with Children and Families in Lancashire’ are consistently applied and that Early Help is offered where appropriate. 3. The effectiveness of safeguarding practice around domestic abuse, including: (a) professional’s responses to disclosures made by mother around relationship difficulties and understanding the links to coercive and controlling behaviours (b) understanding the lived experience of father’s older children who witnessed domestic abuse in their parent’s relationship and how this may manifest itself in father’s new relationship. (c) the multi-agency response to reported incidents of domestic abuse 5.21 There was a history of domestic abuse in father’s relationship with mother 2. Reported incidents were primarily verbal disputes but there were also reported incidents of domestic violence in which father was the perpetrator. 17 5.22 After he and mother 2 separated, father’s conduct towards her and their children Callum and Conner indicated a degree of coercive and controlling behaviour. During 2017, father 2 began reporting concerns to children’s social care about mother 2’s ability to parent Callum and Connor. Despite these concerns not being substantiated by children’s social care, he continued to raise them. 5.23 In 2018 father was successful in obtaining a Family Court direction that Callum and Connor should spend time with him every weekend. By this time father was living with mother. However, both sons were reluctant to spend time with their father and Callum, who was 14 by this time, increasingly avoided contact with his father. Connor, however continued to visit and stay with father and mother and his foot was injured by a cigarette ‘recklessly thrown’ by father in June 2018 which prompted children’s social care involvement which is understood to have consisted of an assessment, CiN plan and Family Group Conference. Following the Family Group Conference, it was stated that the family had a plan to make positive changes. It is unclear who was seen as Connor’s ‘family’ at that time. It had been hoped to view the record of the Family Group Conference in order to understand who was perceived to be Connor’s ‘family’ at that time, but the record is no longer available as the provider of Family Group Conferences was externally commissioned at that time. Family Group Conferencing is no longer externally commissioned. 5.24 On 27th July 2018 Connor was referred to CAMHS by a consultant paediatrician because of what were documented to be ‘behavioural issues’ (‘behavioural issues’ as a term is unhelpful as the behaviours he was displaying appeared to have arisen because he had witnessed domestic abuse) who subsequently referred him to Children’s Psychological Services. Connor did not begin receiving a service from Children’s Psychological Services until 14th August 2020. This was an unacceptably long delay for a child to wait for support in respect of their emotional wellbeing/ mental health. In all the delay amounted to 29 months because the hospital consultant paediatrician promised mother 2 that they would make a referral to CAMHS in March 2018 but there is no record of any referral at that time. Not having heard anything from CAMHS, mother 2 raised the issue with her GP who did not wish to duplicate the consultant’s CAMHS referral. The GP practice did leave a message with the consultant’s secretary but there is no indication that a reply to this was received. On 26th July 2018 Connor was seen by a different hospital paediatrician who noted that the CAMHS referral had not been completed in March 2018 and so this second paediatrician completed the CAMHS referral. However, CAMHS state that they did not receive the referral from paediatrics until 28th January 2019. The referral was accepted and a ‘choice’ assessment was completed on 24th April 2019. Connor’s case was discussed in CAMHS MDT on 1st May 2019 and it was agreed that a referral to Children’s Psychological Services was the most appropriate way forward. On 16th July 2019 Connor attended an initial access appointment with Children’s Psychological Services following which he was placed on an internal waiting list pending allocation to a clinician. The clinician wrote to Connor’s parents to advise that they (the clinician) would be the named contact whilst Connor was waiting and also advised that they could self-refer to the local parenting course provided by ‘The Carers Centre’. In May 2020 Connor was seen by his GP for anxiety and it was noted that he had yet to receive a service from Children’s Psychological Services and a further CAMHS referral was considered by the GP at that point. The GP practice contacted Children’s Psychological Services to express concern about the length of time Connor had been on their waiting list. Children’s Psychological Services have advised this review that they have no record of the GP contact. In July 2020 Children’s Psychological Services attempted to contact mother 2 via telephone to commence 18 an intervention however her contact details were out of date. This led to a further delay until correct details were obtained from Connor’s social worker in August 2020. As stated Connor attended his first intervention appointment on 14th August 2020. 5.25 There are a number of points in the above sequence when professional practice could have been improved particularly the omission by the first consultant paediatrician in not submitting the CAMHS referral, the partial follow up by the GP when mother 2 had heard nothing and the lack of response to the GP’s enquiries by the hospital, the lack of more persistent follow-up by the GP practice at that time, the unexplained gap of six months between the submission of the CAMHS referral by the second consultant paediatrician and it’s receipt by CAMHS and the 13 months Connor spent on the waiting list for intervention by Children’s Psychological Services. The decision to refer Connor to Children’s Psychological Services by CAMHS appears to have been a sound one, despite the concerns expressed at the practitioner learning event that CAMHS tend not to accept referrals where the source of the child’s distress appears to be ‘situational’. In Connor’s case it is understood that his ‘behavioural issues’ were attributed to domestic abuse. A CAMHS manager has advised this review that her service supports high numbers of children with behavioural concerns and co-existing mental ill health and distress, and work closely with children’s social care. She went on to say that the ‘real issue’ is that CAMHS is commissioned and funded for mental ill health as its priority and there isn’t a local Behavioural Support service, nor even a Learning Disability and Autism service and so CAMHS can become the default place to go. The CAMHS manager also advised this CSPR that a key factor in Connor’s long wait for Children’s Psychological Services is the number of unfilled posts in that service. Children’s Psychological Services have advised this review that due to the small size of their team they are disproportionately affected by any vacancies or long term absences. They also point out that there is currently a national shortage of qualified Clinical Psychologists to which Heath Education England have responded by increasing training places in 2020 and 2021. Children’s Psychological Services has made a number of unsuccessful attempts to recruit to the current 1.0 whole time equivalent (wte) vacancy. In localities where Lancashire and South Cumbria NHS Foundation Trust (LSCFT) is the provider for both Children’s Psychological Services and CAMHS, the two services have been fully integrated into one team, which is not currently an option locally due to the services being commissioned by two different NHS providers. This review has been advised that the staffing pressures on Children’s Psychological Services is on the risk register of LSCFT. 5.26 The CSPR has been advised that there is now one SPA for CAMHS and Children’s Psychological Services which should improve co-ordination and information sharing although the services have different information systems. The learning event was also advised that whilst waiting for a specific psychological intervention, children/parents/carer will now receive monthly telephone/online contact from a clinical staff member in Children’s Psychological Services. All young people accepted into the service are allocated to a named clinician for assessment. This clinician then usually takes on the care coordinator role to ensure consistency of support and oversight of any care recommended by the service. Care coordination roles include: being a named contact for parents to speak to outside of planned appointments, referral to any other support services required, and providing the family with advice on other local services and/or online information they may wish to access to support their child. Care coordinators ensure that the monthly contact with families on internal waiting lists includes discussion of any changes which might impact on the child’s care plan. 19 5.27 Notwithstanding the long delay in offering support to Connor, it may have been possible for his GP to posit a link between the emotional difficulties he was presenting with and the trauma he experienced witnessing domestic abuse between father and mother 2 and the emotional abuse arising from having no choice but to visit and stay with father when he became increasingly reluctant to do so. There may have been opportunities for contact between the GP, Connor’s school and the consideration of Early Help. Recommendation 6 That CSAP seeks assurance from Lancashire and South Cumbria NHS Foundation Trust over the steps being taken to reduce waiting times for Children’s Psychological Services and also seeks assurance over the effectiveness of the monthly telephone/online contact provided to children and their families whilst on the waiting list. Recommendation 7 That CSAP seeks assurance that GP’s work with partner agencies to consider alternative approaches to supporting children who present with ‘behavioural issues’ before making a referral to CAMHS. Recommendation 8 That CSAP considers the implications of a lack of a local Behavioural Support Service (and Learning Disability and Autism service – as reported on in previous CSPR for Ryan, Nathan and Amelia) and decides any action which may be necessary. 5.28 In September 2019 the Family Court again considered Connor’s contact arrangements with father after the latter had made application to enforce the previously agreed arrangements for Callum and Connor to spend time with him. Connor told CAFCASS that he wanted his parents to stop arguing, he wanted to have fun when spending time with his father as they didn’t do a lot together and he wanted to spend the day with him rather than staying overnight at the weekend. CAFCASS has advised this review that from reading the notes of their family court advisor’s (FCA) conversations with Connor, there were times when it appeared that Connor had been told what to say to the FCA by his father. The Section 7 report completed by the Local Authority Children’s Services recommended that Connor should not stay overnight with father until he was receiving support from Children’s Psychological Services. The Section 7 report acknowledged ‘the emotional pressure he was under and the necessity for psychological input to address his emotions and behaviour’. It was good practice to delay overnight stays until Connor was receiving support from the Children’s Psychological Service. (Children’s Psychological Services has advised this review that they would not support providing therapy to a child to enable contact if the emotional and behavioural issues resided within the parent’s own behaviour towards the child). 5.29 In March 2020 mother 2 and father 2 attended a police surgery to report that Connor disliked attending father’s address so much that he had ‘threatened suicide’ because father told him that mother 2 didn’t love him and that she was a drug dealer. Additionally, Connor had been left in the care of a female he didn’t know whilst father and mother were out (possibly Woman B – see later). 20 The police advised mother 2 to seek legal advice and passed what she had told them to children’s social care. Children’s social care noted that there had previously been counter allegations by father (although the CSPR has been advised that these counter allegations had been assessed and considered to be unfounded). Children’s social care established that mother 2 was doing everything she could to safeguard the children and was currently preventing contact with father. She was to seek legal advice with regards to contact between the boys and their father. The matter was ultimately considered to be a Family Law matter and no further action was taken. 5.30 In May 2020 Connor was referred to the MASH by his GP after mother 2 reported him to be anxious, tearful and unusually quiet. He said that he no longer wanted to visit his father. It seems possible that Connor’s presentation at that time was linked to his later disclosure that he had been sexually abused by sex offender 2 whilst staying at father and mother’s address. The MASH decided that appropriate services were in place to support Connor. However, the MASH did not link Connor to the recent (25th April 2020) concern that mother had entered into a relationship with sex offender 2. (Children’s Psychological Services have advised this review that they were not made aware of this new information regarding harm to Connor until August 2020. Therefore, their assessment of his presenting needs remained unchanged from the first appointment attended in 2019). 5.31 As he got older, Callum was largely able to avoid visiting father and mother, although the Family Court proceedings initiated by father may have made him fearful that he would be obliged to spend time with him. Unknown to both mother 2 and father, Callum may have been self-harming for the three years prior to September 2019 and began posting material on social media which was described as ‘suicidal’. A factor which appears to have contributed to Callum’s distress was his father’s ‘struggle’ with his son’s sexuality. 5.32 in their contribution to this CSPR mother 2, father 2 and Callum have described the manner in which they say father manipulated and controlled mother 2, Callum and Connor. It was clear that they feel considerable antipathy for father. However, their account is consistent with the behaviour noted by agencies such as the police (Paragraph 5.33) children’s social care, CAFCASS and Children’s Psychological Services (Paragraph 5.52). Looking back at the case agencies could have given greater emphasis to the indications of coercive and controlling behaviour by father towards mother 2. Recommendation 9 When the learning from this CSPR is disseminated CSAP take the opportunity to highlight the many, often subtle forms which coercive control can take in intimate and familial relationships. 4. The effectiveness of safeguarding practice around sex offenders spending time within the family home, including: (a) professional’s response to the risk of sexual abuse of the children living in and visiting the household (b) safeguarding assessments that considered the risk of child sexual abuse (CSA), parenting capacity and parenting ability to protect the children from the risk of CSA (c) assessments that fully demonstrate the lived experience of all the individual children living in and visiting the household 21 (d) information sharing and child safeguarding procedures for sex offender management within Police and Probation services, including when geographical borders are crossed by the sex offender (e) effectiveness of the partnership response, including Child in Need planning, to mother’s earlier relationship with registered sex offender 1. (June to September 2017) Were assessments sufficient to ensure mother’s learning needs and understanding from this work translated into her capacity and commitment to protect her children from sexual abuse? 5.33 On 25th April 2020 mother contacted the police after receiving approximately 30 text messages from father whilst she was at work. Father told the police that he had sent the texts out of concern that mother was in a relationship with sex offender 2, who he believed to be a ‘paedophile’ and pointed out media reporting to this effect he had found on the internet. Mother denied being in a relationship with sex offender 2, who is a prolific non-compliant registered sex offender who had been living in the area since his release from prison in October 2019 and was being supervised by the National Probation Service (NPS) and also managed by Lancashire Constabulary MOSOVO (Management Of Sexual And Violent Offenders). At that time sex offender 2 was also known to children’s social care in the area because of his relationship with a Woman B in respect of whose children there was a child protection plan from March 2019 until April 2020. 5.34 Father later said that he had been mistaken in alleging mother was in a relationship with sex offender 2. The police had made a referral to children’s social care who initially considered a CAFA to be an appropriate response but after father’s retraction, they decided that there was no role for themselves and took no further action. 5.35 This was a missed opportunity to properly consider whether the children in mother and father’s household were at risk of sexual harm from sex offender 2. The Contact and Referral record completed by children’s social care has been shared with this review. Mother’s 2017 relationship with sex offender 1 was considered but there is no indication that children’s social care’s knowledge of sex offender 2’s relationship with woman A was considered. MOSOVO became involved and contacted sex offender 2 to ask him if he was in a relationship with mother, which he denied, which appeared to be accepted at face value. The NPS do not appear to have been invited to contribute information to children’s social care’s decision making although they were no longer supervising sex offender 2 by this time. At that time, NPS was aware of sex offender 2’s relationships with woman A and was also aware of his friendship with father’s brother, his friendship/relationship with father’s brother’s ex-partner and the business partnership with father. 5.36 The police became aware, or were reminded, that father considered himself to be sex offender 2’s business partner when they were called to an incident in which a former partner of sex offender 2 damaged two of his cars. By this time (12th June 2020) sex offender 2 had been arrested and was in prison on remand. There is no indication that any link was made to the 25th April 2020 incident. 5.37 Children’s social care and their partners were only able to establish the truth about mother’s relationship with sex offender 2 and gain an understanding about his access to her children after a referral from children’s social care in another Local Authority area on 18th June 2020. This referral 22 was followed shortly afterwards by a disclosure from Connor that he had been sexually abused by sex offender 2 whilst staying at father and mother’s address. It was also learned that mother had sent a naked image of Emma to sex offender 2. There is no indication that any of the other children living with mother and father were sexually abused by sex offender 2. 5.38 It was whilst children’s social care were carrying out a CAFA following the concerns that mother and father’s children had been exposed to the risk of sexual harm, that Mia was found face down in the bath in which she had been left unattended by her parents alongside her sister Emma. 5.39 The CAFA was initiated following the referral from another local authority area (Paragraph 3.9) and Connor’s disclosure that he had been sexually touched by sex offender 2 (Paragraph 3.10). A strategy meeting took place on 29th June 2020. Section 47 enquiries were completed by 2nd July 2020 and the CAFA was begun. The target date for completion of the CAFA was 10th August 2020. On 19th July 2020 Mia was found face down in the bath after she and Emma had been left unattended in the bath by mother and father. During the three weeks prior to this near drowning incident, children’s social care had substantial contact with mother and father. Clearly children’s social care had serious concerns about mother and father allowing sex offender 2 to spend time in their house although both parents claimed at this time that sex offender 2 had not had unsupervised access to their children. A safety plan was put in place in which comfort was taken from the fact that sex offender 2 was in prison and was therefore assumed to present no risk to the children. This was an inappropriate assumption to make given the potential for contact between mother and father and sex offender 2, albeit it was only later that this contact was found to have taken place. Children’s social care were not concerned about home conditions during this period. Father and mother presented as a couple who were in a relationship which was later found to be false. Clearly there would have been reservations about mother’s capacity for change given the work done with her when she had a prior relationship with sex offender 1 in 2017. However, given the fact that the CAFA was incomplete and that father and mother’s dishonesty in presenting as a couple and claiming not to have allowed sex offender 2 unsupervised access to their children was yet to be established, and that at that time, home conditions were not a cause for concern, there were no further steps which children’s social care could have taken at that time which could have contributed to preventing the near drowning incident which led to the death of Mia. 5.40 The direct relevance of the exposure of the children to the risk of sexual harm through mother’s relationship with, and father’s friendship/business relationship with sex offender 2 to the subsequent death of Mia from drowning after being left unattended by mother and father, has been debated by the LCSPR Panel. Both events were examples of the most serious forms of parental neglect (See paragraphs 5.12 and 5.13). Additionally, there appears to be very little room for doubt that in this household, life did not revolve arounds the needs of the children. In this household the needs of the adults were more important than those of the children and in this household the parents failed to protect their children, albeit from a range of different types of harm. 5.41 On the basis of this case, the whole system for safeguarding children from sexual harm has potential weaknesses which sex offenders may exploit. In particular the benefits of children’s social care’s MOSAIC system (See Paragraph 5.8), which would have allowed a search of Sex Offender 2’s known association with other local children and families were not accessed at the time of the 25th 23 April 2020 incident. Had such a search been made it would have disclosed information children’s social care held on woman A and her children who were known to be at risk from sex offender 2. Whilst it is much more challenging to track the risk of sexual harm sex offenders pose when they move across local authority boundaries, as sex offender 2 regularly did, it is essential that children’s social care are able to respond to new risks of sexual harm to children that a sex offender presents in their own local authority area. 5.42 However, there was much effective information sharing between NPS, MOSOVO and Children’s Social Care. Information sharing between NPS and MOSOVO appeared to be a constant ‘back and forth’. NPS and MOSOVO promptly shared information about safeguarding concerns in respect of sex offender 2’s relationships with woman A and her two children, woman B and her unborn child and possibly woman C and her child which enabled child protection planning to be initiated. However, it is unclear whether NPS advised Children’s Social Care about sex offender 2’s contact with father’s brother’s ex-partner when they first became aware of it. 5.43 To inform this review the Principal Social Worker has examined the reports provide by the police to ICPCs and found them to be of good quality and provide analysis of the accumulating risks sex offender 2 presented. The information from the police reports is copied into ICPC confidential minutes, enabling the allocated social worker, team manager and ICPC Chair to be well aware of risks and links to other families. Recommendation 10 That CSAP obtain assurance that social workers, team managers and Child Protection Chairs ensure they escalate to their senior manager’s that they have identified that a sexual offender is in contact with several families, in order that a review of all the families known to children’s social care and other Local Authority children’s social care services can be undertaken and referral made to MAPPA, if this has not previously been done by NPS or the police. 5.44 When NPS supervision of sex offender 2 ended on 26th February 2020 that appears to have been quite an important loss of regular contact/oversight of him. MOSOVO continued to manage him but the NPS had been very effective at obtaining disclosures from sex offender 2 and following up on information. However, MOSOVO has not submitted a separate chronology to this CSPR and so their actions are visible primarily in the NPS chronology entries. 5.45 At the time of the 25th April 2020 incident, in which the police, children’s social care and MOSOVO became aware of the allegation from father that mother was in a relationship with sex offender 2 – which he then withdrew - Children’s Social Care had just ended their involvement with woman A and her children as her relationship with sex offender 2 appeared to end in January 2020 and the case was transferred to another local authority within the region on 6th April 2020. It was another neighbouring Children’s Social care, rather than that working with Mia and her family, who were working with woman B and her new born child. There seemed to be a delay in taking action in respect of woman C and her child with the ICPC not taking place until September 2020. Children’s Social Care’s involvement with father’s brother’s ex-partner in January 2020 appears to have been informal. 24 5.46 The NPS may have made the assumption that information shared with either local authority's children’s social care would have been shared by each children’s social care with the other but this doesn’t appear to have been the case. 5.47 Both father and his brother’s ex-partner are scout leaders. Father was referred to the Local Authority Designated Officer (LADO) in July 2020 but this was because he was offered employment as independent security at a hospital, an offer which was later withdrawn or put on hold. His role as a scout leader was considered as part of this LADO referral. It is not known if father’s brother’s ex-partner was referred to LADO or if the fact that sex offender 2 had befriended two scout leaders was regarded as significant. 5.48 MOSOVO has contributed to this review and noted that they were not made aware of the contact between mother, father and sex offender 2 following his arrest and remand. Mother and father were listed as telephone contacts for sex offender 2 by his prison and sex offender 2 maintained contact with mother by telephone and letter. Neither the prison service (via the VISOR information system) or children’s social care shared this information with MOSOVO, although children’s social care would have been entitled to assume that Lancashire Constabulary would ensure that relevant information from the child protection process was shared with MOSOVO. 5.49 This case opens a window onto the complex web of relationships a prolific, non-compliant registered sex offender can create with women, many of who have vulnerabilities, in order to sexually abuse their children. Recommendation 11 That CSAP seeks assurance that there is a sufficiently robust process for information sharing between all relevant partner agencies when sex offenders are suspected of presenting a risk of sexual harm to children. In particular, information held by the National Probation Service and the Police MOSOVO should be included in the information sharing process. 5.50 This CSPR has been advised that training has been commissioned to be delivered by a recognised child sex abuse expert and author to all Children Services Team Managers including Early Help, Social Care and Adolescent Services and Youth Offending Team. This CSPR has also been advised that the NPS also plan to access this training. 5.51 Turning to point 4 (e), during the summer of 2017 registered sex offender 1 targeted a number of local families in order to have unsupervised contact with children. This review has been advised that sex offender 1 was assessed as ‘high risk’. He groomed mother and, through this relationship had overnight contact with Adam. He also took Adam swimming which was sex offender 1’s modus operandi for grooming and abusing children. There is no indication that Adam was sexually abused. It is not known whether children from other families targeted by sex offender 1 at that time were sexually abused. 25 5.52 Children’s social care completed a CAFA and a CiN plan was implemented in an effort to protect Adam from the risk of sexual harm. After three months the CiN plan was closed after mother had demonstrated the ability to protect her son. She ceased all contact with sex offender 1, signed a schedule of expectations and was considered to have engaged with the CiN plan. 5.53 The school nurse supported Adam through the NSPCC ‘Talk PANTS’ programme which is designed to help children understand that their body belongs to them, and that they should tell someone they trust if anything makes them feel upset or worried. Adam was 7 years old at that time and transferred school from infants to junior over the summer in which he was exposed to risk from sex offender 1. It is understood that the majority of work was done by his infants school. It is not known how fully the concerns about his exposure to sex offender 1 were communicated to his junior school. 5.54 A potential area of learning from this review relates to the extent to which parents remain vulnerable to grooming by sex offenders even after professionals have formally worked with them to raise their awareness to the risks. In mother’s case she began a relationship with sex offender 2 less than three years after she was groomed by sex offender 1 and her son Adam was exposed to the risk of sexual harm. By the time she began the relationship with sex offender 2, her life circumstances had changed markedly. She was the mother of Emma, Mia and Adam and also supported father in parenting Conner when he was staying with them. Given the earlier intervention following her relationship with sex offender 1, one would have expected her to have had a fairly high level of awareness that she could be exposing the four children to risk from sex offender 1. However, she was vulnerable at the time she met sex offender 2 in that she had given birth to Emma and Mia in fairly quick succession and as well as parenting these young children she was holding down a job in a nursing home where she worked regular night shifts which is likely to have resulted in tiredness during the daytime. She had experienced low mood and her relationship with father, who demonstrated coercive and controlling behaviours in his relationships with intimate partners and his children, had deteriorated. One assumes sex offender 2 would be well practised in picking up on, and exploiting mother’s vulnerabilities. 5.55 However, the possibility that mother - and father - may have colluded with sex offender 2 cannot be ruled out as both mother and father were recorded by the prison in which he was held on remand following his arrest in June 2020 as telephone contacts for him, and sex offender 2 wrote a letter to mother dated 13th July 2020 (contents of letter not known) and she sent him a naked image of Emma from her phone at some point. Lancashire Constabulary’s Management of Sexual Offenders and Violent Offenders (MOSOVO) team has contributed to this review and made the anecdotal observation that, in their experience, it was rare for a woman to be groomed by more than one sex offender. 5.56 There could be value in reflecting on how professionals could work more effectively with parents like mother whose relationship with a sex offender exposed her children to the risk of sexual harm. By the time sex offender 2 entered her circle of family and friends, mother’s situation had changed quite significantly from the period in which she had been involved with sex offender 1. Perhaps more work needs to be done with parents like mother to explore their vulnerabilities and 26 build their future resilience, perhaps exploring how they could keep themselves and their children safe in future scenarios in which they may have increased vulnerability. 5.57 Whilst no criticism is made of the work completed with mother when she was exploited by sex offender 1 in 2017, by 2020 mother’s life circumstances had changed markedly. In her contribution to this review, mother was critical of the work completed with her in 2017, although she may have taken this view in an attempt to excuse her subsequent relationship with sex offender 2. However, she accepted that she could have exercised more care in allowing sex offender 2 to have contact with her family. Recommendation 12 That CSAP seek assurance that work to support women who have been exploited by sex offenders should consider a range of scenarios in which the woman might become vulnerable to exploitation in the future. 5. Did the restrictions imposed as a result of the Covid-19 pandemic have any effect on the single or multi-agency response to this case? 5.51 The Covid-19 restrictions introduced from March 2020 have had a significant impact on the provision of in-person health and social care services. The impact on this case appeared to be health visitor contact being made by telephone and reduced likelihood that professionals would enter the family home (the police noted mother and father’s home to be messy by looking through the window when called to the 25th April 2020 incident). Covid-19 did not adversely affect the CAFA which was in progress at the time of the incident which led to Mia’s death as direct work was done with Connor to hear his voice, wishes and feelings during nine home visits. 5.52 Sex offender 2’s relationship with mother and the exposure of her children to the risk of sexual harm occurred just as the Covid-19 restrictions were being imposed. Researchers at the University of Birmingham are currently investigating how sex offenders have changed their behaviour in response to the Covid-19 outbreak noting that sex offenders are versatile and will change their behaviour according to circumstance and opportunity (4). Good Practice 5.53 The overall management of sex offender 2 by NPS and MOSOVO showed good joint working and all known relationships were reported to relevant area children’s social care teams. 5.54 As stated, once Connor’s referral was forwarded to Children’s Psychological Services in May 2019, he was seen for initial assessment in July 2019. At this appointment attended by father, mother 2 and Connor, concerns about father’s controlling behaviour resulted in the decision to arrange for Connor to be seen at future appointments with just one parent attending alternate sessions. 27 5.55 The injury to Connor’s foot by the ‘recklessly thrown’ cigarette (Paragraph 3.7) was notified to children’s social care by referral from the child’s GP. The review has been advised that this GP referral was very thoroughly completed. 5.56 Children’s social care recommended a delay in Connor’s overnight stays with father until the child was receiving support from the Children’s Psychological Service (Paragraph 5.28). 6.0 List of Recommendations Recommendation 1 That CSAP reminds professionals of the importance of documenting how a child is presenting and the interaction between the child and parent/carer in order to better understand the child’s lived experience. Recommendation 2 That when CSAP disseminates the learning from this case, the opportunity is taken to emphasise the importance of understanding the lived experience of children in blended families, particularly when they are visiting or staying in different households within the blended family. Recommendation 3 That CSAP request all partner agencies to review their information systems in order to consider what changes may be necessary to facilitate professional focus on children in blended families who may move between households or may be affected by events which take place in a household in which they do not normally reside. Recommendation 4 That CSAP ensures that ‘situational risks’ such as house moves and temporary housing are highlighted in the local response to the learning about sudden unexpected deaths in infancy highlighted by the National Child Safeguarding Practice review’s report. Recommendation 5 That CSAP seek assurance that the principles of ‘Working Well with Children and Families in Lancashire’ are consistently applied and that Early Help is offered where appropriate. Recommendation 6 That CSAP seeks assurance over the steps being taken to reduce waiting times for Children’s Psychological Services and also seeks assurance over the effectiveness of the monthly telephone/online contact provided to children and their families whilst on the waiting list. 28 Recommendation 7 That CSAP seeks assurance that GP’s work with partner agencies to consider alternative approaches to supporting children who present with ‘behavioural issues’ before making a referral to CAMHS. Recommendation 8 That CSAP considers the implications of a lack of a local Behavioural Support Service (and Learning Disability and Autism service – as reported on in previous CSPR for Ryan, Nathan and Amelia) and decides any action which may be necessary. Recommendation 9 When the learning from this CSPR is disseminated CSAP take the opportunity to highlight the many, often subtle forms which coercive control can take in intimate and familial relationships. Recommendation 10 That CSAP obtain assurance that social workers, team managers and Child Protection Chairs ensure they escalate to their senior manager’s that they have identified that a sexual offender is in contact with several families, in order that a review of all the families known to children’s social care and other Local Authority children’s social care services can be undertaken and referral made to MAPPA, if this has not previously been done by NPS or the police. Recommendation 11 That CSAP seeks assurance that there is a sufficiently robust process for information sharing between all relevant partner agencies when sex offender are suspected of presenting a risk of sexual harm to children. In particular, information held by the National Probation Service and the Police MOSOVO should be included in the information sharing process. Recommendation 12 That CSAP seek assurance that work to support women who have been exploited by sex offenders should consider a range of scenarios in which the woman might become vulnerable to exploitation in the future. 29 Appendix A Single Agency Actions: Children’s Social Care: The Principal Social Worker has commissioned significant 8 days training for all Children Services Team Manager across Council Early Help Service, Children Social Care Service, Children with Complex Needs Service and the YOT Service. LSCFT: • Robust safeguarding supervision documentation to be embedded in practice through staff awareness of/implementation of LSCFT Safeguarding Supervision Best Practice Guidance. • Routine Enquiry regarding Domestic Abuse to continue to be embedded into practice through online, virtual and face to face training. • Awareness regarding ‘blended families’ will be embedded into practice via a ‘Think Family’ webinar/training available to all LSCFT staff. Webinar link: • https://youtu.be/FalI2-jZ3v8 • Child Neglect half day workshop is available to all LSCFT staff to support understanding/clinical practice around Child Neglect issues and related risks. • ‘Learning on a page’ in respect this and 1 other CSPR with themes around Neglect and Sexual Abuse will be disseminated to staff via safeguarding champions. Education: In order to foster further professional curiosity and improve general safeguarding practice in schools, this review has enabled us to have the following considerations: • Include on the Admission forms of all schools and education settings the space for parents to cite additional significant adults, half-siblings and step-siblings to gain a better understanding of the extended family network. • Include the same additional detail on the annual review of this key information that schools gather to keep their systems up to date. • Improve the Safeguarding training of all staff in schools to understand the concept of professional curiosity and apply it to their daily practice as significant adults caring for children. This would enable Designated Safeguarding Leads to gather information about children’s wider network and understand their lived experience better. 30 References: (1) Retrieved from https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/families/articles/2011censusanalysishowdolivingarrangementsfamilytypeandfamilysizevaryinenglandandwales/2014-06-24#stepfamilies (2) Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf (3) Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/901091/DfE_Death_in_infancy_review.pdf (4) Retrieved from https://www.birmingham.ac.uk/news/latest/2021/01/how-has-the-covid-19-pandemic-altered-sex-offender-behaviour.aspx |
NC046223 | Death of a 5-month-old boy, killed by his mother after she developed perinatal psychosis. No charges were brought. Child JN15 was the parents' second child. There were no concerns about the first pregnancy and no known mental health history for the mother or her wider family. There had been an alleged incident of domestic abuse during the second pregnancy. Issues identified include: parents were both health care professionals with some responsibility for safeguarding in their job, which may have impacted on their willingness to come forward about domestic abuse and mental health issues. Uses the Significant Incident Learning Process (SILP) model to gather information and put forward learning and recommendations. Recommendations include: consider extending information sharing on police notifications of domestic abuse that are graded as standard with relevant health care colleagues, especially when the incident involves a pregnant woman.
| Title: Serious case review: Child JN15: overview report. LSCB: Nottinghamshire Local Safeguarding Children Board Author: Nicki Pettitt Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Final version 9.6.15 1 Serious Case Review Child JN15 OVERVIEW REPORT Lead reviewer: Nicki Pettitt Presented to the NSCB: 26 May 2015 Final version 9.6.15 2 CONTENTS 1. Summary of the learning from this case Page 3 2. Introduction to SILP Page 3 3. Introduction to the case Page 4 4. Family Structure Page 5 5. Terms of Reference Page 5 6. The Process Page 5 7. Background prior to the scoped period Page 6 8. Key practice episodes Page 7 9. Analysis by theme Page 10 10. Conclusions and lessons learned Page 15 11. Recommendations Page 16 Final version 9.6.15 3 1 Summary of the lessons learned from this case 1.1 The lessons to be learned from this review are limited. It has been established that the professionals working with the family had no contact with Mother at the time that she developed a perinatal psychosis. The family were receiving a universal service from the health professionals involved and Mother had not disclosed that she may be suffering from postnatal depression. No signs of this condition were noticed when professionals had seen Mother and when the standard assessments were undertaken. 1.2 The baby (JN15) was 5 months old and was the second child in this family. There were no concerns about the first pregnancy and perinatal period, and there was no known mental health history for Mother or in her wider family. It was concluded that she would not be considered high risk for this type of mental illness. 1.3 No professionals were alerted to the deterioration in Mother’s mental health in the days and hours before the death of JN15. The parents state that it was not evident that Mother was seriously ill. 1.4 Despite this some learning has been identified in this report, and the lessons are: Lesson 1: Nottinghamshire Police followed procedures by informing Children Social Care of a domestic abuse incident in April 2013. The health professionals who were the only people having contact with the family were not informed. It is not current policy to share police notifications with a standard risk with health visitors, school nurses or GPs. The receipt of a police domestic abuse notification could increase the input to a family from universal to targeted. A recommendation has been made in regards to this. Lesson 2: When pregnant a woman is more at risk of domestic abuse. The current national risk assessment tool in use includes pregnancy as a risk factor; however, on its own this does not automatically increase the level of assessed risk. Lesson 3: While information sharing locally was good, information regarding the call out for a domestic incident in another geographical area was not available to Nottinghamshire Police either at the time or for the purpose of this review. The NSCB may wish to inform that area LSCB of this matter. 2 Introduction to the Significant Incident Learning Process (SILP) 2.1 SILP is a learning model which engages frontline staff and their managers in reviewing cases, focussing on why those involved acted in a certain way at the time. This way of reviewing is encouraged and supported in the Working Together to Safeguard Children (2013 and 2015). 2.2 The SILP model of review adheres to the principles of; - proportionality - learning from good practice - the active engagement of practitioners Final version 9.6.15 4 - engaging with families, and - systems methodology 2.3 It has been generally accepted that over recent years the Serious Case Review agenda had become over-bureaucratic and driven by Ofsted ratings. The practitioners in the case had often been marginalised and their potentially valuable contribution to the learning has been under-valued and under-utilised. 2.4 SILPs are characterised by the relevant practitioners, managers and Safeguarding Leads coming together for a Learning Event. All the agency reports are shared in advance and the perspectives and opinions of all those involved are discussed and valued. The same group then invited to a Recall Event to study and debate the first draft of the overview report, and to make an invaluable contribution to the learning and conclusions of the review. 2.5 Nottinghamshire Safeguarding Children Board (NSCB) has requested that the SILP model of review be used to consider the circumstances surrounding the death of a child known as JN15. This systems review is being undertaken in order to learn lessons about the way that agencies in Nottinghamshire work together to safeguard children. 2.6 Working Together 2013 (the guidance at the time the decision was made to undertake this review) states that SCRs and other case reviews should be conducted in a way which; - recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; - seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; - is transparent about the way data is collected and analysed; and - makes use of relevant research and case evidence to inform the findings. 2.7 This serious case review (SCR) has been undertaken using the SILP model, which ensures that these principles have been followed and provides a systems review of the case. 3 Introduction to the Case 3.1 The subject of this review is JN15, a 5 month old boy who died in 2014 of a currently unclear cause. The post mortem stated that the cause of death was inconclusive. The investigating officer told the lead reviewer that it had been stated that the death could have been caused by ‘accidental/overlay/soft smothering’. At the time of the baby’s death JN15 was in the care of his Mother who had previously unrecognised or diagnosed mental health illness. 3.1 JN15 had one sibling who was 4 years old at the time of the death. JN15 lived with the parents and Sibling throughout his life. Sibling was not at home at the time of the death of JN15. 3.2 The family were known to a number of agencies for a universal service. Other than the response to one telephone call made to the Police by Mother regarding an alleged domestic abuse incident before the birth of JN15, the family did not receive any services due to identified safeguarding, child in need, or early help issues. 4 Family Structure Final version 9.6.15 5 4.1 The subject child is to be referred to JN15. The sibling is referred to as Sibling. There are no other children in the immediate family. 4.2 The parents of the subject children are referred to in this report as Mother and Father. 4.3 The children and both parents are of Middle Eastern origin and practicing Christians. Father had always been a Christian and Mother had converted from Islam. They were regular attendees at an evangelical Christian church which Mother told professionals was her main source of support other than Father and she appeared to be committed to the religion. 4.4 The family’s ethnic group and religion were recorded appropriately on agency records. The parents can be described as affluent and educated. They both work as health care professionals. 4.5 A genogram was produced to aid the review. 5 Terms of Reference 5.1 A detailed Terms of Reference and Project Plan guided the conduct of the review. The purpose, framework, agency reports that were commissioned and the particular areas for consideration are all described there. 5.2 It was agreed that the timeframe for this review would be from a date in 2010 (around the time of Sibling’s birth) to the date of JN15’s death in 2014. It has been identified that there may be further learning from the months following JN15’s death, however this will be explored by the NSCB outside the remit of this SCR. 6 Process 6.1 The parents of JN15 were contacted in order to ensure that their views were considered and heard as part of the review. A letter was sent and the author, along with a Nottinghamshire Safeguarding Children Board representative, visited the family on 23 February 2015 and 5 May 2015. The parents understood the requirement to complete the review and were cooperative. The information provided by them has been included throughout this report. 6.2 The Department for Education (DfE) expects full publication of Serious Case Review overview reports, unless there are particular serious reasons why this would not be appropriate. Working to that requirement, some confidential historical family information may not be disclosed in this report. It is written in the anticipation that it will be published, and contains all of the information that is relevant to the professional responses and contact with JN15 and his family. The decision to disclose information has been taken with reasonable caution to prevent the identification of the children concerned and other family members, and to protect the right to an appropriate degree of privacy for the family. 6.3 A meeting for authors of Agency Reports was held on 23 February 2015, where the SILP process and expectations of the agency reports was discussed. A Learning Event took place on 14 April 2015. The agencies involved were represented by both the report author and the majority of staff, including managers, who had been involved during the scope period. 6.4 All the agency reports available had been circulated in advance, to ensure all staff attending were able to fully understand the multi-agency information and focus of the review. Final version 9.6.15 6 6.5 The Recall Event was held on 5 May 2015. Participants who had attended the Learning Event, and some additional practitioners who had been unable to make the first meeting, considered the first draft of this report. They were able to feedback on the contents and clarify their role and perspective. All those involved contributed to the conclusions about the learning from this review. The final version of this Overview Report will be presented to the Nottinghamshire Safeguarding Children Board on 26 May 2015. 6.6 The Coroner is investigating the death of JN15 and this SCR is running parallel to the Coroner’s enquiries. The inquest is due to be heard prior to publication of this report. The Coroner is aware that this review is being undertaken. They have requested that this report be shared with them. (Since this report was finalised the Coroner’s inquest has taken place and a narrative verdict given). 6.7 The NSCB has been informed that the police investigation has been concluded and that no charges are to be brought in this case. 6.8 The sibling is currently living with the parents, and was the subject of a child protection plan. There is currently a child in need plan in place. The parents have cooperated with all professionals since the death of JN15. 6.9 The reviewer in this case and report author is Nicki Pettitt, an independent child protection social work manager and consultant. She is an experienced chair and author of SCRs, and is a SILP associate reviewer. She is entirely independent of NSCB and its partner agencies. 6.10 Working Together 2013 does not require the completion of a health overview report which considers the commissioning of health services and in some circumstances may be helpful in pulling together the related health information. It was agreed with the NSCB that an additional review of this type is not required in this case, as there were no complex health issues identified prior to the death of JN15 that needed to be addressed. 6.11 This process has been effectively administered by the NSCB. 7 The background prior to the scoped period 7.1 Agency authors were asked to consider all of the records held on the subject child, and relevant records on other family members. While they were asked to provide detail and analysis on the period of the scope of this review, they were also asked to provide a summary of information known to them from before the period in question in order to ensure that relevant and pertinent background information was available to the review. 7.2 The family have lived in Nottinghamshire since just after Sibling was born. Prior to that they lived in other areas of the UK. They had lived in Britain for a number of years before having a family. 7.3 Father disclosed to social workers after the death of JN15 that the police were involved briefly in another area of the country after a neighbour alerted them to an argument between Mother and Father. They attended the couple’s home but no further action was taken. Despite efforts to establish the details, this review has been unable to establish any further details of the incident. 7.4 Services for adults or children have no further details about either parent that is of concern during the period prior to the scope of this review. Final version 9.6.15 7 8 Key Practice Episodes 8.1 The period under review has been divided into two key practice episodes. Key practice episodes are periods of intervention that are judged to be significant to understanding the way that the case developed and was managed by professionals. The term ‘key’ emphasises that they do not necessarily form a complete history of the case but are a selection of the activity that occurred, and includes the information that is thought to be key in informing the review. 8.1 The first key practice episode covers from 2010 to 2013. This is the time prior to the birth of JN15 and includes information about the sibling. 8.2 The second episode covers from 2013 to 2014. The period from the birth of JN15 until his death. Key Practice Episode 1: 2010 to 2013. (The period prior to the birth of JN15, and including information about the sibling). 8.3 The pregnancy with and birth of sibling were unremarkable. The Midwife told the reviewer at the recall event that there were no indications of mental illness or domestic abuse. Mother was usually seen on her own. 8.4 Mother told the health visitor she was sharing her bed with Sibling, and advice was given about the dangers of co-sleeping. Mother continued to sleep with the baby. Other than this Mother was cooperative and the family were assessed as requiring a universal health visiting service1. 8.5 Mother and Sibling received routine support including baby massage sessions. They attended clinics and received advice on weaning. As part of the exploration of support available to new mothers the health visitor discussed the family’s church and Mother stated it was a large part of her support network and that she enjoyed attending. It was identified that Mother had little home support other than Father however, which was again noted by the health visitor when Mother was pregnant with JN15. 8.6 The parents consulted their GP a number of times regarding the sibling both before and after the birth of JN15. Appropriate advice and treatment was sought and provided. 8.7 When Sibling was nearly a year old they were referred to the Community Paediatrician due to a concern identified by the parents and health visitor that Sibling’s weight had fallen from the 75th to the 25th centile. Around this time the parents had concerns about Sibling’s regular bouts of diarrhoea and vomiting which they believed was due to Sibling recently starting to attend nursery. There was good information sharing between the heath visitor and GP and a decision was made to refer to a paediatrician. The health visitor also agreed to review Sibling on a three weekly basis. The support that was given included an acknowledgement of the fact that Sibling was a fussy eater and that Mother was anxious about introducing solid foods. 1 The Universal service is the core offer or minimum number of visits to a family i.e. where no additional area of support or need is identified during the comprehensive Health Needs Assessment (HNA). It consists of an antenatal contact (this was targeted in 2010/11 but is now universal), a birth visit by 14 days (10-14 days in 2010/11), a 6-8 week contact, 8-12 months review and 2-2.5 years review. Additional contacts would be client initiated and at drop-in Child Health clinics. Final version 9.6.15 8 8.8 Sibling was taken to A&E on occasion and information sharing between A&E and the community health professionals was appropriate. 8.9 In 2013 Mother was asked by her midwife about domestic abuse. The midwife recorded from a pick list that Mother had answered ‘no, never’. The question was not asked again, although it is noted by the agency report author that best practice sets out a requirement that a woman is asked at least three times about domestic abuse by midwives. This didn’t happen, despite it being recorded that Mother was seen alone on a number of occasions. Mother was also asked routine questions about mental health (her own and her family history) during her pregnancies with JN15 and Sibling, and she said there were no issues. 8.10 Later in 2013 Sibling was seen by the Community Paediatrician. As weight loss and feeding was no longer of concern Sibling was not seen again, but an open appointment for easy contact should concerns emerge was given to Mother. 8.11 The following month Mother made a 999 call to the Police and said that Father had kicked and punched her and that she was 21 weeks pregnant. Around five minutes later she rang back and said Father had left the home, that she was fine, and so she no longer required the Police. She was insistent that they did not attend, but eventually accepted that they had to. The Police established that there had been no previous incidents at the address, but an officer was sent to do a ‘safe and well’ check around 30 minutes later. When the police officer arrived Father had returned to the address but was packing a bag to leave. It was established that the argument had been about whether to give Sibling antibiotics. Mother would not discuss what had taken place, would not confirm there had been a physical assault, and no injuries were observed. Sibling was said to be safe and well and Mother stated she was not scared and was not at any risk. The sibling was not seen by the officer, but it was confirmed that this is not unusual as children are often in bed at the time of the incident. 8.12 In light of the lack of any complaint, no injuries evident and no indication of other risks, the police officer decided the case was standard risk. As is normal practice, the domestic risk assessment completed was checked by the police risk assessment team based within the domestic abuse department and it was agreed that standard risk was appropriate. This is despite Mother being pregnant at the time. 8.13 It should be noted that standard risk assessment notifications of a domestic abuse incident are not shared with health professionals. They are however shared with Children’s Social Care. In this case health professionals were the only ones involved with the family, so the information about the incident was not shared with those who knew the family and the child, or the midwife who was working with Mother during her pregnancy. As the risk was deemed standard the information was not shared with either parent’s employer, although they both work in notifiable positions2. 8.14 The police officer did not ask Mother why she had stated on the telephone that she had been physically assaulted. When the family were visited for this review Mother stated she had not been assaulted and that it was purely a verbal argument. Mother did not recall 2 The Notifiable Occupations Scheme relates to professions or occupations which carry special trust or responsibility, in which the public interest in the disclosure of conviction and other information by the police generally outweighs the normal duty of confidentiality owed to the individual. Final version 9.6.15 9 that she had told the 999 operator that she had been kicked and punched, but said she probably said this as she was angry with Father. 8.15 Sibling broke their arm in 2013. It was reported that they had been jumping on the parent’s bed and fell off. As a result of the fracture Sibling was seen by the orthopaedic consultant seven times in the coming months. A letter was sent to the family’s GP stating that both parents were health care professionals and that they ‘remain very anxious’. Exploration at the Learning Event led to the conclusion that the level of anxiety exhibited was not disproportional or particularly unusual. The consultant confirmed he meets a lot of anxious and concerned parents. An additional appointment at the fracture clinic for six months later was given after what would typically be the seventh and final appointment. An additional x-ray was also undertaken at Mother’s request and showed the fracture had healed well. The consultant confirmed during the review that this was due to the level of the parent’s anxiety and not because they were fellow health professionals. 8.16 This has been identified as a key practice episode because the parents were appropriately parenting the sibling without any concerns other than the telephone call made by Mother regarding an alleged domestic abuse incident in the home. When this review was being planned questions were asked about the perceived anxiety from the parents regarding Sibling’s health during this period, and this will be considered in the analysis section below. Key Practice Episode 2: 2013 to 2014. (The period from the birth of JN15 until his death). 8.17 There is little significant information available regarding the period leading up to the birth of JN15 until his death five months later. When they met with the reviewer the parents spoke of Mother feeling increasingly anxious after the birth of JN15. She described her experience of being a new mother as quite different with the two children. With JN15 she did not want to go out, and was ‘obsessed’ with keeping the baby safe. She avoided taking Sibling to nursery and didn’t like to attend clinics or other appointments with the children. Her memory was very poor at this time and she stated that she struggled to care for both the baby and an active toddler on occasion. This was particularly after JN15 had a urinary tract infection (UTI) at 2 weeks old, and she became even more anxious for the baby. She stated that with hindsight she can see she had post-natal depression, but was either unable or reluctant to acknowledge this at the time. Mother told the reviewer that with hindsight she believes that the psychosis which then developed was very quick and probably only occurred a day or two before JN15 died. 8.18 The health visitor spoke to the family after JN15’s visit to A&E and subsequent admission to hospital for assessment and intravenous antibiotics due to the UTI and stated she felt their anxiety was appropriate. She recognised they used her to double check any health concerns, not just relying on their own knowledge. From the first visit after the birth of JN15 Mother was thought to be attentive and appeared to be very happy with the baby. He was a demanding feeder, and Mother was focused on that, but over-anxiety or low mood was not evident. Sibling had remained in full-time nursery, and was being transported to and from there by Father. Mother brought JN15 to one clinic and to the GP for two immunisation appointments and the 8-week check. Mother was invited to a parent and baby group, she did not attend but this is not unusual with a second child. The family told the reviewer that Mother did take part in family activities during this time such as swimming, however Mother did state that she stopped attending church and preferred to stay home. Final version 9.6.15 10 8.19 All of the professionals involved can evidence they asked Mother how she was and she always stated that she was well. At the time the NICE guidance in use had trigger questions regarding low mood. The health visitor was clear at the learning event that she complies with the guidance, and the status of the parents as fellow medical professionals would not have made a difference. 8.20 JN15 was seen at the hospital regarding a routine issue identified at birth in late 2013. No concerns were identified. 8.21 On the day that JN15 died the ambulance service received a 999 call from a neighbour of the parents. An ambulance was dispatched to a ‘child cardiac arrest’. Father was present when the ambulance arrived. He told the crew that Mother had been unwell for a few days and had possibly been hallucinating. A safeguarding referral was made en-route to the hospital. The child was pronounced dead shortly after arrival at the hospital. 8.22 Father repeated the history when he arrived at the hospital with JN15. He stated that Mother had been acting strangely for around 3 days including claiming that God had appeared to her. It became evident that in the days prior to JN15’s death Mother had made contact with at least one family member by text message and that she had spoken to a friend who was a minister of religion in another city. She had spoken to them of her concerns, including that the world was ending. 8.23 The minister was spoken to by the Police after the death of JN15 and he confirmed that he had spoken to Father early on the day that JN15 had died and explained his concerns about Mother’s health. He said that Father had confirmed he also had concerns and that he would be seeking an appointment for her with someone who could help. When visited by the reviewer, Father stated that he did not even consider that Mother was suffering from a psychosis and that her behaviour over the weekend was not of particular concern to him. 8.24 This is a key practice episode because there was limited professional contact with the family, and what contact there was did not lead to the identification of any concerns about Mother’s mental health or her care of either child. This is understandable as the onset of the psychosis was allegedly very rapid. The only person in direct contact with Mother over the weekend was Father and he states her deteriorating mental health was not evident to him. The minister believed that it was evident that Mother was unwell when he spoke to her 2 days before JN15 died. He did not communicate this to Father until the morning of JN15’s death however. 9 Analysis by theme 9.1 The analysis section of this report will consider the information above, all of which was gained from the Agency Reports, from the staff who had worked with the family and attended the Learning Event, and from the family themselves. At the learning event the key themes in this case were identified. This section will provide a thematic analysis. 9.2 The questions in the terms of reference were considered and answered in the majority of agency reports. The information included in those reports has been considered as part of this analysis. 9.3 The themes that emerged and will be considered are: - Professional status and the families class and culture - Parental anxiety Final version 9.6.15 11 - Domestic abuse - Maternal mental health 9.4 Viewed from a systemic perspective it is important to consider how these themes influenced and impacted on each other, and if they had an impact on the circumstances which are the reason for this review. 9.5 Professional Status and the families class and culture 9.6 At the learning event and in the agency reports, professionals including those working with the family were asked to comment on the impact of the parent’s occupations on the services they received. As both parents are health care professionals the review wished to consider the impact of this on the approach taken by the agencies involved. 9.7 The parents asked for an additional x-ray to reassure them after Sibling’s fracture, they also requested and were given an additional appointment with the consultant regarding the fracture. This does not appear to have been due to the parent’s occupations, but because of the level of anxiety they showed. The consultant said this is not unusual. 9.8 The health visitor is an experienced practitioner who works in an area where predominantly middle class professional people live. She was clear that her work with the family was undertaken regardless of their status or professions. After Sibling had lost weight health visitors provided additional visits to support the family. This was good practice. It was not assumed that because of their jobs the parents could manage without the support. 9.9 Mother and Father knew some of the hospital and community health care professionals involved with the family in a professional capacity, however no issues were identified in regards to this. 9.10 The police officer who attended after the domestic abuse allegation made by Mother was told about the occupations of the parents, and observed their nice home and relatively affluent life-style. He followed procedures however and the status of the family did not appear to have any impact on the assessment he made. 9.11 As both parents are health care professionals who would have some responsibility for safeguarding in their job, it is probable that they would have been aware of the process that follows a domestic abuse visit from the police. In this case it has been identified that both parents were concerned about the potential stigma for both themselves and their child. 9.12 This may have also had an impact on the decision by Father not to alert services to his wife’s deteriorating mental health over the weekend before and on the day that JN15 died. Father fervently denies this however. 9.13 Parental anxiety 9.14 Mother’s anxiety was noted by staff on a number of occasions during their contact with the family. For example in relation to the weaning and feeding of Sibling, Mother asking the health visitor whether taking a baby to church would be harmful due to the loud singing, and the impact on Sibling of the broken arm. It is also interesting to note Mother’s own admission that she became very anxious about infections after JN15’s UTI at just a few weeks old. 9.15 The professionals involved were clear that while Mother was anxious, it was not exceptionally so, and they felt that this was understandable in light of her job and her Final version 9.6.15 12 knowledge of what the potential worst-case scenarios could be. Also being a new mother with no support from her own extended family meant that Mother relied on professionals for support and advice on occasions. 9.16 The extent of Mother’s anxiety regarding JN15 was not identified until after his death. She stated to the reviewer that her anxiety was heightened after the birth of JN15. She stated however that she was otherwise managing well. The family were assessed by the midwife and health visitor, including mother’s mental health, and universal services were thought to be required at this time. The review was assured that had any issues been identified an additional appointment would be made and the concerns followed up. 9.17 Both parents anxiety about the reaction to the domestic abuse allegation and later to Mother’s diagnosis is understandable and probably common. It is particularly significant with their chosen occupations. The impact of mental health and safeguarding concerns on their jobs is potentially significant and would have been a further cause of anxiety for them. 9.18 Domestic abuse 9.19 It has not been possible to access information from the previous area where the family lived regarding the one police involvement after a neighbour called the police. The lead reviewer for this SCR discussed this incident with the parents when she met them. They stated that they were having a row which was loud. They described married couples shouting at each other as their cultural norm, and said that no one was harmed and no violence took place. 9.20 The incident in Nottinghamshire in April 2013 was described in the same way by the parents. Mother stated that she had not been physically assaulted and could not account for why she had told the 999 controller that she had been, other than her being angry with Father. 9.21 In December 2011 the NSPCC, as part of their research for the ‘All Babies Count’ campaign, analysed their collection of SCRs relating to children aged less than one year. Of the 130 babies in England and Wales who had been the subject of a serious case review from 2008 – 2011 domestic abuse was a factor in at least 60 of these cases, and parental mental health was an issue in at least 34 of the cases. In this case however there does not appear to be a link between the death of JN15 and the domestic abuse incidents the review is now aware of. 9.22 In a briefing paper published in November 2013 the NSPCC outlined a number of other factors which can increase the risk to children who live in families where domestic abuse is present. They include mental health problems. As Mother’s mental ill health appears to be directly related to the birth of JN15 there is no evidence that the domestic abuse incident in April 2013 was related to Mother’s mental health problems. 9.23 The NSPCC report also outlines the triggers for domestic abuse, which includes pregnancy, and suggests that a risk assessment is undertaken in these cases. A nationally recognised risk assessment tool was used to complete the assessment after the Police visited the family, and the result was standard risk. This means that there was no requirement for any additional work with the family after the incident. The health visitor and the GP were not informed of the incident. While this would not necessarily have made a difference in this case it might in others, so a recommendation has been made in regards to this. Final version 9.6.15 13 Maternal mental health 9.24 There is no evidence that Mother had any mental health issue prior to the birth of JN15. She had experienced stressful situations in her life, including; moving to a new country; converting to a new religion which she was concerned would affect her relationship with her own family; and undertaking training for a demanding and stressful job. There is no evidence that she had any serious or other mental health concerns at these times. She was also well following the birth of Sibling. 9.25 It is widely recognised that the first three months after the birth of a baby ‘pose the greatest lifetime risk for new mothers in developing mental health difficulties’3. JN15 was 5 months old at the time his mother developed postpartum psychosis, however Mother now recognises with hindsight that she had been suffering from postnatal depression before the episode. She stated that she kept this hidden from professionals and her husband at the time. “Women with mental health needs are often reluctant to seek help because of fears that they will be judged as inadequate mothers and their children will be ‘taken away.’ (Stanley et al 2003). Mother, as a health care professional and an experienced mother, may have been concerned about the impact on her work and her care of Sibling if she had sought help for post-natal depression. 9.26 Mother told the reviewer she was not aware at the time that she was suffering with mental health issues postnatally. She said that while she felt different after the birth of JN15 compared to after the birth of Sibling, she had no idea that she was ill. She stated that she certainly did not foresee that she would have a serious mental breakdown that could put her child’s life at risk. Father also stated he had no idea that his wife was mentally ill. He said that Mother was fine for much of the weekend. She was reading the bible a lot but this was not particularly unusual. She was questioning what was written and asking his opinion, but again he described them having a number of heated religious conversations in the past, and did not feel this was unusual. 9.27 Recent NICE Guidance CG192 Published December 2014 (and therefore after the death of JN15) informs health professionals of a newly clarified expectation; ‘if a woman has a sudden onset of symptoms suggesting postpartum psychosis, refer her to a secondary mental health service (preferably a specialist perinatal mental health service) for immediate assessment (within 4 hours of referral)’. In this case Mother was not referred to any professionals and none had contact with her within the timeframe of her sudden illness. 9.28 Mother stated that she did not have the classic symptoms of post-natal depression. She suffered with insomnia and did not want to go out, but she was not tearful and had a good appetite. Father stated he did not identify post-natal depression in Mother. The NSPCC report 'Prevention in Mind‘4 identifies that postnatal depression effect 15% of women in the antenatal period and 10-20% in the postnatal period. Post partum psychosis however affects just 2 in 1,000 new mothers. Unlike postnatal depression, postpartum psychosis is a psychiatric emergency. ‘It requires urgent assessment, referral, and usually admission, ideally to a specialist mother and baby unit’5. 3 Howe D (2005) Child Abuse and Neglect, Attachment, Development and Intervention Palgrave McMillan New York 4 Prevention in Mind (All Babies Count: Spotlight on Perinatal Mental Health) By Sally Hogg 2013 5 Jones I, Shakespeare J; Postnatal depression. BMJ. 2014 Aug 14;349:g4500. doi: 10.1136/bmj.g4500. Final version 9.6.15 14 9.29 Postpartum psychosis is different from postnatal depression. ‘It is a more severe illness. There are many different ways the illness can start. Women often have symptoms of depression or mania or a mixture of these. Symptoms can change very quickly from hour to hour and from one day to the next’6. The Royal College of Psychiatrists state that postpartum psychosis (or puerperal psychosis) ‘is a severe episode of mental illness which begins suddenly in the days or weeks after having a baby’. In regards to Mother, the symptoms appear to have developed later than is usual, and the reviewer questioned if this may have confused Father, as on-set after the first months of a baby’s life is relatively rare. Father stated that he was not confused, and that Mother did not show any signs of psychosis in the days leading up to the death of JN15. 9.30 The Royal College of Psychiatrists point out that the psychosis can ‘happen to any woman’. And that it often occurs ‘out of the blue’ to women who have not been ill before. What is clear is that ‘it can be a frightening experience for women, their partners, friends and family’. The on-set is swift and professional and specialist help should be gained within hours of the first signs emerging. This did not happen in regards to Mother. No professionals were alerted to the changes which appear to have been developing over the days before the death of JN15, as shown by the statement of the minister of religion who spoke to Mother two days before JN15 died. As is the case for Mother, ‘women usually recover fully after an episode of postpartum psychosis’. 9.31 There are likely to be many factors that lead to an episode of postpartum psychosis. Genetic factors are important. A mother is more likely to have postpartum psychosis if a close relative has had it. Mother told the reviewer that there is no history in her family, to her knowledge. She did point out however that there would be a taboo about discussing mental illness in her culture. Postpartum psychosis is more common in first rather than subsequent pregnancies, and when the birth has been complicated or traumatic. Again, this was not the case with Mother. 9.32 The hospital where Mother had both her children has clear guidelines for the ‘Identification and Management of Women at Risk of Serious Mental Illness.’ It states that a full history must be taken and fully documented at the booking appointment. The midwife is told to enquire about previous and family history using a screening tool. There are clear actions to be followed when concerns are raised. During Mother’s booking appointment it is documented that the guidance was followed and she was asked routine questions around mental health to screen for mental health issues. This mental health screening tool was completed at the booking appointments of both pregnancies. Mother said there were no issues regarding her current or previous mental health and her family’s mental health. 10 Conclusions and lessons learned 10.1 The following is a summary of the learning from the review. Good practice is also identified. 10.2 There are very few lessons to be learned from this review. This is not because the agency report authors or the professionals who attended the learning event and recall day were not rigorous in their task of reviewing and analysing the work undertaken. On the whole practice was good in this case. It appears that both individually and systemically things work well in Nottinghamshire. There were no signs to suggest that Mother was struggling with post-natal depression or that she was at risk of perinatal psychosis. The baby was 5 6 From http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/postpartumpsychosis.aspx Final version 9.6.15 15 months old and was her second child, there were no concerns about the first pregnancy and perinatal period, and there was no known mental health history for Mother or in her wider family. She would not be considered high risk for this type of mental illness. 10.3 The days and hours before the death of JN15 may have been a distressing and concerning time for the family, as well as raising concerns for the care of the baby. However there was nothing that professionals could do as they were not alerted to the deterioration in Mother’s mental health on the day that JN15 died. Had they been, there is an established process of caring for the mother and child in such cases, and it is likely they would have been followed. 10.4 Father insists that there were no signs at the time that Mother was seriously ill and that he would not have left her alone with the baby had he even suspected anything was wrong. This is despite him leaving his friend feeling reassured that he would seek specialist help. 10.5 While the review acknowledges the parents assertions that they were not aware of Mother’s difficulties prior to the death of JN15, the review considered that there is a wider perceived stigma of mental illness among health care staff and it was agreed that this must be acknowledged in this review. Challenging this is a priority for all organisations. Professionals who might be unwell should be encouraged and enabled to access care and support, and commit to treatment. 10.6 Good practice identified: • The family received a good universal health service from all of the professionals involved. • Sibling received a timely and appropriate service in regards to his weight loss and fracture. • Additional support was offered when issues were identified, for example when Sibling was losing weight and was a difficult feeder the health visitor provided additional support. • Despite Mother calling the police to say she no longer required them to visit regarding a report of domestic abuse in 2013, an officer went to the home and spoke to Mother. This was followed by a risk assessment. • There was appropriate information sharing between the hospital and community health colleagues. • All of the relevant professionals asked Mother how she was after the birth of JN15. She replied that she was well and this was clearly recorded in agency records. • The health visitor clearly knew the family well and provided a sensitive and appropriate service to them. • The record keeping was good across agencies. 10.7 While there are relatively few lessons to be learned, Nottinghamshire Safeguarding Children Board can reflect on the following which has been established from this review: Lesson 1: Nottinghamshire Police followed procedures by informing Children Social Care of a domestic abuse incident in 2013. The health professionals who were the only people having Final version 9.6.15 16 contact with the family were not informed. It is not current policy to share police notifications with a standard risk with health visitors, school nurses or GPs. The receipt of a police domestic abuse notification could increase the input to a family from universal to targeted. A recommendation has been made in regards to this. Lesson 2: When pregnant a woman is more at risk of domestic abuse. The current national risk assessment tool in use includes pregnancy as a risk factor; however, on its own this does not automatically increase the level of assessed risk. Lesson 3: While information sharing locally was good, information regarding the call out for a domestic incident in another geographical area was not available to Nottinghamshire Police either at the time or for the purpose of this review. The NSCB may wish to inform that area LSCB of this matter. 10.8 None of these identified lessons would have made a difference when Mother became critically ill and JN15 died. JN15’s death was not predictable to any of the professionals involved with the family. 11 Recommendations 11.1 Each agency report submitted to this review was asked to provide information on any changes within their agencies since the death of JN15. The following were identified, although none were specific to this case: • The relevant NHS Foundation Trust have updated their template for recording information to ensure consistency of information gathering. • Maternal mental health training is being delivered to all health visitors as part of the health visitor implementation plan. • As part of the Healthy Child Programme all mothers will be visited by the Health Visitor antenatally (this was not routine at the time of JN15’s birth) and postnatally. • All midwives were trained and updated in the autumn of 2014 around domestic abuse. A flowchart was also launched outlining the pathway and emphasising that domestic abuse enquiries should be made three times during pregnancy. 11.2 All agencies were asked to make relevant recommendations that are agency specific. Only one single agency recommendation was made, and the lead reviewer accepts that in this case this is appropriate and proportional. 11.3 The agency recommendation that has been made was by the relevant Hospital and states they will ‘conduct an internal audit of ‘routine enquiry’ during pregnancy about domestic abuse’. 11.4 NHS England has very recently (13 May 2015) highlighted the work being undertaken recently in Devon and Torbay, where all women giving birth in hospital are asked by midwives about their mental health and referred onto perinatal heath team if required. Local hospitals in Nottinghamshire will now be considering if they can implement such an approach in the future. 11.5 This overview report makes two recommendations for the NSCB. They are: Final version 9.6.15 17 Recommendation 1: NSCB to share the learning from this review with staff across all partner agencies, and the other LSCB where the first reported domestic abuse incident took place. Recommendation 2: The NSCB should consider the feasibility of extending information sharing on police notifications of domestic abuse incidents that are graded as standard with relevant health colleagues. This is of particular importance when the incident involves a pregnant woman. |
NC52801 | Significant injuries, thought to be non-accidental, to a 3-month-old baby in May 2022. There are likely lifelong health implications as a result of the injuries sustained. Learning themes include: identifying and responding to the vulnerability of babies; pre and post birth levels of need; the importance of understanding contextual parental factors; keeping a focus on the child when there are moves between areas; the role of housing providers in understanding risk; health services information sharing; record keeping; and critical thinking in practice. Recommendations for the Partnerships include: health recording systems should include a holistic assessment of a child's needs which includes contextual maternal and paternal family factors; ensure all health professionals have access to information and guidance when assessing any adults who may be care experienced; implement training for NICU staff about increasing confidence and knowledge when working with domestic abuse; further embedding the ICON 'babies cry, you can cope' programme and increasing awareness of non-accidental injury in babies; ensure effective transfer of information between areas and services; develop a communication pathway between midwifery, health visiting, and GPs to ensure the learning from this review is included in the standard operating procedure (SOP) so that it adequately covers families that move between areas; and safeguarding supervision arrangements for community health professionals should ensure there is a safe space for critical thinking in practice, promote professional curiosity, and enable a trauma informed approach to the family's needs when working with a pre and post birth situation.
| Title: Local child safeguarding practice review: Baby M: unexplained non-accidental injury in children under 1 year. LSCB: South Gloucestershire Children Partnership and Bath and Northeast Somerset Safety and Safeguarding Partnership Author: Sarah Holtom Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 South Gloucestershire Children Partnership & Bath & Northeast Somerset Safety and Safeguarding Partnership Local Child Safeguarding Practice Review Baby M: Unexplained Non-Accidental Injury in children under 1 year April 2023 Report Author Sarah Holtom MSc BA(Hons) DipSW 2 Contents Introduction 1. Reason for the Local Child Safeguarding Practice Review 1.2 What we Did 1.3 Aim & Methodology Baby M & Family 2.1 The Voice of Baby M’s father 2.2 Summary of what happened What was Found 3.1 Findings Summary 3.2 Impact of Previous Local learning: South Gloucestershire Analysis, with Learning for Practice & Systems 4. Key Learning 1: Recognising and Responding to the Vulnerability of Babies 4.1 Pre and Post Birth Levels of Need 4.2 The Importance of Understanding Contextual Parental Factors 4.3 How we support families, understand needs and keep babies safe 4.4 Working with Fathers 5. Key Learning 2: Focusing on the child when families move between areas 5.1 The role of housing providing in understanding risk 5.2 Health Services Information Sharing 6. Key Learning 3: Supporting critical thinking in practice 6.1 Acknowledging the realities of day-to-day frontline practice: 6.2 Record Keeping 6.3 The importance of checking language Recommendations Executive Summary This LCSPR considers Baby M, who suffered serious and significant injuries at age 3 months thought to be non-accidental. There are three key areas of focus: 1. Identifying & responding to the vulnerability of babies 2. Keeping a focus on the child when there are moves between areas 3. Critical thinking in practice Analysis of these areas is given through sections 4-6 of this report and leads to the following recommendations with actions starting at page 22 of the report as follows: 1. Health Recording Systems include a holistic assessment of a child’s needs which includes contextual maternal and paternal family factors 2. The ICON Programme & increasing awareness of Non-Accidental Injury in Babies 3. Effective Transfer of Information between areas and services 4. Safeguarding Supervision arrangements for community health professionals which ensures there is a safe space for critical thinking in practice, promotes professional curiosity, and is trauma informed approach to the family’s needs when working with pre and post birth situations. 3 Introduction 1.Reason for this Local Child Safeguarding Practice Review The reason for this Local Child Safeguarding Practice Review (LCSPR) is to consider Baby M, a three-month-old baby who experienced serious and significant injuries, thought likely to be to be non-accidental1. According to National data2, babies under the age of one have consistently been the largest category of serious incidents notified to the National Panel3. In 2021, 32% of incidents of non-fatal physical abuse involved children younger than a year old. Following a Rapid Review in July 2022 and in consultation with the National Panel, South Gloucestershire Children’s Partnership (SGCP) and Bath and North East Somerset Children’s Partnership (B&NES) jointly agreed the criteria for a local review was met4. The purpose of the joint arrangement was to understand the moves between geographical locations pre and post birth and the implications for both Partnerships in terms of practice and system learning. 1.2 What We Did This Review examines likely non-accidental injuries to a child under 1 years of age. Non-accidental injuries are a serious form of physical abuse and can be life changing with significant long-term disabilities or death. This type of abuse may arise from shaking babies (which is often referred to as abusive head trauma, AHT) or from impact injuries. Such non accidental injuries can often happen when a parent becomes angry or frustrated because of a child’s crying5. The Review Group analysed a ten-month timeframe from July 2021 (Baby M’s 7-week booking in appointment with midwifery services) until May 2022 (presentation at hospital). This covers a 7-month period pre-birth and 3 months following birth. There has been a critical eye on what historical contextual factors were known by agencies about Baby M’s parents prior to this time period and what attention they were given. The aim being to better understand how decisions were reached and why certain actions were or were not taken. The Review considered all the identified key lines of enquiry from the Rapid Review which can be summarised as: • Understanding how professionals assessed risk pre and post birth, paying attention to what was known about parental contextual factors and when suspected parental or wider family behaviours of concern were raised • Analysing professional understanding of what life was like for Baby M when his mother, Ms M, moved between geographical areas • Consideration of how the learning from two previous South Gloucestershire Serious Case Reviews ‘Toby’ and ‘Babies E&F’ have been embedded in practice and systems 1.3 Aim & Methodology The purpose of this Review is to understand the events leading up to Baby M’s injuries by analysing decision and actions within the organisational systems in which professionals work, day to day. Through a systems methodology the review consisted of three phases: • Data gathering and the development of a reconstruction (without the benefit of hindsight) of what was knowable at the time through written records, data, policies, and procedures. 1 Non-accidental injury (NAI) is defined as “any abuse inflicted on a person or knowingly not prevented by a care giver where the injury is not consistent with the account of its occurrence” Rizwan, M et al 2017in International Journal of Integrated Care 2 Child Safeguarding Practice Review Panel Annual Report 2021 November 2022 HMO: Gov 3 The Child Safeguarding Practice Review Panel is an independent panel commissioning reviews of serious child safeguarding cases. They want national and local reviews to focus on improving learning, professional practice, and outcomes for children 4 Child safeguarding Practice Review Panel guidance for safeguarding partners September 2022 HMO: Gov 5 NSPCC Core Information: Head and spinal injuries in children May 2014 4 • Appraisal of practice and explanation for why decisions were or were not taken via a practitioner workshop and meetings with the review panel to agree and appraise key practice episodes. Quotes from practitioners who worked with Baby M and parents are used so as to highlight typical experiences in day-to-day practice • Involvement with family members, being mindful of the police investigation, with regular meetings with the Senior Investigating Officer This Review does not address the question of how Baby M sustained the serious injuries as there are separate parallel processes in place to determine this and make decisions about the child’s future care arrangements. The Review focuses upon how agencies understood the risks and how they worked together and with the family. This Review provides reflections against previous local reviews in South Gloucestershire6 and national learning7. The LCSPR attempts to understand the rationale for strengths and shortcomings seen in practice and considers in the recommendations what additional support is required in individual systems and across South Gloucestershire and B&NES Partnerships to reduce the chance of a similar situation happening. The findings and recommendations for practice and system change were agreed with both Partnerships. The Review finds the majority of direct work with the family was undertaken by a housing provider to the mother, Ms M and Health Services (Midwife Services, Hospital, GP, and B&NES Health Visiting Services postnatally). There was a limited role and input by Children’s Social Care and Police until the injuries were known. The review process involved working with this range of multi-agency professionals. It included those practitioners who knew the family well, managers who provided supervision and senior managers responsible for the services provided so as to best understand Baby M’s day to day experiences and responses to identified needs. This Review appreciates the considerable time and efforts by all agencies involved in preparing written evidence and chronologies and thanks all who contributed. The openness and honesty shared by all professionals working with the family has been invaluable - their ability to look back and reflect on what could have been done differently and what went well lies at the heart of this Report. This has not been easy, because finding out that a baby you have worked with has been significantly harmed is difficult work with a range of emotions felt; the professionals involved in this review have demonstrated a collective commitment and bravery to consider how to strengthen systems and practice in their local areas when working with parents pre-and post-birth when parental vulnerabilities are known. 2.Baby M & Family In order to maintain a level of protection and privacy for Baby M and their birth family, a limited story is provided. This section provides a factual account of what happened pre and post birth during the 10-month timeframe. 2.1The voice of Baby M’s family: The contributions of the family have been sought for this LCSPR to aid system thinking. The maternal family have decided not to participate, likely due to other parallel processes being underway at the same time as this LCSPR. Mr M has shared his views with the Independent Reviewer as part of this process. This has been helpful to better understand what may have helped or hindered multi-agency practice and the Reviewer is grateful for Mr M’s time and reflections. Mr M spoke of his hopes as a 1st time father to Baby M as “wanting to do the best I could as a dad because I did not have the best start or upbringing in childhood. I wanted it to be different”. Mr M has shared great honesty in explaining how he thinks he could have reached out to professionals and asked for more help as a new father, but he worried about doing so given 6 Serious Case Review: Baby E and F 2019 7 The Myth of Invisible Men: safeguarding children under 1 from non-accidental injury caused by male carers, The Child Safeguarding Practice Review Panel September 2021 HMO: Gov 5 his own childhood experiences. Mr M’s biggest fear was that Baby M would end being taken from him and placed in the care system as he was. Mr M said the main issues centred upon conflict and arguments between Mr & Ms M and not having the right support to manage the stresses of becoming new parents, managing disagreements, and working through the range of emotions felt. Despite having some extended family support Mr M said he would have welcomed help regarding ensuring healthy adult relationships and navigating safe ways through when things became difficult. Mr M does not remember any professional who saw the extent of the relationship difficulties or discussed this aspect with him. Mr M reflected upon what could have helped him which included: • Checking out why young people might withdraw from support and services as a care experienced young adult – in this situation Mr M explained how he had not had the best experiences when in care, and the main barrier being a frequent change in workers which made it difficult to feel it was worth investing in relationships. He did not believe it would be any different as a young adult. • Ensuring clear communication regarding the change in personal advisors as Mr M was confused as to who his personal advisor was and how to contact them. • Practical help and support for new parents as Mr M found it hard to budget in times of financial hardships, especially when buying nappies and milk and specific items for Baby M. 2.2 Summary of what happened Baby M and Ms M did not have a settled place to call home during the ante-natal and post-natal period. Baby M’s maternal family originate and live in the South Gloucestershire area and the paternal family reside in B&NES. As a growing unborn baby, Baby M lived in South Gloucestershire initially temporarily in a hostel and briefly in supported housing, before going to live with Mr M and family in B&NES just before birth. This was a critical time to move areas as it resulted in a change in health visiting services from South Gloucestershire to B&NES, with all postnatal care to Baby M and family being provided by B&NES (HRCG). Following a hospital birth, Baby M was discharged back to live with both parents in B&NES to the extended paternal family home. Due to “difficulties” Mr M & Ms M’s relationship ended in April 2022 and Ms M, was provided with a different supported home by the same housing provider back in South Gloucestershire. Baby M had been living in the paternal family home in B&NES in May 2022 at the time of the “floppy” episode which required hospitalisation, where likely non-accidental injuries were found. Very little is known regarding mother, Ms M’s childhood and early adult experiences living in South Gloucestershire; there are general comments seen for this LCSPR such as “she lived in a close and supportive family”. Housing information shows that at the 8-week booking in appointment in July 2021 Ms M was living in a hostel in South Gloucestershire. Ms M self-referred via the Housing Access Team for accommodation and said this was needed as a result of family breakdowns, aged 22 years. Ms M moved to a different supported housing provision in South Gloucestershire from December 2021. There is limited professional exploration of what happened to Ms M and why supported housing was needed in all documentation analysed for this Review. The need for a more enquiring stance is a theme which is considered throughout this LCSPR (see Key Learning 3). Baby M’s father Mr M is a care experienced young adult, who upon reaching adulthood returned to live with members of his extended family. His care status was known by some professionals, namely midwifery and not by others, such as both Health Visiting services and GP Practice in B&NES and the housing provider in South Gloucestershire. In B&NES the current GP Practice (as in line with good practice guidance) is to not record care leaver status via the recording system codes unless permission is given by the young person. The GP 6 practice expectation, which is currently being strengthened in B&NES8 (see Recommendation 1) is that through conversations between the person who is care experienced and the GP, the context, impact of any care experience and decision about how this record is made. A code may or may not be then added to the GP records based upon informed consent with the adult who is a patient and who is care experienced. Leaving care support and services were provided as in line with statutory duties in B&NES9. Baby M’s paternal family history in B&NES is well documented in Children’s Social Care electronic records with evidence of extensive historical adverse childhood experiences. Despite information being readily available on children’s social care systems, the Review finds the care experiences were not understood in any detail by any service or professional working with Baby M. The Review Group discussions have centred upon the importance of ensuring a joined-up approach when working together, especially when key parental information becomes available. In this situation Children’s Social Care and Health Services needed to have had discussions at key points in Baby’s M story regarding Mr M’s childhood and care experiences and assess the impact of his experiences, if any, upon his parenting. There has been debate seen as to which agency should have ensured these conversations were held once Mr M’s care leaver status was identified, as Children’s Social Care held extensive information, but this was not joined up with its own systems and Midwifery became aware of basic information at the booking in appointment. This reminds of the importance of checking out further information once some basic information is known so as understand a fuller picture and determine what this might mean in terms of risk or resilience factors and is explored further in Key Learning 1. The Care Leavers Service became involved in multi-agency work once the rapid review process10 began. Piecing together a picture of what day to day life was like for Baby M during the 1st three months has been difficult as the information seen as part of this process has often lacked detail to understand the narrative of Baby M’s lived experiences. It has taken time to clearly establish from health professionals a simple timeline of where Baby M lived, and it is apparent that this story was not factually held by any one professional until pulled together by this LCSPR. This shows evidence that health agencies assumed Ms M was providing the day-to-day care for Baby M and once this assumption was made, it was not checked further as to where Baby M was living or who was caring for him. This Review finds this was not the likely reality from factual evidence gathered, as despite what records show, it seems more likely from practice discussions that Baby M lived for most of his first three months of life in B&NES with his paternal family. The long-term impact of Baby M's injuries remains unknown; there are likely lifelong health implications as a result of the injuries sustained. 3. What we Found To all initial appearances during the antenatal and postnatal period, a professional picture was seen of Baby M progressing as expected in his parents’ care, with no obvious safeguarding concerns identified. The recorded evidence is clear that Baby M’s physical health care needs were being met with Ms M and Mr M are described as providing “loving care”. Such observations and records are not disputed. Assessing risk is extremely complex work and requires making judgements on the likelihood of harms, when in this situation a wider contextual history is not fully known and understood 8 B&NES GP & Practice Staff resource Pack July 2022 BSW CCG-ICB LAC Resource Pack for Primary Care July 2022 v4.pdf 9 See Children (Leaving Care) Act 2000 www.legislation.gov.uk 10 A rapid review is a multi-agency meeting that is undertaken in response to a serious and significant child safeguarding incident and needs to happen with 15 days of being notified as a serious incident occurrence. 7 by health agencies during pre and post birth times. It requires time to probe further with families; to find out more information when there are gaps seen and time to read historical information held on systems. Alongside this, there needs to be a reflective space available to stop and think, with dedicated supervision sessions for busy professionals to consider all the domains of a child’s life. Much documented research and previous local and national reviews11 show how risk can change very quickly and with dire consequences, especially for very little babies. This Review provides a salutary practice and system reminder of the impact of working in health systems which focus upon the need to complete essential tasks, such as taking blood pressure, testing urine, evaluating, and recording medical history. This can mean there is limited professional capacity to have sufficient opportunities to also ensure a relational approach which focuses upon considering the wider risk factors than a child’s physical health needs alone when working with families. Such systems operate at the detriment of building meaningful connections with families. This is further compounded when there are added complexities then faced by busy professionals, such as when families move between areas. In such systems when on “the face of things” all appears well for very little children, no further questioning is undertaken, and a fixed view can be adopted. Of course, it is unrealistic to think all risks will be known in every situation and in some situations, risk cannot be predicted – working within these levels of complexity and system priorities is the harsh reality faced by health professionals in their day-to-day practice with families. What is required is professionals who are well supported in the systems in which they work to ensure they are enabled to adopt a probing lens. Such inquisitive, open-minded practice should ensure a holistic picture of day-to-day life is obtained. This is needed when working with very little children in particular, due to their innate vulnerabilities, which ensures parental needs, including their own histories are understood and supported and wider family context is considered to safeguard all babies effectively. If a full a picture as possible is known of a baby’s day to day life, along with their wider family systems, this increases the chances of risks being managed, with multi-agency actions taken to keep children safe and support provided to their parents during this time. The purpose of any Child Safeguarding Practice Review is to identify improvements that need to be made locally and nationally to safeguard, promote the welfare of children and to seek to prevent or reduce the risk of recurrence of similar incidents occurring12. This section provides a summary of findings which centre upon three key practice and system areas. 3.1 In summary the findings are - Identifying and responding to the vulnerability of babies: Health services were task focused on Baby M’s physical health needs and this was not balanced sufficiently with ensuring relationship-based approaches to build a connection with parents. • As the focus was on the general physical health and development of Baby M, insufficient attention was given to understand the parents’ contextual history to gain a comprehensive picture of need. • Mr M attended some meetings and appointments: this work could have been strengthened to understand his needs as a 1st time father and what support he needed. • Father’s contextual family history in particular needed joining up with other parts of the professional network so as to understand risk and resilience factors. • Health systems did not support effective working for busy NICU staff, midwives, GPs, and health visitors. 11 National Review into the murders of Arthur Labinjo-Hughes and Star Hobson, The Child Safeguarding Practice Review Panel 2022 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1078488/ALH_SH_National_Review_26-5-22.pdf 12 Child Safeguarding Practice Review Panel Guidance September 2022 www.gov.uk 8 • Limited conversations were held by health professionals with parents to understand their relationship, despite concerns being seen in hospital. Parental mental health needs remained unassessed. • Concerns regarding the paternal family’s language and behaviours seen in different parts of the safeguarding system were not joined up effectively for Baby M. • As a result of different pieces of information being seen in isolation, the levels of intervention were set at too low a level as all assessments of parental abilities were typically made on one-off agency observations and not within a multi-agency context. • This meant statutory partner agencies (Early Help Services/Children’s Social Care) did not work with the family to share information, assess parenting capacity, identify any likely risks, and provide parents with support. • There has been some impact from 2 previous local reviews in South Gloucestershire seen around ICON messages, but further work is required. Keeping a focus on the child when there are moves between geographical area: • Information was not clear about where Baby M lived before or after birth and this meant a picture of his day-to-day life was not known. • No one professional had a grip of who the main carer was for Baby M and assumptions were made likely based upon stereotypical views on parenting roles. • Child Health Records were the primary point of contact to understand moves. The transfer of information between health systems when Baby M moved local areas was reliant on the family/Ms M informing of the moves. • Typically, agencies were reliant on Baby M’s parent informing them of moves. • The focus on the baby got lost, and at times Baby M was hidden in plain sight as assumptions were made that he was living with Ms M despite not being seen by the Housing Provider. • Information sharing was too variable between areas and health services and with housing providers and more collaborative approaches were required. Critical Thinking in Practice • Health professionals did not ask sufficiently probing questions to understand the families’ contextual histories, with current parental needs and unsettled living arrangements pre and post birth in terms of impact on Baby M. • Health visiting record keeping was poor at times, with limited detail seen to provide any story or purpose to the intervention. • The language used at times was factually incorrect / or did not distinguish fact from opinion and was not specific enough to describe what was being seen. 3.1 Impact of Previous Local Learning: South Gloucestershire This LCSPR has analysed the impact on practice and systems of 2 local learning reviews undertaken in South Gloucestershire13. South Gloucestershire health colleagues are able to demonstrate how messaging around AHT and strategies given to parents via the ICON14 programme are beginning to show traction in practice as this was shared by various health practitioners at the Learning Event. The action plans for both local reviews need aligning with this review to ensure messages are cascading across the wider safeguarding network as housing colleagues in South Gloucestershire had not heard of ICON or the messages from either local review. This LCSPR does not make any connected learning with South Gloucestershire Health Visiting Services in relation to previous local reviews as Baby M moved areas just prior to birth and therefore no direct practice undertaken by this service. 13 Serious Case Review Toby, Serious Case Review: Baby E and F 2019 14 The ICON Programme is aimed at helping parents and carers with young babies to cope with infant crying 9 This LCSPR finds some parallels with the SCR Toby around how systems are designed; how well different parts of community and hospital health services work effectively with each other and share information. Key Findings 1 & 2 in Toby’s Review are mirrored in this LCSPR which show maternity services being task focused on maternal and baby health which resulted in a holistic view not being taken, along with children’s vulnerabilities not being properly understood or responded to due to ineffective collaboration between hospitals, community midwives and health visitors. This Review also concurs with the following statement in Toby’s Serious Care Review (June 2020): “At the heart of this case lies the difficulty for professionals of working in a fragmented maternal and child health system that has limited capacity to provide the opportunity to assess and understand…. different elements of information tend to be seen in isolation rather than being collated to form part of a jigsaw that might lead to a holistic assessment and analysis of parenting capacity and need” The action plan for SCR Toby and Babies E&F demonstrate that progress has now been made, however this has been slow and requires SGCP to ensure continued tracking of actions to ensure impact is seen for children. The delay in progress has been impacted by changes in personnel and the impact of Covid-19. A standard operating procedure has been developed to improve and assure on the quality of communication and information sharing between midwifery and health visiting. The original iteration was complete, however following this review, it was identified that primary care inclusion needed to be explored with health partners to triangulate information sharing. The completion of the action has therefore been delayed. The use of ICON messaging has been rolled out across health colleagues, and there is evidence that is being used however this needs to be further embedded across partner organisations. An event to begin this work is scheduled for April 2023. Analysis, with Learning for Practice & Systems This section considers system and practice learning arising from the three main finding areas. The details of the agency support are not provided at length, but rather specific practice episodes are analysed so that learning points can be highlighted, along with a rationale and analysis of the practice barriers found in individual agency systems and across partnership working. 4.1 Key Learning 1: Recognising and Responding to the Vulnerability of Babies This section highlights the key system need to ensure all professionals working with very young children feel confident, skilled, supported, and have effective systems in place to assist them to recognise and respond effectively to ensure all babies safety and range of needs are met. 4.2 Pre and Post Birth Levels of Need The Review Group and those attending the Practitioner Event considered why the levels of support to Baby M were consistently set via the Healthy Child Programme at a universal level of need15 with no consideration at any point to involve other partners such as children’s social care via early help pathways or statutory assessment and services. The multi-agency policies and procedures16 which are embedded in all partnerships across the country to provide unborn babies with protection were not seen to be needed in this situation as no health professionals involved during the antenatal period saw any warning signs or significant risk indicators; in their view there was nothing unusual about the pregnancy or the presentation of either parent recorded. 15 A Guide to Thresholds in B&NES (2022) https://bcssp.bathnes.gov.uk/sites/default/files/2023-01/thresholdsinBaNES.pdf , South Gloucestershire Children’s Partnership The right help, in the right way, at the right time (2021) 16. https://bcssp.bathnes.gov.uk/sites/default/files/2020-09/pre-birth_protocol.pdf 10 This Review finds it would have been helpful to have recognised, collated, and interpreted the contextual family history and assess parenting vulnerabilities further to inform the levels of support required as they were first time, young parents, with some level of housing need, with significant paternal adverse childhood experiences including care experience. This could have been undertaken during the pre-birth period to inform practice direction likely through early help pathways or via statutory children’s social care assessments17 or at key times following birth, where concerns were raised. The reasons as to what got in the way to providing a more effective enquiring lens are further considered in Key Learning 3. One practitioner who knew Mr M well reflected “I think there were a number of indicators that caused a level of concern, and I would question the level of intervention remaining at the universal support level. I thought there should have been a referral to social care even if under the remit of Child in Need as there was a lot of instability for mum (as she was more visible) to health and accommodation services and a lot of unknowns re: dad at the time as he wasn’t really that involved. I thought that there wasn’t a lead professional pulling information together and co-ordinating knowledge and support which would have been really useful to get a holistic overview”. Another health professional said: “I can see that it is hard to piece everything together with mum moving, Covid-19 and differing health reporting systems however a systemic approach to practice – linking social economic factors and thinking about family relationships and connections to professionals - may have been really useful for this family and therefore other families moving forward”. The LCSPR finds that at times the lack of multi-agency information sharing and decision-making incorrectly contributed to Baby M remaining at a universal support level. The practice example of the Domestic Incident Review Meeting (DIRM) in May 2022, following an incident when Ms M’s coat was cut by a member of the paternal family, illustrates how more checks and enquiries were needed to triangulate information with parents, the wider family, and the professional network when Ms M’s coat was cut, and she described feeling worried about being with the paternal family member as he was “unpredictable”. The outcome of the DIRM was analysed in terms of practice thinking. Police information appears not to have been shared in the meeting regarding the adult paternal family members, which arguably resulted in decision making which was set too low. This then negates the need for any further actions to be taken to check concerns through a more thorough multi-agency meeting as Children’s Social Care were not able to “connect the dots” in the DIRM with other paternal adult family members as they were not linked to Baby M. In B&NES the purpose of a DIRM is to triage safeguarding children reports and domestic incidents (crime and non-crime) that have been referred to the Police Lighthouse Safeguarding Unit (LSU) in the 24hr period preceding the meeting. The Terms of Reference are explicit in stating DIRMs are not a replacement for MASH, Strategy or MARAC meetings and they should not be considered as such. The aim of a DIRM is to perform an initial, brief assessment as to which agencies require a Niche report for each given incident based upon their own agency information. Any further assessment of risk is outside the scope of the meetings and should be deferred to the appropriate forum. With the benefit of hindsight, there was a need for more effective coordination between the different multi-agency processes of the DIRM / MASH18 / MARAC19. It would seem that assumptions were made that Baby M was not often in the paternal family home in B&NES with 17Children in need of support may be assessed under Section 17 of the Children Act 1989 or under Section 47 of the Children Act 1989 to decide whether the child is suffering or likely to suffer significant harm 18 Multi Agency Safeguarding Hubs (MASH’s) are co-operative arrangements formed between numerous safeguarding organisations with the aim of collaborative working to safeguard children 19 A Multi-Agency Risk Assessment Conference (MARAC) is a meeting whether information is shared on domestic abuse situations deemed to be high risk 11 the adult of concern, and lived with Ms M, Mother. There was need to check this further given the previous CSC referral concerning this adult’s previous convictions, along with additional Police information raising concerns of a criminal history and poor mental health of the adult who often frequented the paternal family home. A more thorough assessment of the facts and a multi-agency discussion and decision could have led to greater curiosity across agencies. It would have been helpful to be sure at this reachable practice episode that those adults caring for Baby M had the ability and courage to stand up to any adults who may pose a risk or present as intimidating or coercive. It is evident in this Review that the DIRM, in its current structure, where individual discussions are short and last approximately 5 minutes, did not consider the historical paternal parental family factors as the Police did not highlight concerns regarding a member of the paternal family. This information would have been readily available via Mr M’s records as a child in the care of B&NES local authority but was not triangulated. At the Practice Event the Leaving Care Team professionals were surprised they were not consulted at this point for further information to be shared as this would have been typical practice in such a scenario for a family who were described as “well known” to their services, albeit Baby M was not known to this triage service. It has been shared by Children’s Social Care that the current DIRM triage system does not have the capacity to interrogate the different agency systems to understand the level of history and connection between adults in families from the number of Police domestic abuse incidents that are reported on a daily basis. In considering the rationale behind this decision-making the Review requested minutes from the DIRM. It is the typical practice that incidents discussed at this meeting are recorded using a table format and there is a box for the practitioners to record brief notes, but there are no formal minutes. It is therefore difficult to unpick with any great certainty how individual decisions are made and what they are based upon. DIRMs are attended by Senior Practitioners from Children’s Social Care, LSU staff, and IDVAs on behalf of their organisations, rather than managers attending and this may have contributed to this threshold decision of Children’s Social Care not accepting this referral in this situation with the information shared by the Police. 4.2 The Importance of Understanding Contextual Parental Factors When understanding how professionals reached decisions about what level of support and intervention was required the LCSPR finds that there was a focus on current, day to day observations of parenting and not any analysis of the contextual history. The cumulative social factors experienced in Baby M’s maternal and paternal family required a more enquiring stance and this is an unanimously shared view from the Practitioner Event and Review Group discussions as leading to support remaining at the Universal Support Level of Need. Social factors which required further in-depth discussions with both parents and within agencies and across agencies included: • Family relationships and dynamics, including any experiences of parental coercion and control • Wider maternal and paternal family support networks • Adverse experiences during childhood and how this shaped culture and identity and parenting capacity • Parental mental health needs • The impact of being care experienced upon parenting • The impact of poverty upon parenting • The role, expectations and assumptions concerning fathers and mothers in parenting • The parent’s housing situation 12 The first opportunities to begin to understand parental contextual factors would have been with midwifery services in July 2021. The “booking in” midwifery appointment happened in line with procedures with Ms M and due to COVID-19 restrictions was split between a phone discussion and follow-up face to face appointment by the same professional. The purpose of this 1st antenatal appointment is to have a detailed discussion about personal and maternal and paternal family history, and any relevance this may have upon pregnancy. A pregnancy care plan, and options for screening tests are usually discussed. Midwives explained there is often a lengthy discussion at this appointment to gain a picture of the unborn baby’s family and its situation. In this situation, Health Professionals shared openly that this 1st appointment was shorter than usual and not typical practice due to COVID-19. Care was taken to ensure a face-to-face meeting was held after the initial phone call, but due to time constraints and system pressures there was a focus on medical need as opposed to wider social factors. The split appointment between a shorter telephone conversation and then home visit meant that there was less time to observe or engage Ms M and the focus tended to be more upon carrying out set tasks and completing forms. Mr M’s history of being care experienced was recorded as part of the routine booking questions, but no other information was obtained to warrant further exploration of his experiences. Upon reflection, health professionals have requested further guidance to develop their skills regarding when and how to gain a fuller social picture of parents who have various experiences such as being in care. The culture of Baby M is largely invisible in the health records seen, apart from typically seeing a tick box to show he was a white British child. This Review has sought to understand the impact on Baby M of Mother and Father’s childhood experiences upon their parenting styles and behaviours and finds very limited written evidence of discussions held with either Ms M or Mr M regarding their own identities and how this shaped them as parents. The LCSPR considered how being a care experienced parent might have influenced the father’s life, his experiences, and views on parenting. It was considered at the learning event how this was understood by health and housing practitioners in particular and how it did, or did not, guide actions, decisions and any services put in place. The general conclusion from those health professionals that knew father was care experienced, was that they knew this fact but not any detail. Understanding Mr M’s contextual history was not given the time or attention as it should have been so as to build connection further with Mr M and assess whether a referral to any other services might have been helpful to keep Baby M safe and support the parents. The Leaving Care Service who attended the event shared invaluable information and insight which highlights the practice importance of piecing together a family story and deciding when there is a need to include further multi-agency professionals so as to understand and assess any risk factors that might be present. This of course depends upon parental consent if at an early help or child in need of support level, though it would seem from reflections of both parents by professionals that they would have been open to receiving support and services at early help or statutory levels. Evidence shows that professionals and parents tended to work effectively together, (as seen with Mr M being involved in Care Experienced Groups over time), which would tend to suggest if more dedicated time had been spent building more effective connections with both parents, a picture might have been obtained of Baby M’s day to day life and any potential parental struggles might have been clearer. The Review Group have considered the role of the Children’s Social Care (CSC) and in particular the knowledge held by Care Experienced Service in B&NES, when understanding when and how information was known about Mr M becoming a father. Baby M was referred to CSC on two occasions, the first in relation to a police referral about paternal family member and a previous conviction, and the second as a result of Ms M reporting an incident with the same family member. On both occasions no further action was taken and significantly the connection did not seem to be made that Mr M was B&NES Care Experienced and therefore the information was not shared with the relevant team. These were opportunities to learn more 13 about Baby M’s situation, the relationship between his parents and Ms M’s parenting capacity as extensive records were held on Mr M and his wider family. CSC have reflected and in hindsight have acknowledged this connection should have been made, and more exploration and assessment undertaken. This LCSPR makes the recommendation to check the current DIRM processes to ensure information is shared within CSC Teams and structures and when working together, particularly in needing to discuss with Mr M the benefits of sharing information with GP, midwifery and health visiting services regarding his care experiences and what support/assessments may be required as a new parent. As highlighted in Baby M’s story of what happened, the LCSPR has struggled to find any information about the reasons why Mother was living in supported housing. There are some contradictions seen which remain unexplained as it describes maternal wider family as supportive and loving and also makes references to asking her to leave their homes. It is therefore an appropriate conclusion to wonder about how professionals made sense of this information and what weight, if any, they gave to understanding more about parental contextual factors and the implications these may have upon parenting Baby M. The Review also sees evidence when analysing what information, the Neonatal Intensive Care Unit (NICU) had regarding the parental contextual factors and how the various IT systems used by midwives/hospitals/health visitors and GPs do not link or align and therefore operated in isolation. NICU staff shared their frustrations at the system issues which result in them having very limited paperwork or information shared via systems as they do not have access to midwifery computer systems, which means they often do not receive the midwifery “booking in” forms or any other relevant documentation concerning parents. One comment made was how this means often “things will slip through the net”. NICU staff shared how they have to chase for information and when working in busy intensive medical situations. Things can get missed as there is a reliance on staff to spot things and request information. In this situation it impacted as NICU staff did not knowing about Mr M’s care experience or that Ms M had previously lived in supported accommodation. There is work underway at the Hospital concerned to remedy this situation as it is known that there are information sharing and feedback issues between midwifery teams and NICU. A new computer system will be introduced in the summer of 2023 which it is hoped will resolve this and ensure the information flow is in place. If a child in NICU is subject to statutory assessments or interventions via children’s social care, or there is parental need identified, then multi-agency meetings are held each week to discuss individual needs, including safeguarding – these are seen as helpful by NICU staff. This LCSPR notes the significance of these meetings which are held on a Tuesday; Child M was not inpatient on NICU on a Tuesday as his admission was Wednesday to Monday. 4.3 How we support families, understand parental need and keep babies safe Healthy relationships and the risk of domestic abuse are key areas which midwives are expected to consider in ante-natal discussions with parents. The timing of when such mandatory discussions should or can take place was a feature of this Review as during one visit Mr M was present and it was decided to be inappropriate to discuss the nature of the parental relationship. There is evidence that during the booking-in face-to-face meeting with Ms M the routine screening for domestic abuse was completed. However, it has also been highlighted by professionals attending the Practitioner Event that having such conversations should not be a one-off initial enquiry and tick box procedure undertaken at this 1st meeting and more-so a series of conversations as the professional and parent get to know each other. It is arguably not the best approach adopted by professionals as parents may feel reluctant to share such sensitive information on a first meeting, especially when the purpose tends to be task focused on physical health matters. 14 To raise such conversations when first meeting an individual is a tall order for any professional as they will need to understand relationship history and understanding of safe and healthy relationships with both parents. The opportunities to continue discussions were further impeded by the moves between areas and changes in worker. The Review finds this should have been a more focused area of assessment and especially given the later concerns observed by NICU staff regarding Mr M’s allegedly “controlling” behaviours towards Ms M and was not effective via a one-off routine screening enquiry. The Review Group heard evidence that health visiting records prompt for a question to be held regarding domestic abuse at the new birth visit, but the “institutional” practice of most health visitors is to not to ask any questions about relationships, stress of a new baby and the impact it may be having on the family, if “the partner is present”. This is further considered in Recommendation 1. Becoming first time parents can feel and be over-whelming and daunting and the extra pressures of coping with the additional responsibilities can in some situations lead to post-natal depression20. The Review has identified that Ms M had some self-reported low mood, which would have benefited from further understanding by the professional network. Ms M self-reported to midwifery services and the GP to feeling psychologically well during most of the pregnancy. Ms M did disclose low mood at her last midwife appointment and was given appropriate advice, with Mr M also signposted to local services for dads. The historical housing records show Ms M described having some level of post-traumatic stress on her initial housing application following a previous relationship experience, along with becoming homeless due to reported family issues. She told her housing support worker on three occasions how she felt “low” during her pregnancy due to physical health conditions and not wanting to live in the hostel. This information was not shared with a wider network. Similarly, during a routine health visitor home visit in March 2022 when Mr M is seen with Baby M, he shares information about his own mental health needs in the past and apparent “paranoia”. Although assurances are given by health professionals this was discussed in detail with Mr M at the time, with signposting to seek further support from the GP, no follow up is evident in any health records reviewed and this was not flagged to the GP. NICU records show Ms M was nervous around handling Baby M and in particular is described as appearing reluctant to hold her son; these are not typically unusual behaviours seen in any new parent tasked with caring for their new-born child. Baby M remained on NICU to ensure parents were provided with support and advice on caring for their child. It is particularly reassuring to see how focused work is in place around ICON training for new parents. As one NICU staff member affirmed: “All staff on NICU have now had or will soon have ICON training and safer sleeping and will be able to train and speak to all parents and care givers prior to discharge from NICU”. What the Review wanted to unpick further whilst Baby M remained in NICU was the request from Ms M to go home 12 hours following birth to have a shower and rest; in returning back to NICU late and then asking for a separate room to Baby M due him being described as making lots of noise and Ms M was unable to sleep. Through debate at the Practitioner Event, experienced NICU staff all concluded these were not unusual behaviours seen in new parents on the intensive unit and so did not cause any professional alarm bells to ring. This view was not shared with other health professionals as part of the Review Group and is a practice reminder of the need for single and multi-agency discussions when there is a difference of professional opinion to ensure the needs of the child remain the paramount consideration. Monitoring of Baby M and support was given to both parents before discharge to ensure confidence levels were adequate to ensure day to day needs were being met. Some new parents can often look to their own parents or wider family for support during the first few weeks of a baby’s life. The wider family support networks available via the maternal 20 Soothing a crying baby www.nhs.uk 15 family were not evidenced in any records seen for this Review and the paternal family, although well known to B&NES children’s social care, remained unassessed in terms of providing wider family support. There was a general assumption made that as no risk indicators were identified and support was set at a universal level of care, there was not a need to understand the levels of wider family support further and whether there were any concerns pertaining to this. This was required and particularly on the paternal side, given concerns raised on two separate occasions regarding a male paternal family member and his behaviours and convictions. 4.4 Working with Fathers Most services provided across the UK during antenatal and the early months of life remain predominately woman-facing, and less accessible to fathers. For example, there are often limited flexible approaches to providing out of hours or at weekend provisions to maximise a father’s involvement. As a result, fathers are not provided with important information about becoming a parent and how to safely feed and handle new-borns and meet their range of needs during the first few weeks of life and beyond. There is a general expectation that mothers will share important/relevant information with their partners/fathers, and it is not known in this situation whether Ms M did or did not share information, such as safe sleeping. Much research, along with local and national reviews21 show that engagement with fathers is often characterised by shallow assessments and weak engagement, with services often not knowing who fathers are nor the risks or resilience factors they present. This Review shows that midwifery services and health visitors from B&NES area did consider Mr M and he was involved in some meetings pre and post birth. The general consensus shared by all multi-agency practitioners and the Review Group is that more assessment of Mr M’s history and current situation was required through adopting a more probing lens and building a greater connection with him to ensure he was supported as a new father and any risks were understood. Mr M is described in records as a polite and amenable young man who accessed services and it is likely he would have taken the opportunity, either with the support of his care leaver worker or on his own, to work more closely with health services if this had been offered. The Review Group considered the impact of possible professional unconscious gender bias which may have arisen through stereotypical views on parenting which are still seen in society to be split via gender roles. Assumptions were made by professionals that Ms M was undertaking all the main parenting role for Baby M and without further checking out the professional view was adopted that when the parents’ relationship ended and Ms M was allocated a further supported home in South Gloucestershire, she remained the main carer for her child. Through analysis in this Review, it is likely this was not the situation and Baby M remained with his father, Mr M in the extended family home in B&NES. The Review highlights the need for high quality supervision where discussions can be offered which provide support to professionals and challenge to their work, including around any possible unconscious or conscious bias based upon gender, class, race, identity, or sexual orientation. The LCSPR analysed the provision of safeguarding supervision to maternity/community midwives at the time that Child M’s mother was under the care of maternity services at NBT (July 2021-March 2022). In July 2021, the Named Midwife for safeguarding was unable to offer the frequency of safeguarding supervision required (as per the safeguarding supervision policy) of quarterly (to community midwives) due to operational pressures in the maternity unit, caused by sickness absence. During this period, group supervision was not provided to either of the community teams who provided care to Child M’s mother. The maternity unit responded to the operational pressures, and since April 2022, a consistent offer of quarterly provision has 21 The Myth of Invisible Men: safeguarding children under 1 from non-accidental injury caused by male carers, The Child Safeguarding Practice Review Panel September 2021 HMO: Gov 16 been made, with all community teams participating in safeguarding supervision (Sept-Dec 2022). There continues to be one member of staff (the named midwife for safeguarding) who delivers safeguarding supervision to maternity staff, which is a limitation on staff choice of supervisor and also means there is no provision when the named midwife is away from work. In analysing the health visiting supervision during the period under Review in B&NES it appears that there was not any systematic review of complex situations or empowerment of practitioners to reflect on their practice, identify strengths and other protective factors within families as well as risks. There is no evidence that record keeping was reviewed, and no assurance that practice standards were being met. It also appears from a sample of the records seen that fixed views were not challenged, hypotheses and evidence base were not assessed or tested for assessments and decisions and action plans were not formulated to contain risks. The situation today is different. 1:1 Safeguarding Supervision was introduced in November 2022 and B&NES practitioners are aware that they need to bring a family situation; it is protected time and takes place quarterly. Ad hoc supervision is also offered as required and this is now documented. 5. Key Learning 2: Focusing on the child when families move between areas When a family moves between geographical areas and between local authorities and health service boundaries it can be a particular system and practice challenge. This was a significant factor in this LCSPR and one highlighted both by various health and housing professionals who attended the Learning Event and identified by the Review Group. The impact of the geographical moves of Ms M upon professional understanding are considered in this section. This review finds confusion as to where Baby M lived in the first 3 months of his life. This was not clearly understood by any one agency, and this meant at times there was insufficient professional curiosity about Baby M’s day to day experiences. In practice reality, professionals did not think they needed to intervene in Baby M’s life as no safeguarding concerns had been identified and living in supported accommodation and having care experience was seen as not unusual or of significance to professionals to check what this may have meant to Baby M via further enquiries. The need to adopt a more enquiring stance to ensure baby are kept safe and support and services are provided to parents is covered in Key Learning 3. 5.1 The role of housing providers in understanding risk The Review identified three homes which offered support and services to Ms M by two housing providers in South Gloucestershire during the period under review; two being during the ante-natal period (short initial period in a hostel before moving to more secure supported housing) and one following birth when the parental relationship ended. Ms M was initially referred to the housing association by South Gloucestershire Council Housing Needs Service. The provision offers homes for young families or single people who have approached their local authority saying they are homeless or at risk of being homeless. The application paperwork seen for this LCSPR provides limited information as to the reason why Ms M was homeless and contradicts other reports which assess the maternal family home as being providing support. The attempts at providing Ms M with support and advice in the ante-natal period show a determined approach by the support worker as missed appointments are seen and followed-up, with connection often seen as more effective via text messages or phone calls. The Review finds that the flow of information sharing to and from the housing provider was ineffective with gaps in following up matters seen by the housing association and similarly midwifery and health visiting services not sharing key pieces of information to the housing provider. This can be evidenced in the following practice examples: 17 • When Ms M leaves the supported home in the ante-natal period as she is unhappy and says she is feeling “low”, this information is not shared by the housing provider to any health services, such as GP or Midwifery • The fact that Ms M was often not staying at the home during the ante-natal period and Baby M was not seen by Housing Support Staff in South Gloucestershire in the supported home following birth did not raise sufficient curiosity. The Housing Provider was not pro-active in thinking further regarding whether a referral to health services would have been helpful to understand who was caring for Baby M • The Housing Association was not made aware by Midwifery Services of Mr M’s care status and at the Practitioner Event expressed their “shock” at learning more of the contextual family history, which if known the Manager commented would have meant a more diligent approach by the Housing Association and probably a decision that the supported housing being not suitable for a young mother and her baby In discussion with various professionals working in the housing sector it is evident that in South Gloucestershire the key messages arising from previous local reviews concerning non-accidental injuries in non-mobile infants has not been cascaded to inform and strengthen practice. 5.2 Health Services Information Sharing Health professionals attending the Learning Event shared some practice examples when information sharing between midwifery services and health visiting resulted in a good handover of information. However, this was either not recorded or not recorded fully enough and so needs to be taken at face value. The Review Group has considered how health systems are reliant upon parents telling professionals of moves between areas and completing the transfer forms when they move. The Review debated how only children identified with additional support needs, including safeguarding concerns, would have a handover discussion and Baby M was not identified as having any additional needs. It is seen in records that information was shared between South Gloucestershire health visiting services and B&NES regarding the paternal family member. This LCSPR also finds gaps in information sharing or ineffective information sharing between health services which confirms the previous learning in South Gloucestershire and also apply to health systems in B&NES. There were various reasons why information sharing regarding Baby M was at times not as it needed to be in health agency networks, and which failed to then “connect the dots” in gaining a full picture of need. This was due to different community and hospital systems for recording which were incompatible and especially when transferring data between areas or, due to an inaccuracy in recording of information. At the time there was not a formalised process for administrative staff to report to the Health Visitor when an antenatal visit was declined. There is a new Standard Operating Procedure agreed with maternity services (signed off on 14.12.2022 but not yet fully embedded) and a new Sirona Antenatal visit pathway (signed off Feb 2023 but not yet fully embedded) which describe a new process to ensure admin staff share information with a Health Visitor when an antenatal visit appointment is not booked (this include declined offers for contact) and ensures an opportunity for Health Visitors to discuss identified women with midwives at a monthly liaison meeting. Midwifery and health service capacity issues and how systems are structured when at a universal service of need were considered. Since 2011 Health Visitors have offered a Public Health Service which includes 5 routine contacts: pre-birth, new birth, 8-week check, 1 year check and 2.5-year check. The opportunity was missed to build relationships with health visiting and parents prior to the child’s birth as the antenatal home visit (as recommended in the Healthy Child programme guidance[1]) was declined by Ms M who was moving imminently 18 to B&NES. An Antenatal home visit invite letter was sent to Mrs M at 32 weeks’ gestation with a follow up phone call 2 weeks later. During the phone call Mrs M declined the visit offer. Antenatal contacts are offered to all women in South Glos from the Health visiting service from 28 weeks to just before their expected due date. Letters to invite women to an antenatal visit are sent when women are 28-32 weeks’ gestation where they are known to the health visiting service. Midwifery services were involved and assessing the family strengths, needs and risks and would have been able to identify what additional support may be required as new parents. Ms M delivered her baby within 2 days of South Glos health visiting being aware of her move of address. Even with a reasonable and proportionate response by all in health, this may not have enabled a contact in her new residency prior to delivery. The South Glos health visiting team did update change of residency on the central computer spine systems that can be viewed by Primary Care/Midwifery and health visiting. A flag /alert system may have been beneficial but would only alert staff if systems are checked routinely by staff prior to contacts. This meant that any trusting relationships with Ms M, were restricted as she was not seen by South Gloucestershire health visiting professionals prior to birth and had a delayed start with midwifery and B&NES health visitors due to missed appointments with the family explained by the” busyness of Christmas”. The move in area, and professionals being reliant upon the family to inform of the moves, further slowed down joining up the dots between midwifery services and health visiting services. 6 Key Learning 3: Supporting critical thinking in practice This Review has tried to understand the reasons why Child’s M journey through his first three months of life were not understood in more depth in order to keep him safe. As previously analysed, the main likely reasons centred upon the impact of the moves between local areas coupled with the parental contextual factors not being unpicked with a sufficiently inquisitive lens. The practice reasons why limited critical thinking was likely applied is considered in this section. As detailed in the health records from midwifery, health visitors and GP, Baby M was seen to be well cared for; growing and developing as expected, and with warmth observed when in his parent’s care. When busy, task focused health professionals who observe and are given assurances that all is going well by parents, it is understandable to see why practitioners might not sufficiently probe beyond what is in front of them, and especially when feeling under pressure. The parallels in SCR Toby22 are noted as when a busy professional is faced with competing demands “a trade-off” in priorities can take place. When there is a tendency for a practice culture of focusing on tasks as opposed to being person or child focused, the risk is that professionals can narrow down their focus, which can result in “tunnel vision”. This tends to make the job feel more manageable to the busy professionals as they can complete the form and tick the box but can mean wider issues outside of that narrow focus are not seen or are given the attention they require. Health practitioners reported at the Learning Event that they knew that being a care leaver was a flag to unpicking further, however, they did not have the time to do this and did not know what factors would be considered as a “red flag” and did not want to appear to make assumptions about the experiences of those who had been in care. Such feedback is important when understanding safeguarding cultures and how effective specific training is, when the likelihood of ensuring it is embedded in practice can be limited due to pressures on practitioners’ workloads to do the more probing, analytical work, along with not knowing in practice how to apply the learning. The importance of critical thinking in practice is well cited23 as a cornerstone of working effectively with families and in and across agencies. This LCSPR has focused upon key 22 Serious Case Review: Toby 2020 23 Child Safeguarding Practice Review Panel 2021 Annual Report : Patterns in practice, key messages and 2022 work programme 2022 HMO: Gov 19 practice episodes when professionals were either working directly with the parents or with single or inter-agency colleagues to understand whether sufficient enquiry was seen to understand day to day life for Baby M. This section analyses what facts and information were available during the period under review and how and what professional observations were undertaken to form the judgments reached and subsequent actions taken. In providing a rationale for why certain matters were not discussed in more depth needs setting within the systems within which multi-agency professionals operate each day. It is not the intention of this review to make any individual feel they did anything “wrong” by not probing further but rather to illustrate the importance of self-reflection in practice. It is also to consider what opportunities there are for individuals to have space and time to discuss their thinking with supervisors or multi-agency colleagues so as to remain open-minded to different perspectives or hypothesises and to develop a confidence in practice. This was the approach used in the Practitioner Event to ensure a multi-agency reflective dialogue to consider together what happened and what might have been done differently. It is complex work to do and unpick as part of this LCSPR as it requires a process whereby the Reviewer and Review Group interpret the information gathered at the time, alongside what individuals recall they saw in practice along with their own professional experiences and skills which are set within their own agency systems. Critical thinking is of course not problem solving and this Review seeks to understand the thinking patterns of those professionals working with the family and pay attention to these so as to understand how they may have been hindered by barriers in the systems in which individuals work. It is within this context that the following underlying system issues were raised by practitioners at the Learning Event and through Review Group analysis: 3.1 Key Learning: Acknowledging the realities of day-to-day frontline practice: “There is no time to think” As highlighted in the Annual Review of LCSPR24 many of the issues that undermine the effectiveness of safeguarding practice are to do with high volumes of work and serious resource shortages, along with staff turnover or use of agency or “bank” workers. This Review identifies a consistent theme shared by many practitioners from a range of agencies present at the Practitioner Event, and particularly health services who talked with courage and honesty about their realities of day-to-day practice. It is important for senior leaders locally and nationally to listen to these reflections as it shines a light on the pressures faced by many frontline professionals when working with children and their families. The aim is to set this review and its findings within a wider contextual organisational understanding of why certain things happened in the way that they did and why certain actions and decisions were taken. The reasons given by practitioners from health agencies attending the Learning Event as to why there was an over reliance on taking information at face value and not asking more probing questions or showing a more inquisitive stance when working with both parents is consistently described as “workload demands”. Workers described often feeling “overwhelmed” by the number of demands on their day or shifts. One community health professional described this as “ricocheting from one visit to another”. A mixture of texts/ telephone discussions / face to face appointments at paternal home and in clinic are seen – with some patterns of appointments that did not take place as Ms M or the wider family explain there was maternal ill health, both physical and mental. The Midwife and Health Visiting Services showed diligent approaches in following up these missed appointments and although some gaps in time were seen, eventually Ms M was met with, and no concerns were identified. Such practice examples show despite the system challenges, 24 Child Safeguarding Practice Review Panel 2021 Annual Report: Patterns in practice, key messages and 2022 work programme 2022 HMO: Gov 20 there was a persistent approach to work undertaken, as in the midwifery service adopting a flexible approach during COVID19 during the “booking in” appointment. Determined work like this needs to be highlighted as the “norm” to ensuring creative professional practice and not as seen in this LCSPR as an example of good practice. The Review considered what the purpose was of the various housing, midwifery, and health appointments and visits with Ms M. As detailed, the community health focused work with parents and Baby M tended to be to complete a physical health task, with more limited time to build a more meaningful relationship to understand how life was going for a young new mother to be / mother, and a father with some adversity known in his childhood. The practice shared by health visitors and midwives who attended the Learning Event can be summarised as task focused and ensuring there is “a tick in the box” to complete what is required of that visit or discussion with the parent. If effective relationships are built in practice, it enables more possibilities for asking the more difficult questions as a connection has been established. The professional needs to connect first before entering into discussions of content as this provides an effective framework from which a professional might pursue why something is or is not happening or unpick any parental worries. This LCSPR finds that health professionals in particular needed more focused time to spend building a connection with both parents before completing the task requested and to feel less pressured to move on to the next task at hand. In enabling this culture of practice, alongside ensuring opportunities for informal and formal supervision discussions, is more likely to yield results which look beyond an observational approach which focuses on the presenting behaviour and allows a more analytical style to probing into other contextual factors, when relevant to do so. In the Review of Child Protection undertaken by Professor Eileen Munro25 we are reminded of how “instead of doing things right” (i.e., following procedures) the systems in which professionals practice needed to be focused upon “doing the right thing” (that is checking children and families are being helped). This review shines a light on how staff morale is impacted when working at all levels of need when there are pressures felt from lots of demands to do and complete as opposed to empowering professionals to feel they are helping families and in so doing making a difference to day to day lives. Professionals talked of the need to have time to think and slow down, build the relationship rather than merely “doing” as being important to job satisfaction. Hearing professional reflections provides a more probing and critical lens so as to answer why there may have been shortcomings in practice, which are not intentional but more likely as a combination of factors. This Review also suggests the answers to addressing some of the issues outlined sit with Senior Leaders nationally and locally in partnerships and organisations who are committed to problem solving some of the harsh day to day realities of practice. There are, of course, no simple solutions or written action plans to resolve these organisational issues and creativity is required if practitioners are to be supported to do the best that they can and in doing so ensuring children are kept as safe as possible and for their families to feel and be supported. 6.2 Key Learning: Record Keeping Good quality record management is important when working with families because it tells a child’s story over time in a cultural context, which can be shared with others, when necessary, alongside ensuring compliance with policies and procedures, data collection and data protection. Having concise, analytical records also helps identify gaps in what is and isn’t known and helps professionals understand immediate and cumulative risk factors – in short, good quality records positively support critical thinking and focuses discussions for practitioners in supervision and when working in a multi-agency forum. 25 The Munro Review of Child Protection: Final Report, 2012 DfE: Assets Publishing 21 The Review sees several examples in both geographical areas of poor-quality record keeping and detailing when handover conversations have been held which suggests there is a system wide issue which requires a more focused approach than is currently in place in community health (hospital, midwifery, and health visitors). The Review has heard there are ongoing management supervisory discussions or training opportunities in both geographical areas as a practice reminder of the need for good quality record keeping, ensuring what information has been shared and to whom and for what purpose, but this is currently having limited impact on what is being recorded as evidenced in this review. The review finds basic information missing on several records seen such as which family member was present for the visit/appointment; where the intervention took place; what the purpose was and what was agreed. The poor quality of the records seen in this review means during the period analysed, other professionals who may have needed to read the notes or reports written by health colleagues following a telephone call, appointment or home visit would also not have been clear of what was seen or discussed and with whom. The records would have benefitted from more than just the basics being noted, with further analysis of the topics discussed, such as details about safe sleeping and how the ICON messages were understood and received. A more detailed written explanation of what discussions took place concerning healthy adult relationships and domestic abuse would also have been beneficial as again these were lacking. As previously highlighted in Key Learning 1 further practice consideration should have included more exploration of the family’s cultural identity and what meaning was given to Mr M’s adversity in childhood and care experiences and whether other cumulative social-economic factors influenced parental interactions. This was not seen in any records. 6.3 Key learning: The importance of checking what language and phrases mean to assess impact on children The language we use can impact how we view children and their families and how we form our professional judgements, and this may result in how risk is seen, and support is given. It is important as it can also alter how realistic the picture is of a child’s day to day experiences. In the Review there has been analysis regarding what and how language or certain key phrases have been used and considered in terms of professional levels of understanding or weight given to certain key pieces of information. Following birth and when in NICU the word ‘controlling’ was used to describe Mr M’s behaviours and was recorded in documents. This phrase needed more description attached to it so as to understand whether this referred to words used or physical actions or a combination of the two. With a simple phrase with no analysis of what was being reported by the professional in terms of risk for Ms M and of course Baby M’s safety, it can be left open to various interruptions and different levels of weight can or cannot be attached to it. In some situations, such statements can take a precedent when based on single pieces of evidence or assumption and in other situations they can lose their significance if not recorded specifically, with some level of analysis and professional curiosity provided. In this scenario a situation arose of “Chinese whispers” whereby the phrase was passed to some professionals, but significant others were missed such as the next NICU Nurse who could have checked the information more closely had it been shared appropriately. The result being that as the original understanding was not clear, it became even less clear and confused as it passed down the professional network and assumptions can then be made. The community midwifery team is seen sharing the information with the health visitor that a “verbal altercation” has taken place but is not able to add any further context. The practice danger is that the incident either loses importance and risk is not seen or leads professionals to think there is risk when there is not. It is important to unpick such comments made and this was not done – this meant there was a potential unassessed risk of coercion and controlling behaviours from adult to adult and to Baby M. When working to understand a child’s world it 22 is important to use factually correct language as this too can affect how risk is or is not seen by the professionals group. The key is in accurate, timely, recorded descriptions when considering all aspects of a child life. For example, this LCSPR has seen various health records which state Ms M lived in a “mother and baby unit”. There are many significant differences between supported housing for young adults and a mother and baby unit, and although likely made as a simple practice error in recording, can have significant consequences in terms of being clear about a child’s journey and what level of support or monitoring may be required. In this situation it held no significance which adds further weight to the need for a more curious approach to have been adopted and to probe further to understand why a “mother and baby unit” might have been needed for Baby M, but as previously analysed this inquisitive approach was not seen. Recommendations – For South Gloucestershire and B&NES Children’s Partnership Both BCSSP and SGCP will ensure the following recommendations are translated into a smart and achievable action plan which is overseen in the respective partnership’s quality assurance groups. Given the previous learning reviews in South Gloucestershire concerning non-accidental injuries to children under 1 years, a critical focus is now required to ensure change is made, monitored, and embedded in practice and systems with the hope of reducing the likelihood of similar situations happening again for babies who move between areas. Systems & Practice which Focus on the vulnerability of babies 1. Recommendation: Health Recording Systems include a holistic assessment of a child’s needs which includes contextual maternal and paternal family factors Action: Work to improve understanding about support available to Care leavers from the action plan for CSPR Family A, along with the GP & Practice Staff Resource Pack are shared by Bath & North East Somerset, Swindon & Wiltshire Care Board to all health agency leaders to ensure all health professionals have access to information to guidance when assessing any adults who may be care experienced Action: Training for NICU staff about increasing confidence and knowledge when working with Domestic Abuse and how to ensure curiosity and response to Domestic Abuse. This needs to take place within 9 months of publication of Baby M review. Action: The HCRG Care Group for Health Visitors and South Glos Public Health Health Visitors to ensure through broad discussions at the new birth visit the routine question of domestic abuse is recorded and covers healthy adult relationships at every health visitor contact. This should include further training for all health visitors on how to identify and discuss domestic abuse and healthy relationships in light of new legislation. Action: Current work underway in B&NES that strengthens information sharing between GPs and midwifery about fathers’ risk and resilience factors is replicated across all health agencies in South Glos and B&NES (SIRS - Sharing Information regarding safeguarding) Action: B&NES Children’s Social Care to review their DIRM procedures to ensure the pathways for information sharing between all CSC Teams and with other statutory agencies (when relevant/required) are effective for children. B&NES CSC to assure the BCSSP of their work within 6 months of publication 2. Recommendation: The ICON Programme & increasing awareness of Non-Accidental Injury in Babies Action: Further embedding of the ICON Programme across South Glos agencies (statutory and voluntary) which links to the previous South Glos LCSPR action plans 23 and pays particular attention to training for non-health partners including Housing Support Workers in South Glos. The housing provider to share learning from this review with practitioners to promote critical thinking in practice. A multi-agency event “ICON: Working Well Together” to take place on 19th April 2023. Action: BNSSG Non- Mobile Baby Policy update, and associated family leaflet needs to be signed off in Bristol and North Somerset. When this work is done all documents will be uploaded to the partnership website. Action: B&NES to ensure their non-Mobile baby leaflet is available to all practitioners on the partnership website. Action: B&NES Public Health Senior Leaders to decide whether or not to implement the ICON programme. Systems & Practice when Children Move between Areas: 3. Recommendation: Effective Transfer of Information between areas and services Action: BNSSG Working Group work further on developing a communication pathway between midwifery, health visiting, and GPs which will ensure the learning from this review is included in the Standard Operating Procedure (SOP) to ensure it adequately covers when families move between areas Action: B&NES current SOP needs to be reviewed in light of the BNSSG SOP development to ensure it covers the effective transfer of information between GPs, midwives and health visitors Action: HCRG Care Group process for transferring health information from Health Visitor to Health Visitor when family move area needs to be shared with South Glos Public Health Health Visitors so that this approach can be considered Supporting & Strengthening Critical Thinking in Practice: 4. Recommendation: Safeguarding Supervision arrangements for community health professionals which ensures there is a safe space for critical thinking in practice, promotes professional curiosity, and is a trauma informed approach to the family’s needs when working with pre and post birth situations. Action: Decision to move from group to 1:1 safeguarding supervision for health visitors needs to be implemented and embedded by South Glos and B&NES and assurance given to both Partnerships that this is a guaranteed offer. Work will be undertaken to establish how impact of the new system is measured by referral rates & quality and staff retention. Action: NBT and UHBW Maternity services to review its supervision offer and ensure all community midwives can access high quality, sustainable safeguarding supervision (either 1:1 or group) and the frequency of this is checked. Action: B&NES HCRG mandatory training package will continue to be rolled out to all practitioners in health visiting service to set standards and expectations when recording information about individual family members. The B&NES HCRG will quality assure this training package by undertaking an audit of records within 9 months of publication of this review. Action: B&NES to ensure the routine MORS tool to understand perinatal mental health assessment for both parents (HCRG Care Group/Wiltshire PIMH Pathway - Mild to Moderate Symptoms Pathway), which includes the use of all questions regarding contextual history, are followed by auditing of a sample of situations to check it is being applied |
NC049199 | Sexual abuse by Isobel's mother's partner from a young age; she was assaulted by him when she threatened to disclose the abuse. Isobel was referred to hospital for enuresis where a medical explanation was sought but not found. The issue was not investigated further and there was no involvement of the school or school nurse. Isobel's mother sought help when she became drug dependent and a referral was made to children's social care. The mother's partner had alcohol and drug dependencies and poor mental health but no consideration of the impact this might have on Isobel or his family was considered and no safeguarding referral was made. The family was in debt. Identifies learning points: professionals did not always recognise when they needed to ask questions, share information or follow up with colleagues about a child's wellbeing and struggled to address Isobel's thoughts "I just wanted someone to ask me"; lack of professional curiosity when faced with adults who misused drugs and alcohol; inequality in the way the mother and partner were treated following drug misuse; organisational systems were not in place to enable practitioners to see children and young people on their own. Isobel did not want the report published in its entirety, so this review sets out emerging themes and highlights the learning points. There are no recommendations included.
| Title: Lessons learnt from a serious case review: BSCB 2016-17/1: “I just wanted someone to ask me” – Isobel. LSCB: Birmingham Safeguarding Children Board Author: Eleanor Stobart Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Lessons Learnt from a Serious Case Review BSCB 2016-17/1 "I just wanted someone to ask me" - Isobel Independent Author: Eleanor Stobart 2 | P a g e CONTENTS 1. BACKGROUND ................................................................................................................ 3 2. THE REVIEW PROCESS .................................................................................................... 3 3. EMERGING THEMES ....................................................................................................... 3 3.1. Diagnosis-led models of care ....................................................................................... 3 3.2. 'Soft' signs of abuse and professional curiosity ........................................................... 4 3.3. Making space and time for children and young people .............................................. 4 3.4. The invisible man ......................................................................................................... 5 3.5. Lost histories ................................................................................................................ 5 3.6. The cumulative impact on children ............................................................................. 6 4. A PRACTITIONER LEARNING EVENT ............................................................................... 7 5. LEARNING POINTS .......................................................................................................... 8 3 | P a g e 1. BACKGROUND Isobel lived with her mother, her mother's partner and sibling in Birmingham. Her mother's partner sexually abused her from a young age and assaulted her when she threatened to disclose the abuse. 2. THE REVIEW PROCESS A Serious Case Review was commissioned by Birmingham Safeguarding Children Board (BSCB) to examine the case in detail, to identify important learning that can be shared with relevant agencies. Isobel and her mother were consulted and helped inform the development of the terms of reference. Agencies were required to submit reports detailing their involvement in the case. An independent panel of experts reviewed the information reports, the overview report and a consultative practitioner learning event was held attended by professionals involved in the case, so their views could be incorporated into the review. Isobel asked BSCB not to publish the report in its entirety. In order to respect her wishes the BSCB developed a "lessons learnt" report to be published instead. This report sets out the emerging themes from the original serious case review and highlights the learning points that were identified. 3. EMERGING THEMES 3.1. Diagnosis-led models of care When Isobel was referred to Birmingham Children's Hospital for enuresis, the focus of attention was on finding a medical explanation for her enuresis. There was no evidence to suggest that thought was given to a non-medical cause for her symptoms. There was little exploration about her life, who she lived with and no investigation into any particular stressors. The hospital did not make enquiries of any other agency or indeed contact her school or copy the school nurse into any of the letters sent to her GP. Furthermore, her GP did not investigate the issue further by involving the school nurse. Had any of these actions taken place, Isobel might have been offered support at school or via the school nurses; which in turn may not only have provided more appropriate opportunities for her to disclose the abuse that she was suffering, but also assist practitioners to identify some of the 'soft' signs of abuse that she was displaying. As it was, there was not even a mention of enuresis in her school records. The issue of a diagnosis-led model of care also occurred in her mother's partner's case. For example, both his GP and the staff within the intensive care unit at the hospital focused on his 4 | P a g e health problems without wider consideration to the impact that his dependence on drugs and alcohol might have on those around him. 3.2. 'Soft' signs of abuse and professional curiosity Isobel's mother felt that both Isobel and her sibling showed signs of distress during the period under review. Undoubtedly, the sibling was displaying aggressive behaviour (described by the GP Practice Nurse); the sibling was clinging towards the mother (described by the school); and often sought attention (described by the social worker). Indeed, Isobel's behaviour at school was described as attention-seeking and disruptive. Furthermore, as the hospital never found a medical cause for Isobel's enuresis, other causes should have been considered. Despite all these potential signs of abuse, no professional gave Isobel the opportunity or space to describe what was happening in her world. Professionals should have been more curious and we know from Isobel herself that she simply wanted someone to ask her because she felt too afraid to disclose. The National Institute for Health and Care Excellence (NICE) has recently (February 2017) produced draft guidance for consultation suggesting that professionals should be alert to abuse and neglect if a child displays signs such as:1 Low self-esteem Wetting and soiling Recurrent nightmares Aggressive behaviour Withdrawing communication Habitual body rocking Indiscriminate contact or affection seeking Over-friendliness towards strangers Excessive clinginess Persistently seeking attention. 3.3. Making space and time for children and young people It was obvious from reading Isobel's medical records that she was rarely seen alone. She described being unable to discuss the sexual abuse she was suffering in front of her mother because her mother would be hurt. There were a couple of occasions when doctors asked Isobel whether she was sexually active but it was not clear from the records how the question had been phrased. If she was asked whether she was sexually active, had a 1 For further information see http://www.bbc.co.uk/news/education-39038529 – accessed online 22 February 2017 5 | P a g e boyfriend or could be pregnant, it would not necessarily have elicited information from her about sexual abuse. There was another occasion when Isobel appeared to try to tell a professional about life in her family. She told a social worker that her mother and her mother's partner argued a lot but this was not explored further. She told staff at her school that a boy had touched her inappropriately – it is not clear, but she may have done this to see if anyone would take such allegations seriously. Being professionally curious is not simply about asking the question. It is about the language used, creating a trusting relationship, a safe space in which to disclose and giving time to children and young people so they do not feel pressured. Professionals would have needed to be much more enquiring to help Isobel to articulate what was happening to her, especially as her mother's partner said he would kill her if she told anyone what was happening. 3.4. The invisible man There was clearly a disparity in the way in which professionals regarded Isobel's mother compared to the way they viewed her mother's partner. For instance, when Isobel's mother took an overdose of cocaine, a referral was (rightly) made to Children's Social Care. Nevertheless, when her mother's partner presented at hospital having collapsed at a party, it was known that he drank over 300 units of alcohol a week in addition to taking cocaine daily. Despite this, little consideration was given to his home circumstances (his records simply stated that he lived with his wife) and no safeguarding referral was made. At various times, her mother's partner spent around £400 a week on drugs and alcohol; whilst at the same time Isobel's sibling was being described by Children's Social Care as "underweight and small" and the school had concerns about the sibling's "poor appetite". Agencies such as the drug and alcohol service allayed their concerns by viewing Isobel's mother as a protective factor for Isobel and her sibling. Indeed, the partner's GP also never explored his home situation despite the Practice's knowledge of his poor medical health and his dependence on substances. 3.5. Lost histories The partner's GP Practice described him as a "fairly pleasant and docile" man, who during consultations was "pleasant and placid and did not come over as a controlling individual". In fact, the GP went as far as expressing surprise (when interviewed for the serious case review) that he had committed such a crime. Therefore, it is a concern that as far back as 1999 the same GP Practice had referred him to the Birmingham and Solihull Mental Health Foundation Trust because of his violent outbursts. His anger was clearly an on-going concern because he was again referred to mental health services by his GP in 2003. It 6 | P a g e appeared that his history of violence towards his then partner and their 4-month-old child did not 'travel' with him and was not overtly flagged on his records. Thus, over time this information became 'lost' in the background of his records and he became viewed as a "fairly pleasant and placid" man. 3.6. The cumulative impact on children It was notable that this case featured domestic abuse, parental mental ill-health and parental substance misuse. These three facets in family life are often referred to as the 'toxic trio' and are indicators of increased risk of harm to children and young people. Yet professionals from health, education, Children's Social Care, and drug and alcohol services failed to recognise the cumulative impact these issues might have on Isobel and her sibling's life at home. One of the difficulties for agencies working with domestic abuse, parental mental ill health and parental substance misuse is that they are working with the adults in a household. Sometimes adults choose not to engage with services, and this was certainly the case with Isobel's mother's partner. Furthermore, services that provide support to adults are designed around adults and they do not always come into contact with their children and so fail to consider them. Professionals did not explore more widely and 'think the unthinkable' even though (with hindsight) the signs were there. Isobel said her mother and her partner argued and her mother described her relationship with her partner as "fractious". Despite this, she was never referred to a specialist domestic abuse service that could provide support to her and her children. Both Isobel's mother and her partner were referred to mental health services. The partner's anger was never really assessed or addressed. Research2 shows that a third of perpetrators and victims of domestic abuse disclose mental health issues and/or substance misuse. The partner openly discussed his dependence on drugs and alcohol and Isobel's mother actively sought help when she became dependent on cocaine. It was known that the family were in debt. Isobel's mother told professionals it was because her partner spent the family money on drugs and alcohol. Again, professionals did not enquire further to understand how this affected the rest of the family even in basic terms such as how did Isobel's mother manage to provide her children with food, housing, heating and clothing. 2 See www.safelives.org.uk In plain sight: The evidence from children exposed to domestic abuse, CAADA Research Report February 2014 – accessed online 23 February 2017 7 | P a g e 4. A PRACTITIONER LEARNING EVENT A practitioner learning event was held to specifically address some of the issues raised in the course of the review and those raised by Isobel and her mother. It was attended by 27 managers/practitioners from a range of agencies including: Birmingham and Solihull Mental Health Foundation Trust Birmingham and Solihull Women’s Aid Birmingham Children’s Hospital Birmingham Clinical Commissioning Group Birmingham Community Health Care NHS Foundation Trust Child and Adolescent Mental Health Service (CAMHS) Children’s Social Care Community Mental Health Team Drug and alcohol services – Change Grow Live Birmingham City Council Education Services GP Practice Heart of England NHS Foundation Trust School Solihull Clinical Commissioning Group West Midlands Police It was clear from the event that the children and their mother were viewed separately to the mother's partner by the majority of agencies i.e. most agencies either worked with the partner and did not consider his family; or they worked with the children and their mother and did not explore the partner's influence on the family dynamics. Health practitioners were focused on the health issues that family members presented and little thought was given to the wider context of their lives. For example, Birmingham Children's Hospital did not consider non-medical reasons for Isobel's enuresis and the partner's GP did not consider the impact of his health and alcohol use on the family. All agencies struggled to address Isobel's thoughts – "I just wanted someone to ask me". This was for a number of reasons: Practitioners felt uncomfortable insisting that young children should be seen alone Organisational systems were not in place to enable practitioners to see children and young people on their own 8 | P a g e Practitioners had difficulties "thinking the unthinkable" Practitioners felt they did not have the skills to ask searching questions Although practitioners recognised a range of signs of abuse, these signs were not seen as a whole and therefore when taken in isolation did not raise concerns. 5. LEARNING POINTS Professionals did not always recognise when they needed to ask questions, share information or follow up with colleagues about a child's wellbeing There was a lack of curiosity when faced with adults who used significant amounts of drugs and alcohol. Professionals did not establish their domestic circumstances or the implications for children living in the household and did not consider compromised parenting capacity. There was an inequality in the way in which professionals treated Isobel's mother when she overdosed on drugs compared to the way they treated her mother's partner when he presented with high levels of drug use i.e. in Isobel's mother's case a referral was made to Children's Social Care whereas no one asked whether the partner had (or lived with) children No professional gave Isobel the opportunity or space to describe what was happening in her world. They did not have the confidence to ask difficult questions – "I just wanted someone to ask me". Professionals felt uncomfortable asking to see children on their own Little consideration was given to home circumstances and family composition – i.e. adult services tended to focus on adults (to the detriment of children) Agencies did not routinely have systems that could flag an individual's history |
NC52723 | Alleged interfamilial sexual abuse of female Child A (9-years-old in 2017) by male sibling B (11-years-old in 2017) in May 2017 and April 2021. Family history includes domestic abuse perpetrated by the birth father against the birth mother, criminal activity, and the children living with their birth father and stepmother. Learning includes: ensuring the voice of the child and understanding their experience is a focal point in education system record keeping; the importance of looking at family history within a social work assessment to avoid focusing on a single issue, and to include all adults with parental responsibility in the assessment; the need to risk assess parent safety plans to ensure sibling abuse does not re-occur; professionals understanding the complexity of the health information recording system; the impact of a criminal investigation on working with a family and delays to intervention; fully considering the role of the non-resident parent; practitioners acquiring the right skills to support young people who behave in a sexually harmful way so appropriate interventions take place; and making sure the knowledge, understanding and use of the processes and policy around sexually harmful behaviour are embedded in practice. Makes no recommendations but documents system changes made since 2017.
| Title: Child A: local child safeguarding practice review. LSCB: Stockport Safeguarding Children Partnership Author: Nuala O’Rourke Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child A - Local Child Safeguarding Practice Review.Nuala O'Rourke – Head of Safeguarding and LearningThe purpose of this reviewThe alleged interfamilial sexual abuse of A was notified to the Stockport Safeguarding Children Partnership and after a rapid review meeting it was determined that an independent author would be appointed to conduct a Serious Case Review into the circumstances surrounding the events leading to the allegation.The Purpose of the review was to identify any local learning regarding our current practice and areas that could be developed to prevent future incidents.A multi-agency chronology was developed to analyse the information and key events. Alongside this, a practitioners' event was held to explore key lines of enquiry to identify learning.Family views have also been gained as part of the review process.The review explored services engagement with the family from May 2017, when A first alleged she had been sexually assaulted to April 2021, when the second allegation was made.Subject of the review:Young Person ASignificant othersSibling – Young Person BSibling – Young Person CFather -Adult D Step-Mother – Adult EGrandfather – Adult F Mother – Adult GMethodologyThe review was started by an independent author and finalised by the Safeguarding and Learning Head of Service. The practitioner event was facilitated by the Independent Chair of the Safeguarding Children Partnership (SSCP)There were 27 practitioners involved, and they represented the following agencies.•Youth Justice Service•GP Practice•Independent Reviewing Officers•Safeguarding Training•Complex Safeguarding Service•Children’s Social Care•School Nursing•Mental Health team•Greater Manchester Police•Stockport Clinical Commissioning Group•Safeguarding in Education•Community Health Services.The practitioners were split into two breakout rooms where facilitators guided the conversation, and the practitioners were asked to consider the following:•Are there any issues that arise from this information for you? (Pen Pictures and Chronology of significant events)•Has anything changed in your agency since 2017 that may lead to a different intervention for A or B?•How are you supported when working with parent(s) who are professionals? •Are there any barriers in this area of practice for you/your agency and what would help?•When assessing sexually harmful behaviour in a family, what is important when approaching the assessment?•Multi-agency information sharing continues to be a barrier in many cases where reviews take place. What do you think is the reason for this and how can we support any change in this as a partnership?Key Lines of EnquiryThe review seeks to explore key lines of enquiry identified from the combined chronology:•Determine whether decisions and actions in the case comply with the policy and procedures of named services and the SSCP; •Examine the effectiveness of information sharing and working relationships between agencies and within agencies;•Examine the effectiveness of case handovers/transfers, information sharing and working relationships across borders;•Examine the involvement of other significant family members in the life of the child, and family support provided to the subject family; •Establish any learning from the case about the way in which local professionals and agencies work together to safeguard children; •Identify any actions required by the SSCP to promote learning to support and improve systems and practice. •Examine the effectiveness of the local safeguarding children arrangements including Team around the child / Early Help processes and arrangements for managing difference of opinion. •Examine the effectiveness of support for victims of Child Sexual Abuse.•Examine the effectiveness of arrangements to manage young people who develop harmful sexualised behaviours towards others.•Consider the effectiveness of family support in cases where high levels of supervision has been identified for the protection of other children in the family who would otherwise be considered at risk of significant harm.•Examine the role of school in recognising, assessing and supporting children exhibiting concerning or sexualised behaviours. •Consider the effectiveness of the local arrangements for proving quality “Keep Safe” work for individual children who are at risk of or have experienced sexual harm.Family TreeGranddad FD’s grandfather Child AFocus of this reviewChild BSibling Child CSiblingMum - GMother to A, B, CFather DFather to A, B, CStep Mum EStep mother to A, B, CAbout the child / their key issuesG -Mum (35)• Domestic abuse• Mental ill-health• Substance misuse issues• AssaultA – (13) Focus of the reviewChild of G & D• Early Childhood neglect• Sexualised behaviours• Hurts self• Domestic AbuseB -Brother (15)Child of G & D• Mental Health difficulties • Domestic AbuseC - Brother (8)Child of G & D• Domestic AbuseE -Step Mum (45) D -Father (39)• Domestic Abuse• Cognitive ability• Criminal activityF –Granddad (83)Significant Family History•Between 2005 and 2019, mum, G, is listed a victim of domestic abuse. She is also noted as an offender between 2005 and 2017 for a series crimes; production of cannabis, s.39 assault, possession of a weapon, public order and racially aggravated damage. •Between 2005 and 2014, D, the children’s father, is listed as a perpetrator of 10 domestic abuse offences involving G, the children’s mum. He has also been a victim of criminal damage and theft of a motor vehicle•B and C are listed in 4 of the domestic abuse incidents and A is listed as a secondary subject to 6 of themPen Picture – Child AA is now 13 years old.A now lives with her mum, G. At the time of the incidents she was living with her dad, D and step mum E. A has two siblings, B (16) and C (8)A struggled with being able to see/ spend time with both parents and how this will affect the other one.A loves both of her parents and her step mother, E who she has a strong relationship with. A likes the typical things a teenager is interested in and she’s described as a pleasure to work with. Pen Picture – Child BB is 16 years old and has aspirations for his future education and career. B has a close bond with his grandfather F and spends a lot of time with him. B has struggled in his relationships with dad, D, and step mum, E. B does have a good sibling relationship with C and it is felt that this is due to C being in B’s life from being a baby. B does not see A as much of a sibling mainly due to her coming into his life during his junior years. B has found it difficult to form a sibling bond with A.B also struggles with his mental health. This has been ongoing for some time. Chronology of Significant EventsDateEventJanuary 2016B was referred to HYMS (now known as CAMHS) after experiencing visual and auditory hallucinations. B was prescribed medication and the following month he was referred to an alternative service and closed to HYMS. There were further referrals made to the CAMHS service for B on numerous occasions as he continued to struggle with his mental health. August 2016B reported being bullied at primary school which caused him anxiety. May 2017A (9) told a professional in school that B (11) had orally sexually assaulted her. This led to involvement from GMP and Stockport Children’s Social Care. B was arrested for the alleged offence and GMP completed an investigation. The family didn’t support criminal charges and the report crime was finalised as No Further Action (NFA)May 2017B was attending High School and there was a lack of information shared with them in relation to the allegation and living circumstances following the report of abuse from A. May 2017B’s GP was unaware of the allegation of sexual abuse made against him. The GP continued to receive information from the paediatric team and CAMHS in relation to B’s appointments and investigations into his hallucinations and headaches. Chronology of Significant EventsDateEventJune 2017The SW assessment concludes. The SW also makes reference to Brook Traffic Light tool which would classify this as a “red” incident for B requiring intervention. The assessment concludes it was likely that A has been sexually assaulted by B and that risk remains. There was a safety plan in place for how the family would supervise and monitor B and A to safeguard her. The family were closedto social care at this stage. Schools were asked to complete work with the children in relation to sexually harmful behaviour and to offer support. June 2017A was seeing her GP for a number of concerns for her welfare; She was vomiting several times a day and reported struggling with toileting. A said she wishes she was dead. It was reported that A hits her head on walls and she is not meeting her educational targets. (The GP was not aware of the sexual abuse allegation)October 2017October 2017 Police were called when mother, G, refused to give the children back to father, D, after spending the day with them. D has residency of the children therefore they were returned to his care (no onward referrals made)February 2019School noted some concern for A that she was using sexualised language beyond her years with other children.September2019GMP responded to a domestic abuse incident at G’s home with a partner who had assaulted her. Record reads that children do not live with G therefore no onward referrals made.January – February 2020A’s School noted a number of concerns for her behaviour in school. Low-self esteem, becoming disruptive in class and concerns were raised by another parent that A is often seen outside her house talking to strangers. They were worried for her safety. Theschool also reported A talking about not wanting to live any more and becoming upset. Chronology of Significant EventsDateEventMarch 2020There were continued reports of A’s behaviour deteriorating in school and she wasn’t completing homework. April 2020Home based online learning due to COVID 19 pandemic. July 2020Concerns were raised in school in relation to A offering to send indecent images of herself to other pupils in school.September 2020A started in high school. Concerns were raised that she had drank alcohol. Teachers talked to her about this and A spoke about her feelings of abandonment saying that her mum abandoned her years ago for ‘drink and drugs’. Additional 1:1 support was put in place for A at school. Information was shared with the school safeguarding team.October 2020 A was admitted to hospital after experiencing blood stained vomit. This was put down to gastritis. This continued to happen, alongside abdominal pain, over the next few months. A’s GP sent off blood tests and referred her to a specialist team in January2021. March 2021E had a telephone consultation with the GP reporting concerns for A’s behaviour. Gave background of early childhood experiences.E reported her worries for A’s difficulties with regulating her emotions - hits self, damages personal property, cuts things, breaking items at home and with no identifiable reason. Struggles with friends. School not offering any formal support due to COVID. Areferral was made to HYMS (now known as CAMHS) for A (there was no mention of former sexual abuse allegation)April 2021A’s disclosures of further sexual assault are reported to GMP by E. Issues to considerThe Voice of the child•It was not evident that A was being listened to by professionals around her, as there were several key times when she was asking for help. Especially in the education setting.•The children’s voices were not strong within the assessment to understand their daily lives and lived experiences.The Social Work Assessment•Lack of exploration of the children’s family history led to a limited assessment focusing on a single issue rather than considering previous events experienced by the children.•The father did not appear to be present in the assessment and much of the communication was with the children’s step-mother.•The children’s birth mother was not included in the assessment.•The children’s father's role and history of being domestically abusive was not reflected in the assessment to consider how this may have impacted upon the children. • Was there an assumption that stepmother was able to safeguard without enhanced support due to her employment as a professional in a safeguarding profession? • There is a need to give staff stronger support and guidance on working Sexually Harmful Behaviour e.g. co-working with another worker so there is two social workers and not one working with the family.• Lack of curiosity in exploring the children’s history and formulating a chronology meant that the response was focused on a single issue rather than considering the previous events experienced by the children holistically.Information Sharing. • It was noted that, here an issue can be seen as minor by one agency, this can be escalated into a more significant risk when shared with similar issues from other agencies. • There are elements of good practice, however there is a need to invite wider agencies to meetings where these are circulated, such as GPs and school nurses. • It is important that professional curiosity is initiated with regards to earlier life experiences, particularly when services have been accessed in a different Local Authority; safeguarding will override consent with regards to information sharing. • Sharing of information directly with GP’s and to also gain their information about the children.• Sharing of and quality of information when transitioning schools.Issues to considerCriminal Investigations•The fact that there was a criminal investigation taking place as a barrier to supporting B in 2017. It appeared to cause lack of clarity around what information can be shared.•The length of time criminal investigations take to complete leads to further impact on the victim, A in this case and the family. The outcome of the investigation may impact the future intervention for the family. •A child’s ability to take responsibility and talk about what has happened in incidents of sexually harmful behaviour and abuse maybe influenced by the severity of the allegations and implications within the criminal justice system. This will also be influenced by legal advice and parental views. Lack of admission from a young person in situations where there is a lack of other evidence to proceed with a criminal charge, or in this case where parents did not support proceeding with prosecution, may therefore limit what action can be taken in terms of use of the AIM assessment process. The role of the birth mother•The issue of who had parental responsibility was not explored within the intervention.The health system. • There is an assumption that a referral to Health as a single service is assumed to be sufficient, when there are several different services and NHS Trusts; information needs to be shared or gathered from all agencies so that a holistic picture of the family is gained. • It should be considered whether there is a sound understanding amongst agencies of the organisational structures of Health provision across the workforce. For example, informing the GP of will not mean CAMHS will have access to the same information as they do not share the same recording system for patients. Information also needs to continue to be shared with Health agencies.Issues to considerSexually Harmful Behaviour (SHB)• Are professionals armed with the right tools in order to work with families around sexually harmful behaviour?• Considering the role of co-working when there are challenging conversations to be had.• The importance of using an evidenced based assessment tool to assess the risk of sexually harmful behaviour. i.e. the AIMS* assessment where good quality training is provided to complete this.• An effective multi-agency assessment with a sound hypothesis of a situation can allow for more effective and targeted support.• Are agencies familiar with the GM protocol and AIM processes for responding to sexually harmful behaviour to ensure the right people are invited to initial AIM strategy meetings and child protection conferences.• The complexities of working with a child who has reported SHB and does not admit this and where this is not evidenced via a Police investigation.• The understanding of the SHB Policy was lacking as this was not followed during the time that Social Care worked with the family. For example the Policy states that two workers should be allocated and that the Youth Justice Service should be present at the strategy discussion. • There was also complexity with how Children’s Social Care support families where a criminal investigation is ongoing and SHB is present. Investigations can take a significant period of time and or not lead to a conclusion. With the allegations finalised with no further action by GMP, this led to no one being able to evidence the allegations A made against B. Parents ViewsBirth Mother - G• G’s first and foremost views were centered around communication and information sharing. G said “I wish someone just told me” in relation to A’s first disclosure of sexual abuse in 2017. G was upset that she didn’t know what was going on for her child and wanted to be able to support her. • G was upset that she was not included in the initial Social Work Assessment and felt as though this was a priority as to her knowledge D does not hold formal legal parental responsibility for the children. G raised the issue of ensuring that all parents with Parental Responsibility are part of the Social Work assessments.• It was felt that the Social Work assessment did not consider the family history and the domestic and sexual abuse that G suffered that was allegedly perpetrated by D. G said “no one would want me involved to erase the history, like it didn’t happen.”• G shared that child B witnessed some of the abuse she suffered and feels as though this will have impacted upon him. It was suggested that this could have contributed towards his alleged sexually harmful behaviour towards A.• G shared her view that information was not successfully shared or transferred when the children went from living with her in one borough to living with their father, D, in another area. G felt that this information and history should have been shared to ensure that it was known as she felt that D continued to pose a risk to the children, and this was not considered. At the time G was spending time in hospital due to her mental health declining and this was the catalyst for the children being in D’s care. Parents ViewsBirth Father, D and Stepmother E•D spoke about his involvement in the Social Work assessment in 2017, where he cannot recall meeting the Social Worker in person. D said that he spoke to the worker on the phone, and he agreed for E to be the point of contact for the assessment.•E felt as though the service offered by CAMHS was poor. She reported how after many referrals no treatment was provided for B which was worrying giving his recurring mental health difficulties, hallucinations and anxiety. •E described information sharing as a challenge and how the children’s school would not share information with each other. She felt this was important as it has continued to be a theme and information sharing protocols could be improved. •In relation to the support provided by services in 2017 to help D and E mange the safety of the children within the home from any potential sexually harmful behaviour, E acknowledged that they were more vigilant in the home and that had slipped more recently as time went on. •D and E did not recall a safety plan being discussed with them and they didn’t have a hard copy of anything like this. •E stated that she only met the assessing Social Worker once and D was not there on this occasion. Following this visit the case was closed. •E wasn’t sure if her job within the safeguarding profession impacted the actions of the Social Work assessment or not. E felt as though it was likely this was why she was not given thorough advice and support on how to manage sexually harmful behaviours. She believes there was a sense that she would ‘know’ how to ensure the safety of the children within the home; because of her profession. •D’s learning difficulties were not considered in the Social Work assessment, and he felt that this impacts his ability to engage in work like this as he doesn’t understand what is being said without E’s support to interpret thisSystem changes since 2017•The team around the school is more mature and embedded within practice and this would have led to more robust information sharing and joint planning.•Information sharing between the Stockport Children’s Social Care and Mental Health Services has improved. There are now Mental Health Practitioners based within the Multi Agency Safeguarding and Support Hub (MASSH) leading to a better triangulation of information with partners.•A trauma informed approach is being embedded across Stockport with multi agency training being rolled out across the public and voluntary sector.•Since 2017, work across borders with other Local Authorities has improved, there is also a more effective use of chronologies and work with families is now stronger through use of a trauma-informed approach. •Most schools now use electronic means for record-keeping, this allows for more timely and accurate extraction and sharing of information when required. •There has been a focus on practice in relation to sexually harmful behaviour. This has included learning circles and a task and finish group to improve practice and tools available for practitioners working with sexually harmful behaviour.•In 2019 AIM* training was delivered to a number of Social Workers and Youth Justice Officers within Stockport Family. There is also now a desktop AIM’s assessment that the Youth Justice Service can complete with children who display SHB when there is no conviction or criminal investigation. This would however require the child to be honest about this so that meaningful work can take place. •*Assessment intervention and moving on –farmworker for assessing and intervening with young people who display sexually harmful behaviour The AIM Project – The AIM ProjectLearning1The influence of the voice of the child and understanding of her experiences is not a focus in the record keeping within the education system. For example, when A is asking for help and saying statements like she wants to die; no one is asking her why or being curious about the reason for her unhappiness.2The safety plan in place for parents to ensure there was no possibility that B could abuse A again was not risk assessed robustly. There was too much reliance upon parents to continue to do this without additional support or direct work.3The importance of looking at the family history, exploring and understanding historical information within the social work assessment was a factor. The assessment focused on a single issue, narrowing the scop of the assessment to understand the children’s lives and experiences holistically.4It was evident that not all professionals understand the complexity of the health information recording system, leading to information not being shared with the right part of the system.5Sharing information continues to be problematic and is reliant on the right agencies being invited to and attending meetings to be able to receive or share information.6There is a need to understand how a criminal investigation might impact on working with a family leading to a delay to move forward with interventions7The role of the nonresident parent was not fully considered by practitioners, leading to information being missed and the parent not being included in the assessment.8Practitioners are not always equipped with the right skills to support young people who behave in a sexually harmful way leading to appropriate interventions not always taking place.9The knowledge, understanding and use of the processes and policy around sexually harmful behavior needs to be further embedded in practice. |
NC50717 | Life threatening and life changing neglect of a 3-year-6-month-old girl in September 2017. Rosie suffered neglect within her home environment by both biological parents and required emergency admission to a hospital children's ward with on-going specialist care. Rosie was found to be malnourished, unkempt, in poor physical health, socially isolated and developmentally delayed. Family was known to universal health services and receiving care from GP, health visiting and maternity services. Father was known to police relating to domestic abuse against a previous partner and substance misuse services. Evidence to suggest that both parents have learning difficulties. Rosie is White British. Learning includes: children who are suffering from neglect (and other forms of child maltreatment) may be 'hidden in plain sight'; pre-birth planning and assessments offer early help and support to vulnerable parents and ensure the future safety and well-being of the unborn child; more needs to be done to promote collegiate working, respect and mutual understanding of others' roles and responsibilities, including the limitations in practice; all those delivering care to children, young people and their families must have the relevant competencies to do so. Recommendations include: seek assurances that practitioners are asking parents/carers why young children are not accessing early years' provision; ensure that practitioners delivering care to children, young people and their families have achieved, as a minimum, the competencies set out in the relevant professional guidance, including oversight from an appropriately qualified professional.
| Title: Serious case review: Rosie: overview report. LSCB: Bedford Borough Safeguarding Children Board Author: Catherine Powell Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review Rosie OVERVIEW REPORT BBSCB 10th October 2018 Lead Reviewer Catherine Powell PhD, BNSc. (Hons.) RGN RSCN RHV Child Safeguarding Consultant 2 Governance My credentials as an independent author and reviewer are that I am currently working as a freelance Child Safeguarding Consultant after a long career in the public sector, having specialised in child protection and safeguarding since 1994. I have prior experience as an independent author/lead reviewer for serious case and learning reviews and am actively supporting a number of individuals and organisations in learning and improvement in their safeguarding practice. I declare that I have found no conflict of interest in leading this review and am independent to the Bedford Borough Safeguarding Children Board (BBSCB) and partner agencies. I am grateful to those individuals who have supported the review process, contributed to the learning, and been resolute in seeking to improve the services provided to children and their families. Attempts have been made to contact Rosie’s parents, as their views on the services provided, would have enriched this report. Unfortunately, a meeting has not proved possible. It is hoped that the learning from this review will strengthen services to expectant and new parents, especially those who are additionally challenged by personal, social and economic difficulties. The report has been commissioned by, and written for, the Board. In reflecting the importance of accountability to the wider public, the report will be published on the BBSCB website. As such, the details of the child and their family, and the individuals providing care to them, have been anonymised in accordance with statutory guidance and best practice. Catherine Powell 10th October 2018 3 Contents 1.0 Introduction 5 2.0 Methodology 7 3.0 Narrative chronology 10 4.0 Discussion of key findings 17 5.0 Learning points for consideration by the Bedford Borough Safeguarding Children Board 30 References 33 Appendix one: Lines of enquiry 36 Appendix two: Practitioner Learning Event Appendix three: Additional audit questions Appendix four: Overview of the Healthy Child Programme (HCP) 38 39 40 4 Abbreviations ACE – Adverse childhood experiences ASQ – Ages and Stages Questionnaire BBSCB – Bedford Borough Safeguarding Children Board CAF – Common Assessment Framework CIN – Child in need (plan) CPP – Child protection plan CSC – Children’s social care DNA – Did not attend EHA – Early help assessment ELFT – East London NHS Foundation Trust EPUT – Essex Partnership NHS Trust GCP2 – Graded Care Profile 2 GP – General Practice/Practitioner HV- Health Visitor HCP – Healthy Child Programme iHV – Institute of Health Visiting KLOE – Key lines of enquiry MASH – Multi-agency safeguarding hub NICE - National Institute for Health and Care Excellence NSPCC – National Society for the Prevention of Cruelty to Children SCR – Serious Case Review SIRG – Serious Incident Review Group TAC/F – Team around the child/family TWSCB – Telford and Wrekin Safeguarding Children Board WNB – Was not brought WTE – Whole time equivalent 5 1.0 Introduction 1.1 This overview report sets out the findings of an independently-led thematic serious case review (SCR) commissioned by the Chair of Bedford Borough Safeguarding Children Board (BBSCB). It concerns Rosie, a three-and-a-half-year-old White British child, living with both biological parents. Rosie was found to be suffering from life-threatening and life-changing neglect within her home environment. She required an emergency admission to a hospital children’s ward and will need on-going specialist care to meet her health and developmental potential into the future. Child protection and legal proceedings have ensured her safety. 1.2 At the time of her admission, Rosie and her parents were known to universal health services and were receiving care from a GP-practice, health visiting and maternity services. The family had also had previous, but minimal, contact with adult mental health services, an emergency department, the children’s assessment unit, the paediatric department, orthopaedic outpatients and children’s social care services. Father had been known to the police service and substance misuse services. 1.3 Rosie’s case was discussed at the BBSCB Serious Incident Review Group (SIRG) in November 2017. After due consideration of the circumstances, the case was deemed to have met the criteria for a SCR, as defined in the statutory guidance in place at this time1 (HM Government, 2015). This is because Rosie had suffered serious neglect and there was a need to review the ways in which agencies had worked together to ensure her safety and welfare2. 1.4 The features and impact of neglect on Rosie’s health and wellbeing can only be described as ‘shocking’. She was found to be severely malnourished, unkempt, in poor physical health, socially isolated and developmentally delayed. These findings raised important questions about the quality and provision of local services to young children and their families, and the possibility that other children may be at risk. 1.5 Such concerns also reflected the emergent findings of another serious case review concerning neglect (Family Q)3 in progress at the time. The Overview Report of that review has now been published (Telford and Wrekin Safeguarding Children Board (TWSCB), 2018). 1.6 The similarities in the two cases, together with a concurrent BBSCB-led strategy to improve the recognition and response to child neglect (reflecting learning and improvement activity following other recent SCRs where neglect was a feature), led to the inclusion of a requirement within the commissioning brief for this review to: ‘consider the quality of the current professional recognition and response to child neglect in the early years in Bedford Borough’ 1 HM Government (2015) Working Together to Safeguard Children: a guide to inter-agency working to safeguard and promote the welfare of children London: DfE. This guidance was reissued in April 2018 and July 2018. 2 Regulation 5 of the Local Safeguarding Children Board Regulations 2006 5(2)(b)(ii) 3 This review was led by TWSCB, but refers to a period of time when the family lived in Bedford Borough. 6 1.7 The involvement of practitioners and managers has been fundamental to all stages of the review. A practitioner event, hosted early in the process, enabled those practitioners involved in Rosie’s care to share her story and to begin to identify the areas for learning and improvement. Towards the end of the review a second practitioner event was held to test out the emergent learning and recommendations. 1.8 Whilst Rosie’s case is central, we have also audited the pathways and experiences of six additional young children at risk of neglect who were receiving local services at the time of this review4. Practitioners who were known to the audit subjects were invited to take part in this process, along with their managers. 1.9 The overview report aims to provide a succinct summary of learning from the experiences of Rosie and her family, as well as from the cases we reviewed through audit. The report seeks to reflect an understanding of wider strategic and organisational issues, as well as individual practice. Where practice has been over and above what is expected, this good practice is recognised. Whilst the learning points that conclude the report are primarily for BBSCB to consider, the learning from this review may also have national relevance and application, particularly at a time when austerity and public health cuts are impacting on the provision of universal health services to children. 1.10 Rosie’s case review has a degree of complexity that reflects the contextual nature of neglect, as well as the agreed timeline for the review. The timeline begins in the prenatal period and concludes with Rosie’s admission to hospital; a period of more than four years. This timeline has been essential to highlight potential opportunities for learning and improvement in practice and provision in Bedford Borough. 1.11 Whilst being mindful of the core requirements for the conduct of reviews (see box below), and particularly the need to understand practice from the viewpoint of individuals and organisations involved at the time, the retrospective nature of the review has led to the identification of key episodes and points of contact where action could, and at times should, have been taken to safeguard Rosie’s welfare. Understanding the reasons that prevented a timely response to this child’s neglect forms the crux of this report. Core requirements of SCRs: • To understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • To understand practice from the viewpoint of the individuals and organisations involved at the time, rather than using hindsight; • To be transparent about the way data is collected and analysed; and • To make use of relevant research and case evidence to inform the findings. HM Government (2015:74) 4 The audit took place in June 2018. 7 1.12 The overview report opens with a brief description of the terms of reference and the methodology of the review. This is followed by a narrative chronology that describes the significant events in Rosie's life and the services provided to the family. The findings are then summarised, discussed, and synthesised with the findings of the audit. Reference is made to the literature, including other local reviews, and to recent developments in improving the response to neglect in the Borough. The final section of the report outlines the recommendations and learning points for consideration by Bedford Borough Safeguarding Children Board. 1.13 If there is one message to take forward from this SCR it is that Rosie was not, as was initially hypothesised, a child who was ‘hidden’; until she was two years and four months of age, she was seen regularly by health professionals. Rather, she was a child who was ‘hidden in plain sight’, neglected by parents whose capacity to parent had almost certainly been limited by their own adverse childhood experiences and multiple known difficulties in their adult lives. 1.14 This critical history and background were not sufficiently incorporated into assessment and care-delivery. The findings support the need to ensure a holistic approach to assessment and to reflect the ‘urgency’ (Sidebotham et al., 2016) of responding where there are emergent concerns about child neglect. 1.15 Addressing intergenerational patterns of adversity and disadvantage through the provision of early help and support is key, as is the need for service providers to ensure that practitioners remain focused on the health, development and daily lived experiences of children, particularly those who are impoverished by the circumstances of their very being. 2.0 Methodology 2.1 The overview report is best considered to be a published summary of the key findings and learning points from a serious case review. The report is not an 'endpoint' in itself; the SCR is an iterative and collaborative process with learning and improvement commencing at the earliest opportunity and continuing to be embedded after the report is published. This section sets out the terms of reference and the methods employed to ensure that the review has been as robust and comprehensive as possible to inform a ‘step-change’ in practice. Terms of reference 2.2 In line with the statutory guidance (HM Government, 2015), BBSCB has developed a tradition of taking novel approaches to commissioning serious case reviews. This includes utilising a thematic approach where neglect (and disability) have featured. In scoping the current review, BBSCB identified the need for assurance that practitioners who work with children and young people recognise neglect at the earliest opportunity, and that they are enabled to provide a timely and helpful response. The Board also wanted to discover whether there were blocks in the safeguarding system and, if so, for reviewers to make suggestions as to how these may be addressed. 2.3 BBSCB have thus commissioned a short and concise thematic review that centres on Rosie’s case, but also considers the learning from other local SCRs where neglect was a theme. The review was additionally to provide a window on the current child safeguarding 8 system and ensure that children, young people and their families are provided with the best possible support. 2.4 A SCR Thematic Review Panel was established to support the review process. This was chaired by the Lead Reviewer and membership determined by the SIRG, as follows: • Dr Catherine Powell – Lead Reviewer/Author/Chair • Manager for Safeguarding and Quality Assurance – Bedford Borough Council Children's Services • Senior Officer for Public Health, Children and Young People – Bedford Borough Public Health • Detective Chief Inspector – Bedfordshire Police • Designated Nurse for Children and Young People – Bedfordshire Clinical Commissioning Group • Named Nurse for Safeguarding Children – Bedford Hospital NHS Trust • Head of Service Safeguarding Children – Essex Partnership University NHS Trust (EPUT), services now provided by Cambridgeshire Community Services NHS Trust • Pathway to Recovery Worker - East London NHS Foundation Trust • BBSCB Business Manager 2.5 The panel met face to face on three occasions to oversee the process and contribute to the learning. Members have additionally commented on an early draft of this overview report. 2.6 In scoping the terms of reference for the review, the SIRG, together with the Panel, developed and refined several key lines of enquiry (KLOE). These reflect a systematic approach to the review, drawing on the requirement to consider strategic and organisational learning and improvement, as well as learning from practice at the frontline. Appendix one provides more detail of the KLOEs. Integrated chronology 2.7 At the outset of the review, involved agencies were asked to draw up a chronology of significant contacts and events in the life of the Rosie and her family. These covered the period from 6th July 2013 to 5th September 2017 (pregnancy booking until Rosie’s admission to hospital) and were compiled by safeguarding leads from the following agencies: • Bedford Borough Council Children’s Services • Bedfordshire Clinical Commissioning Group (on behalf of GPs) • Bedford Hospital NHS Trust • (Former) South Essex Partnership NHS Trust/Essex Partnership University NHS Trust • East London NHS Foundation Trust • Bedfordshire Police 2.8 The chronologies also listed key contacts with agencies prior to the agreed timeline for the review. This has provided important background. Once chronologies had been completed they were amalgamated to provide a detailed and helpful history of Rosie and her family’s contacts with universal and specialist agencies. 9 2.9 The contributing leads utilised the ‘comments’ section to raise important questions and began to identify the issues for learning and improvement that have been central to this review. The quality of the chronology is largely commendable. Practitioner Learning Event 2.10 A practitioner learning event, facilitated by the lead reviewer, was held on 27th April 2018. This was attended by six members of the thematic SCR panel and 11 practitioners who had been involved in the care of Rosie and her family, including those from universal and specialist health services, children’s social care and the police. 2.11 Two health visitors, and a midwife, who were unable to be at the practitioner event, met separately on a one to one basis with the lead reviewer. 2.12 Practitioner involvement was fundamental to the review process. The main purpose of the event (and one to one meetings) was to build on the findings from the chronology and to discuss the delivery of services to Rosie and her family. 2.13 Attendees were also invited to contribute to the learning from the review, including identifying the points at which action could, or should, have been taken. Current practice was also discussed. Appendix two provides a summary of the learning generated by participants. Informal feedback from this event has been very positive. 2.14 A second practitioner event, held on 13th September 2018, enabled feedback, clarification and refinement of the emergent learning from this review. The event was attended by seven practitioners and managers from universal and specialist health services, children’s social care and the police. Members of the SCR panel were also in attendance. Deep-dive audit 2.15 BBSCB required that in addition to undertaking a retrospective review of Rosie’s case, the reviewers also considered the quality of the current professional recognition and response to child neglect. 2.16 To achieve this, the Thematic SCR Panel led a ‘deep dive’ audit and case discussion. This aimed to gather evidence of the pathways and experiences of six additional young children at risk of neglect, who were known to local services at the time of the review. 2.17 The audit and case discussions took place over the course of one day, 8th June 2018. Three cases were subject to review in the morning, and three in the afternoon. Practitioners and managers associated with each of the cases were invited to attend. 2.18 The audit was guided by an adapted version of the Pan-Bedfordshire Safeguarding Children Boards Audit Tool (as agreed by the Thematic SCR Panel). The adaptations reflected the emergent learning from Rosie’s case (for benchmarking purposes) and the creation of a ‘box’ for the Panel to make a judgement (see Appendix three). Family involvement 2.19 At the outset, on-going criminal proceedings meant that Rosie’s parents were not able to be invited to make an early contribution to the SCR. Once permission was granted, 10 the parents were contacted by letter to inform them of the review and to be invited to engage with the process. However, despite further attempts to make contact, it appears that parents have disengaged from services, and thus have not been able to contribute their views. Summary 2.20 This section has set out the terms of reference and the methods employed to ensure that the review has been as robust and comprehensive as possible. The diagram below illustrates the methodological ‘building blocks’ that have enabled the learning and contributed to the conclusions and recommendations of this report. 3.0 Narrative chronology 3.1 This section has been informed by the integrated tabulated chronology of key events and reports of agency contacts with Rosie and her family. These help to begin to build a picture of her life-story, to understand who was involved in her care, what they did, and why. The practitioner event enabled a deeper understanding of the family’s experiences of receiving care from universal and specialist services. 3.2 The narrative chronology is divided into four time periods. These reflect some background prior to the timeline for the review; the period leading up to Rosie’s birth and the key significant events from the time she was born until her admission to hospital aged three and a half years. Background prior to timeline 3.3 Clinical records for Rosie’s father indicate that he was known to mental health and substance misuse services in 2008, with further contact in 2010. Alongside these difficulties, he also has a criminal record relating to serious offences, for which he was found guilty in 2009. There is a police report of domestic abuse against a previous partner in 2011. In the same year he was referred to mental health services by his GP who noted that he was ‘sleeping on the streets, using drugs and alcohol and feeling that life was not worth living.’ 3.4 Similarly, in 2012, Rosie’s mother had an overnight admission to a mental health assessment unit, due to having suicidal thoughts. At her midwifery booking appointment in Integrated ChronologyPractitioner Learning EventsDeep-dive AuditFamily involvement[attempted but not achieved]Thematic SCR11 2013, she also reported having had a history of misusing substances, including alcohol, cocaine and MDMA5, having stopped over a year before the pregnancy. 3.5 Following Rosie’s admission to hospital, mother reported to police officers that her difficulties relate to her own experiences of child abuse and neglect, and subsequent entry into the care system. It has not been possible to verify this information. 3.6 There is some evidence to suggest that both parents have learning difficulties. This includes mother’s report that she attended a special school. Seemingly, neither parent spent their childhood in Bedford, and this has impacted on agency information gathering. At the time of her pregnancy with Rosie, mother was in her mid-30’s and father his late 30’s. Pre-birth to one year of age (6th July 2013 to 7th February 2015) 3.7 Rosie’s mother was booked for ante-natal care when she was 10 weeks pregnant. This was noted to be her first pregnancy (father later shared that he had an older child, born in 2006). The midwife identified mother’s history of mental health issues, homelessness, substance misuse history and lack of family support. She was referred for Consultant Obstetrician care and a single-agency information sharing document was completed outlining the safeguarding concerns. 3.8 Subsequently, the midwife completed a Common Assessment Framework (CAF), and made a referral to children’s social care (CSC), citing concerns about mother’s history as noted above. The referral also noted that parents had been together for two years and that father had reported support from his (large) extended family. Mother was attending all her ante-natal appointments and was said to be in good health. The CAF was undertaken at the GP practice. 3.9 CSC advised that because the concerns were ‘historical’, and mother was well supported, a Team Around the Child (TAC) should take place and that no further action would be taken by them at this time. Parents had also stated that they were ‘reluctant to have anyone else involved’. 3.10 A TAC meeting was scheduled, but subsequently cancelled due to sickness. 3.11 The health visitor made two attempts to call mother to make an appointment for an ante-natal contact, as per the mandated visits protocol. Mother’s phone had no message facility and the calls were unanswered. A planned visit was then cancelled by the HV administrator, due to staff sickness. 3.12 The TAC meeting was rearranged, but the midwife informed that a HV would be unable to attend due to sickness. The meeting went ahead, with both parents, the midwife and a children’s centre worker in attendance. Mother was approximately 36 weeks pregnant at this point and attending all her ante-natal appointments. Parents agreed to be supported by the children’s centre and reported that they had bought baby equipment. 3.13 A few days later, after several attempts to make contact, the HV spoke to the midwife to gain feedback from the TAC. She confirmed that there would be no input from CSC as 5 3,4-Methylenedioxymethamphetamine, commonly known as ‘ecstasy’. 12 ‘mother was attending all her appointments’. A further attempt was made to carry out the ante-natal HV contact; but mother did not return the HV call. 3.14 Rosie was born on 7th February 2014 by elective caesarean section, at 37 weeks gestation. There were concerns about her growth in utero and her breech presentation. Father was in attendance. Rosie’s weight at birth was 2116 grams, just below the 9th centile, and she was admitted to the neonatal unit because of low Apgar6 scores and, given a history of maternal substance misuse (albeit not during the pregnancy), the possibility of neonatal abstinence syndrome. 3.15 Maternity staff noted that both parents were of a ‘neglected appearance’. They had arrived at the hospital without nappies or clothes for their daughter, reporting that they had no money and were awaiting a benefits payment. The parents also reported that they had been surprised by Rosie’s early arrival. Staff were reluctant to discharge mother and baby without ensuring that support was in place and made an urgent referral to children’s social care. 3.16 The following day a social worker visited parents on the ward and followed up this visit with a home visit with father to assess home conditions and preparations. The social worker observed that the bedsit was clean and tidy, with a Moses basket, steriliser and sufficient clothing for the baby. Father reported needing the benefits payment to buy nappies. Mother and baby were subsequently discharged from hospital to the care of community midwives four days after the birth. There was no further involvement of CSC at this time. 3.17 Community midwives visited the home on six occasions over the following three weeks. The health visitor (HV) also made contact and called to undertake a new birth visit, when Rosie was 17 days old. 3.18 Liaison took place between the midwife and HV, prior to the new birth visit, with reports that there was poor interaction between mother and baby. The HV has recorded that a referral was made to CSC by the midwife, but this appears to reference the referral detailed above, rather than a further referral relating to concerns about the relationship between mother and child. 3.19 At the new birth visit the HV noted that whilst mother was gentle with Rosie, she did not talk to her. The HV recorded the mother’s depression and medication. When encouraged by the HV to smile and talk to Rosie, mother replied that ‘she did this all the time.’ Due to concerns about Rosie’s failure to gain weight and feeding difficulties a paediatric referral was made and Rosie and her mother were admitted to the ward for two days for observation and support from the infant feeding team. 3.20 Follow-up and growth monitoring was provided by the nursery nurse and community staff nurse, who liaised with the named HV. Rosie was not taken to a follow-up appointment at the children’s assessment unit one week post her discharge; albeit there appears to have been a mix up over the date of this appointment. 6 Apgar score is a simple assessment of a newly born infant. A low score suggests the possibility of medical assistance being required. 13 3.21 The day before this failed appointment she was, nevertheless, seen at the hospital by the orthopaedic service with a diagnosis of congenital hip dysplasia following her breech position in utero. This was treated conservatively with a hip harness until Rosie was four months of age. 3.22 The health visitor undertook a second home visit when Rosie was 26 days old. There had been some weight gain. Parents were assessed as being competent with basic baby care and were asked to attend local services for future input and support from HV service. 3.23 When Rosie was six weeks old there was a further overnight admission to hospital with concerns about feeding and weight gain. She was also seen by the GP for a routine six-week check, which noted the hip harness, but no other concerns. Over the next few weeks there are occasions where professionals had recorded difficulties in contacting each other to liaise about Rosie’s weight or feeding regime. The chronology suggests that some recorded failures in attending appointments/baby clinic were due to clashes on the day (with hospital appointments). 3.24 When Rosie was eight weeks old she was seen in the Emergency Department following a house fire and smoke inhalation. Admission was unnecessary. The GP was informed of this event, and the HV became aware when she saw this on the shared health record. 3.25 At nine weeks old Rosie was taken to the practice nurse for a vaccination. Mother reported that she had accidentally banged Rosie’s head on a door frame. A small graze was noted by the nurse. 3.26 Slow weight gain was recorded over the next few weeks, with weekly/two weekly attendance at the clinic. The HV contacted the paediatrician to query whether there was any underlying condition to explain this, e.g. foetal alcohol syndrome. It is unclear how this was followed up. 3.27 At four months of age Rosie was seen in paediatric outpatients. Her weight and height were below the 0.4 centile. A further referral was made to the dietician to offer support with weaning. No other developmental concerns were raised at this time. 3.28 At six months of age, Rosie’s weight was noted to be static. She was reported to have been eating carrots and encouragement was given to mother to add other foods to her feeding regime. 3.29 At seven months of age Rosie was seen in the orthopaedic clinic, x-rays showed normal spine, hips and feet. She was re-appointed for further follow-up in six months. 3.30 At 11 months of age Rosie was not brought to a hospital paediatric appointment. Clinic staff attempted to call parents, but their mobile phone was ‘turned off’. The GP practice was notified of this failure to attend and her subsequent discharge from the paediatric clinic. The practice followed up with a letter to the HV asking if the family had moved; this was responded to by a confirmation that the current address was correct. 14 One year to three and half years of age (7th February 2015 to 21st August 2017) 3.31 At 14 months of age Rosie was seen at the orthopaedic clinic; again, the finding was of normal spine, hips and feet. 3.32 Two invitations were sent for Rosie to attend a one-year review by the HV service; one for an appointment at home, the other for review in a group session. This review eventually took place at the family home, when Rosie was 15-months old. This noted a good emotional bond between Rosie and her mother, but also some developmental concerns, including the fact that she was not weight-bearing, that her (solid) food intake was poor and that her growth was still below the 0.4 centile. An ‘ASQ’ tool (ages and stages questionnaire) was not completed at this visit. 3.33 Also at 15 months of age Rosie was seen by the GP for a problem with her ears/teething. The GP also asked parents to make an appointment to discuss the missed hospital appointments. This was not attended. 3.34 When Rosie was 16 months old the GP contacted the HV with concerns that mother was struggling with depression, and that there was a past history of alcohol abuse and homelessness. This call also noted that she had a mild learning difficulty and no family support. 3.35 Mother rejected an offer of support from the nursery nurse and declined a visit. This was reported back to the GP, with the HV sharing a plan to encourage mother to attend the children’s centre. 3.36 The HV also telephoned mother to monitor progress. Mother said that Rosie was now drinking less milk and eating more food. The HV shared her concerns about the non-weight bearing and offered to accompany them to the children’s centre. 3.37 The HV attempted to call mother the day before the planned children’s centre visit, but there was no answer and the message facility not enabled. On arrival at the home the following day, there was no one in. A letter was sent to mother to arrange a further home visit. 3.38 On arrival for the visit, the HV and nursery nurse found father at home, with a report that mother had left with Rosie 10 minutes previously. Father said that Rosie was standing alone. Subsequently, a telephone call was made to mother, who denied that she was deliberately avoiding HV contact. The HV was clear that she needed to assess Rosie, and that she would escalate her concerns regarding avoidance of health professionals to the GP and CSC. 3.39 The HV returned to the home the following day, accompanied by a HV colleague. Some developmental progress was noted, including the fact that Rosie could stand on tip toe and point to apps on a tablet. Advice was given about feeding; parents reported that she does not eat ‘normal food’ for her age and discards most of it. The ASQ was not recorded as being used as a tool for the assessment. Rosie’s growth was noted to be below the 0.4 centile. 3.40 Mother reported that she was not keen to attend the children’s centre as she was intimidated by groups but agreed to go with Rosie and Rosie’s father. At this visit father 15 disclosed that he had an older child, born in 2006, who he had little contact with. Mother’s mood was assessed, and no low mood reported. The findings, including that Rosie was meeting her developmental milestones, were reported back to the GP. 3.41 At 20 months of age Rosie was again seen at the orthopaedic clinic. She was noted to have started crawling, but not walking. 3.42 A two-year funding voucher to support nursery attendance was issued in January 2016 and the family invited to attend a Book-start Party at the Children’s Centre. An attempt to contact parents was made as follow-up, but it is reported that the phone was not working. There is no evidence to suggest that Rosie attended any early years’ childcare provision or groups. 3.43 At 22 months Rosie was seen by the GP for a fungal infection of her skin, the GP gave advice about scalp care. In February 2016, when Rosie was two years old, the family moved and registered with a new GP practice. 3.44 A health care assistant carried out a ‘new patient check’ the following month. This noted that Rosie was not yet walking. This was said to have been reported to the GP. 3.45 In April 2016, Rosie was not taken to an appointment with the consultant orthopaedic surgeon. The GP was not made aware of this failed appointment. A further appointment was sent. 3.46 Rosie was not taken to two subsequent orthopaedic appointments; the hospital safeguarding team, HV, and GP were made aware and clinic staff made ‘numerous attempts’ to contact mother. 3.47 When Rosie was two years and three months old, an appointment to assess her development at home7 was sent by the health visiting (0-19) service, together with an ASQ (for parental completion). This review was to be undertaken by a nursery nurse. However, on her arrival, the family were not in. There is no evidence that this outcome was shared with the HV. A further appointment was sent; again, there was no access. This time the HV and GP were made aware. 3.48 Also aged two years and three months, Rosie was taken to the emergency department, and subsequently seen by the ‘out of hours’ GP service with a viral illness. It appears that this is the last time prior to her hospital admission in September 2017 that Rosie was seen by a health professional. 3.49 A week later the HV made an opportunistic visit to gain access and see Rosie but found no one at home. A card was left asking mother to make contact. Rosie was now just over two years and four months of age. The two-year developmental assessment did not take place. 3.50 When Rosie was three years old there was a further failed appointment at the orthopaedic outpatients’ clinic. This time the decision was made to discharge her from the clinic, with a letter to the GP requesting that they make contact if Rosie was still under their care. No known contact was made. 7 This assessment can take place between two and two and half years of age. 16 3.51 The HV wrote a letter to mother regarding the failure to attend the orthopaedic appointments and asked her to contact them. This does not appear to have happened or been actively followed up. 21st August 2017 to admission to hospital on 5th September 2017 3.52 On 21st August 2017, a midwife made a home visit to undertake an ante-natal booking for mother’s second pregnancy. The midwife had seen the mother just over a week previously at the GP practice, and had concerns regarding mother’s unkempt appearance, poor dental hygiene and low-weight. Mother had reported that she ate well but had always been slim. She was said to be 13 weeks pregnant and had attended the practice alone. 3.53 The midwife contacted the multi-agency safeguarding hub (MASH) in advance of the home visit to ask if the mother was known to CSC; the response was that they were not. 3.54 The initial appointment offered five days after the midwife had seen mother at the practice had to be postponed due to staff shortages. The contact was made a few days later. 3.55 Mother, father and Rosie were at home when the midwife called. Rosie was seen to be very small, developmentally delayed, drinking milk from a bottle and dressed in a baby-grow (she was three and a half). On enquiring about whether she had had her two-year HV assessment, the midwife was informed by parents that she had, and that there were no concerns. 3.56 The midwife followed this up with further enquiries and escalated the need for a HV to see Rosie. This liaison took place on the 23rd August. 3.57 On 4th September two HVs called at the house to see Rosie. Parents appeared to be stressed at their visit and initially reluctant to allow entry. The HVs negotiated entry, completed an ASQ and found Rosie to be grossly delayed in all domains of her development. There were additional, multiple, physical and behavioural signs of neglect that have already been described in this report as ‘shocking’. Father also reported that his sister had ‘dropped’ Rosie two months previously. 3.58 Growth monitoring at this visit showed that very little weight had been gained in the two years since Rosie’s weight had last been recorded. The proximity to the 0.4 centile showed a markedly negative trend. The centile charts showing Rosie’s growth monitoring have been shared as part of the review. They reflect stark evidence of malnutrition and failure to thrive. 3.59 Rosie was referred to the GP for medical assessment later that day; the GP made an immediate referral to the children’s assessment unit at the hospital. This is on the same site. A referral was also made to the children’s social care by the HV via the MASH team. 3.60 Parents did not take Rosie to the children’s assessment unit that evening. This was followed up the next day by hospital staff who had been expecting her arrival. Parents were contacted by them, and Rosie brought. A full paediatric assessment, including a child protection medical, followed. 17 3.61 There were some constructive discussions at the practitioner event about the procedures, processes and events surrounding the referral and admission to hospital. These issues, which were evidenced in the tabulated chronology, include managing a disagreement between police, social care and health about the ‘grading’ of the urgency of the referral. 3.62 At the time of Rosie’s admission to hospital, there was also a query regarding the actions that could be taken if parents decided to remove her from the ward. A plan to escalate to police protection was put in place prior to the strategy discussion that took place on the 6th September. The strategy discussion resulted in a legal planning meeting and the granting of an Emergency Protection Order.8 4.0 Discussion of the key findings 4.1 The discussion of the key findings in the review have been largely structured around four over-arching, but inter-related, themes that aim to inform learning and improvement across the system. Reference is made to the literature, including other local reviews, and to recent developments in improving the response to child neglect in the Borough. Care has been taken not to overburden partners with a lengthy analysis that repeats information already being shared in other recent local reviews or as part of the wider neglect workstream. The findings from the audit help to shine a light on current practice. 4.2 The themes identified in this review relate to: • Pre-birth planning and assessment • Working with resistant parents/disguised compliance • Assessment of child health, development and lived experience • Workforce/organisational issues that impacted on practice 4.3 We begin by summarising Rosie’s story, highlighting the identified key episodes and points of contact where action could, and at times should, have been taken to safeguard her welfare. The summary also provides the basis for the identification of the four themes outlined above and the discussion that follows. Hidden in plain sight 4.4 The chronology clearly identifies that both Rosie’s parents had a long history of adverse health behaviours and social problems; including substance misuse (alcohol and street drugs) and homelessness. In addition, there was evidence that mother had experienced abuse in her own childhood and had been ‘in care’ and that father had a history of violent offending and perpetrating domestic abuse. 4.5 Both parents had been known to mental health services and there was some evidence to suggest that parents, particularly mother, had a degree of learning difficulty. The fact that father had had a previous child who he had little contact with came to light when Rosie was 15 months old. 8 An Emergency Protection Order, widely referred to as an EPO, is granted under s.44 of the Children Act 1989. This would have prevented her removal from the hospital. 18 4.6 At the ante-natal booking, the midwife appropriately identified historical concerns, further noting that mother had a lack of family support. The midwife completed a CAF9 and made a referral to children’s social care (CSC). The father reported the support of his large extended family. CSC advised that because the concerns were ‘historical’, that mother was attending all her appointments, and that the family appeared to be supported, a ‘team around the child’ (TAC)10 should take place. There would be no further action by them at this time. 4.7 Even with the benefit of hindsight, this decision may be seen to be questionable. As unanimously recognised by those attending the practitioner event, given the risks presented by the constellation of vulnerabilities in the parental background and history, the referral to CSC should have led to pre-birth planning and assessment, rather than a TAC, to safeguard Rosie’s future welfare. This may in turn have led to statutory intervention (e.g. child in need plan under s.17 Children Act 1989), and importantly, would have enabled the expertise of social work assessment and oversight. 4.8 The TAC meeting did not take place until a week before Rosie’s birth and attendance was limited to parents, a midwife, and a children’s centre worker. The proximity to the birth meant that there was little, if any, opportunity to offer early help and support to the family. Father said that they would attend the children’s centre and stated a reluctance to have ‘anyone else’ involved. 4.9 Whilst the early help assessment and TAC process require consent of parents (and older children), and parents co-operated in the meeting, the reluctance of parents to receive additional support should have been a potential red flag for their future engagement with services. Furthermore, there appears to have been no clear follow-up of the plan or identification of who would ‘hold the ring’ when the maternity services discharged mother and baby. 4.10 The health visitor (HV) was unable to attend the TAC, or to undertake an ante-natal visit, due in part to management and staffing issues, but also because of difficulties in contacting parents to make the necessary arrangements. Health visiting, as a universal service, was critical in this case, and the challenges facing the service, both at a local and national level are discussed later in this report. The difficulties in contacting parents were another possible indicator of concern. Later, there are more stark examples of parental resistance and disguised compliance and these form a second theme for learning and improvement. 4.11 The care around the time of Rosie’s birth was good. This includes maternity staff’s referral to CSC arising from concerns about the parents’ neglectful presentation and the provisions being made for their new baby. The home visit by a social worker was good practice, albeit a joint visit with a health professional may have been helpful in reviewing background history and discussing the potential for additional support. 4.12 Rosie was a small baby, and her faltering growth was evident from the early days of her life. At the new birth visit the HV recorded poor weight gain and concerns regarding her 9 The CAF has now been replaced by the Early Help Assessment (EHA) 10 The TAC is now usually referred to as a TAF (team around the family) to reflect a Think Family approach in the Borough. 19 observations about mother’s interaction with her baby. Her encouragement for mother to smile and talk to her baby was met by the response that ‘she did this all the time’. 4.13 The level of care provided through the Healthy Child Programme (HCP) (Department of Health, Department for Children, Schools and Families, 2009) was noted to be ‘universal plus’ in recognition of the additional input that would need to be provided to the family. More details of the HCP can be found in Appendix four. 4.14 The HVs concerns about Rosie’s weight led to a referral to the hospital and admission to a children’s ward, with follow-up provided by a dietician. Support for feeding continued through home visits by a nursery nurse and a requirement to attend the community baby clinic for weight monitoring. A second admission followed when she was six weeks old. Rosie was also seen on a regular basis at the hospital orthopaedic clinic for follow-up of unstable hips and by the practice nurse for immunisations. 4.15 During her first year, Rosie’s attendance at health appointments appears to have been generally unproblematic, with occasional non-attendance followed-up and found to be due to confusion about dates/times or a clash of appointments. There was no evidence during this first year of any developmental delay, and although Rosie remained very small, there was evidence of a parallel growth trajectory. 4.16 The chronology records some apparent difficulties in professionals being able to contact each other, as well as confusion as to the role of community v. hospital in monitoring weight. A lack of shared records created further challenge (an improvement in recent times has been reported). Given Rosie’s slow weight gain, and maternal history, the HV made enquiries as to whether there may be an underlying condition, for example foetal alcohol syndrome. As noted in the chronology, it is unclear how this enquiry was followed up. 4.17 After the immediate postnatal period, contact with health professionals usually took place at a clinical setting, rather than at home. These were scheduled or routine appointments, with two important exceptions; one being the attendance at the emergency department following a house fire when Rosie was eight weeks old, and the other the disclosure to the practice nurse at nine weeks that mother had accidentally banged Rosie’s head on a door frame. The HV was not alerted to these concerning events in a timely manner. 4.18 What is striking about the health professional contacts is that although these were relatively frequent when compared with a ‘similar child’, they were very ‘task focused’; for example, on weight, feeding, immunisation or examination of hips. There was scant evidence of a more holistic approach to assessment of Rosie’s health, development and lived experience. This is important because it would have provided an earlier, clearer picture, of the inadequacy of parenting and the emergent indicators of child neglect. This theme is further explored below. 4.19 Just before her first birthday, Rosie was not taken to an appointment at the hospital paediatric clinic. Although this was followed up by a letter to the HV asking if the family had moved, she was discharged from the clinic without being seen. (Later, when Rosie was just over two years old, the family stopped attending the orthopaedic appointments; albeit her hips had been noted to be stable at this juncture). 20 4.20 Discussions at the serious case review panels have provided assurance that any failures in following the hospital ‘was not brought’ policy are being addressed. 4.21 The next contact with the 0-19 team was for the routine one-year review. After two failed appointments, this review was undertaken at home, when Rosie was 15 months of age. Whilst an ASQ was not completed, the review highlighted concerns about gross motor development (i.e. non-weight bearing) and diet. Rosie’s growth was noted to be below the 0.4 centile; but this remained in line with her projected growth trajectory. There is sound evidence of the use of professional judgement at this visit. 4.22 Three key contacts took place with health services when Rosie was 20 months, 22 months and 23 months of age (see 3.41 to 3.44). These took place in clinical settings and include an orthopaedic review, a visit to the GP with a skin infection and a new patient assessment arising from a change of GP. There is no record of her being weighed or measured at these contacts. 4.23 However, the fact that Rosie was not yet walking was recorded, but no apparent follow-up of this striking gross motor developmental delay undertaken. Again, there was a focus on the ‘task’ in hand. These were missed opportunities to recognise and respond to the increasing evidence that Rosie’s presentation and developmental delay may be associated with poor parenting capacity and the emergent picture of neglect. 4.24 When Rosie was two years and three months of age, appointments were sent by the HV team for her two-year review. This was to be undertaken at home. However, there were two ‘no access visits’ and a further attempt by the HV to visit opportunistically to undertake the review also failed to find the family at home. 4.25 Despite these attempts, the 0-19 service management has subsequently raised the question of a lack of persistence in securing the review. However, it also recognised that there may be a culture of accepting parental choice in this matter. It is pertinent to note that those responsible for delivering the HCP have no statutory right to ensure compliance or gain entry to the home. 4.26 A month later, Rosie was taken first to the emergency department, and then signposted to an out of hours GP, suffering from a viral illness. This should have provided a further window of opportunity for health professionals to assess her developmental needs, monitor her growth, and potentially to identify indicators of neglect that may have been present at that time, including parenting capacity. 4.27 When, just over a year later, the extent and seriousness of Rosie’s neglect was identified by a midwife the response did not reflect the urgency of the need for rescue. Whilst a discussion with the HV team would have aided decision-making, the findings on this visit should have resulted in a referral to children’s social care and the police, with a potential for immediate action to invoke removal under police protection powers. 4.28 It should, however, be acknowledged that practitioners retrospectively identified good practice in the midwife’s ‘think family approach’ and in the persistence of the HVs in gaining access to the home and making an urgent referral to the GP. The challenges raised by the MASH HV in relation to the grading of the referral and the need for urgent access are 21 exemplary. It is pertinent to note that concerns about the grading of a MASH referral feature in another local SCR concerning neglect (Child Patrick BBSCB, 2016). 4.29 This summary has focused on the input from health professionals, however, it is also notable that Rosie did not attend any early years’ provision, despite funding being available. Whilst there is no compulsion for young children to attend a nursery, it is unusual to find that by three and a half years of age, a child has not been given opportunities for socialisation and learning. A recommendation will be made for children’s centre staff and other professionals to make enquiries and actively follow-up any child who is not attending such provision. 4.30 A further comment is made here on the role of neighbours and the wider community; not least because this review will be in the public domain. As in the tragic case of Kyra Ishaq, who was also severely neglected and malnourished, there may well have been family members or neighbours concerned about Rosie’s welfare, and it is important to understand why no concerns were raised by members of the public (Birmingham Safeguarding Children Board, 2010). 4.31 Building social capital (i.e. social networks, neighbourliness) can help to create more cohesive and supportive communities that help to prevent child neglect and other forms of maltreatment (Turney and Taylor, 2014). This becomes especially important in times of austerity, both because of the increased risks to children who live in poverty and because of cuts to public services. Pre-birth planning and assessment 4.32 Although it is recognised that pregnancy and childbirth can offer a unique window of opportunity for change, there is a wealth of evidence to show that parental difficulties may have a significant impact in pregnancy and on the longer-term health of the child (Lushey et al., 2018). Furthermore, even where such concerns are historical, it is widely understood that there is likelihood of relapse and increased risk to children (see for example Reder and Duncan, 1999). 4.33 In Rosie’s case, pre-birth assessment and planning to ensure her safety and well-being, was inadequate. Whilst the midwife appropriately identified the need for parenting assessment, and undertook a CAF, the ensuing referral to CSC led to no further action by them at that time. The convening of a TAC, which, due to apparent staffing issues, took place very late in the pregnancy, was further limited by the absence of key attendees, including the HV. 4.34 Despite several attempts to make contact, the HV was also unable to secure an ante-natal visit. This would have provided a further opportunity for a health professional to identify the multiple vulnerabilities of the expectant parents and make a professional judgement on the need for pre-birth planning and assessment. 4.35 According to guidance for commissioners of the HCP, universal and targeted visits are crucial to securing improvements in child health and well-being, in particular it notes that: 22 ‘[the] universal reach of the HCP provides an invaluable opportunity from early in a child’s life to identify families that are in need of additional support and children at risk of poor outcomes.’ (Public Health England, 2016:6) 4.36 In Bedford, multi-agency pre-birth planning and assessment guidance and tools have evolved over the past few years and are now incorporated into the Pan-Bedfordshire procedures (currently section 1.4.17). The guidance sets out some examples of their application; • History of domestic violence • Poor physical or mental health • Substance misuse • Social isolation • Poor housing • Poverty • Parental history of care • To assess learning difficulties and to provide support 4.37 It is self-evident to note that in Rosie’s case, all the above applied. The last point, regarding assessment of parental learning difficulties, is particularly apposite. Provision to support parents, and parenting, may or may not have enabled adequate care, but it would almost certainly have provided opportunities for early intervention to protect Rosie from harm. 4.38 In referencing the literature, the pre-birth planning and assessment guidance raises two questions that are aimed to help practitioners and their managers decide whether the procedures might apply: ‘Will the new born baby be safe with these parents/carers?’ ‘Is there a realistic prospect of these parents/carers being able to provide adequate care throughout childhood?’ 4.39 Multi-agency pre-birth planning and assessment has been noted to be a significant omission in learning from serious case reviews concerning neglect nationally (NSPCC, 2015), and locally (Baby Sama, BBSCB, 2017a, Thematic Review on Neglect and Disability BBSCB, 2017b). However, their use is evidenced in a recent local SCR (Faith, BBSCB, 2017c). 4.40 As noted above, there was unanimous agreement at the practitioner event of the relevance of the pre-birth planning and assessment procedures in Rosie’s case. The importance of their application will be reflected in the recommendations and learning from this review. 4.41 Furthermore, in the meetings with the HVs and the midwife it became apparent that there was a general reluctance amongst health professionals to challenge decisions made by CSC, for example regarding the outcomes of referrals, despite there being procedures for escalating concerns. 23 4.42 A perceived hierarchy between these professional groups was a finding of a previous local SCR (Adam, BBSCB, awaiting publication). Reflecting the literature, that review commented: ‘professional disagreement is not uncommon in the complexity and emotion of child protection practice; escalation and management of concerns is a sign of a well-functioning system, not a failure in professional practice (Sidebotham et al., 2016).’ 4.43 It is therefore pleasing to see the current strategic developments in Bedfordshire in promoting formalised opportunities for work shadowing across early years, social care and health services. This should enable greater understanding, collaboration and collegiate relationships that can only be of benefit to children, young people and their families. The process, detailed in a ‘brochure’ for practitioners and their managers, could usefully be shared more widely and is an example of good practice. Working with resistant parents/disguised compliance 4.44 Working with parents who are resistant to services and who show partial or disguised compliance is a challenging aspect of child safeguarding and one that calls for authoritative practice. This is helpfully defined as an ability to demonstrate professional curiosity, respectful uncertainty, and being able to challenge both parents and other professionals (Tuck, 2013). 4.45 Disguised or partial compliance is characterised by features that may include deflecting or controlling conversations, telling workers what they want to hear, sporadic compliance (i.e. co-operating ‘just enough’ so as not to raise suspicions) and not attending, cancelling and/or rescheduling appointments. This includes active avoidance of home visits, such as ‘being out’ when workers call. 4.46 This behaviour is a frequent finding in serious case reviews and has been a feature of other reviews undertaken in Bedford, (e.g. Baby Sama, BBSCB, 2017a, Adam, BBSCB, awaiting publication, and Family Q, TWSCB, 2018). 4.47 It is apparent that in Rosie’s case, parental resistance to professional input began to emerge during the ante-natal period, albeit this may be better acknowledged retrospectively. For example, at the TAC meeting, parents had expressed reluctance to allow anyone else to be involved and provided a smokescreen of assurance that father’s family were supportive. 4.48 Later on, there were clearer signs that parents were less willing to engage with health services and this was recognised by professionals. For example, despite parental resistance and failed appointments, when Rosie was 15-months old the HV managed to negotiate entry to the home (with a colleague) having been clear about the need to follow-up her growth and developmental progress, and to put sanctions in place should parents not comply. This was a good example of authoritative practice that was replicated at the HV visit on 2nd September 2017. 4.49 Further examples of poor or disguised compliance include mother’s rejection of nursery nurse support and failure to attend the children’s centre, despite an assurance that she would do so, father’s explanation of working at night rendering him too tired to take Rosie to nursery and various (false) assurances in telephone consultations with the HV about Rosie’s diet and development. 24 4.50 Parental resistance to professional intervention and the increasing evidence of partial/disguised compliance with advice and support intended to promote Rosie’s health and welfare during her third year is illustrated in the chronology that contributes to this review. 4.51 For example, there was a reluctance to accept visits to the home, particularly when they were unannounced. This may well be related to the fact that evidence found at the time of Rosie’s admission to hospital suggests that substance misuse had once again become a feature of the parents’ lives. 4.52 It is possible that parents found professional input in their lives problematic. In Rosie’s early years they were having to manage appointments to see two different hospital specialists and attend the baby clinic, as well as coping with new parenthood and their own needs and vulnerabilities, without any apparent support from family. 4.53 NICE guidance for working with pregnant women who have complex social factors suggests, it is good practice to ask such clients about their satisfaction with the services that are provided (National Institute for Health and Care Excellence, 2010). This is also expected practice in undertaking serious case reviews, and it is regrettable that an opportunity to meet with both parents was not forthcoming. 4.54 In their review of the role of neglect in SCRs, Brandon et al., (2014) remind us of the importance of being compassionate, but also of the need for practitioners themselves to be supported to make well-reasoned judgements. In a paper presented to the BBSCB in April 2018, the public health commissioning lead for the 0-19 Healthy Child Programme recognised the need for consistency, trust, honesty and understanding in building relationships with vulnerable mothers [sic] and their families and in securing improvements in child health and wellbeing. 4.55 The use of the NSPCC’s Graded Care Profile 2 is currently being rolled out in Bedford and forms an important element of the BBSCB strategy to address neglect. A benefit of this tool is that is balances family strengths and weaknesses and provides a clear means to work with in partnership with parents on what needs to change. 4.56 There are four issues for practice learning and improvement that should be mentioned in the closing paragraph of this sub-section; the use of genograms, chronologies, supervision and being child focused. These are already being addressed in the learning and improvement from other recent SCRs in Bedford and their importance in working with resistant parents/disguised compliance is reiterated and summarised here. 4.57 Had a genogram (family tree) been drawn up with expectant parents it may have identified the fact that Rosie had an older half-sibling and enabled a discussion about circumstances around father’s parenting and contact. 4.58 The use of a chronology should be routine; it can provide emergent evidence of deteriorating circumstances for a child and their family. This is starkly illustrated by the chronology that informs this review. The recent introduction of a chronology template onto SystmOne electronic clinical records in Bedford is good practice and will be a welcome improvement for those working in primary and community health services. 25 4.59 Embedding robust systems of supervision enables critical reflection, challenge and support. Compassion is a foundation for building resilience and delivering relationship-based interventions. It can also help to tackle issues of recruitment and retention in the workforce and prevention of ‘burn-out’ (Institute of Health Visiting, 2015a). There is some evidence of improved leadership and support in local health visiting services, but also of the impact of the national picture of shrinking numbers and cuts in service delivery. 4.60 The final, and arguably most important issue for practice, is to ensure that all contacts focus on the health, development and daily lived experience of the child. This can be difficult to achieve where there are high levels of needs and/or resistance to services. 4.61 To quote Laming (2003), these practice issues reflect ‘doing the basics well’ to safeguard and promote the welfare of children. Good practice will help to tackle the drift that can feature in neglect cases and ensure a timely response when there are emergent concerns about a child. A core principle of safeguarding policy, as highlighted in the statutory guidance in place at the time of commissioning this review, is that ‘for children who need additional help, every day matters’ (HM Government, 2015:7). Assessment of child health, development and lived experience 4.62 Rosie and her family lived in an area of Bedford that is characterised by high levels of deprivation, poverty, worklessness (including zero hours contracts) and poor housing stock. It is some distance from the central amenities. Parental substance misuse in the town is higher than national averages, with recognition that it is both a cause and consequence of wider issues including poor physical and mental health, difficulty in securing and sustaining employment, homelessness and criminality (McGovern et al., 2018; Public Health England, 2018). 4.63 Practitioners described the reality of the impact of working in this area with large caseloads of high need families and the adoption of practices and a mind-set that ‘normalises’ deprivation and expectations of parenting and poorer outcomes for children. 4.64 The issue of normalisation is extensively discussed in the Family Q review (TWSCB, 2018) and is well-recognised in the child protection literature. In coping with the delivery of services in challenging circumstances, Brandon et al. (2014) describe the mindsets adopted by practitioners that reflect fears about being considered judgemental when working with families who are vulnerable, poor, socially excluded and who have made particular life-style choices. This can result in undue professional optimism, an acceptance of sub-optimal parenting practice, a ‘down-grading’ of neglect, and a failure to appreciate the child’s lived experience. 4.65 The ASQ can help to address these failings through ensuring a comprehensive developmental assessment and early intervention for unmet need. The two to two-and-a-half-year review, for example, can utilise an ASQ that acts as an aide memoir for discussion of healthy eating, keeping active, managing behaviour, encouraging good sleeping habits, dental hygiene, safety and immunisations (Institute of Health Visiting, 2015b). 4.66 Whilst the use of tools should not replace professional judgement and critical thinking, they can assist in providing objectivity in benchmarking care, health and developmental progress. Both the ASQ, and the GCP2, can also help to engage parents in 26 understanding children’s developmental needs and working to achieve the best outcomes for their child. Assurance has been received that improvements in the uptake and use of these tools is now in place in Bedford. 4.67 Another significant finding in common with the Family Q review (TWSCB, 2018), worthy of note here, is of a task-focused approach to the delivery of care. In Rosie’s case this includes a reductionist approach to weighing, assessment of a viral illness and checking hips. The importance of a more holistic assessment that includes the opportunity to identify any safeguarding issues is an approach that is recognised in professional standards and guidance (see below). Feedback at the second practitioner event was that this can be difficult to achieve in tight timings for appointments and current workload pressures. 4.68 The Royal College of Paediatrics and Child Health (2018) recognise the need for staff working in urgent and unscheduled care to be trained in child health and development and aware of child safeguarding issues. This is particularly important as there is widespread evidence that vulnerable families make greater use of these settings to access their health care. 4.69 Equally, the Royal College of Nursing (2017), recognise that general practice offers valuable opportunities for early intervention, family support and recognition of children who may be at risk of harm. Acknowledging that the practice nursing team may include health care assistants, the guidance on expected competencies for working with children includes the ability to provide preliminary advice and support with feeding, weaning and speech development and to understand normal parameters for growth, together with the ability to recognise children who have faltering growth or failure to thrive. 4.70 Whilst the health visiting service and delivery of the HCP is critical in Rosie’s case, this report will make a recommendation in respect of the need to ensure that opportunities are taken at all contacts with health professionals to take a wider approach to assessment of a child’s health, development and lived experience. This may well be a training issue. Workforce/organisational issues that impacted on practice 4.71 The input from the SCR panel’s health safeguarding leads has led to a clearer understanding of the workforce and organisational issues that impacted on the services provided to Rosie and her family. Given the overlap in timescales, many of these factors are also reflected in the Family Q report (TWSCB, 2018). 4.72 The issues affecting the delivery of health visiting services include changes in management and leadership, relocation, high caseloads, increased travel time and the introduction of mobile working that led to a reduction in informal peer support (TWSCB, 2018). There were long term vacancies, staff absences and attendant high levels of stress and low morale in the teams. The contractual pressures to deliver the universal element of the HCP, meant that less time could be given to families with additional needs. A feeling of being overwhelmed and undervalued by other professionals was also mentioned. 4.73 There is evidence that welcome changes and improvements are being made in the Borough. These include reallocation of staff with reduction in caseloads (i.e. from 620 to 440 27 children11) and improved systems for support and supervision. The opportunity for health visitors to be part of the work-shadowing programme should help partners to better understand their expertise in child health and contribution in the wider safeguarding arena. 4.74 Whilst this improving picture in Bedford may be a reason for some optimism, nationally the profession is facing a crisis. Following a programme of growth, the numbers of qualified HV in England has dropped from 10,309 in October 2015, to 8,275 in January 201812. 4.75 This reduction in the workforce nationally has been linked to the transfer of commissioning of the service from the NHS to local authorities (Institute of Health Visiting, 2017). The climate of austerity in public services is recognised to be challenging for families, as well as professionals (Brandon et al., 2014). 4.76 Further concerns have been raised by the Institute of Health Visiting annual state of HV survey [n.1413] that practitioners are managing risk, rather than offering a universal service, feeling stretched (more than 21% of respondents had caseloads between 500 – 1000 children) and being concerned about the possibility of a child protection tragedy in their locality. 4.77 There are likely to be significant challenges nationally in managing the future delivery of the Healthy Child Programme given the austerity measures affecting the commissioning and delivery of public health services and the shortfall in health visitor numbers. The BBSCB will be mindful of the impact of this on partners, but also on the safety and well-being of the most vulnerable children, young people and families in the Borough. 4.78 Whilst there was minimal contact with CSC, organisational practice was recognised as needing improvement at that time (2013). This may have impacted on the ability to manage the initial referral from maternity services. Various improvements have since been put in place. This includes better systems for managing contacts and linking children and adults. The midwife’s enquiry in August 2017 that resulted in a ‘not known’ regarding the mother would not be the case now. However, this would not have materially affected the outcome for Rosie. 4.79 Thus far, the discussion has centred on Rosie’s case and the findings that emerge suggest learning and improvement in relation to pre-birth planning and assessment; working with resistant parents/disguised compliance; the assessment of children’s health, development and lived experience; and the impact of workforce/organisational issues. 4.80 The discussion has referenced other local SCRs, as well as learning from other published SCRs concerning neglect. There are pointers towards an improving picture. The next section makes further reference to the BBSCB-led neglect workstream and the findings of the audit of current cases. 11 However, professional bodies for HV recommend caseloads of no more than 250 children per WTE. 12 https://digital.nhs.uk/data-and-information/publications/statistical/nhs-workforce-statistics/nhs-workforce-statistics---january-2018 28 Current professional recognition and response to child neglect in the early years in Bedford Borough 4.81 Concerns about the recognition and response to child neglect arising from previous local SCRs (as referenced in this report) have helped to inform a Pan-Bedfordshire Neglect Strategy that has been updated and refreshed (BBSCB et al., 2017). This has raised the importance of the early recognition of neglect, the need to work with families in a positive and empowering way, and to offer a range of provision from early help services through to statutory intervention. 4.82 A neglect conference, attracting high profile speakers and held in March 2017, was well-evaluated, with learning and improvement followed up by a post-conference survey. The GCP2 tool for assessing neglect and monitoring improvements in parental care has been launched, and there is evidence of its use in practice. 4.83 There is also evidence that the BBSCB partnership are addressing the recommendations of a recent inspectorate review of child neglect nationally, albeit the focus of this review is of the older neglected child (Ofsted, 2017). This includes work being undertaken to promote an understanding of the potential seriousness of the impact of neglect on child health and wellbeing across agencies. 4.84 The need for a more widespread appreciation of the impact of neglect on child health and development has been reflected and discussed in other local reviews and is well-described in the literature (e.g. Brandon et al., 2014). This factor, and the learning and improvement work already being undertaken, is acknowledged here, rather than raised as an additional learning point from this review. 4.85 In seeking to reflect the quality of current practice, the thematic SCR panel led a ‘deep dive’ audit and case discussion. This aimed to gather evidence of the pathways and experiences of six additional young children at risk of neglect, who were known to local services at the time of the review. The cases were selected by the panel member for Cambridgeshire Community Services NHS Trust, based on agreed criteria, as outlined in the box below: 1. Cases that may help to identify good practice; as well as areas for learning and improvement. A balanced approach will be taken. 2. The child was less than five years of age on 1/04/18 and lived with their family in Bedford Borough. 3. Concerns about neglect had been identified in the past year (Beginning April 2017 – end March 2018). 4. These concerns have led to assessment and/or the provision of additional services that includes one (or more) of the following: • Universal plus, or universal partnership plus health visiting (0-19) services • An early help assessment (EHA) • A referral to children’s social care (s.17 or s.47) • The use of GCP 2. 4.86 The deep-dive audit took place on 8th June. Three cases were discussed in the morning and three in the afternoon. Practitioners and managers from health, early help services and CSC attended for each case and their involvement was invaluable. Whilst six 29 cases cannot be representative or inclusive of all children in need in Bedford, the process did shine a light on the quality of current practice in universal and specialist agencies. 4.87 The SCR panel members had taken responsibility for their agency’s ‘pre-completion’ of the audit tool and this was added to during the audit by the BBSCB manager, who then ensured a combined tool was made available. The following paragraphs provide a summary of the audit findings. 4.88 The index children were aged between nine weeks and four years of age. With one exception, they all had siblings. Most of the children had been born into families with extremely complex problems and vulnerabilities; including parental physical and mental health issues, substance misuse, learning disability, domestic abuse and criminality. The children themselves had a variety of needs, such as those linked to prematurity, and often had frequent attendance at the GP practice. 4.89 There was extensive evidence of missed health care appointments, but also that these had been appropriately followed up. Several of the siblings had learning disabilities and/or poor physical health and problematic school attendance, sometimes linked to their neglected presentation. 4.90 All the children were known to CSC, although at the time of the audit some input had been ‘stepped down’ to early help services. The most common intervention was a ‘child in need’ (CIN) plan, but there had also been EHAs, TAC/family input and in some cases child protection plans. Pre-birth planning and assessment as per BBSCB guidance was not generally evident, although it should be acknowledged that this was not included as part of the BBSCB procedures during the pregnancies of the older children. 4.91 Referrals had followed a variety of concerns including; squalid home conditions, the impact of parental difficulties outlined above, neglect of children’s health needs (not being taken to appointments) or because of services involvement primarily for siblings. 4.92 The Pan-Bedfordshire multi-agency audit tool, adapted slightly for the purpose of this review, encourages practitioners, managers and the audit panel to consider ‘what’s gone well’ and ‘what could have better’. It also allows for self, and multi-agency, evaluation using the Ofsted grading of Outstanding/Good/Requires Improvement and Inadequate in eight domains. The overall judgement reflects the lowest domain grading, meaning that even if 7:8 judgements are good or better, a lower judgement will be made overall (as was generally the case). 4.93 Despite the overall grading of ‘requires improvement’, the panel concluded that there was sound evidence of an improving picture, with most domains graded as ‘good’ by the practitioners/panel. Comments taken from completed audit tools demonstrate both critical thinking and reflection on practice: ‘Following social care intervention, the family did engage well with Early Help under a joint working arrangement and there was positive impact.’ ‘Good reflections of observations of [child] with family throughout assessments/ reviews. This along with ‘voice’ of older siblings was in case recording and plans to keep them safe- good outline of the voice of each child in CIN meetings in particular.’ 30 ‘At the point of Dec 17 referral, there was comprehensive info sharing and discussion with mother whereby she said she wanted help and just felt overwhelmed. Rather than again recommending she engage in an EHA, the decision was to progress to SA [single assessment13] which considering the history of referrals was appropriate.’ ‘There appears to be a good relationship with the family from social care in that mother is able to be open and honest about her views of support/ professionals and engagement however, it makes me question whether this is disguised compliance or what impacted on this level of engagement with the TAF previously.’ 4.94 Where less good practice was seen, or room for improvement identified, this was also acknowledged. For example, there was some mention of difficulties contacting the universal health services (0-19) team and of limited engagement with them to gain their input in CSC-led single assessment. In two cases the question of parental voice being ‘sought, heard and responded to’ was judged as requiring improvement/inadequate because the father’s voice was absent. However, overall the findings of the audit reflect positively on the current provision of services in Bedford and how these are providing benefits to vulnerable children, young people and their families. 5.0 Learning Points for consideration by Bedford Borough Safeguarding Children Board 5.0 This overview report has set out the findings of an independently-led thematic SCR commissioned by the Chair of BBSCB. It concerns Rosie, who was found, aged three and a half years, to be suffering from life-threatening and life-changing neglect within her home environment. The review has not only sought to understand Rosie’s story, but also to consider the quality of the current professional recognition and response to child neglect in the early years in Bedford Borough. 5.1 The involvement of practitioners and their managers has been fundamental from the outset of the review, as has the support of the local SCR panel. The learning points that are set out for consideration by the BBSCB reflect the collaboration and insight provided by their engagement and expertise. Learning point one Children who are suffering from neglect (and other forms of child maltreatment) may be ‘hidden in plain sight’. The BBSCB are spearheading an NSPCC poster campaign to raise awareness of neglect to a wider public audience, for example those using local leisure facilities, health services, libraries and children’s centres. The findings of this review strongly support this initiative which will, we understand, be reflected in an update of the Pan-Bedfordshire Neglect Strategy. Recommendation • The BBSCB and partner boards should consider how the refreshed Pan-Bedfordshire Neglect Strategy can impact local initiatives aimed at building social capital across communities. 13 Single assessment is led by CSC and requires contribution from other involved agencies. 31 Learning point two This review has highlighted the importance of pre-birth planning and assessment in offering early help and support to vulnerable parents and in ensuring the future safety and well-being of the unborn child. Recommendation • The BBSCB should seek assurance regarding the utilisation of the Pan-Bedfordshire pre-birth planning and assessment guidance in practice. This may, for example, include joint-agency audit activity to ascertain the frequency and timeliness of use and the outcomes (i.e. early help/child in need/pre-birth child protection planning). Learning point three This review has found that there remains evidence of a perceived ‘professional hierarchy’ and a reluctance to escalate disagreements with decisions made at the front door of CSC. More needs to be done to promote collegiate working, respect and mutual understanding of others’ roles and responsibilities, including the limitations in practice. Recommendations • BBSCB should seek assurance that partners are able and willing to engage in the Shadowing Project through monitoring activity. • BBSCB should seek assurance via the scrutiny and assurance group that the findings in learning point three are not a wider systemic issue regarding referral pathways. • BBSCB to raise awareness of the Escalation Procedures to frontline staff. Learning point four This review has found limitations in the delivery of child health care that reflects both a focus on task, and a failure to appreciate wider aspects of health, development and the child’s lived experience. All those delivering care to children, young people and their families must have the relevant competences to do so. Professional guidance referenced in this report can greatly assist in the development of an upskilling programme (RCN, 2017), as can ensuring that practitioners can utilise the ASQ tools to support good practice in assessment. Recommendation • That the Clinical Commissioning Group and Public Health Commissioners should seek assurance from providers that practitioners delivering care to children, young people and their families have achieved, as a minimum, the competences set out in the relevant professional guidance, including oversight from an appropriately qualified professional. A report should be made to the BBSCB accordingly. 32 Learning point five This review has highlighted the unusual finding of a three-and-a-half-year-old not attending any early years’ provision or groups. Such provision helps children’s developmental progress, socialisation and ‘readiness for school.’ It also provides an additional safety-net for vulnerable children and their families and a source of additional parental support. Recommendation • BBSCB to seek assurances that practitioners are asking parents/carers why young children are not accessing early year’s provision. Early Years Services to report to the BBSCB on the processes currently in place and what could be done to assist and strengthen them. This should include outlining the resources available locally that can provide one to one support to those parents who do not want to attend group sessions. 33 References Bedford Borough Safeguarding Children Board (2015) A Child Centred System: Understanding Thresholds Information on early help, prevention, and statutory services for everyone working with children and families. Bedford Borough, Central Bedfordshire and Luton Safeguarding Children Boards Procedures Manual http://bedfordscb.proceduresonline.com/chapters/contents.html [accessed during the review period] Bedford Borough, Central Bedfordshire and Luton Safeguarding Children Boards (2017) Neglect Conference Report of Conference 30th March 2017 Bedford Borough, Central Bedfordshire and Luton Safeguarding Children Boards (2017) Pan-Bedfordshire Neglect Strategy 2017 - 2019 Bedford Borough Safeguarding Children Board (2016) Child Patrick Serious Case Review BBSCB. Bedford Borough Safeguarding Children Board (2017a) Serious Case Review Overview Report relating to Baby Sama BBSCB. Bedford Borough Safeguarding Children Board (2017b) Children First: Thematic Serious Case Review (Neglect and Disability) BBSCB. Bedford Borough Safeguarding Children Board (awaiting publication) Serious Case Review Baby Adam Overview Report BBSCB. Bedford Borough Safeguarding Children Board (2017c) Serious Case Review on Faith BBSCB. Birmingham Safeguarding Children Board (2010) Serious Case Review: Case Number 14 BSCB Brandon, M., Glaser, D., Maguire, S., McCrory, E., Lushey, C., Ward, H. (2014) Missed opportunities: indicators of neglect – what is ignored, why, and what can be done? Research report London: Department for Education. Brandon, M., Bailey, S., Belderson, P., Larsson, B. (2014) The role of neglect in child fatality and serious injury Child Abuse Review 23: 235-245. Department of Health, Department for Children, Schools and Families (2009) Healthy Child Programme: Pregnancy and the First Five Years London: DH. HM Government (2015) Working Together to Safeguard Children: a guide to inter-agency working to safeguard and promote the welfare of children London: DfE. Institute of Health Visiting (2015a) Developing Resilience in Practice: A Health Visiting Framework London: iHV. Institute of Health Visiting (2015b) Using the Ages and Stages Questionnaires (ASQ-3™) as part of the two year health and development review London: iHV. Institute of Health Visiting (2017) Annual Report: Five Years on London: iHV 34 Laming, Lord (2003) The Victoria Climbié Enquiry: Report of an Inquiry by Lord Laming, Cm 5730. London: The Stationery Office. Lushey, C., Barlow, J., Rayns, G., Ward, H. (2018) Assessing parental capacity where there are concerns about an unborn child: pre-birth assessment guidance and practice in England Child Abuse Review 27:97-107. McGovern, R., Gilvarry, E., Addison, M., Alderson, H., Carr, L., Geijer-Simpson, E., Hrisos, N. Lingam, R., Minos, D. Smart, D. & Kaner, E. (2018) Addressing the impact of nondependent parental substance misuse upon children: A rapid review of the evidence of prevalence, impact and effective interventions Public Health England. National Institute for Health and Care Excellence (2010) Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors https://www.nice.org.uk/guidance/cg110 (accessed 17/08/18). National Society for the Prevention of Cruelty to Children (2015) Neglect: Learning from Case Reviews https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/neglect/ (accessed 20/08/18) National Society for the Prevention of Cruelty to Children (undated) Graded Care Profile 2: Measuring Care, Helping Families https://www.nspcc.org.uk/services-and-resources/childrens-services/graded-care-profile/ (accessed 23/07/18) Ofsted (2017) Guidance for joint targeted area inspections on the theme: children living with neglect London: Ofsted. Public Health England (2016) Best start in life and beyond: Improving public health outcomes for children, young people and families: Guidance to support the commissioning of the Healthy Child Programme 0-19: Health Visiting and School Nursing service London: PHE. Public Health England (2018) Parental drug and alcohol use: a toolkit for local authorities London: PHE. Reder, P., Duncan, S. (1999) Lost Innocents London: Routledge. Royal College of Nursing (2017) Getting it right for children and young people: Self-assessment tool for general practice nurses and other first contact settings providing care for children and young people London: RCN. Royal College of Paediatrics and Child Health (2018) Facing the future: Standards for children in emergency care settings London: RCPCH Sidebotham, P., Brandon, M., Bailey, S., Belderson, P., Dodsworth, J., Garstang, J., Harrison, E., Retzer, A., Sorensen, P. (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 London: Department for Education. Telford and Wrekin Safeguarding Children Board (2018) Serious Case Review Family Q Overview Report TWSCB. Tuck, V. (2013) Resistant parents and child protection: knowledge base, pointers for practice and implications for policy. Child Abuse Review 22:5-19. 35 Turney, D., Taylor, J. (2014) Interventions in chronic and severe neglect: what works? Child Abuse Review 23:231-234. 36 Appendix One: Key Lines of Enquiry Strategic & organisational issues • How does this thematic review resonate with the wider neglect work-stream? What have we learnt from previous national & local SCRs (neglect)? • Local picture v. national picture (e.g. numbers of children subject to CPP for neglect; second and subsequent plans, length of time on plan; escalation to legal intervention) • Thresholds/criteria for action/early help/statutory intervention/pathways, role of MASH/Single point of contact (SPOC) • Are the multi-agency/BBSCB policy and procedures for recognition and response to neglect understood and applied? (include pre-birth protocols) • Impact of commissioning changes in public health provision (health visiting or health visiting and school nursing); impact of policy on mandated visits; service specifications for the delivery of the healthy child programme; other universal provision (e.g. children’s centres/nursery) • What level of universal service was provided? How does this compare with any similar child? • Workforce issues, to include caseload/workload, skill-mix, vacancies, sickness levels, learning and development opportunities, provision of clinical/child protection/case supervision, management oversight • Are there any other system-based issues/additional factors that have affected the service provision, such as resources, management culture, team dynamics, supervision and support? Issues for practice • What evidence is there of good practice? • Was this a child/family who were ‘unseen’? • If so, how is it possible for a child to be so unseen in this day and age and what is the likelihood that there are other children living in such chronic neglect without any universal services involvement or knowledge? • How do we demonstrate the impact of neglect on children and young people? How do professionals understand children’s lived experiences and how do they ask, ‘what must these children’s lives be like living in this family?’ Do professionals ask themselves, what does this child mean to the parent and what does the parent mean to the child? • Do professionals accept the fact that neglect is not only harmful but can also be fatal should be part of their mind set as it would be with other kinds of maltreatment? • What is the impact of poverty and deprivation on children, young people and families and how does this impact on practitioner response? • Quality of assessment/use of ‘tools’ for assessing neglect (e.g. GCP2), children centred practice, understanding of developmental milestones; parenting capacity, including impact of substance-misuse & past history; assessment of ‘wider family and environmental issues’; use of genograms; care planning & evaluation. 37 • How do we encourage both adult and children professionals to ask basic questions about family structures (who lives in the family home), language barriers, what and support networks are available to the family? • What is the protocol for following up children who are 'not brought' (Did not Attend) their health care appointment? • Professional optimism; professional expectations of parenting; drift and delay; understanding of non/partial/disguised compliance; use of professional curiosity; authoritative practice; are there low expectations by professionals of parents, based on experience of disguised or partial compliance and little or no evidence of positive change? • How do we define what is ‘parental support’ and how and when should professionals challenge when parents/carers decline the support offered to support/improve their parenting/care? How do we get professionals to challenge parents self-reporting? 38 Appendix Two: Practitioner Learning Event Learning from the Case What would you like to see in the review around good practice? • HV joint visit/working on the case – they challenged the parents and were persistent. They challenged the GP apt and assessed the situation as a CP concern. • Midwife booking appt for the second baby – think family looking at [Rosie] and raised concerns. • Early care offered at [Rosie’s] birth – Dietician and Orthopaedic. • Detailed HV assessment to the Police. • Description of the home visit by the HVs. • Detailed observation and thinking of the HVs at the home visit. • Clear accurate communication about the risks they had assessed to [Rosie]. • HVs planning around the leave taken by staff. What can we learn from this case? • That a pre-birth assessment should have been carried out. • ACE [adverse childhood experiences] impact on parenting • EHA continuously updated • Was not bought needed to have a more robust approach. DNA could also mean Do not accept! • Follow up of referral. • Information sharing between Health services. (Need to be clear about what how the systems are talking to each other now). • HVs work via postcode and they felt the service worked better when they were aligned to GP surgeries • What if conversations are now recorded by the MASH. Clear lessons to be learnt 1. Golden thread – at several points there was a lack of follow up. 2. Pre-birth assessment – homeless and vulnerable multi-agency. 3. A lack of provision for adults who have learning difficulties – lack of pathways/procedures 4. Father’s role/voice – parenting responsibilities of the father. 5. Need to look at the big picture – info sharing (Hospital paper records) 6. Joined up individual roles. 39 Appendix Three: Additional Audit Questions SCR Panel: How did the care of this child and family benchmark/compare with that provided to ROSIE and her family? Consider for e.g. Identification of neglect/impact of neglect on child/child’s lived experience Identification & response to parental vulnerabilities Pre-birth assessment/other assessments Risk/cumulative risk Follow-through & follow-up Response to Was Not Bought/no access visits/working with resistance/partial/non-compliance Role of fathers/men in household Evidence of authoritative practice/ ‘respectful uncertainty’ Impact on worker/ ‘normalisation’/lone-working/supervision & support Caseload/workload issues 40 Appendix Four: Overview of the Healthy Child Programme The Healthy Child Programme (HCP), published in 2009, outlines the provision of universal health care and support for children from pre-birth to 19 years of age in England. Building on a tradition of child health surveillance and screening, it introduced a greater focus on ante-natal care, health promotion, social determinants of health and well-being and the need to include fathers. The programme supports the early identification of families who may require additional help and/or factors that may put their children at risk of harm, offering the opportunity for extra supportive measures on top of the universal approach at each stage. The programme is delivered by midwifery and health visiting teams, children’s centres, GPs and practice staff. It includes, as a minimum, contacts by the 12th week of pregnancy, a neonatal examination and screening, a new baby review (at around 14 days of age), a 6-8 weeks examination and reviews at one year and two to two and a half years of age. It links to the child health immunisation programme (normally delivered in general practice). Five mandated contacts by health visiting staff have been detailed as part of the transfer of commissioning from health to local authority public health departments: • A health-promoting visit at 28 weeks of pregnancy • A new-baby review at 10-14 days after birth • A six to eight weeks assessment • A one-year assessment • A two to two-and-half-year review A model of health visiting services introduced as part of a drive to increase capacity, sets out how additional support can be offered from community-based services and targeted visits at a universal plus and universal partnership plus level of assessed need (Department of Health, 2011). See: Department of Health, Department for Children, Schools and Families (2009) Healthy Child Programme: Pregnancy and the First Five Years London: DH. Department of Health, Department for Children, Schools and Families (2009) Healthy Child Programme: from 5-19 years old London: DH. Department of Health (2011) Health Visitor Implementation Plan: a call to action London: DH. Public Health England (2016) Best start in life and beyond: Improving public health outcomes for children, young people and families: Guidance to support the commissioning of the Healthy Child Programme 0-19: Health Visiting and School Nursing service London: PHE. 41 |
NC047205 | Death of a 6-week-old baby in Spring 2014 caused by inflicted injuries. Following a review of the evidence, parents were informed they would not be the subject of any further enquiries. Family had been referred to children's services but were not assessed as in need of intervention. Parents and Child H lived with the mother's adoptive parents. Mother had a history of: childhood abuse and neglect which resulted in her being taken in to care, anger management issues, mental health issues and special educational needs. Issues identified include: failure to share information about bereavement and illness in mother's family, which if shared should have led to a re-assessment of parenting capacity; confusion around whether the mother was eligible for support from the Learning Disability Service; over-estimation by social services of the role of the hospital's psychosocial meetings with the mother in monitoring the family's support needs; and incomplete record keeping within children's services. Recommendations include: the Local Safeguarding Child Board should promote understanding of adult learning disability and eligibility for services and the Borough should ensure its quality assurance arrangements are sufficiently robust.
| Title: Serious case review: Child H: overview report. LSCB: City & Hackney Safeguarding Children Board Author: Kevin Harrington Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review Overview Report – Child H April 2016 Author: Kevin Harrington JP, BA, MSc, CQSW 2 CONTENTS 1. INTRODUCTION ................................................................................................. 3 2. FAMILY COMPOSITION ...................................................................................... 3 3. ARRANGEMENTS FOR THE SERIOUS CASE REVIEW.......................................... 3 4. METHODOLOGY USED TO DRAW UP THIS REPORT ......................................... 4 5. KEY EVENTS ........................................................................................................ 5 5.1 Background ........................................................................................................ 5 5.2 October to December 2013 ............................................................................... 5 5.3 January to April 2014......................................................................................... 7 5. 4 May 2014 ........................................................................................................... 8 6. THE FAMILY ...................................................................................................... 10 6.1 Ms M and her family ....................................................................................... 10 6.2 Mr F and his family .......................................................................................... 10 6.3 Conclusions ...................................................................................................... 11 7. THE AGENCIES .................................................................................................. 12 7.1 The General Practitioners ............................................................................... 12 7.2 London Borough of Hackney, Children’s Social Care ..................................... 13 7.3 Homerton University Hospital NHS Foundation Trust ................................... 15 74 East London NHS Foundation Trust ................................................................ 17 7.5 City and Hackney Clinical Commissioning Group – the Health Overview Report .............................................................................................................. 18 7.6 The Children’s Centre ...................................................................................... 19 7.7 Metropolitan Police Service ............................................................................ 19 7.8 London Ambulance Service NHS Trust ........................................................... 19 8. CROSS-CUTTING ISSUES .................................................................................. 19 8.1 Learning disabilities and learning difficulties ................................................. 19 8.2 Psycho-social meetings ................................................................................... 22 9. CONCLUSIONS AND KEY LEARNING POINTS ................................................... 24 10. RECOMMENDATIONS TO THE CITY AND HACKNEY SAFEGUARDING CHILDREN BOARD ............................................................................................ 25 APPENDICES A The Lead Reviewer .......................................................................................... 26 B The Terms of Reference .................................................................................. 27 3 1. INTRODUCTION 1.1 Child H died at the age of six weeks in the spring of 2014. Medical advice indicated that the death had been caused by inflicted injuries. 1.2 The circumstances of the death therefore met the statutory requirement1 that a Serious Case Review (SCR) be conducted and that was formally confirmed by Mr Jim Gamble QPM, the Chair of the City and Hackney Safeguarding Children Board (CHSCB), on 15th July 2014. This is the Overview Report from that SCR. 2. FAMILY COMPOSITION 2.1 Ms M and Mr F are in their twenties. Ms M lived with her parents (MGM and MGF), and Mr F had also lived there for about for 2 ½ years. The couple had formed a relationship a year before that. His family live in Kent. 3. ARRANGEMENTS FOR THE SERIOUS CASE REVIEW 3.1 The CHSCB convened an SCR Panel (the Panel), consisting of senior representatives from relevant agencies, to lead the SCR. That panel was chaired by Mr Rory McCallum, Senior Professional Advisor to the CHSCB. The CHSCB appointed a suitably experienced independent person – Kevin Harrington2 - to act as Lead Reviewer and to write this report. 3.2 All relevant agencies were required to submit an Individual Management Review (IMR), either containing a narrative and an analysis of their involvement where that had been significant, or a narrative account of events where involvement had been less significant. Those agencies are detailed in the table below, and are subsequently referred to by the acronyms / abbreviated forms provided. AGENCY NATURE OF INVOLVEMENT London Borough of Hackney Children’s Social Care services (CSC) CSC carried out an assessment of the family situation during the pregnancy. The General Practitioners (GP) The family was well known to their GPs Homerton University Hospital NHS Foundation Trust (HUHFT) This Trust provided maternity and health visiting services to the family. Some other HUHFT services were indirectly involved. East London Foundation Trust (ELFT) This Trust carried out an assessment of Ms M’s mental health during her pregnancy. City and Hackney Clinical This agency has provided an overview of 1 This is set out in the government’s guidance, Working Together to Safeguard Children (2013), referred to in this report as “Working Together”. 2 Appendix A of this report contains brief autobiographical details. 4 Commissioning Group (CCG) all health services contributing to this report. Children’s Centre This agency had no direct contact but was involved in determining which services might be offered to the family. Metropolitan Police Service (MPS) The MPS had no significant contact before the identification of the injuries which led to the death of Child H. London Ambulance Service NHS Trust (LAS) The LAS has confirmed that they conveyed Child H to hospital when her fatal injuries were reported. 3.3 The Terms of Reference for the review are at Appendix B. They are drawn from Working Together, amended to reflect issues specific to the circumstances of this case. The review considers the period between October 2013, when the pregnancy was confirmed, and June 2014 when Child H died. 4. METHODOLOGY USED TO DRAW UP THIS REPORT 4.1 This report is based principally on the IMRs, background information submitted and subsequent Panel discussions and dialogue with IMR authors and other staff. Both of Child H’s parents, and their extended families, have met with the author of this report and spoken about the services the family had been in contact with. 4.2 This report therefore consists of: • A factual context and brief narrative chronology. • Commentary on the family situation and their input to the SCR. • Analysis of the part played by of each agency, and of their submissions to the review. • Closer analysis of key issues arising from the review. • Conclusions and recommendations. 4.3 The conduct of the review has not been determined by any particular theoretical model but it has been carried out in accordance with the underlying principles of the statutory guidance, set out in Working Together: The review, • “recognises the complex circumstances in which professionals work together to safeguard children; • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight3; 3 This review does not rely on hindsight, and tries not to use hindsight in a way that is unfair. It does use hindsight where that promotes a fuller understanding of the events and their causation. 5 • is transparent about the way data is collected and analysed; and • makes use of relevant research and case evidence to inform the findings” 4.4 The government has introduced arrangements for the publication of Overview Reports from SCRs, unless there are particular reasons why this would not be appropriate. This report has been written in the anticipation that it will be published. 5. KEY EVENTS 5.1 Background 5.1.1 Ms M was adopted at an early age, having been the subject of serious abuse and neglect in her infancy. She has since then lived with her adoptive parents (referred to throughout this report as her parents), though she has had some continuing contact with some members of her birth family. Her parents had also adopted an older child, a boy, who had a number of difficulties in his life. He died during the period under review in this report. 5.1.2 Ms M’s GP has helped her with anger management and some mental health issues, believed to be linked to her experiences in her early years. However it was never necessary, prior to her pregnancy, that she should have contact with specialist mental health services. Mr F has had no significant previous contact with health or social care services. Both parents had some special educational provision as children. 5.1.3 In May 2011 Ms M was brought to hospital by police following a disturbance, in which she was said to have threatened her boyfriend with a knife. She was seen by psychiatrists who found no evidence of mental disorder. She was discharged and no follow up by psychiatric services was judged necessary. This appears to have been an isolated incident – there is no knowledge of any similar event. 5.1.4 Ms M is at times described by agencies as having learning difficulties or a learning disability. That issue is discussed separately below. 5.2 October to December 2013 5.2.1 In October 2013 Ms M’s pregnancy was confirmed by her GP who made referrals to maternity services and the Perinatal Mental Health Team. The GP also contacted a Learning Disability Liaison Nurse for advice. 5.2.2 Ms M had an ante-natal booking assessment when she was 9 weeks pregnant. She was reported to be in a good mood and feeling well. The midwife noted a history of depression and “mild learning disability”. The midwife referred her to “Stop Smoking” services and the Consultant Obstetrician. Ms M was then compliant with 6 ante-natal services throughout the pregnancy and this chronology does not contain a detailed account of subsequent contacts. 5.2.3 The midwife also completed a Common Assessment Framework (CAF). The CAF is a national “tool” used for identifying and assessing the situation of children, including unborn children, who may have additional needs, which require the involvement and co-ordination of more than one agency. 5.2.4 In Hackney a Multi-Agency Team (MAT), led from the Children’s Centre covering the home address, is responsible for the oversight of arrangements which seek to help families at an early stage. The MAT assessed the report from the midwife and, while noting that referral to CSC might be necessary, concluded that Ms M be invited in the first instance to attend a parenting group. 5.2.5 Ms M attended the Perinatal Mental Health Team in early November for her initial assessment, which was conducted by a senior nurse. She was accompanied by Mr F. That assessment was detailed, and concluded that Ms M did not suffer from any acute mental health problems. Her GP was already prescribing some medication to help her when her mood became low and that should continue. The risk posed by the patient to herself or others was judged to be low. Her partner was considered knowledgeable and reliable in the event that her mental health deteriorated. 5.2.6 The perinatal mental health nurse noted that the GP had made revisions to medication prescribed for Ms M, and so one further follow-up appointment was arranged for later that month. From that second meeting the nurse concluded that Ms M had “personality issues and anger management issues” but that there was again no evidence of severe or enduring mental illness: any necessary treatment could be provided by the GP. 5.2.7 Ms M had initially agreed to attend the group for expectant mothers but then decided that she did not wish to do so and declined offers from the midwife to assist her with this. The midwife therefore, as a result of her non-engagement, made a referral to CSC for an assessment of Ms M’s overall situation and parenting capabilities. 5.2.8 That referral was considered promptly at CSC and allocated for assessment with specific reference to: • Ms M’s parenting capabilities in the light of her possible learning disability • The extent of any learning disability and her functional abilities • Current living and support arrangements • The nature and extent of engagement with maternity services • The relationship with Mr F and the extent to which he would be supportive 5.2.9 The CSC assessment was based on two visits, the first in mid-November and the second in early December, and on checks with other agencies. Ms M and Mr F had been in a relationship for about 3 ½ years and lived together for 2 ½ years. There 7 had been some difficulties between them, including a brief separation in 2011. There was some evidence of Ms M having difficulties in managing her anger. However CSC concluded that the situation overall was stable, Ms M was well supported and that there was probably no need for their continuing involvement. After the second visit the plan was to close the case once all checks with other agencies had been carried out. 5.2.10 Just before Christmas the case was reviewed by the MAT at the Children’s Centre. The MAT noted that CSC were now involved and suggested that they consider a “step down” referral – an arrangement where specialist providers, such as CSC, are terminating contact with a family and make a referral back to universal or less specialised services. CSC did subsequently consider this but decided that there was not sufficient indication of cause for concern to make such a referral. 5.3 January to April 2014 5.3.1 Around the turn of the year there was an argument between Ms M and her parents. She and Mr F left the home and went to his home but returned in early January. The home situation then appears to have settled down although Mr F lost his job around that time. 5.3.2 In early February, CSC liaised with the “Learning Difficulties Team” (sic). A social worker in that team advised that their only knowledge of Ms M was that some years previously she had been in touch to request a travel pass. They had never made any assessment of her. 5.3.3 CSC closed the case in mid-February. It had been established that both extended families were supportive, there was good engagement with maternity services and Ms M was compliant with her medication regime. This was explained to the family (but they were not given a copy of the assessment, as they should have been). All relevant agencies were informed of this decision and the recording also states that “Notification of case closure is to be sent to Adults Learning Difficulties Team (sic) in Hackney”. It is not clear why this team was to be notified. They had had no significant involvement in the past and there was no plan for any future involvement. 5.3.4 In early April, Ms M saw her GP and said that her father had been diagnosed with a terminal illness. She told the GP that she was often tearful and was irritated by her mother. She was worried that she might develop post-natal depression and expressed anxiety about her ability to look after the baby in the future. She declined re-referral to the perinatal mental health team but said she would like some counselling and support. The GP made a referral to primary care psychology services (PCP), requesting an urgent appointment. There was no telephone number on the referral so PCP wrote to Ms M inviting contact. She did not respond and the PCP service closed the case. Around this time Ms M’s brother died after a long illness. 8 5.3.5 A midwife contacted the local authority’s Learning Disability Team at the end of April and spoke to a social worker, who suggested that the midwife could make a formal referral to them if she felt an assessment was indicated. A referral was made and Ms M was eventually seen after the death of Child H. 5.4 May 2014 5.4.1 In early May, a midwife and a Health Visitor carried out a pre-birth visit but Ms M and Mr F had gone to the hospital as they felt that the birth of the child was imminent. MGM told the midwife and health visitor that she had concerns about Ms M’s ability to care for the baby, describing her background, her immaturity and the problems of bereavement and illness currently facing the family. The HV decided to provide an enhanced level of input after the child was born. 5.4.2 In fact the baby was born, at home, later that day. Ms M had been sent home from hospital as she was not in established labour when she went there. The baby was born some hours later, delivered by Mr F, and was then admitted to hospital after an ambulance had been called. The baby went to the Special Care Baby Unit and Ms M was admitted to the post-natal ward. 5.4.3 Staff on the post-natal ward asked for an assessment of Ms M’s mental health and she was seen, with Mr F, by a junior psychiatrist. Ms M reported no concerns and no unexplained 'odd' experiences or episodes of low mood. She presented with stable mental health and reported that she was compliant with medication. She wanted to leave the hospital and was discharged with advice on recognising symptoms of low mood, restlessness or difficulties in relationships, which might signal a recurrence of depressive illness. A letter was sent to the Perinatal Mental Health Team requesting a follow-up appointment because of Ms M’s history. 5.4.4 The baby remained in hospital for 12 days. During that time the situation was discussed at a regular psychosocial meeting and staff contacted CSC. CSC advised that the situation had been recently assessed, that there would be no concerns about discharge to the family home, because of the support and supervision of family members, and that continuing input from CSC was not necessary. CSC had not been made aware of the death of Ms M’s brother and the terminal illness of MGF when giving this advice. 5.4.5 Ms M and Mr F visited the hospital at least once daily and participated in the care of the child. Good interaction with the baby was noted. The child had a minor physical problem, a tongue tie, which can cause difficulties in feeding and was referred to the maxillofacial team for this to be addressed. 5.4.6 While the child was in hospital the HV and midwife made a joint visit to the family home. There was no immediate evidence of cause for concern but they talked with the family about making a re-referral to CSC, and referring to Learning Disability services, and the parents agreed to this. 9 5.4.7 On the day that the baby was discharged a perinatal mental health nurse telephoned the family, in response to the referral from maternity services, and spoke to Ms M. She reported feeling very well and that her partner was supportive. She did not feel the need to see the perinatal mental health team, and was therefore discharged to the care of her GP. 5.4.8 Over the next two weeks the HV and midwives saw the family, in total, three times and had no specific concerns. They observed good physical care of the baby, who was undressed by the midwife. The HV discussed the family with the GP and it was agreed that there were no current concerns regarding the care of the baby. However they acknowledged the stresses of bereavement and terminal illness in the family, and agreed that the midwife would re-refer to CSC. 5.4.9 However, the following day an ambulance was called to the family home. Mr F reported that the child had appeared well that morning but later he had found the baby was blue. Child H was admitted to hospital and was found to have intracranial bleeding .The parents and extended family members attended and were directly asked about the possibility of trauma and non-accidental injury but were all adamant that this could not be the cause of the problems. CSC and police were contacted and child protection investigations commenced. 5.4.10 Child H was promptly transferred to Great Ormond St Hospital (GOSH) where further investigations revealed a fracture to her left ankle. She remained unconscious for nearly two weeks and then died. 5.4.11 The provisional cause of death was noted as “head injury”. While in GOSH it became apparent that the injuries might have been inflicted. Both parents were arrested on suspicion of murder. Neither offered any explanation or knowledge of the cause of the child’s injuries. 5.4.12 A full review of the evidence was conducted by both the CPS and a QC from the CPS Special Case Unit. It was accepted that the injuries were non-accidental, but the evidence did not indicate with sufficient certainty when the fatal injuries were inflicted, nor who was looking after Child H at the relevant times. 5.4.13 On the basis of the evidence available the prosecution could not allege homicide against either parent, nor could they allege the other parent was an accomplice. No other/alternative charges were deemed suitable. In August 2015 both parents were informed that they would not be the subject of any further enquiries. 10 6. THE FAMILY 6.1 Ms M and her family 6.1.1 Ms M’s father died soon after the death of Child H. (As indicated above, her brother also died during the period under review). Ms M and her mother met with the author of this report to discuss the events under review. 6.1.2 There was no disagreement between Ms M and her mother in their views of the services they had contact with. They could not recall much about the contact with the social worker but spoke highly of all the health professionals they had been in contact with during the pregnancy and Child H’s short life. The exception to that was when, immediately before the birth of Child H, they had presented at hospital but had been sent home because Ms M’s labour was not sufficiently advanced. The baby had then been born soon after they returned to their home. 6.1.3 That would of course be a difficult situation for any family to manage. In the course of this SCR maternity services were asked to review their actions on that day and they did confirm that the decision not to admit Ms M had been in line with the hospital’s guidance. They could not have foreseen that the labour would progress so quickly. 6.1.4 The family had mixed feelings about their involvement with police. They described the way in which Ms M had been arrested when the injuries to Child H were identified. The arrest took place very publicly at the hospital, involved several police officers and was of course distressing for the family. However they also wanted to stress how much support, as a family, they had subsequently received from the police Family Liaison Officer. 6.1.5 After the death of Child H, Ms M had received specialised counselling at Great Ormond Street Hospital. She had chosen to bring her mother with her to these meetings and both described how helpful they had been. 6.1.6 Looking back, Ms M’s mother wondered if they might have tried to make better links with local community services for new and vulnerable mothers. She acknowledged that she had adopted her children as toddlers and it was a new experience for all of them to have a baby in the house. She also thought that Mr F had little idea of how to care for a small baby, giving examples of him behaving inappropriately when handling the child, without due regard to the baby’s safety. 6.2 Mr F and his family 6.2.1 Mr F has left London and returned to live with his family. He, his mother, sister and maternal grandparents were all involved in a meeting with the author of this report. 11 6.2.2 Overall, like Ms M and her mother, they spoke warmly of many services they had been in contact with. Like Ms M they referred in particular to the help they had received from the Public Health Midwife in Hackney, and some staff at Great Ormond St Hospital after the injuries to the baby. Like Ms M they also had reservations about the contact with maternity services on the day that the baby was born. 6.2.3 The point they stressed most strongly was that agencies failed to give sufficient weight to the news that Ms M’s father was diagnosed as terminally ill. As well as the overall emotional turmoil this caused, it meant specifically that the capacity of Ms M’s parents to support Ms M as a new mother was weakened. They also felt that agencies then did not share that information adequately. These causes for concern have already been recognised and accepted by the relevant agencies. 6.2.4 Mr F’s family felt that he had taken on most of the responsibility for the practical care of Child H, and that agencies perhaps under-estimated the amount of help Ms M needed. They contrasted this with events after the injuries to Child H, when they felt some hospital staff did not liaise adequately with the paternal family. 6.2.5 Overall the family feel that the agencies failed to recognise the strains in a situation involving: • Two young people who had not previously been parents • The sudden and terminal illness of Ms M’s father • Ms M’s limited capability to parent her baby The agencies then did not share information about these issues thoroughly with each other. 6.3 Conclusions 6.3.1 Although there is no contact now the two families had got on well before the events leading to this review. Ms M’s mother talked of how they had happily taken Mr F into their home and helped him over the years that the couple had been together. Mr F’s family similarly had some warm memories of the families doing things together. 6.3.2 Meeting Ms M, it is evident that she has what she calls “special needs”. However that is not the case with Mr F, whose presentation would not suggest any such conclusion. It is understandable that professionals meeting them before the injuries to Child H might have assumed that his presence would be supportive and reassuring, and indeed there is no evidence to the contrary. 6.3.3 Ms M’s family environment is warm and caring, something which was evident when visiting the home, despite the stresses necessarily arising from all the losses they have suffered since she became pregnant. 12 6.3.4 All those factors go some way to setting the context in which the family was seen by professionals, and the judgments made by those professionals. This was not an unhappy or troubled family situation where cause for concern was evident. 7. THE AGENCIES 7.1 The General Practitioners 7.1.1 The first contact with professionals during the period under review was with the GPs, when Ms M’s pregnancy was confirmed. All the members of this family, including more recently Mr F, had been with the same GPs for some years and were well known at the practice. Overall the way in which the GPs dealt with them through these events was appropriate. 7.1.2 When Ms M first discussed her pregnancy with the GPs their response was thorough. Appropriate referrals were made promptly to maternity and mental health services. The GP also sought to make a referral to learning disability services and this issue is discussed further below. 7.1.3 The most significant learning point for the GPs, which they accept, relates to information sharing. During the pregnancy the GPs became aware of the terminal illness of MGF. However they did not share that information appropriately, within their practice or across the network of agencies. 7.1.4 The IMR explains that“Ms M accompanied by Mr F told the GP that her father was ill and she was anxious about the future. At around the same time, her parents also told different doctors (at the practice) about his ill health and concerns they had about the future”. However “A connection was not made by different clinicians that the grandfather’s illness might impact on the grandparents’ ability to support Child H’s parents in caring for Child H”. 7.1.5 The GPs had referred Ms M to psychological services but did not take any further action in respect of Child H on receipt of the information about MGF’s ill health and Ms M’s concerns about caring for the baby. It would have been appropriate to reconsider whether the overall arrangements for supporting Ms M and Mr F, which were very dependent on the grandparents, were sufficiently robust. It would have also been appropriate to have discussions with child care services at this time. This may have been significant to the course of events because CSC, in deciding to terminate their involvement, had placed a substantial emphasis on the role of the grandparents in both a protective and a supportive capacity. 7.1.6 It is important to be mindful of the clarity that hindsight can bring. Had the GPs, as a whole, been fully alert to the changes in the family situation they probably would have re-referred to CSC, who probably would have re-assessed. But even then there is no indication that such a re-assessment would necessarily have resulted in actions that would have altered the overall course of events. 13 7.1.7 Nonetheless this further underlines the need for a “Think Family” approach, and it offers an important learning point for these GPs and more widely. National research4 has found “anecdotal evidence that GPs in particular do not see the Think Family approach as part of their role, and that information sharing with GPs is a particular challenge. Nonetheless…GPs are universal, non-stigmatising parts of society, and their engagement in whole-family working would be likely to increase its purchase across all services”. 7.1.8 These GPs have developed appropriate changes to the way information is shared between doctors and other relevant services at their practice, and there is consequently no recommendation from this report. 7.2 London Borough of Hackney, Children’s Social Care 7.2.1 The family were visited twice by a social worker, in November and December, following the referral from maternity services. These visits and the standard checks which were made with other relevant agencies constituted the evidence base for the assessment by CSC. 7.2.2 The input from CSC was generally proportionate to the referral they received. There was no evidence to suggest any cause for serious concern. The maternal grandparents were seen as protective, the relationship between Ms M and Mr F seemed generally stable when the visits were made and they were both happy and positive about the pregnancy. The suggestion that Ms M had a learning disability should have been explored more thoroughly and that is discussed separately below. There was no indication that continuing involvement from social workers was necessary or appropriate. 7.2.3 However, in closing the case, there was an expectation within CSC that it would be considered at “psychosocial” meetings at the hospital. The social worker wrote to the Named Midwife asking that the meetings be used for tracking the case. In fact those meetings usually only monitor situations involving children subject to child protection or formal “child in need” arrangements. That begs the question of how the situation of unborn children, who may be “in need” but not subject to a Child Protection Plan is addressed. The Named Midwife did not respond to the notification from the social worker so the service remained unaware that the case would not automatically be considered at these meetings. The agencies need to clarify this, and the issue of the use and understanding of psycho-social meetings is considered separately below. 7.2.4 When this case had first been considered by the MAT they had recommended use of “step-down” arrangements if and when contact with a social worker was concluded. This was considered at the relevant time by CSC but it was decided that there was no need for such arrangements, largely because of the judgment that the extended family would provide continuing support. That was a reasonable 4 SCIE: Think Child, Think Parent, Think Family 14 assumption although when stresses in the family emerged – the death of Ms M’s brother and the illness of her father – these changes should have prompted a re-evaluation of the situation. The social work team was not made aware of these changes and the need to re-assess. 7.2.5 Service arrangements for social work with children and families are unusual in Hackney. The IMR explains that “Hackney Children’s Social Care operate a Unit model whereby cases are jointly allocated to small units. Each Unit is led by a Consultant Social Worker who has responsibility for the management and decision making in respect of all cases. Case supervision and management is undertaken within Unit meetings and recorded on individual children’s files”. A Consultant Social Worker is deliberately not “just” a manager, but will also work directly with families. So, where the officer carrying out an assessment is the Consultant Social Worker in that Unit, that officer may also be responsible for “signing it off” and closing the case. That was the case here. 7.2.6 The Hackney model has attracted a great deal of positive comment, broadly to the effect that it promotes a collaborative approach within teams, avoids the pattern of losing skilled social workers to the ranks of management and engenders a working environment that proactively seeks to develop the skills of its workforce. The service reports that “Hackney’s model of social care promotes conversation, discussion and dialogue. Senior managers sit alongside practitioners, are accessible to staff and are regularly involved in case consultation. The weekly unit meeting, which is led and chaired by the Consultant Social Worker, is the key mechanism for risk assessment, analysis and decision making. Service Managers and Heads of Service regularly attend unit meetings to provide additional oversight. All practitioners receive individual professional development supervision. Consultant Social Workers receive monthly supervision from a Service Manager. Hackney also has a comprehensive quality assurance framework in place, including a monthly audit programme and quarterly thematic case review days involving all senior managers”. 7.2.7 This review does raise issues about aspects of these arrangements. The Consultant Social Worker made no case records following the two visits to the family. The IMR judges that concerns about this are lessened because of the work model used in Hackney, where cases are frequently discussed by the responsible Unit and that discussion is recorded. But recording of one’s individual involvement, assessments and actions is a fundamental professional requirement. The IMR accepts that this is a weakness, commenting that “if the records available were complemented by more detailed case notes this would better enable the reader to understand what the analysis was based upon”. 7.2.8 There was also a degree of apparently avoidable drift in the management of the case. This was not an assessment that needed to be concluded quickly and the Panel noted the IMR’s comment that “the London Borough of Hackney hold dispensation for assessment timeframes agreed by the Department for 15 Education5”. Nonetheless there was no reason why some of the tasks in the assessment might not have been done more promptly. In particular the assessment process at the outset identified cause for concern in relation to “untested parenting (in context of learning disabilities)”. This had been raised as a potentially significant issue by both the GP and by midwifery services. However it was not until February, three months after their work commenced, and after the decision to close the case had already been taken, that the Consultant Social Worker liaised directly with Learning Disability services. 7.2.9 That contact was then not sufficient – it served to confirm that Ms M did not have a learning disability, as far as services were aware, but did not explore whether the issue should now be assessed by the relevant service. (In fact, having met Ms M for the purposes of this review, it was clear to me that she has some degree of intellectual impairment, and she acknowledged that directly). There is no recording to suggest that this change in emphasis was a deliberate decision – a judgment, after seeing the family, that the issue did not have the significance suggested by the original referrals. Rather, it appears gradually to have been perceived as less significant while that shift was not identified by any supervisory or management arrangements. 7.2.10 These weaknesses – insufficient recording, drift in executing work plans and a failure to meet all the requirements of a plan – are frequently identified in case reviews. It is not suggested that more conventional approaches to managing casework are guaranteed to prevent them. However the difference here was that there was no routine managerial process to identify and deal with those problems. The responsible social worker was not required to report to a named manager on the detail of the progress of the casework, nor on the rationale for deciding to close the case before all necessary investigative tasks had been carried out. The level of oversight offered by the Unit meetings did not provide an adequate challenge to the drift in the case, and the failure to make adequate case records was not identified until this review. 7.2.11 Subsequent reviews within the CSC service have not found problems similar to those identified here. However they could be systemic issues – that is, they could recur in the service arrangements as they are currently designed. There is consequently a recommendation that this be examined further, with a view to building in continuing quality assurance arrangements as necessary. 7.3 Homerton University Hospital NHS Foundation Trust 7.3.1 This Trust provided maternity and health visiting services, the Primary Care Psychology service (PCP) and was the employing agency for the Learning Disability Liaison Nurse. This was also the Trust providing a range of services in respect of MGF’s serious illness. 5 Hackney has been working with the Department for Education since March 2011, trialling more flexible ways of working and has been granted dispensation on a number of statutory requirements, including not imposing fixed timescales for completing assessments. 16 7.3.2 The report from this Trust identifies one incident outside the period under review, which may be relevant. In 2011 Ms M was brought to hospital by police after an incident in which she was said to have threatened someone known to her with a knife. Police were concerned about her mental health and her understanding of the situation. 7.3.3 This was an isolated incident which did not lead to any continuing contact with services and is probably in itself not significant. However maternity services, from the same hospital, and health visiting services, had no knowledge of it. As the Health Overview report notes “This suggests that within HUHFT it may be possible for a patient to present to one department without staff being aware of previous presentations to different departments”. 7.3.4 As indicated above Ms M’s contact with maternity services was largely unremarkable. She was entirely compliant with the requirements and expectations of the service. From her first contact her vulnerabilities were identified. The Health Overview report notes that “the case was held by a public health midwife and a targeted service was offered. The public health midwife is a senior midwife with additional knowledge, skills and expertise in working with vulnerable clients”. 7.3.5 This Trust also manages the relevant Health Visiting service. SCRs have often commented on issues arising in respect of handovers from maternity to community health services. There were no such problems here, with evidence of good liaison between the two services and early involvement by the Health Visitors, in recognition of Ms M’s vulnerabilities. 7.3.6 The documented work of these services illustrates how the agencies could not have envisaged the injuries to Child H. A few days before the fatal injuries were inflicted a Health Visitor saw the family at home and recorded that “The post-natal and neonatal checks were completed … and no concerns were noted, baby was gaining weight…. parents’ interaction with (baby was observed and) …they handled her well including dressing, making formula and feeding”. There had been a degree of concern while the child was in hospital about the parents’ understanding of how to feed the baby safely, so it was reassuring that this no longer appeared to be a problem. 7.3.7 However this “joined up” approach of maternity and health visiting services was not similarly evidenced between maternity and psychology services. Maternity services were unaware of the GP’s referral to PCP, and PCP staff, although they knew of Ms M’s pregnancy, did not liaise with colleagues in maternity services when seeking to contact the family. Had they done so they could have been provided with a contact telephone number, which would have offered a speedier and perhaps more effective way of contacting Ms M in response to the GP’s urgent referral. Ms M did not respond to their letter and this was a missed opportunity to engage her when she was asking for help. The service has made changes to their administrative processes so that, if patients do not engage with the service 17 following GP referral, a referral back to the GP, requesting re-assessment, is automatically triggered. 7.3.8 The Health Overview report judges that the intervention by the PCP service could generally have been more thorough, especially in relation to the lack of response from Ms M: “This referral was flagged by the GP as urgent. Ante-natal depression, anxiety and bereavement are independent predictors of post-natal depression and so failure to engage in the presence of those risk factors should be considered as a possible safeguarding concern. The Primary Care Psychology service should recognise the risk and should have clear processes with regard to identification, risk assessment and management of clients that fail to engage with the service. For such clients there should be prompt referral back to primary care combined with an explicit requirement for re-assessment”. 7.3.9 The Primary Care Psychology Service is a service for adults and it may be of value for the service to provide training in relation to the “Think Family” concept. This approach is widely promoted in adult mental health and other services to ensure that staff working with an adult think about the impact of the adult’s difficulties on children in the family. This will increase the awareness of the risks to children when their parents suffer from poor mental health. Two training sessions have already been agreed for all relevant staff. 7.3.10 As with all the agencies involved with the family there was confusion around the issue of learning disability, which HUHFT acknowledges in its IMR: “There is a need for a greater understanding of the care and assessment pathway for learning disabilities in the context of parenting and appropriate support of vulnerable parents”. 7.4 East London NHS Foundation Trust 7.4.1 This agency worked directly with the family through the City and Hackney Perinatal Mental Health Service (PMHS). The PMHS works with women who have moderate to severe mental health difficulties in pregnancy or within the first year after childbirth. Ms M was seen by the PMHS for two assessment appointments in November 2013, following which she was discharged as not requiring further intervention at that time. 7.4.2 Ms M was then seen on the post-natal ward by an on-call liaison psychiatrist, the day after the baby was born, and re-referred to the PMHS. A Clinical Nurse Specialist from the PMHS telephoned Ms M some 10 days later. Ms M reported that she was well, that Child H would be discharged from SCBU that day and that she was confident about being able to look after the baby. She did not feel that she needed to be seen by the PMHS and said she would contact her GP if necessary. 7.4.3 Recording of the two contacts with the PMHS has been provided to this review. The assessments of Ms M’s mental health are thorough and find “no symptoms indicative of a mental illness”. The assessment reports do comment that “she does 18 appear to have anger management issues possibly related to her personality”. Ms M was on continuing anti-depressant medication and the assessment included advice on managing her medication as her pregnancy progressed. 7.4.4 The assessments place a significant emphasis on Mr F providing support to Ms M, and to his responding to any significant changes in her mood or presentation. It was noted that he “seems very knowledgeable about her relapse indicators and the importance of getting help should she not identify and seek professional support”. 7.4.5 The issue of learning disability is touched on, to the extent that it is noted that Ms M described herself as having “special needs” (as she immediately did when she met the author of this report). There is no further exploration of that issue. The Modern Matron carrying out the assessment did liaise with CSC but there is no indication that learning impairment was discussed between them, although, as described above, this had been a headline area to be investigated when CSC first became involved. 7.4.6 The GP had not specifically mentioned learning disability in referring Ms M to mental health services. However the subject was discussed between the GP and a psychiatrist from ELFT who rang the GP, prior to the assessment visit, principally to advise on medication. 7.4.7 In framing their submissions to this review agencies were asked to consider the question “Were practitioners alert and responsive to any indicators of additional needs that the parents may have had?” We now know that Ms M’s IQ was subsequently found to be in the category of those with a learning disability. It may be that issues potentially arising from her self-proclaimed “special needs* should have been recognised and given greater weight in this assessment of her mental health. That is a judgment informed by hindsight but there are undoubtedly aspects of Ms M’s presentation that indicate some degree of intellectual impairment. All other professionals who had contact with her noted this. 7.5 City and Hackney Clinical Commissioning Group – the Health Overview Report 7.5.1 The City and Hackney CCG has submitted a Health Overview Report in line with local and national requirements. Its purpose is to review all the health services provided to the family during the relevant period. The findings of the Health Overview Report are in line with those emerging from this report. 7.5.2 The report notes that we do not know the circumstances in which Child H was injured but comments on the stresses all new parents experience when caring for a baby. It mentions developmental work underway in Hackney to address this: “Research shows that babies’ crying is associated with parental stress, depression and relationship problems. Crying can disrupt parents’ developing bonds with their babies, and in extreme cases, can cause parents to get angry and harm their babies. Hackney is currently working with the NSPCC, piloting the Coping with 19 Crying programme in Children’s Centres. This programme involves showing a short film to new parents. The film is designed to help parents in the UK care for a crying baby and reduce the risk of them becoming stressed and harming their baby. Evaluation suggests that the film is helping to keep babies safe: • 99% of parents remembered the film 6 months after watching it • 82% of parents said they used advice from the film when caring for their baby • the rate of reported injuries among babies with feeding, sleeping or crying difficulties was lower if their parents had seen the film” 7.6 The Children’s Centre 7.6.1 The Children’s Centre had no contact with the family. Their only involvement was to manage the process arising from Ms M’s first contact with maternity services. Those arrangements were satisfactory. 7.7 Metropolitan Police Service 7.7.1 The MPS had no contact with any family member during the review period and no significant contact before then. 7.8 London Ambulance Service NHS Trust 7.8.1 The LAS was involved only in responding to a 999 call from MGM on the day that Child H’s injuries came to light. There was no delay in their response and Child H was promptly conveyed to hospital. There are no matters arising for the LAS from this SCR. 8. CROSS-CUTTING ISSUES 8.1 Learning disabilities and learning difficulties 8.1.1 This case serves to illustrate a confusion, which is not uncommon, about whether parents may be eligible for services provided by multi-agency Learning Disability teams. This often arises from a lack of clarity about what constitutes a learning disability and can be linked with an inaccurate, interchangeable use of the terms “learning difficulty” and “learning disability”. It is also an area in which precise assessment is difficult. 8.1.2 The terms may also carry additional complexities, with a socio-political dimension to their use: People First6, an advocacy organisation, prefers only to use the term “learning difficulty” “when we talk about people with learning difficulties, we mean ‘people labelled as having a learning difficulty’. …We choose the term ‘learning 6 www.peoplefirstltd.com 20 difficulty’ instead of ‘learning disability’ to get across the idea that our learning support needs change over time”. 8.1.3 Broadly a learning difficulty does not affect general intelligence. Examples of a learning difficulty would include dyspraxia or dyslexia. A learning disability is linked to an overall cognitive impairment. 8.1.4 Looking at the events in this case, the key issue is that there was no assessment by the Learning Disability service when such input would have added to the agencies’ understanding of the overall situation, and what can now be recognised as the vulnerabilities in that situation. 8.1.5 There was a “side issue” here arising from a quirk in the organisational arrangements for learning disability services. Those services are provided by the multi-agency, multi-disciplinary Learning Disability service which is located organisationally within the local authority. However there was also one “stand-alone” post, funded by the CCG and physically located at the Homerton Hospital, of a “Learning Disability Liaison Nurse”. The hospital’s report to this review explains that the post forms “part of the adult community nursing service and provides an advice and signposting service for general practice who have queries about patients who may have a learning disability. She advises on how to refer to the Learning Disabilities Service but is not employed by the London Borough of Hackney’s LD service”. 8.1.6 The GP, as part of her first response to the pregnancy, contacted this nurse. They discussed whether Ms M might be eligible for and appropriately assisted by learning disability services. The nurse advised the GP to make a referral to the mainstream Learning Disability service where an assessment would be conducted. The GP recalls making such a referral and the Health Overview report states that “The referral is recorded in the GP records”. However the service has no record of receiving any such referral. This review has been unable to determine what happened in this respect. 8.1.7 Setting that aside, the difficulty is that this post of Liaison Nurse, which clearly provided accessible advice for GPs, also constituted another link in referral arrangements. Experience tells us that the simpler such arrangements are, the more effective they are likely to be, and it became clear in the review process that there was confusion across agencies about the role and responsibilities of this post. In fact, in part as a consequence of the learning from this review, agencies are considering changes to organisational arrangements. That could include this post being managed within the mainstream Learning Disability service, where it could be integrated with other services for adults with learning disabilities and their families. 8.1.8 In any event the starting point was the GP’s uncertainty about whether Ms M might be eligible for services from the Learning Disability service. That uncertainty is understandable because there is a considerable variety across the country in the 21 arrangements used by services to determine eligibility for such services. Eligibility will be determined by an assessment of the individual’s IQ and their social functioning. Commonly, to satisfy eligibility criteria, individuals will need to have: • A significant impairment of intellectual functioning (an IQ score of below 70 for a mild LD and below 50 for a moderate to profound LD), and • a significant impairment of adaptive behaviour/social functioning (difficulties with learning, understanding, communicating or daily living skills) 8.1.9 Following the death of Child H there was an assessment by the Learning Disability service which eventually concluded that there was insufficient evidence of difficulty in social functioning to satisfy the eligibility criteria, although Ms M’s IQ did meet that requirement. The Health Overview report confirms this: “The psychology assessment showed her to be in the LD range but the OT assessment showed that she had sufficient life skills to operate independently and therefore was not eligible for the services of the LD team”. 8.1.10 If Ms M had been assessed before the death of her child, had satisfied both criteria and had been offered services, it is still of course not necessarily the case that such services would have made a significant difference to her parenting capability. However it is possible that the assessment would have prompted the Learning Disability team to liaise with children’s services. That would be sensible because, among other considerations: • in general terms, adults with very low IQs are unlikely to be able to parent adequately • there is evidence for a genetic link between parental learning disability and child developmental delay • vulnerability to developmental delay may be compounded by lack of environmental stimulation • behavioural problems may arise when the child’s intellectual capacity exceeds that of their parents. 8.1.11 In fact one would expect, even if an assessment did not meet the criteria for the provision of services by the adults’ team, that it might still have prompted liaison with children’s services. There must be eligibility criteria but inevitably they are not an exact science and, in any event, the fact that an individual does not meet such criteria does not mean that they might not need and welcome assistance with parenting. 8.1.12 Taking a step back though, one might have expected that CSC themselves would have asked the Learning Disability service to conduct an assessment. There was only one brief contact from CSC to the Learning Disability service, in February when a decision had already been taken by CSC that there should be no continuing social work input. The CSC IMR notes that “Contact with the Learning Disabilities Team …confirmed that Ms M did not have a diagnosed learning disability”. That is 22 correct, literally, but one reason why she had no such diagnosis is that there had been no assessment which could have produced a diagnosis. 8.1.13 The IMR from CSC tells us that the social worker recognised that Ms M “presented in a number of respects in a way that was consistent with information received about her having a learning difficulty”. It is unclear then why the social worker did not suggest that there be an assessment by the Learning Disability service. The GP and the Health Visitor both felt such an assessment would be helpful. In fact one of the principal aims of the social work assessment had been to evaluate “parenting capacity in the light of her possible learning disability”. 8.1.14 The IMR notes only that “an additional assessment may not have significantly influenced the assessment on the case”. Equally that indicates that such an assessment may have been significant. In any event the aim of this review, which has the benefit of hindsight, is to identify learning which might be useful in the future –the learning point here is that the Learning Disability service was never asked to carry out an assessment. Yet there seems no reason not to seek this additional contribution to the overall assessment, and no reason why this was not explored at an earlier stage – certainly before the decision by CSC to close the case. 8.1.15 We now know that Ms M’s IQ was found on assessment to be in the category of those with a learning disability. Whether or not she acquired a label of “learning disabled” and received continuing services from the Learning Disability team, that level of intellectual impairment was significant to her parenting capability and a factor that might be expected to introduce new stresses into the family situation. The Health Overview report helpfully suggests that “It may be helpful to produce a tool to assist agencies to assess parenting when learning difficulties are present that do not formally meet the learning disabilities threshold. This is not an action for health services alone but may warrant consideration across the partnership”. 8.1.16 That suggestion is reflected in a recommendation from this report. Also the Learning Disability service has already taken action that allows for strict eligibility criteria to be waived and direct liaison with CSC to be prompted when they become involved in situations such as this. A “pathway” to be followed is being developed across the key agencies. 8.2 Psycho-social meetings 8.2.1 The term “psycho-social meetings” refers to arrangements often in place in hospitals for discussing cases where input from social care or mental health services may be appropriate. A range of hospital staff might attend these meetings with, sometimes, input also from external agencies such as CSC. They are used at HUHFT and they come to attention on two occasions during the events under review. 23 8.2.2 When the social worker was closing the case in February following her assessment she referred to the psycho-social meeting as one of the potential monitoring arrangements. She apparently assumed that Ms M’s situation would be raised as necessary at these meetings. That was an incorrect assumption because those meetings at HUHFT only considered situations involving children formally assessed as “in need” or for whom there was a Child Protection Plan. Unborn children can be subject to such arrangements, where that level of need or concern is anticipated, but that was not the case here. 8.2.3 The social worker may also have over-estimated the extent to which these meetings could be relied upon as a monitoring arrangement, even if the case had met their criteria. They offer a useful opportunity for cases to be highlighted and discussed where there may be cause for concern but they are not constituted or administered so as to form part of a rigorous case monitoring system. The extent to which they are multi-disciplinary is limited with social workers often not in attendance. 8.2.4 The arrangements in Hackney also target the early stages of pregnancy, as the Terms of Reference7 make clear “The meeting is a forum for multi-agency discussion of psychosocial concerns about the pregnant woman and their unborn or mothers and their babies in the very early neonatal period”. Consequently the meeting was not designed to serve as a continuing monitoring arrangement. 8.2.5 However a few days after the baby was born there was a neonatal unit psychosocial meeting at which the family situation was discussed. The meeting recommended that ward staff contact CSC and they did so. CSC confirmed their previous contact and advised that “as long as Ms M remained in the home of her adoptive parents, they would have no concerns about Ms M taking baby home. However if Ms M at any time left the family home, a new referral would need to be made to CSC”. 8.2.6 That advice again illustrates the significance placed on the grandparents by CSC and, yet again, the fact that MGF was so seriously unwell was not communicated to them. 8.2.7 Overall there are risks associated with a reliance, or a presumed reliance, on the psychosocial meetings as part of inter-agency case management arrangements. It was clear from discussions at the SCR Panel that there was a lack of clarity across the agencies on the purposes of these meetings. The agencies should re-issue the Terms of Reference for the psychosocial meetings, to ensure that their role is understood, or review them if it is felt they can usefully be updated. 7 Psycho-social meetings- Terms of reference 24 9. CONCLUSIONS AND KEY LEARNING POINTS 9.1 The death of Child H could not have been anticipated by any of the services or professionals involved with the family. This sort of review with its close scrutiny of a complex set of multi-agency relationships and responsibilities will inevitably identify learning points. Nonetheless, even if those matters had been addressed, it is very unlikely that there would have been evidence suggesting that this baby would suffer serious inflicted injuries. 9.2 The potential causes for concern were identified immediately by the GPs and maternity services and appropriate referrals were made. Subsequently there was good liaison and collaboration between maternity and health visiting services. 9.3 Ms M and Mr F co-operated with specialist assessments by social care and mental health agencies. Those assessments were generally thorough although the issue of Ms M’s intellectual impairment and its potential consequences was not given adequate weight by either service. 9.4 There was some avoidable drift and incomplete case recording within Children’s Social Care services. This was not identified before this review and that may be linked to the service model in Hackney. 9.5 There was confusion across the network of agencies as to whether Ms M had a learning disability, how that should be assessed and addressed and how the relevant specialist services were configured and accessed. Consequently there was no referral to learning disability services until shortly before the death of Child H. 9.6 During the pregnancy there were some significant changes in the family’s circumstances as a result of serious illness in the immediate family and the death of a relative. That information was not shared comprehensively across the network of agencies. Had it been shared there should have been a re-assessment by children’s social care services though this would not necessarily have led to any change in service provision. 9.7 The review revealed some confusion across agencies in respect of the role and purpose of “psychosocial meetings” in maternity services. The family circumstances, in themselves, would not necessarily trigger a referral to psychosocial meetings, and those meetings do not provide continuing monitoring of a family situation. 9.8 The family did not avoid contact with services. Ms M talked to her GPs about her fears and apprehensions about being a parent. The GPs made an appropriate referral to psychological services but the referral did not lead to any contact. Those services, aimed at adults, may not have been sufficiently alert to the child care implications of the GP’s referral. 25 10. RECOMMENDATIONS TO THE CITY AND HACKNEY SAFEGUARDING CHILDREN BOARD 10.1.1 These recommendations to the Board reflect the key lessons to be learned from this review. They draw on the views of the SCR Panel and the author of this report. 10.1.2 The review does not make a recommendation for every point of learning that has been identified. These recommendations are complemented by more detailed recommendations, specific to each agency, contained in the management reviews conducted by those agencies. Recommendations 1. The Board should promote, across all agencies, a clearer understanding of the nature of adult Learning Disability and the thresholds for eligibility for Learning Disability services. 2. East London NHS Foundation Trust to provide reassurance to the Board that appropriate assessment guidance is in place, that this guidance is explicit with regards to engaging relevant specialists when learning disabilities are either known or suspected, and that ELFT staff adhere to this guidance. 3. The Board should require the London Borough of Hackney to review the local protocol for assessment as required by statutory guidance in Working Together 2015. LBH should ensure this protocol is understood by staff and clearly sets out and clarifies how statutory social care assessments are informed by, and inform, other specialist assessments, including those on learning disabilities. 4. The London Borough of Hackney should provide reassurance to the Board that its quality assurance arrangements for all individual cases (including those where a Consultant Social Worker is working directly with a family) are sufficiently robust to test the quality, thoroughness and timeliness of social work activity. 5. The Board should require the Homerton University Hospital Foundation Trust, in the light of the issues identified in this review, to review their arrangements for: • psychosocial meetings • liaison between maternity services and the Primary Care Psychology Service. • promoting awareness of child safeguarding issues across adult mental health services (in partnership with East London NHS Foundation Trust). 26 APPENDIX A - The Lead Reviewer Kevin Harrington Kevin Harrington trained in social work and social administration at the London School of Economics. He worked in local government for 25 years in a range of social care and general management positions. Since 2003 he has worked as an independent consultant to health and social care agencies in the public, private and voluntary sectors. He has worked on more than 50 SCRs in respect of children and vulnerable adults. He has a particular interest in the requirement to write SCRs for publication and has been engaged by the Department for Education to re-draft high profile SCR reports so that they can be more effectively published. Mr Harrington has been involved in professional regulatory work for the General Medical Council and for the Nursing and Midwifery Council, and has undertaken investigations commissioned by the Local Government Ombudsman. He has served as a magistrate in the criminal courts in East London for 15 years. 27 APPENDIX B - The Terms of Reference Review scope Building on learning from previous cases, the objective of this review is to consolidate learning about what is working well and what presents challenges to organisations both child and adult-facing. We will do this in line with the principles in Working Together 2013 as outlined below. The review will follow the principles laid out in Working Together to Safeguard Children 2013 (4:10): SCRs and other case reviews should be conducted in a way which: • recognises the complex circumstances in which professionals work together to safeguard children; • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way data is collected and analysed; and • makes use of relevant research and case evidence to inform the findings. Agencies will be asked to comment on: 1. Were practitioners aware of and sensitive to the needs of the child in their work, and knowledgeable both about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare? 2. When, and in what way, were the child’s experiences ascertained and taken account of when making decisions about the provision of services? Was this information recorded? 3. What were the key relevant points/opportunities for assessment and decision making in this case in relation to the child and family? Do assessments and decisions appear to have been reached in an informed and professional way? Did you agency liaise/engage appropriately with other agencies? 4. Did actions accord with assessments and decisions made? Were appropriate services offered/provided, or relevant enquiries made, in the light of assessments and was the family signposted to appropriate support? 5. Were there any issues, in communication, information sharing or service delivery, between those with responsibilities for work during normal office hours and others providing out of hours services? 6. Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability of the child and family, and were they explored and recorded? 28 7. Were senior managers or other organisations and professionals involved at points in the case where they should have been? 8. Was the work in this case consistent with each organisation’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards? 9. Were there organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? Was there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case? 10. Was there sufficient management accountability for decision making? Agencies are asked to comment specifically on: • Where vulnerabilities were identified in pregnancy, what measures were taken? • Where agencies sufficiently alert to the role of the father or need to include in assessments? • Where practitioners alert and responsive to any indicators of additional needs that the parents may have had? |
NC50862 | Death of 13-week-old infant due to non-accidental traumatic head injury in March 2017. Father was charged with manslaughter and was subsequently acquitted. Baby K lived with his mother, father and older brother. Baby K and his brother were only known to universal services. Mother had regular interaction with Community Midwife and health visitor, including routine discussions of strategies to cope with a crying baby, prevention of a shaken baby and Sudden Infant Death syndrome (SIDs). Routine domestic abuse enquiries made with disclosures. In November 2016 during a development review with a Nursery Nurse, mother disclosed she had suffered domestic abuse with her previous partner; no record of any report to Police or other agencies of this. No evidence was found to suggest that any agency had the opportunity to foresee or prevent the death of Baby K. Ethnicity or nationality not stated. Learning includes: the intrinsic vulnerability of babies; areas of consistent established practice, e.g. recognising and acknowledging that the absence of any indicators of abuse does not eliminate risk; agencies to consider alternative contacts to accommodate working fathers to be able to attend home visits or appointments; risk assessments to have a reflective review by supervisors; the benefits of having an open, non-incident based approach to all forms of abuse within the family, supported by structured enquiry, professional practice and awareness that a victim may not disclose or even identify the existence of abuse. There are no recommendations.
| Title: Serious case review: Baby K: overview report. LSCB: Newcastle Safeguarding Children Board Author: Newcastle Safeguarding Children Board Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. CONFIDENTIAL 1 SERIOUS CASE REVIEW Baby K Overview Report October 2018 ViSOR Safeguarding Limited CONFIDENTIAL 2 1. INTRODUCTION 1.1. On 7th March 2017 Newcastle Safeguarding Children Board (NSCB) Case Review Committee considered details of the unexpected death of Baby K, aged 13 weeks old, who died from a non-accidental traumatic head injury. 1.2. Regulation 5(1)(e) of the Local Safeguarding Children Board (LSCB) Regulations 2006 requires the Board to undertake reviews of serious cases (SCRs) and 5(2) defines a serious case to include one where ‘abuse or neglect of a child is known or suspected, and the child has died.’ 1.3. In 2015 Chapter 4 of the guidance within “Working Together to Safeguard Children” emphasised the importance of a Learning and Improvement Framework which includes Serious Case Reviews and stipulates that such reviews should be completed in a way which: - • recognises the complex circumstances in which professionals work together to safeguard children; • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way data is collected and analysed; • makes use of relevant research and case evidence to inform the findings. 1.4. The guidance further states that LSCBs may use any learning model which is consistent with its principles, including the systems methodology recommended by Professor Munro. 1.5. It is an unusual aspect of this case that Baby K and his siblings were previously known only to universal services, there were no apparent indicators of any failings in the work undertaken by agencies to protect children nor were there any indicators of concern about abuse and neglect. However, a CT scan gave evidence of a bilateral acute subdural haematoma, brain oedema and massively raised intracranial pressure. Medical opinion stated that Baby K had died of an inflicted and traumatic non-accidental injury and this became the subject of a criminal investigation by the Police. The Independent Chair found that in these circumstances the criteria for a Serious Case Review were met. 1.6. Baby K’s mother and father were made aware that a Serious Case Review had been commissioned in March 2017 and subsequently invited to contribute when the criminal proceedings concluded in August 2018. Neither parent responded to the invitation. 2. SCOPE OF THE REVIEW 2.1. In view of the short life of Baby K and the limited contact with services, this is an unusual case for review and therefore it is appropriate to consider the entire life of CONFIDENTIAL 3 Baby K and indeed where relevant take reference from similar contact his siblings had with services. 2.2. Simple questions in this case remains the same, were there any missed opportunities for • Effective information sharing? • Robust single and multi-agency assessments? • Identification of any risk factors? • Provision of support services to the family? 2.3. However, and again reflecting on the unusual circumstances, it must be stated at the outset that there was no evidence of any concern for Baby K and thereby no incidents that could have benefitted from information sharing between agencies to protect him from abuse or neglect. This review has therefore stretched the normal scope in the search for any potential learning from this case. 3. METHOD OF THE REVIEW 3.1. All the agencies known to have been involved with the child were asked to review their records, prepare a chronology and identify any records relevant to the SCR. 3.2. Three agencies were asked to submit individual Serious Case Review Reports, these were: • North East Ambulance Service (NEAS) • Newcastle Gateshead Clinical Commissioning Group • The Newcastle upon Tyne Hospitals NHS Foundation Trust (NuTH) 3.3. It is relevant that, other than the investigation after the discovery of Baby K’s death, no other agencies were involved in the child’s life. 3.4. The SCR has been carried out in accordance with the statutory guidance and principles set out in Chapter 4, Working Together to Safeguard Children 2015. 3.5 During the preparation of the chronology the authors identified and spoke to key members of staff. One further interview with a key practitioner was undertaken during the preparation of the single agency reports. 4. PARALLEL PROCEEDINGS 4.1. Northumbria Police conducted the criminal investigation following the death of Baby K and father was charged with manslaughter. He was subsequently acquitted by the Court of the charge. The Senior Investigating Officer has offered full support to the review process. CONFIDENTIAL 4 5. TIMESCALE FOR COMPLETION OF THE SERIOUS CASE REVIEW 5.1. The anticipated timescale for completion of a Serious Case Review set out in statutory guidance is six months. The review commenced on 7th March 2017 and has been delayed due to the parallel criminal investigation. 5.2. Progress of the review was in partnership with the NSCB and it was the responsibility of the relevant partners to respond to all issues as they emerged. 6. A REVIEW THAT IS FAIR AND THOROUGH 6.1. As well as the scrutiny and evaluation of the events in the short and tragic life of this baby the SCR has sought to consider all potential areas of learning. The absence of any cause for concern prior to death has led to the consideration of scenarios founded on limited evidence but nevertheless parallel to relevant learning from research, legal precedent and a previous SCR in Newcastle. 6.2. Like many SCRs there has been an advantage to not only be able to review the composite history of professional involvement with the child but also to do so with the corresponding resource and time to forensically examine those events. 6.3. It has been considered that such scrutiny may indicate to frontline practice that signs and symptoms of abuse could have been recognised and acted upon. However, the search for learning and service improvement should not be construed as a gap in agency or partnership practice. 7. GENOGRAM 7.1. HB – Half-Brother, B1 - Brother Ex-partner Father Mother HB B1 Child K 13 weeks CONFIDENTIAL 5 8. SUMMARY OF THE CASE 8.1. Baby K was born at 39 weeks pregnancy following a normal delivery from which no concerns were raised. Baby K and mother were discharged the following day. 8.2. Between April 2016 and July 2016 Baby K was seen by professionals on nine separate occasions. 8.3. The Community Midwife visited Baby K on 3 occasions in April 2016. During one of the visits it was noted by the Community Midwife that Baby K was gaining weight and was described as a normal and well baby. This was confirmed on a follow up contact whereupon Baby K was discharged by the Community Midwife and transferred to the Health Visiting Team. 8.4. Baby K was seen on 4 occasions by Health Visitor between April and July 2016 and was also seen at home by the health visitor and a student nurse for the Primary Visit. Routine topics that were discussed included shaken babies, coping strategies for an unsettled baby, prevention of Sudden Infant Death (SIDS), home safety, safe sleeping and the availability of local services. It is documented in the health visitor records that Baby K was continuing to gain weight and parents were observed to be handling Baby K confidently with warm and loving interactions. Mother informed the health visitor that Baby K had a repeat hearing test appointment in May 2016. 8.5. Again, in May 2016 Baby K was observed to be gaining weight, alert and responsive. The health visitor risk assessed Baby K as having no additional needs above universal provision of the healthy Child Programme and arranged a 6-week appointment. Mother reported that Baby K had passed the hearing test carried out the previous day. 8.6. Later in May 2016 the health visitor undertook the routine 6-week appointment. Mother stated Baby K was slow to smile. A routine domestic abuse enquiry was made with no disclosures, SIDS guidelines and safe handling were also discussed as were the signs and symptoms of low moods or anxiety, but mother stated she had recovered from the birth and denied any low mood. It was observed that home safety equipment was in place and that there was interaction and contact between mother and baby throughout the visit. There was also a note that the family were planning to move home. 8.7. In July the health visitor visited the family in their new home. Mother stated she was feeling well both physically and emotionally and happy to be living in a new home. A further routine enquiry was made about domestic abuse, but mother dismissed any such any abuse. Safe alcohol use, SIDS guidelines as well as strategies to cope with a crying baby were again routinely discussed. Baby K was observed to be vocalising and smiling with good head control. Mother stated she had no problem settling baby K; good routines were in place for bedtime and although he did not get upset often, when he did, he easily settled when held. CONFIDENTIAL 6 8.8. The other health related contacts were for a routine hearing test and a GP six-week check-up. No concerns were identified. 8.9. Interviews with the health visitor enabled further consideration of frontline practice and observations of Baby K. 8.10. Mother was undertaking a childminding course and had been subject to home safety checks by Ofsted. She was always polite and appeared prepared for visits but would openly say that she would ‘do things her own way’, she had high expectations of her older children and was vigilant of home safety. She had seemed offended at the question of domestic abuse and discussion was extended to cover wider aspects of abuse beyond physical. The health visitor felt that visits seemed “superficial” in nature on the part of mother, she retained a strong desire to design the care for her children and the practitioner considered the possibility that she may not disclose any issues if they had been present. 8.11. Father was seen only once at the primary visit at which time it was noted that he had a healthy interaction with one of the older children. The practitioner recalled there was no direct verbal interaction between mother and father as he was looking after the older sibling, but he did respond to the health visitor when she asked questions. The health visitor had no concerns with father’s engagement during this visit and has since reflected and commented that the behaviour of the child father was looking after did not change after he left. 8.12. There were no signs of concern for any of the children, indeed many positive features were noted in their welfare and development. 9. OTHER RELEVANT HISTORY 9.1. B1 was born in 2014 and records show Health Visitor conversations regarding coping with crying baby and prevention of shaken baby and prevention of SIDs were discussed with mother on two separate occasions. This was associated with relevant observations of the interaction between mother and B1 9.2. In November 2016 during a routine 9-12-month development review with the Nursery Nurse, mother disclosed that she had suffered domestic abuse with her previous partner, and that she had left of her own accord. There is no record of any report to the Police or other agencies of this. 9.3. The Community Midwife discussed the issue of domestic abuse with mother while alone in September 2016. 9.4. In December 2016 HB was seen by a GP in response to suspected asthma, the records of the GP comments that the ‘family appears complex’ but it has not been possible to clarify this any further. 9.5. Interviews with staff and records demonstrate regular communication between the Nursery Nurse and Health Visitor about the care and welfare of B1. CONFIDENTIAL 7 9.6. HB suffers from allergies (Atopy) and B1 has an intolerance to milk. Medical records demonstrate a commitment by M to respond positively to these demands and access medical care. 9.7. It is understood that father was in full-time employment. 10. RESEARCH CONSIDERED 10.1. In a triennial review of SCRs, evidence suggests that 41% related to babies under one year old, which reflects the intrinsic vulnerability of babies who depend on their parents for care and survival (Sidebotham et al 2016). 10.2. Newcastle Child J Serious Case Review was considered but in the absence of any issues of concern in this case the findings from Child J were broadly discounted. 11. APPRAISAL OF PRACTICE 11.1. The history of this case demonstrates regular interaction with mother and, in line with procedure, routine discussion of strategies to cope with a crying baby, prevention of a shaken baby and the prevention of SIDs. There are records of clear and relevant observations of the interactions between mother and baby including mother’s own input into her successful techniques. Despite the confidence of mother, practitioners have reflected on the superficial interaction by her with professionals and her robust stance to design the care of her children ‘her way’ as everything was always ‘fine’, prompting practitioners to consider if mother would have disclosed issues if things were not ‘fine’. 11.2. There is evidence of limited interaction with father. In the context of the tragically short life of Baby K it is difficult to consider the impact of this on the assessment of risk. There is nothing to suggest that father was deliberately absenting himself from business and that such absence was only due to his employment which is not unusual with working parents. Indeed, practitioners demonstrated that they have taken the opportunity to observe the behaviour of B1 and note that behaviour was consistent whether father was present or not. This also presented an opportunity to speak to mother separately from father and there is a clear demonstration that this did not restrict the assessment of care provided by mother alone. Whilst the involvement of father over a longer period would have benefitted the ongoing assessment, the opportunities taken by practitioners is a further demonstration of professional sound practice. 11.3. The assessments of the care for Baby K appear well founded on the evidence at hand and the completion of risk assessments clearly demonstrate a structured decision making in considered judgements. These assessments are strengthened by the regular communication with the nursery nurse for B1. There is no evidence of formal supervisory oversight, but this does not detract from the assessments CONFIDENTIAL 8 within this review. This assessment and the interviews with practitioners demonstrate that the assessment does not discount areas of uncertainty or dismiss areas of risk, moreover there is a clear cognisance of these considerations as discussed within this section. 12. EMERGING THEMES AND LEARNING FROM THIS REVIEW 12.1. The intrinsic vulnerability of babies. 12.2. Areas of consistent established practice e.g. recognising and acknowledging that the absence of any indicators of abuse does not eliminate risk. 12.3. Agencies considering alternative contacts to accommodate working fathers to able to attend home visits or appointments. 12.4. Risk Assessments to have a reflective review by supervisors. 12.5. The benefits of having an open, non-incident based approach to all forms of abuse within the family, supported by structured enquiry, professional practice and awareness that a victim may not disclose or even identify the existence of abuse 13. CONCLUSION 13.1 There is no evidence to suggest that any agency had the opportunity to foresee or prevent the tragic death of Baby K. 14. RECOMMENDATIONS 14.1. There are no recommendations from either the Overview or the individual chronologies prepared as part of the review papers. CONFIDENTIAL 9 15. References Cuthbert, C; Rayns, G; Stanley, K. (2011), All Babies Count. NSPCC HM Government 2013: Working Together to Safeguard Children. DfE HM Government 2015: Working Together to Safeguard Children. DfE Newcastle Safeguarding Children Board (2016): Serious Case Review Child J Sidebotham et al. (2016), Triennial Analysis of Serious Case Review 2011-2014. DfE |
NC52426 | Death of an infant in 2020. Learning includes: the need for a whole systems approach to safeguard unborn babies; where a child is subject to a child in need (CIN) plan due to neglect, and isolated incidents occur such as an injury, these should be managed with the same rigor as that for children not previously known to children's services; history not always being drawn on to provide context for new assessments; all case discussion should include discussion about the legality of a child's living arrangements; information sharing practice in CIN cases may not be robust; professionals were insufficiently curious, and they did not ask pertinent questions to better inform their plans. Recommendations include: ensure frontline workers receive clear and consistent messaging on how to refer and work with pregnant women where there are concerns for unborn babies; professionals are encouraged to challenge and take an active role in progressing cases, escalating cases where insufficient progress has been made; agencies conduct holistic assessments inclusive of all individuals linked to the subject child; information is shared with all staff groups regarding how to recognise when a child is a looked after child versus a child living within a family arrangement; information sharing in cases where children are subject to a CIN plan is timely, recorded and shared.
| Title: Extended child safeguarding practice review [VS] LSCB: Sandwell Children’s Safeguarding Partnership Author: Nicki Walker-Hall Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Appendix i – combined chronology of key events Extended Child Safeguarding Practice Review March Nicki Walker-Hall Final Report July 2021 2 | P a g e Table of Contents 1. Introduction 3 2. Summary of learning themes 3 3. Context of the Review 3 4. Succinct summary of case 4 5. Methodology 5 6. Key Lines of Enquiry 6 7. Engagement with family 6 8. Review team 6 9. Timescales 6 10. Analysis of the Key Lines of Enquiry 7 11. Themed analysis 15 Appendix I – Key to acronyms/ abbreviations 19 Final Report July 2021 3 | P a g e 1. Introduction 1.1 This Review has been commissioned by the Chair of Sandwell Children’s Safeguarding Partnership (SCSP), following a decision by the Rapid Review Group that, in Accordance with Working Together 20181, this case met the criteria for a Child Safeguarding Practice Review (CSPR) as abuse or neglect was suspected. 1.2 Upon reflection of the identified themes of the case, the panel concluded there were similar themes to a number of recent local SCR/CSPRs and considered that a deep dive of the actions taken following these reviews, including close scrutiny of their implementation, would provide valuable insight into how successful Sandwell had been in embedding previous learning. 1.3 An extended CSPR was proposed to, and agreed by, the National Panel. This extended CSPR will take into account the guidance in Working Together and the principles of the systems methodology recommended by the Munro review.2 It will draw on the principles of Child Safeguarding Practice Reviews in accordance with Protecting Children in Wales: Guidance for Arrangements for Multi-agency Child Practice Reviews (Welsh Government 2012). 1.4 Of note, the death of VS occurred during the first lockdown of the pandemic creating unique and adverse circumstances for all professionals on both a local and National basis. 2. Summary of Learning Themes 2.1 The following are the main learning themes. Sandwell needs to promote: • multi-agency partnership working • end silo working • increase the use of history • improve its information exchange between services at key points • develop its golden thread between strategic vision and frontline practice • provide enhanced, coordinated services • develop its Quality Assurance processes • increase professional curiosity • foster challenge within and between services • develop a process for managing change as a result of SCR/CSPR recommendations 3. Context of Child Safeguarding Practice Reviews 3.1 The responsibility for how the system learns the lessons from serious child safeguarding incidents lies at a national level with the Child Safeguarding Practice Review Panel and at local level with the safeguarding partners. The purpose of the review is to identify improvements to be made to safeguard and promote the welfare of children. Locally, safeguarding partners must identify and review serious child safeguarding cases which, in their view, raise issues of importance in relation to their area. Serious child safeguarding cases are those in which: 1 HM Government (2018) Working Together to Safeguard Children https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf 2 The Munro Review of Child Protection: Final Report: A Child Centred System (May 2011). Final Report July 2021 4 | P a g e • abuse or neglect of a child is known or suspected and • the child has died or been seriously harmed 3.2 This review will: • recognise the complex circumstances in which professionals work together to safeguard children; • seek to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • seek to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • be transparent about the way data is collected and analysed; • make use of relevant research and case evidence to inform the findings. • provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence; • be written in plain English and in a way that can be easily understood by professionals and the public alike; and • be suitable for publication without needing to be amended or redacted, ensuring that the subject child and/or family cannot be identified. 4. Succinct summary of case 4.1. Mother registered her pregnancy with VS with health professionals in autumn 2019. VS has a sibling born to mother and a previous partner in 2013. Sibling was already known to SCT. Sibling had been made subject to a CP plan in 2018 following an incident and had been placed with maternal grandparents where she reportedly thrived, and her lived experience seemingly improved. Sibling’s case was deescalated in 2019 when sibling was made subject to a CIN plan which remained in place at the time of VS’s death; sibling had an allocated Social Worker (SW). 4.2 Midwifery informed MASH of the pregnancy via email when mother was 11 weeks pregnant. The information that mother was pregnant was forwarded to sibling’s SW but was not followed up as a new referral as it was in an e-mail and not a MARF. Mother was referred to Perinatal Services when she was approximately 17 weeks pregnant. The service was aware sibling was residing with maternal grandparents due to a ‘neglect incident’. Mother’s engagement with services was often sporadic, with multiple appointments for herself and sibling not being attended. In early 2020, sibling’s SW contacted midwifery enquiring about the progress of the pregnancy. When mother was 28 weeks pregnant, two referrals were made to MASH one by the Health Visitor who, having reviewed the case file, was concerned due to the family’s extensive history and subsequent high risk to the new born, and the other by sibling’s SW’s Team Manager. Following receipt of the referrals, a separate SW was tasked with completing a pre-birth assessment. This is not the usual practice within SCT but was due to the SW for the sibling being off work sick, and the need for the assessment to be completed. The assessment was completed 4 weeks later and a strategy meeting held with the police when mother was 34 weeks pregnant. A birth plan was formulated and an ICPC booked for 4 weeks hence, however mother gave birth to VS 37 weeks into the pregnancy, prior to the conference. 4.3 In the later stages of mother’s pregnancy and post VS’s birth, Covid-19 altered agencies ways of working. The psychiatrist from Perinatal Services completed mother’s assessment post VS’s birth via video link. Discharge of VS and mother post birth happened quicker than it may have done under normal circumstances. Staff Final Report July 2021 5 | P a g e were discharging all babies at the earliest opportunity due to the risks associated with transmission of coronavirus and were keen to discharge VS who was well. Whilst there was a plan in place, the plan lacked clarity for hospital staff regarding discharge. The hospital contacted the Emergency Duty Team (EDT) to confirm VS could be discharged with mother to maternal grandparents’ address. The EDT assumed that maternal grandparents had been assessed as connected carers so there was no reason not to discharge. 4.4 Both mother and father were known to the police. Of note, mother had been subject to domestic violence in a previous relationship and had a caution for child cruelty (wilful neglect) relating to her locking sibling in a room whilst intoxicated. Father was known for drug offences, violence and domestic incidents. There was no known violence between mother and father. It is known that mother and VS visited father each day following VS’s discharge. 4.5 On the morning of VS’s death an ambulance was called to maternal grandparents’ home in response to a child in cardiac arrest. Following a short attempt to resuscitate the subject child, VS was pronounced dead at the scene by ambulance staff. VS presented with vomit in the airways and had a 2mm bruise to the right cheek, 7mm red mark to the chin and yellow fluid around the eyes and nose. Sandwell SUDIC protocol was followed, the Police attended the address and mother was taken into police custody. Concerns were immediately raised by Police and SCT about the home environment in which the subject child and sibling were living – an excessive amount of alcohol was observed at the scene as well as cannabis balls, and the kitchen area was very unkempt. This led to sibling being removed and placed with foster carers as the subject of an Interim Care Order. 4.6 The police have since concluded their enquiries and are taking no further action, and the coroner has completed an inquest. 5. Methodology 5.1 Following agreement to undertake an Extended Child Safeguarding Practice Review, a chair and reviewer, Nicki Walker-Hall, was commissioned. 5.2 An initial set up meeting was held where the proposed key lines of enquiry (KLOEs) and the methodology were discussed agreed. 5.3 Three separate events were proposed in order to examine whether the golden thread from strategic vision to frontline practice was evident. Key practitioners were identified. The Practitioners event was a 2.5-hour event involving 12 practitioners from across the local authority, health, and police, and was facilitated by the lead reviewer. The managers event was a 2-hour event involving 6 managers. A series of questions were provided to strategic managers. The events focussed on the subject’s journey through the system and explored the KLOEs to establish how learning from reviews is being used to drive forward improvements to processes, services and practice. 5.4 The reviewer completed a draft report for analysis by the panel. Partner organisations via the Panel were then given an opportunity to agree actions to address blockages and barriers identified before the final report was agreed. 5.5 The panel considered the most appropriate method to share the learning across the workforce in Sandwell. 5.6 It is intended learning from the full report will be made available to the public but only after consideration by the SCSP. Final Report July 2021 6 | P a g e 6. Key Lines of Enquiry (KLOE) 6.1 The following KLOEs were agreed: 1. pre-birth procedures/referrals/arrangements/unborn baby network 2. application of thresholds in relation to neglect/injuries 3. progression and escalation of concerns (ICPC) 4. making use of history in relation to domestic violence, and drug and alcohol use 5. involvement of fathers 6. management of unregulated placements 7. assessments 8. information sharing 9. disguised compliance 10. professional curiosity 6.2 A small task group identified the following four additional KLOEs needed to be considered: 11. why the changes suggested through the SCR/CSPRs are not seeming to have had a sufficient impact 12. how Sandwell manages change 13. the process for disseminating learning 14. communication 7. Engagement with family 7.1 The reviewer met with mother and maternal grandmother to gain an understanding of their experiences of the services provided. The reviewer is grateful to them both for sharing their reflections and experiences. The reviewer has offered to meet them both again, to provide an opportunity for the content of the report to be shared. 8. Review team 8.1 The Review Team consisted of members of Sandwell Children’s Safeguarding Partnership Review Subgroup, which included senior safeguarding representatives from the following agencies: • Police • Clinical Commissioning Group (CCG) • Sandwell & West Birmingham NHS Trust (SWBNHS) • Public Health • Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) • Sandwell Children’s Trust (SCT) • Sandwell Metropolitan Borough Council (SMBC) • Sandwell Children’s Safeguarding Partnership (SCSP) 8.2 The Review and team were led by Nicki Walker-Hall. Nicki is an experienced independent reviewer from a health background. Nicki has an MA in Child Welfare and Protection and an MSc in Forensic Psychology. 9. Timescales 9.1 There is an expectation that all Reviews should be completed within 6 months of initiating it, unless there are good reasons for a longer period being required. In this instance, this timescale was not met. Initiation of the review was impacted by Covid-19. Final Report July 2021 7 | P a g e However, once initiated, the review was completed in line with the agreed methodology within 6 months. 10. Analysis pertaining to the Key Lines of Enquiry Pre-birth procedures/referrals/arrangements/unborn baby network 10.1 Within Sandwell there are multiple procedures/processes relating to unborn babies. The purpose of all these procedures is to give guidance to those working with pregnant women and create safety for the unborn baby. What is unclear is how all these processes and procedures dovetail to ensure consistent and clear guidance is provided to frontline workers in order to safeguard the unborn. Within the West Midlands, there are nine local areas that collaborate with regards to child safeguarding procedures. Within those procedures there are specific pre-birth procedures which indicate referrals should be made at the earliest opportunity and are clear around the process and timescale. There is clarity on when a pre-birth conference should take place with an expectation this will be as soon as the pre-birth assessment has been completed and at least 10 weeks prior to the due date of delivery. 10.2 In addition, SCT practitioners have Pre-birth guidance which set out the following principles: • Where there is a risk of harm to an unborn child, that a proportionate response will be offered by the Trust to assess risk, offer support to vulnerable parents and ensure that a robust plan is in place, where necessary before baby arrives. • That parent(s) are helped to understand what they are required to do to keep baby safe. • That practitioners and partner agencies work effectively together to share information, minimise risk and ensure good contribution to pre-birth assessments. 10.3 The guidance is clear. Within the guidance there is reference to the SCSP unborn baby protocol on the now redundant LSCB website. Embedding of this protocol was a recommendation of a SCR published in January 2020. This protocol has been superseded by the unborn baby network. 10.4 Sandwell Safeguarding Children Partnership set about developing the Sandwell Unborn Baby Network (SUBN) following a recommendation from a SCR in 2019. The remit of the multi-agency SUBN is as a forum for sharing information about high risk, high vulnerability women and their unborn babies. Fathers are also discussed and information is shared to form part of the pre-birth assessment intervention and plans. 10.5 At the practitioner’s event it became clear that some agencies were unaware of/unclear of SUBN and how to access or refer families. Managers indicated that this case would not have met the criteria as sibling was on a CIN plan and would have met the threshold for statutory intervention, the thinking being that SUBN is for children who don’t meet the level for statutory intervention or if they have been referred in at that threshold but declined support. However, the procedures do not indicate this. 10.6 The development of the SUBN has been slow and it is still not up and running effectively two years after being a recommendation. SUBN development was tasked to SCT and maternity services on behalf of the SCSP and has gone through phases of Final Report July 2021 8 | P a g e development and pause. The delay in its development means Sandwell children are yet to reap the benefits its development was intended to bring. The governance of the SUBN is currently being reviewed by SCT and the SCSP Business Unit as it has been recognised that it needs strengthening. Whilst a referral form has been developed, this has yet to be ratified prior to circulation/promotion. (See section 11.1) Learning point: The interface between all the policies, procedures and processes is unclear and has not been well articulated. A whole systems approach to safeguarding unborn babies needs to be adopted. Recommendation: SCSP and its partners to agree Sandwell’s strategic approach to safeguarding unborn babies and conduct a mapping exercise of all policies and procedures to ensure frontline workers are receiving a clear and consistent message on how to refer and work with pregnant women where there are concerns for the unborn. Application of thresholds in relation to neglect/injuries 10.7 There is clear evidence that initial concerns regarding neglect of sibling did result in action being taken. Once sibling’s case was de-escalated from CP to CIN there was a less robust response to new concerns. 10.8 When sibling received a burn to her arm there is no evidence that there was consideration to convene a Strategy Meeting to consider the injury and whether this should have led to a joint investigation between the police, SCT and health as would be expected practice. The reviewer has considered sibling’s account of the incident and the description of the burn and is not sufficiently assured that the two correlate. This incident provided an opportunity to investigate whether the injury matched the explanation and whether the current arrangements were sufficiently robust. Sibling’s safety was given some consideration and grandmother agreed with the SW to keep sibling in her care. This did not happen, mother took sibling from grandmother’s to her boyfriend’s, as was her right, and there was no immediate consideration as to what action may now be necessary to ensure a) sibling was safe and b) grandmother was in a position to keep her safe. Sibling’s living arrangements should have been revisited with mother who, at that time, might have had mental capacity3 to agree to sibling being accommodated under section 204. Any refusal of section 20 should have led to exploration of whether the threshold had been met to consider more formal arrangements in order to secure sibling’s safety. 10.9 This informal arrangement was explored within a CIN meeting regarding sibling and features in sibling’s CIN plan three months after the incident. At that time there was a plan to complete a viability assessment for maternal grandparents and a risk assessment for father. Neither of these assessments had been completed prior to VS’s birth some six months later. The birth plan acknowledges recent concerns regarding neglect but does not distinguish whether the neglect of sibling was as a result of the care afforded by grandparents or parents. 3 Mental Capacity Act (2005) – The Mental Capacity Act (MCA) is designed to protect and empower people who may lack the mental capacity to make their own decisions 4 Section 20 Children Act (1989) – Sets out the provision of accommodation in various circumstances. Final Report July 2021 9 | P a g e 10.10 An Ofsted inspection5 in 2017, prior to the SCT formation in April 2018, found that in too many cases, risk, while identified, was not subject to timely or appropriate interventions. There was drift and delay in progressing work and, in a large number of cases seen, this had led to children being left for too long in situations of risk without effective action to reduce that risk and to sustain better outcomes. The same issues are apparent in this case. 10.11 Through managerial oversight it was identified that VS’s case had not been progressed and an appropriate referral was made however, managerial oversight has not addressed the lack of progression of assessments and the quality of those assessments that had been completed. The reviewer has had sight of all CIN plans for the review period. The plans are often repetitive, with completion by dates for actions extended with no clarity on why the proposed date has been missed, and do not contain a clear focus on the risks/potential risks to the child. Although there is a place for managers’ comments this is not being made use of. It would be helpful for partner agencies to be sighted on managers’ thinking in order to effectively challenge drift. Learning point: Where a child is subject to a CIN plan due to neglect, and other isolated incidents occur, such as an injury, these should be managed with the same timely response and rigor as that for children not previously known to SCT, or children subject of a CP plan. Recommendation: SCSP to seek assurance from SCT that all referrals of concern relating to children open to SCT are investigated with the same rigor as those for children subject of a CPP or referred for the first time. Learning point: Managers are not making use of existing tools to demonstrate oversight and the progression of cases in CIN. Recommendation: SCSP to seek assurance from SCT that plans for CIN cases are being progressed, where progress has not been made managers are sighted on this and partner agencies are better placed to challenge. Progression and escalation of concerns (ICPC) 10.12 SCSP procedures indicate an ICPC should be held as soon as the pre-birth assessment has been completed and at least 10 weeks before the due date of delivery. In this case the pregnancy was known about in the first trimester and there should have been ample time to complete a pre-birth assessment and hold the conference. 10.13 Confusion at the point SCT were informed of the pregnancy led to a delay in the pre-birth assessment taking place. Whilst the pregnancy was known and the SW involved with sibling was made aware of the pregnancy, it has been recognised that midwifery should have sent a MARF to SCT when they first became aware of the pregnancy. However, the issue here was a decision made in the MASH team to pass the information on to the SW for sibling, without requesting the informant submit a MARF, or responding to and progressing by making enquiries. Since this case, there is now a named midwife for safeguarding in post, who is addressing loopholes within midwifery. Now staff would be told to submit concerns for an unborn as a new referral on the appropriate form. 5 Ofsted. (2018) Sandwell Metropolitan Borough Council Re-inspection of services for children in need of help and protection, children looked after and care leavers https://files.ofsted.gov.uk/v1/file/2755854 Final Report July 2021 10 | P a g e 10.14 At the practitioners’ event, those present reflected that any agency who knew mother during pregnancy could have submitted a MARF regarding VS, and all had enough information to suggest that further questions could have been asked to ascertain the situation. Attendees stated they felt uncertain about whether there was enough information for a MARF and there was also an assumption that as mother was pregnant and sibling was open to SCT, that actions were already being taken for VS. 10.15 A strategy discussion was held; no health discipline was invited. A decision was made to take the case to ICPC. This triggered an automatic notification to the QAS who arrange the conferences. The ICPC was booked for the 15th working day following strategy discussion, within timescale. However, by that date mother would have been 38 weeks pregnant. The lack of a health representative at the strategy meeting meant an opportunity to request an earlier date for the ICPC was missed. When the date was set, staff were not aware that they could have challenged this decision, based on the fact that all pregnancies are considered full-term from 37 weeks’ gestation, and there was significant likelihood that VS would be born prior to this date. VS was born at 37+ weeks prior to the proposed conference date. Since this time an appropriate health representative is now invited to strategy discussions. 10.16 Whilst there were no meetings, there is evidence of communication between the social workers for VS and sibling. Sibling was said to be making good progress with grandparents so there was an assumption that this was a safe place for her and VS; this, and a lack of progression of a formal assessment of grandparents, impacted on decision making. The health visitor also spoke to the social worker in early May and was told that grandparents were a protective factor. Practitioners indicated that there was a clear birth and discharge plan on the system which was discussed between maternity and the social worker. Grandmother indicated that she had not been contacted prior to VS’s birth and was unaware of the full content of the plan. Mother and grandmother indicated that they knew father was allowed to attend the birth and had assumed, because of that, he was ok to have contact with VS after discharge. The reviewer has had sight of the plan and it lacks detail of mother’s caution for wilful neglect, the reasons why discharge is to maternal grandparents, and clarity on the risks posed by father. There was no written agreement. Learning point: The slow progression of action in both children’s cases impacted adversely. The passing on of information rather than undertaking an enquiry when midwifery shared that mother was pregnant was pivotal. Too many assumptions were made that enquiries were under way and that grandparents were a protective factor. There were many opportunities for professionals to challenge the lack of progress, and get this case back on track, but this did not happen. Lack of progression of grandparents’ viability assessment could also have been challenged within CIN meetings. Those professionals not involved with sibling, but involved with mother and her unborn, should have been anticipating a meeting would be held and questioning when this did not happen. Lack of progress of actions within the CIN plan suggests there was a lack of effective managerial oversight and challenge. Recommendation: SCSP to seek assurance from its partners that all professionals are being encouraged to challenge and take an active role in progressing cases, challenging slow progress and escalating cases where insufficient progress has been made. Final Report July 2021 11 | P a g e Making use of history in relation to domestic violence, drug and alcohol use and involvement of fathers 10.17 There is evidence that professionals made use of mother’s history of mental illness within their practice. Mother was referred to perinatal services in light of her history during her previous pregnancy. In respect to domestic abuse, Midwifery were following guidance regarding routine enquiries concerning domestic abuse; mother answered no to all routine enquiries. Whilst there was no evidence of domestic abuse between the couple it would have been helpful for all professionals to have knowledge of both parents’ histories. There was little consideration of history in relation to mother’s drug and alcohol use. Whilst mother appeared to share a lot of information with perinatal services this did not include key elements, including her alcohol misuse, as a factor when sibling was removed. 10.18 There is very little information regarding father. This is a national issue that has been noted in many SCR/CSPRs. 10.19 Historically local maternity services focussed almost exclusively on mothers. Whilst in recent years that focus has moved to focus more on fathers, perinatal services are currently working on moving away from a ‘mother-centric’ approach and are including ‘Think Family’ in all supervisions. 10.20 The pre-birth assessment provided an opportunity to assess father. The assessment took place late in the pregnancy and is not considered by SCT to be an in-depth assessment, although it was deemed complete. Mother indicated to the reviewer that father was present when she met with VS’s SW on the first occasion. 10.21 As part of sibling’s CIN plan, a risk assessment of father was required, this remained incomplete at the time of VS’s death. The lack of risk assessment meant clarity on the safety of contact between father and VS had not been established and, although it is recorded mother agreed to no contact between VS and father post birth, mother disputes this. In fact, there was little to prevent contact with no written agreement in place. The lack of risk assessment, coupled with evidence of non-compliance previously, should have led to a more robust plan. 10.22 SCT have introduced three generational cultural genograms which will provide practitioners with a useful tool by which they will be able to consider wider family issues. Hidden men training has also been developed and will be available to practitioners. Learning point: History is not always being drawn on to provide context and background information to new assessments and inform resultant plans. Lack of assessment of father left an omission to the plans with regards to contact between father and VS. Recommendation: SCSP to seek assurance that its partners are conducting holistic assessments inclusive of all individuals linked to the subject child. Management of unregulated placements 10.23 When sibling was made subject to a Child Protection Plan and placed with maternal grandparents, thought was given to accommodating sibling under Section 20 of the Children Act 1989. The LA has a duty to accommodate under Section 20 if the person who has been caring for the young person is unable to continue to provide suitable Final Report July 2021 12 | P a g e care and accommodation. It is good practice for the LA to obtain written consent before placing a child under S.20. At that time mother was experiencing acute metal illness and was not deemed to have capacity to consent to S.20. Sibling remained in the care of maternal grandmother from 2019. This was determined as a 'private family arrangement'. 10.24 Whilst a private family arrangement can be made directly between the parent(s) and the relative, friend or connected person, if the child is placed by Children’s Services, as in this case, the relevant framework should be applied. 10.25 Where a child is placed with a family friend, family member or other connected person, Regulation 24 of the Care Planning, Placement and Review (England) Regulations 2010 sets out the regulatory framework for the first 24 weeks. 10.26 It is possible to assess the carer as a temporary foster carer so that a child can be placed immediately but the full assessment must be conducted within 16 weeks of the child being placed; this can be extended for a further 8 weeks in specific circumstances. If a child is placed with a connected person who is not approved under Regulation 24, the placement is unregulated and may be unlawful. 10.27 Maternal grandmother was never assessed under Regulation 24 sibling was therefore living in an unregulated placement. Unregulated provision is allowed in law but usually when children (usually over the age of 16) need support to live independently rather than needing full-time care. 10.28 SCT own guidance6 indicates “The social worker will need to complete a regulation 7 report, which will contain details of the child, circumstances that led to request to place young person in an unregulated placement, which will include the extent that placement searches have taken place, risks involved and safety plan, which included level of monitoring of the placement”. 10.29 In February 2020 the government proposed making it illegal to place under-16s in unregulated accommodation; a provision in law that is likely to be implemented later in 2021. 10.30 Latterly the allocated SW in this case requested the placement be regulated, however the SW was told it was a private family arrangement. The reviewer was told this was not unusual however there should be evidence that this has been assessed; this arrangement was not challenged. 10.31 The significance of whether sibling was in a regulated or unregulated placement is that this determines the way the placement is supported and frequency of visits. Grandmother reported that she saw sibling’s SW every now and then and no concerns where highlighted. Learning point: Sibling was thought to be living with grandparents as part of a private family arrangement but was in fact in an unlawful, unregulated placement. SCT have taken the necessary steps to ensure no child in Sandwell is currently in the same situation and have completed specific training around the differences and requirements around regulated, unregulated, private family arrangements and private fostering. All case discussion should include discussion about the legality of arrangements and a prompt is needed for all cases to check the relevant framework if the child is not living with its birth parents. 6 Sandwell Children’s Trust (2018) Guidance Note - Unregulated Placements Final Report July 2021 13 | P a g e Recommendation: SCSP and its partners to develop a 7-minute briefing to be shared with all staff groups regarding how to recognise when a child is a looked after child versus a child living within a family arrangement. Assessments 10.32 Sandwell SCP procedures state that a pre-birth assessment should be undertaken on all pre-birth referrals as early as possible, preferably before 20 weeks, where: • a parent or other adult in the household, or regular visitor, has been identified as posing a risk to children • a sibling in the household is subject of a child protection plan • a sibling has previously been removed from the household either temporarily or by court order 10.33 The need for a Section 47 enquiry should be considered and, if appropriate, initiated at a strategy meeting/discussion held as soon as possible following receipt of the referral. The expected date of delivery will determine the urgency of the meeting. 10.34 SCT have a pre-birth assessment tool to be used to assess all unborn babies, providing an effective framework for assessing risk. 10.35 As previously discussed, there was a four-month delay in a pre-birth assessment being conducted. This delay reduced the amount of time available to the SW. There is evidence of communication between the SW and health services to inform the assessment, however not all services were contacted directly. The SW sought information regarding engagement with services from the perinatal service. The perinatal service gave a largely positive picture, however if the drug and alcohol service had been contacted directly, they would have indicated that mother was not engaging. Grandmother informed the reviewer she had not been contacted and had therefore not been consulted regarding her ability to support mother or to care for VS. The lack of complete information to inform the assessment likely led to a more positive view of the case. 10.36 In addition to being delayed, not all elements of the assessment had been completed prior to it being signed off which is a concern. Learning point: No assessment should be considered complete until all elements of the assessment have been completed. Recommendation: SCSP to gain assurance from SCT that quality holistic assessments, that address all the needs of the individual child, are being completed prior to sign-off. Information sharing 10.37 Evidence of information sharing between services is limited. There is evidence of a number of conversations between professionals on an adhoc/email basis. The lack of formal referrals, regular CIN meetings, allocation of VS to a separate SW in an alternate team and limited information gathering practices between partners have reduced the level of information sharing usually seen in such cases. Information that was shared was largely verbal in nature with no formal reports between services. The exception to this is the perinatal service letters to the GP. 10.38 Subjects in CIN were not receiving the same level of protection as those in CP. Lack of information sharing led to reduced opportunities for professional challenge. School staff requested new dates for CIN meetings following cancellation but these Final Report July 2021 14 | P a g e were not immediately forthcoming. Whilst there were the required number of CIN meetings to meet statuary requirements, there were fewer meetings during mother’s pregnancy with VS than the previous 12 months. Learning point: The reviewer is unsure whether information sharing practice in this case is representative of practice across Sandwell in general. If this is representative information sharing practice in CIN cases may not be robust. Recommendation: SCSP and its partners to seek assurance that information sharing in cases where children are subject to CIN is timely, recorded and shared as per agency information recording and sharing policies. Disguised compliance and Professional curiosity 10.39 Disguised compliance is a regular feature within SCR/CSPRs. To detect disguised compliance, professionals needed to be curious, questioning what they are told and putting it into context of the wider picture. It is almost impossible for a single agency or sole worker to gain clarity on whether they are being deceived or misguided by a parent or grandparent. It is only through a multi-agency approach that allows the professional to test out any concerns that disguised compliance can be fully recognised and responded to. In this case, professionals only held part of the picture. Most services knew sibling lived elsewhere and had a social worker but didn’t know that sibling was subject to a CIN plan. Services knew there was an assessment in respect of VS and that sibling was staying with grandparents, however there was a lack of curiosity about why this was. 10.40 Evidence suggestive of disguised compliance on the part of both mother and grandparents was not sufficiently explored and therefore went unchallenged. Self-report by sibling that she was spending nights with her mother, and on occasion mother’s partner, provided an opportunity for professionals to gain a greater understanding of the dynamics within the family. 10.41 Sibling’s reports were clear evidence that the agreement for sibling to reside with maternal grandparents was being broken on multiple occasions. This suggested either no agreement, non/disguised compliance on the part of grandparents, an inability of grandparents to enforce the agreement, or a lack of understanding regarding the agreement. Either way, greater clarity and more stringent measures to ensure sibling’s safety were not considered or taken. Given the evidence it would be wrong to conclude there was disguised compliance. Learning point: Professionals were insufficiently curious. They did not ask pertinent questions to better inform their thinking and plans in this case. Examples of Good Practice: 1. SCT representatives felt the level of support and encouragement after the death of VS was excellent. SCT held learning events and staff training and although these were challenging, one staff member felt it had helped her to be a better manager, to learn and be more reflective. 2. The mental health of mother was well cared for during the pregnancy. 3. The summary of involvement from perinatal services to the GP was excellent. Final Report July 2021 15 | P a g e 4. CCG have developed Level 3 training for all GPs on safeguarding which includes lessons from reviews. 11. Themed analysis Why the changes suggested through the SCR/CSPRs are not seeming to have had a sufficient impact. 11.1 The Quality Assurance (QA) process which scrutinises actions following recommendations from SCR/CSPRs has not been robust. Action plans are too task-focussed and are not sufficiently sighted on the intended aim to improve outcomes for children. 11.2 It has been reported that both the recommendations and single agency action plans are monitored on a quarterly basis by the Sandwell Learning and Practice Reviews (SLPR) subgroup, with some updates shared at the SCSP meetings on a case-by-case basis. Agencies provide evidence/updates in relation to the action plans, which are then discussed at the SLPR subgroup – any outstanding actions are addressed by the SLPR representative for the agency. 11.3 When a particular area of work comes under scrutiny via SLPR, this can be signposted to the Quality of Practice and Performance (QPP) for further work e.g. a specific audit. This appears to be the only mechanism for testing whether the action has had a positive outcome. 11.4 For example, the Pre-Birth Network group was developed in 2018 and agreed largely by 2 key agencies; SCT and Health (midwifery). The group went through a change/rebrand under the MASA arrangements in April 2019 to Sandwell Unborn Baby Network (SUBN): this included revision of the Terms of Reference (ToR), Pathway and Procedures in July 2019 which were shared and approved by the then Independent Scrutineer in Dec 19 and accepted by members of QPP in February 2020. The SUBN has continued to meet since that time, and these meetings are currently under review for the effectiveness. 11.5 The SUBN was initially led by Children’s Services and then picked up by Sandwell Children’s Trust when they were commissioned. There was a delay in its development and progress during this transition. 11.6 The ToR’s included governance arrangements indicating a quarterly report relating to prevalence, measurable outcomes, referrals in, outcomes and impact was to be submitted to the QPP board. The SUBN did not gain traction. This has been raised at various forums i.e. SSCB/SCSP meetings and the SCR/Sandwell Learning from Practice Reviews (SLPR) subgroup. A proposed review has currently stalled due to the Pandemic and change within senior management in SCT. 11.7 There has been lack of clarity regarding the referral criteria to the SUBN across the wider partnership including knowledge of its existence beyond the membership. SCT have always taken the lead and chaired this group, however cases discussed are below the threshold for statutory intervention. The development of a referral form to this group is very new and has only just been shared in health, it remains unclear if this has been extended across the partnership. The review of this group is ongoing as the partnership still does not have assurance that the group is fit for purpose. 11.8 At present, it would appear that there is little awareness of the SUBN outside of the 2 leading agencies that introduced the model, whilst there is evidence that this is Final Report July 2021 16 | P a g e mentioned in training, including when and how to make a referral. For the period Oct – Dec 20, no referrals were received for consideration at the SUBN by any agency other than health (midwifery). This questions whether other agencies are aware, accept any ownership, or see themselves as having any responsibilities for referring cases of concern to this group. There is also no evidence of a communication strategy, it may therefore be possible that this model was not communicated beyond the agencies that formed the group. 11.9 A box has now been added to all action plan forms to include ‘How do we know we have made an impact?’ which needs to be completed in addition to the Progress Update/RAG rating. 11.10 The SCSP has employed an independent scrutineer to consider key areas of work, including the development of the quality assurance cycle, monitoring of actions and responses to reoccurring themes seen in CSPRs. In some instances, further assurance could be given on how the action has led to an improvement in outcomes for children. 11.11 The reviewer has been unable to establish whether the action regarding the development of the SUBN was ever signed off as complete. What is clear is the lack of pace in which recommendations are completed, the lack of challenge from partners to this lack of pace. The reviewer has found insufficient evidence of multi-agency ownership of the issues, evidence of silo working on multi-agency issues, and a lack of partnership working to address the issues. Learning point: Sandwell partners are not jointly owning and addressing their issues. Whilst it is understandable that task and finish groups complete some of the operational elements of recommendations, the oversight and monitoring of successfully introducing or making changes to enhance and have a positive impact on its children, remains the role of the partnership. Recommendation: SCSP and its partners to consider how it currently oversees action plans from SCRs/CSPRs and external inspections and ensure the focus moves from the task to the outcome. How Sandwell manages change 11.12 Change, including systems and processes for multi-agency working, is undertaken via consultation across the partnership, children, young people and families, and led by one of the subgroups. This is usually by way of establishing short-life Task & Finish groups covering specific elements. The final process will be tabled for approval at a meeting of the SCSP before being circulated across the partnership and published. 11.13 Sandwell has not managed to make effective changes following recommendation from a number of SCR/CSPRs or inspections and needs to aim to reach a point where it knows itself well and is not reliant on SCR/CSPRs to identify shortfalls in its systems and processes. Sandwell has had a number of cases that have identified the same issues and, while it is evident some work has begun to address the identified areas for improvement, this work has lacked pace and effect. Ofsted7 in their most recent inspection made a number of recommendations that were repeats of 7 Ofsted. (2018) Sandwell Metropolitan Borough Council Re-inspection of services for children in need of help and protection, children looked after and care leavers https://files.ofsted.gov.uk/v1/file/2755854 Final Report July 2021 17 | P a g e recommendations made in previous inspections that had not been enacted upon sufficiently to address the issue. This is of concern. 11.14 On a positive note, it is reported that there has been a recognised change in values over recent years which has led to a cultural change on reflection, transparency and support. 11.15 Sandwell currently has no intention to introduce a ‘new’ change process, however SCSP is executing its responsibilities to review all elements of the safeguarding arrangements for effectiveness - this is its current approach in reviewing the SUBN. It is hoped this will provide assurance that the process works for local children and families and to identify where further improvements may be required. 11.16 The SCSP has recently created a conference style event called ‘Safeguarding Today’ to improve communication between the SCSP and the children’s workforce. This is seen as one of the platforms to be used to share, disseminate, and launch safeguarding messages. 11.17 Within SCT there is an SI Plan which tracks any recommendations made and cross references to each other – this is now being enhanced and extended to track previous recommendations and to be able to tie in repeats. Learning point: Sandwell has developed an inclusive change management style seeking the opinions of partners and service users before making changes. Whilst this is to be commended, the partnership is yet to be assured that the current process is assisting it to make necessary changes to immediately reduce risks and have a positive impact on children and young people’s lives. Recommendation: SCSP to progress at pace the review of the SUBN and in doing so test the effectiveness of their change process. The process for disseminating learning 11.18 Learning is disseminated using a range of methods: firstly, via the SCSP membership who are tasked with cascading the full report and 7-minute briefings to their agencies. It is also disseminated via the SLPR subgroup reps and publication/ promotion is discussed at the SLPR subgroup. The reviewer learned that one health discipline on receipt of the 7-minute briefings will edit these to only include the relevant bits for their discipline; these are then circulated on a monthly basis. Within SCT the learning is also disseminated via Trust Communications and through monthly QA Reports. Updates are given during the Core Working Together safeguarding training sessions. 11.19 The dissemination to frontline practitioners is dependent on organisation/agency – some services seem to have greater knowledge than others of learning from reviews, which suggests that the sharing of learning is not consistent across all agencies. This is due for discussion at SLPR in March 2021 with ideas such as recorded webinars with the author upon completion, a publication learning event for practitioners and question and answer sessions being some of the new methods of sharing learning to consider. New ‘Learning from Reviews’ drop-in sessions will commence from April 2021 which the whole workforce can access. Learning point: Whilst the new developments are likely to reach a wider audience, the process is not robust and it may be a significant period of time before the learning reaches some frontline practitioners and brings about a change in practice. Final Report July 2021 18 | P a g e Recommendation: A process needs to be introduced to ensure learning is disseminated consistently across and within all organisations to all practitioners. Communication 11.20 A number of services which serve Sandwell residents also serve residents from neighbouring authorities. Communication when working with multiple agencies in an area where organisations are not coterminous geographically adds an additional layer of complexity to an already complex issue. Communication between services across health disciplines is a national issue. It has long been recognised that the multiple disciplines and multiple recording systems within health add an extra layer of complexity to communicating, both within and between health disciplines and their partners. There is a lack of electronic connectivity between health services which can make it difficult to share information between different teams and organisations. There are some specific examples in this case where important information, which would have been useful to partner agencies, remained in health. Letters from the Perinatal Service were only copied to the GP not the social worker. 11.21 Sandwell Safeguarding Health Partnership has developed a Safeguarding communication pathway within Sandwell Health Economy which is designed to bring clarity. If the pathway is for health only use it is likely fit for purpose however, the author is not clear that it would provide partners with sufficient clarity. 11.22 Communication complexities require careful consideration and clear strategies to manage them. Sandwell has lacked a communications strategy. Currently there is a communications strategy in development; this will be ratified by the SCSP before roll-out across Sandwell and its neighbouring authorities. 11.23 Sandwell does have good cross border working relationships with neighbouring authorities, and 50% of the statutory partner members of the SCSP provide services spanning more than one LA boundary. Within this role is the responsibility for disseminating information to all represented agencies. Cross-border colleagues are also invited to and have access to attend local events, i.e. training, briefings, conferences, audits etc. Learning point: There has been a lack of strategic vision regarding communication in Sandwell which has left a gap. The current development of a Communications Strategy has the potential to address this. Following its development, all communication pathways need to be aligned to the strategy, and their clarity for all the partners considered. Recommendation: SCSP and its partners to assure the newly developed Communications Strategy and agencies communication pathways are aligned and driving communication across the partnership. Final Report July 2021 19 | P a g e Appendix i – key to acronyms/ abbreviations BSMHFT Birmingham and Solihull Mental Health Foundation Trust CCG Clinical Commissioning Group CIN Child in Need CP Child Protection CSPR Child Safeguarding Practice Review GP General Practitioner ICPC Initial Child Protection Conference KLOE Key Lines of Enquiry LA Local Authority LSCB Local Safeguarding Children’s Board MARF Multi-Agency Referral Form MASA Multi-Agency Safeguarding Arrangements QA Quality Assurance QPP Quality Practice and Performance RAG Red Amber Green SCR Serious Case Review SCSP Sandwell Children’s Safeguarding Partnership SCT Sandwell Children’s Trust SI Serious Incident SLPR Sandwell Learning and Practice Reviews SMBC Sandwell Metropolitan Borough Council SSCB Sandwell Safeguarding Children’s Board SUBN Sandwell Unborn Baby Network SUDIC Sudden Death in Childhood SW Social Worker SWBNHS Sandwell & West Birmingham NHS Trust ToR Terms of Reference |
NC52644 | Death of a 3-week-old baby in June 2020. At the time of their death Child Ba was co-sleeping with their mother who was intoxicated through alcohol and had taken cocaine. Learning themes include: the child's voice and lived experience; alcohol use and misuse; unsafe sleeping arrangements; the step down process and basis for decisions; the impact of over optimism by professionals; safeguarding within East Midlands Ambulance Service (EMAS); and the impact of Covid-19 restrictions. Recommendations for the local safeguarding children's partnership include: ensure that all professionals have a better understanding of the implications and risks associated with parental alcohol misuse including historical alcohol misuse and how this is harmful to children; ensure parents and carers are aware of safe sleeping advice through the 'Every sleep a safe sleep' campaign; consider implementation of the National Panel's suggested 'prevent and protect' practice model for reducing the risk of SUDI; seek assurance that step down procedures are operating effectively and rigorously; consider what needs to be put in place to support grandparents, and other family members, who are acting as a protective factor to parental risks to safeguarding children; and training partners in the 'Signs of Safety' model of practice which includes all family members that are to be regarded as a protective factor.
| Title: Child safeguarding practice review (CSPR): Child Ba. LSCB: Northamptonshire Safeguarding Children Partnership Author: Russell Wate Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Final Page | 1 Child Safeguarding Practice Review (CSPR) Child Ba Independent Author: Dr Russell Wate QPM Final Page | 2 Child Safeguarding Practice Review (CSPR) 1. Why is a Child Safeguarding Practice Review required? Key Circumstances Child Ba was only a few weeks old when they died at the beginning of June 2020. At the time of their death Child Ba was co-sleeping with their mother who was intoxicated through alcohol and had taken cocaine. It is suspected by professionals that Child Ba may have died as a result of having been overlaid by their mother. There were concerns pre-birth with regards to the mother of Child Ba, these included misuse of alcohol, low mood depression (for which she was receiving medication) but primarily it was physically violent domestic abuse concerns in relation to Child Ba's father, who was in prison prior to Child Ba's birth and afterwards, including at the time of Child Ba's death. Four months prior to their birth, Child Ba, was placed on a Child Protection Plan due to these concerns. This was under the category of neglect. Due to the mother's progress whilst living with Child Ba’s maternal grandmother, the case was stepped down to Child in Need (CIN) at a Child Protection Conference review. The Child in Need plan was closed at a meeting at the beginning of June 2020, which was four days before the death of Child Ba. Although Child Ba lived with their mother at the maternal grandmother's (MGM) address they did on occasions stay at their paternal grandparents’ address. On the 27th of May 2020, East Midlands Ambulance Service (EMAS) attended a call to treat the grandfather, whilst there they observed the mother had been drinking alcohol and Child Ba was also present. They also observed that Child Ba was in an unsafe sleeping environment i.e., the Moses basket had a pillow placed over it. When mother was asked about this she became verbally abusive to the paramedic who observed that mother's speech was slurred. Police were not called but a safeguarding concern was generated, however, this information was not shared with relevant partners until after the death of child Ba. Child Ba and their mother left the maternal grandmother’s house because the maternal grandmother did not agree with the mother's alcohol consumption. They went to stay at mother's friend's address temporarily until an unfurnished council flat became available. The mother's friend was known to be a chronic alcoholic. He had apparently not seen the mother for months, but she had turned up unexpectedly and asked to stay as she had nowhere else to go. The friend and mother consumed five litres of alcohol between them on the night of Child Ba's death. The mother was arrested for neglect and provided a blood sample which subsequently revealed that at the time of Child Ba's death the level of alcohol would have been 194mg per Final Page | 3 100ml of blood1. Having been released under investigation mother was admitted to hospital as a voluntary inpatient in relation to her mental health. The Northamptonshire Safeguarding Children Partnership (NSCP) Rapid Review Group recommended that, with reference to the requirements as set out in Chapter 4 of ‘Working Together to Safeguard Children’ (2018), the threshold was met to commission a Child Safeguarding Practice Review (CSPR) in respect of Child Ba. The strategic leads for the partnership agreed with this recommendation and the CSPR formally started on the 1st September 2020. The Rapid review group set a period for this CSPR as 1st November 2019 - June 2020. The reason for this period is because it covers the time when Child Ba was placed on a Child Protection Plan as an unborn up to the date of their death. Agencies were asked to include historic events with the family relevant to the learning aims for the review. All agencies involved with Child Ba and their family were asked to provide chronologies and where they had had extended agency contact, to produce key incident reports. An Independent author was appointed who is Dr Russell Wate, he is totally independent of all agencies within Northamptonshire. The Rapid Review document that was completed was particularly useful and the review author is grateful for the work undertaken by those involved. The review has also benefited greatly from a well-attended practitioner event, where everyone freely contributed their views to assist with the learning from this case. 2. Key themes, analysis and lessons identified The following key themes have been identified by the author and panel for this CSPR. These themes have been developed taking account of the analysis and learning from the rapid review process, agency reports, and information provided to the questions the author has asked and additionally themes raised from the practitioner event. The themes for this review are professionals understanding of: Analysis Themes • Child Ba's voice and lived experience • Alcohol use and misuse • Unsafe sleeping arrangements • Step Down process and basis for decisions- Impact of over optimism by professionals • Safeguarding within East Midlands Ambulance Service (EMAS) • Impact of Covid-19 restrictions 1 the drink drive limit in England and Wales is 80mg per 100ml of blood. Final Page | 4 2.1. Child Ba’s family background, their voice and lived experience Child Ba was the sole child living with their mother during the period of the review. Child Ba had four siblings with a different father (FS) with whom they resided from 2017, the mother was allowed supervised access. The father had custody of the children through a private arrangement with the mother. There is information shared with the review regarding father objecting to mother's alcohol consumption which also mentions domestic abuse, including that on some occasions mother may have been the perpetrator of that abuse. The information highlights two occasions when the mother was violent and abusive to the father (FS) and the police were called. One time was when the father (FS) came to collect the siblings after having received several calls from mother to extend their visit but when he arrived discovered both mother and maternal grandmother (MGM) to be drunk and Child Ba, who was only four days old, was also present. The father (FS) called the police, but they did not deploy until the following day. When the police spoke to the mother and MGM later that day, the police officer accepted their account of events that a malicious complaint had been made by FS. A PPN was submitted on this occasion, this was shared with MASH and the allocated Social Worker. The second occasion, on 26th March 2020, occurred when mother and MGM attended the father's (FS) house to try and see the siblings and the police were called again. This time the police attended and discovered mother in the vicinity with Child Ba. No PPN2 was completed by police for the second event although reported as a domestic incident, a DASH (Domestic Abuse, Stalking and Honour based violence) form was completed. The officer who dealt with the incident, subsequently in their reflective account said, they could have, and would now consider neglect of Child Ba in relation to mother being drunk in charge of a child in a public place. Children's Services had been aware of mother from 2012 including when she was heavily intoxicated and unable to care for her 1-year-old daughter, and in 2014 two of her children were made subject to Child Protection Plans under risk of physical/emotional abuse because of a serious domestic abuse incident. Between 2017 and 2018 Children's Services were notified of ongoing domestic abuse concerns. Targeted support was provided to mother due to concerns regarding alcohol abuse, domestic abuse, homelessness, and neglect. In December 2017, the four siblings moved to live with their father (SF). Child Ba never met their own father because he was in prison for the whole period of their life. However, Child Ba’s father's prolific physical domestic abuse of previous partners and Child Ba's mother is a key factor considered by professionals in relation to Child Ba's life and how their safeguarding was managed. The following historic events, although before the review start date of 1st of November 2019, were included by the police, which the review 2 Police Protection Notice a referral form highlighting concerns for a vulnerable child Final Page | 5 author considers is relevant in building a picture of both mother and father's behaviour which may have influenced subsequent decisions. The domestic abuse against mother culminated in a Domestic Violence Prevention Notice (DVPN) being served on father of Child Ba on the 16th of October 2019 when mother was 21 weeks pregnant. The police also identified that mother needed support in relation to her mental health and did not appear to be protecting herself or her unborn baby. This was another occasion when the police officer did not complete, as they should have, a PPN for the unborn child. A few days later on the 19th of October 2019, both mother and father (despite DVPN) were involved in heavy drinking and violence against a third party. Father was arrested but mother managed to evade being seen by police. On the 22nd of October 2019, Child Ba’s father tried to find mother who was hiding from him, and at the time he forced entry to the premises she was hiding under a bed. He was arrested for assault but then imprisoned for other offences and remained in custody for the rest of Child Ba's life. Probation have stated that father had a history of domestic abuse, some of which he was convicted for, and they feared he would not adhere to his licence conditions on release (including not visiting mother or Child Ba). The father never met Child Ba but has been informed of their death. Despite the father being in prison his domestic abuse history appears to have been the prime consideration in all subsequent decisions regarding Child Ba's safety. Other key factors relating to mother's behaviour appear to have been given much less significance. This is surprising considering the risk factors in mother's life included domestic abuse, mental health issues, alcohol and drug abuse issues, unstable housing (often homeless and moving between addresses, including MGM and PGM's homes), failing to engage with support services, including health, heavy smoking and avoiding contact with professionals. As already stated earlier in this report, Child Ba, lived with their mother and maternal grandmother, at the maternal grandmother's (MGM) home. Maternal Grandmother was considered a positive and controlling influence, providing additional support which was considered a key part of the safeguarding plan for Child Ba. There was one occasion, when Child Ba did stay (along with mother and MGM) at another address belonging to the paternal grandparents, an incident of note which occurred at that premises. EMAS responded and the analysis of this response is covered in detail later in the report. However, only 2 days after Child In Need (CIN) plan closed, the maternal grandmother challenged mother regarding her alcohol consumption (did not want mother to drink) and mother took Child Ba to live temporarily with a friend who was a chronic alcoholic. It was at this friend's address that Child Ba died whilst co-sleeping with their mother in a double bed. Mother was prescribed medication during her pregnancy but continued to drink, although minimalised this, smoked heavily, even though advised of the risk associated with both of these behaviours, missed appointments, e.g., for blood tests and did not engage with support services, e.g., S2S and Bridge (Drug and alcohol services) in relation to impact of domestic abuse on children and substance misuse, respectively. Final Page | 6 Family support appears to have been provided mainly by the maternal grandmother, and as highlighted above, sometimes with paternal grandparents. There was support provided under the CIN plan, but this was closed on the 2nd of June 2020 and after it was closed MGM did not notify services that mother, and Child Ba had left her address on the 4th of June 2020. In the 'Voice of the Child' report by OFSTED (2011)3 there are three areas of learning in it which have resonance with the life of Child Ba. a) 'Parents and carers prevented professionals from seeing and listening to the child' The Mother was often found by professionals as very hard to contact - she kept changing her phone number and sometimes shared the phone with her abusive partner (could be a coercive controlling element of domestic abuse). She moved between addresses and this was given as a possible explanation as to why she did not receive letters. She failed to attend several appointments with several services e.g., blood tests during pregnancy to monitor effectiveness of iron supplements – checks to Child Ba’s low growth rate, mother did 'not support a referral', mother did not engage with ‘Bridge’. The Health Visitor was told not to attend home by MGM with her concern re COVID-19, The Freedom Program was 'stopped as needed a break' and also attendances at case conferences. These all point to mother being unable to prioritise Child Ba (unborn and born) and her health needs e.g., continued heavy smoking during and after pregnancy against advice regarding its impact on Child Ba and her own health, failed to keep some appointment with midwife. Although when asked she denied drinking alcohol, but this does not compare with the facts. There were some face-to-face meetings with mother where positive comments regarding her interaction with Child Ba were made. Also, sometimes when seen on a WhatsApp video call. Whilst these were helpful the face-to-face interaction would have helped to establish if mother was actually drinking, as the Health Visitor could have been able to smell alcohol if present. Disguised compliance, telling services what they wanted to hear appears to be evident in this case coupled with avoiding contact to support their non-compliance. b) 'Practitioners focused too much on the needs of the parents, especially on vulnerable parents, and overlooked the implications for the child.' Implications for Child Ba were clearly carefully considered, as is evident from them being placed on a Child Protection Plan when still an unborn child in relation to neglect. However, the key factor this plan focused on appears to have been the domestic abuse in relation to father. Although it was indeed an important factor, it, however, seems to have been considered the overriding factor with a continued emphasis that mother must accept that the domestic abuse's impact on her child Ba. When the father was imprisoned at the end of 3 Microsoft Word - The voice of the child.doc (publishing.service.gov.uk) Final Page | 7 October 2019 there were clearly factors reducing that particular risk, primarily because he was in custody, but on release there were licence conditions regarding contact. What does not seem to have been given the emphasis it deserved were all the risk factors in mother's life: • alcohol abuse • neglect of unborn child - continued heavy smoking and drinking alcohol against advice, evidenced by low growth rate and induced labour because of these concerns • Historic involvement with children services in relation to some of her other children including being found intoxicated in care of one-year old daughter and Child Protection Plans in relation to two of her children where domestic abuse between her and partner. All four of her other children are now with their father (SF) with a private agreement where she has supervised access. On one of these visits both her and MGM had been drinking. • housing issues/homelessness • mental health - low mood depression/ADHD • Unplanned pregnancy • committing criminal offences with the father • domestic abuse where she might have been considered the perpetrator • not keeping appointments As well as these general safeguarding risk factors there was also evidence that Child Ba had a low birth weight, a premature birth and coupled with the mother’s heavy smoking are all important risk factors for Sudden Unexpected Death Infancy (SUDI) including Sudden Infant Death Syndrome (SIDS)4. 4 Statistics on SIDS - The Lullaby Trust Final Page | 8 c) 'Agencies did not interpret their findings well enough to protect their child' Hindsight bias in reviews can feature in reports, but in this case, there does appear to have been more than sufficient grounds for maintaining the Child in Need plan rather than deciding to close it. The practitioner event discussed this and there were conflicting opinions. There is equal weight to argue for Child Ba to not actually have been stepped down to a Child in Need from the Child Protection Plan at its review. Father was also due for release on 3rd July 2020, removing the protective factor of him being in custody, with control relying on his licence conditions and mother not contacting him. These statutory safeguarding processes are multi-agency and so the agencies with these important jigsaw puzzle pieces were involved but unfortunately do not appear to, or were not able to build a more accurate picture of the risk to Child Ba. It is now clear that Probation did not attend the closure meeting. Police did not attend either the first, or second, Child Protection Review meetings stating "no relevant information to share at conference at this time" however, it was subsequently identified by police that if their records had been checked on the day of the conference there was relevant information to be shared in relation to incidents involving her other children and their father (SF), mentioned earlier in this report, which involved mother having been drinking and a very young Child Ba being with her. (Identified as a learning action by Police report author). 2.2. Alcohol use and misuse This theme of alcohol use, and misuse, are a recurrent theme from Child Ba's birth up to their death and is a constant factor in mother's life prior to this, including with her other children and in her relationships. The mother's use of alcohol whilst pregnant, combined with her heavy smoking is very likely to have impacted on Child Ba's development in the womb and resulted in their low birth weight and subsequent growth below the 10th percentile at one stage at 0. Whilst this damaging behaviour is recognised and, in this case, the mother was quite rightly strongly advised about it by health professionals. Alcohol was not only a factor pre-birth and during Child Ba's short life but also appears to have been a contributory factor in Child Ba's death. In early June after the Child in Need plan had closed, the mother left the maternal grandmothers address as the maternal grandmother was concerned at Child Ba’s mothers alcohol consumption, she went to stay with a friend who was a chronic alcoholic, together they consumed over five litres of alcohol plus mother took cocaine. Levels at time of death following mother voluntarily supplying a blood sample were subsequently recorded as 194mg/100ml blood when drink drive levels are 80mg/100ml. Final Page | 9 The mother left the home address where there were some protective factors from MGM and moved to a high-risk environment with Child Ba where she not only consumed alcohol but also cocaine (Drug use - cocaine discovered post incident.) As there was apparently no appropriate sleep arrangements for Child Ba, they shared a double bed with their intoxicated mother, who it appears, overlaid them and they died. It is very difficult for pathologists to give conclusive proof of cause of death (as tell-tale signs of suffocation for an adult are not always observed in a very young child). Although as discussed at the practitioner event there is not an offence until after a child has died. If the advice given was stronger in relation to co-sleeping, including that there is a specific criminal offence of: s.1 (2) (b) Children and Young Persons Act 1933 (amended from 3/5/15 under Serious Crime Act 2015) Death of infant under 3 caused by suffocation while the infant was in bed (in or on any kind of surface or furniture being used for the purpose of sleeping) with some other person over 16 years who when went to bed or at any later time before the suffocation, was under the influence of drink or prohibited drug be deemed to have neglected the infant in a manner likely to cause injury to its health. Penalty Max 10 years imprisonment. The fact that this might occur in these circumstances should be used as a stronger preventative message. Many professionals, including some police officers, are not aware of this specific offence which was amended as recently as 2015 to include drugs as well as alcohol (drink drive limits used as a guide) and clarify that 'bed' would include other sleeping surfaces e.g. sofa. There appears to be a general over optimism by professionals that the mother was doing well in relation to her use of alcohol. This was agreed by professionals at the practitioner event as an area for learning. It was known that the mother had a significant history in misusing alcohol; however, she self-reported that she was not drinking, and this appeared to have been accepted rather than taking the opportunity to check out what mother was saying to confirm how she was managing. The mother self-reported she was accessing services, but this was not checked by professionals. ‘Bridge’ is a substance misuse programme based in Northampton primarily funded by Northamptonshire County Council that mother attended, but mother had a pattern of limited engagement and showed no expressed desire to change by the mother of Child Ba. See below: • 30.1.20 - inducted • 6.2.20 - missed appointment due to family emergency (missing other appointments also at this time) Final Page | 10 • 13.2.20 - completed paperwork • 4.3.20 - telephone call in which mother expressed her intention to attend • Despite numerous calls, letters (problems with changing telephone numbers and addresses) no further contact with mother. Although some professionals, were not seeing mother drinking, (other than the police and EMAS) there is clear evidence that alcoholism does not just go away and if there had been some professional curiosity around mother’s self-reporting, this may have led to a different level of monitoring and support to her and Child Ba. It can be difficult for many reasons for professionals to challenge alcohol use, however, the focus should be on the impact that alcohol misuse has on a parent’s ability to care for their child safely and appropriately. In this case, it appears professionals have differing recordings on the level of alcohol mother may or may not have been drinking. In March 2020, the Department for Education published ‘Complexity and challenge: a triennial analysis of serious case reviews 2014-2017’. Within this report it highlights from the study an extremely high-risk factor of parental alcohol abuse. Table 12: Parental characteristics - frequency noted in SCR final reports (n=278) The Department for Education (DfE) published in December 2018 ‘Guidance Safeguarding and promoting the welfare of children affected by parental alcohol and drug use: a guide for local authorities.’ Within this guidance it highlights research which is important for professionals Final Page | 11 to understand and acknowledge in their practice into parental substance misuse which includes alcohol. ‘Problem parental alcohol and drug use is a common feature in serious case reviews (local enquiries into the death of, or serious injury to, a child where neglect or abuse is known or suspected, including where drugs were ingested by the child). In a Department for Education analysis of these reviews, parental alcohol and drug use was present in over a third of reviews (37% and 38% respectively), with at least 1 of these presents in 47% of cases.’ The same DfE report pointed out that in many families, where there had been a sudden infant death of children aged 0 to 9 months (where maltreatment was not a direct cause of the death) they appeared to have led chaotic lives which included substance misuse. Parental misuse of alcohol is a key issue for this review. 2.3. Unsafe sleeping arrangements There are several records of safe sleeping advice being given to mother and recorded in the Personal Child Health record which is commonly known as the Red Book. As previously mentioned in this report there were numerous risk factors present linked to SUDI and SIDS. The EMAS attendance and the observation of the Moses basket and pillow over it are an example of behaviour being challenged but the mother not accepting it. When no-longer under a CIN plan the mother left MGM's home and moved to a friend's house where, as already explained in this report, she drank alcohol and took cocaine. She then went to sleep (although she could not remember details nor recall what time she had gone to bed) with Child Ba in a double bed. Mother woke up in the morning and discovered child Ba in the bed purple in the face and not breathing. They had marks on face, chest and knee which suggested they had been laid on. Together with white skin compression marks on forehead, nose and around mouth to suggest they were lying face down. The NSCP subscribe to the Tri.x policies and procedures manual. The only mention of safer sleeping within this manual is within the neglect section which highlights a quote from a previously published triennial review of Serious Case Review’s which state: "The majority of neglect related deaths of very young children involve accidental deaths and sudden unexpected deaths in infancy… issues include the risks … and the dangers of co-sleeping with a baby where parents have substance and/or alcohol misuse problems” (Brandon et al, 2013). Final Page | 12 The NSCP have on their website a section titled ‘Safe sleeping for your baby - Share a room, not a bed.’ This section was updated in September 20205. Northamptonshire Public Health are in the process of updating its Safer Sleep guidance and a campaign to ensure all parents are aware of how to always ensure their baby sleeps safely. The title of the section on the website is extremely relevant to the death of Child Ba who died whilst sleeping with their mother in a bed. Within the information under this section, it highlights risks to avoid, which states: ‘Don’t take risks: Smoking, drinking alcohol and medication or drugs can make you sleep more heavily and further increase the risks.’ This information is in line and supported by the Lullaby Trust (2019) evidence base which states: SUDI risk factors • Unsafe sleep position (prone or side) • Unsafe sleep environment: – co-sleeping in the presence of other risks (including bed sharing) – overwrapping (head covered, use of pillows or duvets) – soft sleep surfaces (soft or second-hand mattress) • Tobacco – pregnancy and environmental exposure • Alcohol and drugs – during pregnancy and when co-sleeping • Poor post-natal care – late booking and poor ante-natal attendance • Low birth weight (under 2,500g) and preterm birth (less than 37 weeks’ gestation)6 The review author has applied the bold mark up to two of the bullet points above. The information provided to this review is that the mother of Child Ba was continually being given advice pre- and post-birth about alcohol and smoking. The National Child Safeguarding Practice Review Panel published a report (July 2020) titled. ‘Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm’ (Final report July 2020)7. Within this report it highlights a risk which directly correlates with the circumstances of the evening and the night that Child Ba died. It states: ‘Most incidents that were reviewed occurred when routine infant sleeping arrangements were disturbed by changing circumstances. This could follow a critical incident, or a period of escalating safeguarding risk related to particular family events. They all involved co-sleeping and almost all were alcohol and/or drug related. A key 5 http://www.northamptonshirescb.org.uk/about-northamptonshire-safeguarding-children-partnership/news/safe-sleeping-baby-campaign-launched/ 6 Lullaby Trust (2019). The Lullaby Trust: Evidence Base. https://www.lullabytrust.org.uk/research/evidence-base/ 7 The Child Safeguarding Practice Review Panel (July 2020) ‘Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm’ (Final report) Final Page | 13 question is the extent to which SUDI in out-of-routine circumstances, while not predictable, can nevertheless be made more preventable’. The learning from this publication and the death of Child Ba is for professionals to continue to highlight the risks of co-sleeping, in particular if there is any change to normal routines. For example, in this case where the mother left MGM and went to stay with her friend. The professionals at the practitioner event were also of the opinion that the safe sleeping advice should be as wide as possible, not just to mothers, but also other carers such as fathers and other family members. The publication also highlights the need for safer sleeping advice to be imparted by multi-agency individuals. ‘Co-ordinated multi-agency guidance and training can help promote a shared understanding about a safer sleep environment and enables practitioners to reflect on their individual role in promoting safer sleep messages and recognising risk.’8 The figure below from the publication highlights where these key multi-agency professionals could fit in. Northamptonshire Police Officers are being urged by their management to think broader when called to incidents. This would include consideration of Safer Sleeping. 8 The Child Safeguarding Practice Review Panel (July 2020) ‘Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm’ (Final report) Final Page | 14 Northamptonshire health colleagues have created a crib sheet to support multi-agency partners which include Police Officers and Social Care staff in reviewing sleeping arrangements. 2.4. Step Down process and basis for decisions A referral was made by a Health professional as soon as they became aware that the mother was pregnant for the fifth time. The Social Worker reviewing the referral information, whilst brief in detail, rightly made the decision to proceed straight to assessment. Once considered by the Duty and Assessment Team, a Social Worker was allocated and made efforts to contact mother but with limited success. The case was firstly being assessed under the Child in Need criteria. Due to the numerous (six) attempts to contact mother as part of the assessment and the information held by professionals it was felt that there was a need to hold a strategy meeting. This was held on 23rd October 2019, and concerns were raised by Social Care, Health and Police surrounding historical domestic abuse, current incidents of domestic abuse, mothers’ previous children not being in her care, non-attendance at health appointments and general difficulties in getting mother to engage with assessment and professionals. The outcome of the Strategy discussion was for the case to proceed to Initial Child Protection Conference (ICPC) and a conference convening request was made the following day with ICPC being held on 13th of November 2019 which was good and positive work. The outcome of the ICPC was that the unborn should be made subject of a Child Protection (CP) Plan under the category of Neglect. At the first review CP conference on 23rd March 2020 (conducted by phone due to COVID-19 restrictions) it was recorded that: • Mother and MGM were awaiting housing • No concerns re parenting • Focus on understanding Domestic Abuse and its impact on children • Father does not have access and was in prison • Living with MGM to ensure remained safe and adhered to safety plan In terms of decision making, it would appear there was a focus on father being the risk and as he was in prison, that risk had been removed. There appears to be little consideration of mother’s extensive history of alcohol misuse, the reasons for the removal of her other children to the care of their father, [the review is aware that this was a private agreement between mother and father. However, the professionals at this meeting were unaware at that time] and any potential implications around Child Ba's low birth weight in terms of cause or Final Page | 15 vulnerability. There appears to be little consideration given to whether mother wanted to re-establish her relationship with Child Ba's father when he was released. Evidence of progress of the CP Plan and subsequent CIN Plan was essentially self-reported by mother (probable disguised compliance) as access to the home, and direct access to Child Ba was very significantly restricted during the COVID-19 lockdown. Given the very long previous history of concerns about domestic abuse and the impact of mother’s alcohol use, the review author agrees with the professionals present at the rapid review meeting, who expressed concern that the step down from CP Plan to CIN Plan and then CIN Plan to closure at the beginning of June took place very quickly, within only 40 days of Child Ba’s birth. The Northamptonshire Safeguarding Children Partnership (NSCP), Thresholds Guidance 2018: ‘The right support at the right time’ states within the document: ‘Some services described as early help or targeted support are also used by children open to children’s social care, e.g., Children in Need (CiN) or children on Child Protection (CP) plans. The following considerations may apply: • Children can and do move from one level of need to another, sometimes very quickly.’ Although the review author fully understands what the above information is saying, he believes that in this individual case the CIN Plan was closed prematurely. The main reason for believing this is that the actions of the CIN Plan had not been completed prior to the case being closed. It is unclear as to what had changed that had provided confidence that mother could protect Child Ba. The father in prison was due for release relatively soon. CP Plan was only four months old (Three months of which pre-birth). It is also unclear why the CP Plan ended and was stepped down to CIN in the first place given the vulnerabilities such as domestic violence, mother's alcohol abuse and other risk factors listed earlier. The fact that her other children left her care; father removed them from her care under a private agreement and they remained with him –was not recorded in the CP Plan. In the Rapid Review it also mentions that in 2018 all four of her other children were on Child Protection Plans. There was an action in the CP Plan for a referral to Substance to Solution (S2S) for alcohol treatment (detox, rehabilitation and 1:1 work, and to Bridge to provide a mentor who had been through the recovery process). It has been confirmed that there was no referral made to S2S and it is unclear why Bridge was chosen as a support service. The rationale for closing the CIN plan when a key referral was not completed is not known. Considering that Child Ba's father was due for release shortly from prison in early July, there was no discussion with Probation Services to understand how this was going to be managed. From the perspective of the Probation Service records it suggests they were not invited to the meeting. From the perspective of Children’s Services, their records indicate Probation Officers Final Page | 16 were invited. It is not clear from the records if the Conference Chair queried this non-attendance. There are unresolved conflicts in the records as to who attended meetings or who was invited e.g., probation. Probation says they only received a call to say the case had been closed. The probation officer re-iterated this strongly at the practitioner event. It is acknowledged that there were identified problems with IT systems during COVID-19 and different agencies used different virtual platforms. There was an understanding within the partnership at this time that if core group or Child in Need meetings were not able to get together the social worker would contact professionals individually by telephone, which may explain discrepancy between different agency records. The Health Visitor records are not clear if they contributed to decision making on the step down from the CIN plan, but Children Services records show Health Visiting Service as part of CIN Plan meeting on 2nd June 2020 with an input via a WhatsApp message. The only concern recorded by professionals appears to have been mother's understanding of domestic abuse and impact on children, the report stated, ‘that all professionals agreed with the decision making'. The NSCP have recently (September 2020) updated their guidance ‘Case and Conflict Resolution Protocol’ which states: ‘The Partnerships Case and Conflict Resolution Procedure has been updated and re-launched to ensure that all members of the partnership are aware of the process and expectations. Effective safeguarding of children is based on practitioners and front-line staff wanting the very best for children. They need to be ready to stand up in the best interests of children to enable collective responsibility for problem solving, even if this brings them into disagreement with other practitioners, with other organisations or with their own managers and employing bodies.’ As can be seen by this guidance NSCP agencies are encouraged to challenge any decisions they do not agree with and address these with the Social Worker or the Service Manager, that didn’t happen in this case as it should have done because there was not an agreement for the case to be stepped down. There was an impact of over optimism by professionals, particularly with the step-down process and closure, but there are several comments raised in the information recorded by professionals throughout Child Ba’s case that do not provide assurance that risks to child Ba had been mitigated. There is a frequent expression 'no evidence to suggest' in the key event analysis from the acute hospital involved, which is also included in the rapid review analysis. What there isn’t Final Page | 17 provided for in meetings was if there was actually any evidence to support that there had been any positive changes? This only relied on what the mother self-reported as positive. Some examples of the comments that relate to the mother not engaging/non-compliance/disguised compliance/self-reporting • E.g., Bridge (as detailed in the information earlier in this report). • E.g., Social Worker 'There has been missed appointments because of the mother being tired. It seems that the mother would only engage when necessary. • E.g., Health Visitor did attempt to have face to face contact but the family were reluctant, other contact methods were offered. • Acute hospital involved - father not there so no obstruction to attending appointments. • Acute hospital involved - high risk pregnancy - not attending appointments - what was happening ? - implications for future lived experience of Child Ba. • Acute hospital involved - appeared professionals did not have a full understanding of mother’s alcohol use, not challenged by professionals that found her intoxicated on two occasions whilst pregnant. • Acute hospital involved - alcohol use not examined effectively in view of her non-engagement and lack of therapeutic service intervention. 2.5. Safeguarding within East Midlands Ambulance Service (EMAS) EMAS undertook a Serious Incident review following an attendance to the paternal grandparents’ address on the 27th of May 2020. This was to attend paternal grandfather. Whilst in attendance, maternal grandmother, mother and Child Ba were present and it was observed that a pillow had been propped across the Moses basket to block out the early morning light getting into the Moses basket. One of responding paramedics appropriately gave mother safe sleep advice; however, she became verbally aggressive and hostile. The crew considered that mother was significantly intoxicated but that paternal grandfather, although he had had a drink, was able to be protective and they did not assess the situation as requiring immediate protection for Child Ba. On leaving the property, the crew correctly completed a safeguarding referral which they sent to EMAS’ Safeguarding Team; however, the referral did not include Child Ba's details and just gave mother’s first name. Due to this the Safeguarding Team were unable to progress the referral and returned it to the attending crew asking for further detail. By the time the crew were able to get the information and return it to EMAS’ Safeguarding Team, Child Ba had died. EMAS, as with all ambulance services, their front line clinicians do not have any access to child protection information about named individuals. Neither were EMAS able to access CPIS (Child Protection Information Sharing) at that time, but which they can now access in a limited Final Page | 18 capacity, a phased implementation is in progress to provide further access. They can flag addresses for risk information, but not individuals or public places. This is clearly an issue for EMAS and this issue extends nationally. The Serious Incident investigation being undertaken by EMAS has scoped its terms of reference which includes looking at improving processes when potential child protection concerns are identified following attendance at an address, including when concerns are identified for a child who is not normally resident at that address. The CPIS electronic register of child protection and looked after children can be accessed by acute trusts, A & E and maternity services. If EMAS had had access to it at that time it could have influenced the CIN plan step down decision. However, as this was, a call to paternal grandfather CPIS would not have been able to have been accessed for child Ba, who resided elsewhere. Other safeguarding concerns such as mothers alcohol intoxication, unsafe sleeping may have been highlighted though through the referral process. It is the view of the author that the giving of Safer Sleep Advice by the paramedic was excellent practice, but EMAS in their report to the panel state that with this level of concern the police/social services should have been contacted immediately and attended the address. Safeguarding concerns need to be reported (as they were in this case, albeit with limited information which resulted in a significant delay), but if of this nature then police or social services should have been notified sooner. This would have had the added benefit that those services would have had additional information available to them. The now completed Serious Incident has made a number of useful recommendations for EMAS. The ones that are relevant to this review are: a) to add in safe sleeping advice to core training b) to separate and clearly add in immobile baby risks c) to give a clear guidance on immediate and urgent referrals. This supports their earlier view that on this occasion they felt the crew should have made an immediate referral. The review author and panel clearly support these recommendations. 2.6 Impact of COVID-19 restrictions This phrase appears in records "But due to COVID-19 this was not completed" (CSPR minutes) - e.g., in relation to contacting Bridge, substance misuse programme - whilst COVID-19 was a factor it was more so due to the mother's use of it as disguised compliance. Some other examples below where COVID-19 is mentioned but mother appears to have used this as a reason not to interact. Sometimes saying family/MGM did not want visitors at the home because of COVID-19. Bridge - "Due to the lack of contact and attendance, support has unfortunately been very limited." Final Page | 19 Health Visitor - the number of contacts with mother via telephone during COVID-19 restrictions were more than the normal number of face-to-face contacts that would have typically taken place. Health Visitor did attempt face-to-face contact but the family were reluctant, so as a result other contact methods were offered (e.g. WhatsApp mentioned and used) Meetings were affected by COVID-19. Probation say that they only received a call to say that the case had been closed whilst social care records say that probation were invited. Problems with IT and different agencies using different virtual platforms – there was an understanding that if core group in CIN meetings did not meet together the social worker would contact professionals individually by telephone - this may explain discrepancy between different agency records? 3. Conclusions The main themes to learn from in this CSPR are firstly for professionals to assess the impact of parental behaviour more robustly on the state of the child. This can sometimes be aided by hearing the voice of the child, although in this instance, Child Ba was not yet verbal, it was not a reason not to hear their voice. There is a need for professionals to have a deeper understanding of the impact of parental alcohol misuse on children. The third is unsafe sleeping arrangements. Unsafe sleeping has been a factor in a number of recent child deaths in Northamptonshire, this has triggered a separate review of a refresh to current practice in relation to advice and support given to expectant and new parents around safe sleeping and how this can be further strengthened. Linked to this theme and another recent CSPR in Northamptonshire is co-sleeping. A further repeated theme running through this review into the death of Child Ba is that practitioners focused too much on the needs of the mother and overlooked the implications for her child and their lived experience. In this case they focused too much on the domestic violence/abuse in relation to the father and overlooked numerous recognised risk factors associated with mother. • Alcohol abuse • Neglect of unborn child - continued heavy smoking and drinking alcohol against advice, evidenced by low growth rate and induced labour because of these concerns • Historic involvement with children services in relation to some of her other children, including being found intoxicated in care of 1-year old daughter, and Child Protection Plans in relation to two of her children where there was domestic abuse between her and her partner. All four of her other children now with their father (SF) and a private agreement where she has supervised access. On one of these visits both her and MGM were drinking. Final Page | 20 • Housing issues/homelessness • Mental health - low mood depression/ADHD • Unplanned pregnancy • Committing criminal offences with father of Ba • Domestic abuse where she might have been considered the perpetrator • Not keeping appointments • As well as being general safeguarding risk factors they also, along with low birth weight, premature birth and heavy smoking are important risk factors for SUDI including SIDS. Another theme was the step-down from CP to CIN to closure. The reasons for these step downs are still not clear, as neither of the plan outcomes had been achieved/ It might be assumed practitioners were over optimistic but there is no specific evidence for this. If any professionals had disagreed at the meetings no challenges are recorded, and although a disputed fact, some key professionals may not have attended. The Health Visitor at the practitioner event advised that although child Ba may have been stepped down from CIN they were still on her Universal Plus Partnership Level 3 care, which although is a step down from safeguarding still warrants involvement. The HV did not know mum had left MGMs home. Some professionals had been critical of MGM for not notifying professionals that mum had taken Child Ba out of her household, but professionals commented that they felt that she had thought that she had gone back to the paternal grandparents, which was a much less risky environment, than with the friend whom she actually went to stay with. There is in this case, and in other cases, assumptions about the capacity to protect, that professionals make around grandparents with very little consideration to clarify with them what expectations are required of them. In this case, notifying professionals that the mother was misusing alcohol whilst on a CIN plan and then had left with Child Ba very shortly after the CIN plan had closed. Learning is required on how best to support these older family members in their required protective role. There is no doubt that COVID-19 had an impact in this case, firstly it allowed the mother to avoid any face-to-face contact or intrusive involvement in the home. Secondly, the step-down process was carried out less rigorously due to COVID-19 restrictions. 4. Recommendations Recommendation 1 The NSCP should ensure that all professionals have a better understanding of the implications and risks associated with parental alcohol misuse including historical alcohol misuse and how this is harmful to children. Recommendation 2 a) The Northamptonshire Public Health and the NSCP Safer Sleeping campaign has been re-launched. In light of the learning from this review and a recent previous review it is Final Page | 21 recommended that the campaign ensures parents and carers are aware of Safe Sleeping advice. The campaign is titled ‘Every sleep a safe sleep’. b) The partnership to examine the learning from the National Panel, SUDI review and consider implementation of the National Panel’s suggested preventing and protect practice model for reducing the risk of SUDI. (Please see Appendix B for details). Recommendation 3 The NSCP should seek assurance that step down procedures are operating effectively and rigorously. Recommendation 4 The NSCP and partners should consider what needs to be put in place to support grandparents, and other family members, of whom they have an expectation that they are to act as a protective factor to parental risks to safeguarding children. To help with this consideration The Children’s Trust have adopted the ‘signs of safety model of practice’, within this model it includes all family members that are to be regarded as a protective factor. This is in mid implementation phase. The NSCP Partners should also be trained in the signs of safety practice model and there is training available for them to access. Final Page | 22 Appendix A SCOPE & TERMS OF REFERENCE The Rapid Review Group recommended that, with reference to the requirements as set out in Chapter 4 of Working Together to Safeguard Children (2018) that the threshold was met to commission a Child Safeguarding Practice Review (CSPR) in respect of Child Ba. The Strategic Leads agreed with this recommendation and the CSPR formally started 1st September 2020. The purpose of the review is to identify improvements which are needed and to consolidate good practice. Safeguarding Partnership’s and their partner organisations will need to translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children. The following principles should be applied by the Safeguarding Partnership and its partner organisations to all reviews: • There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice. • The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined. • Reviews of CSPRs should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed. • Professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith. • Families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring the child is at the centre of the process • Final reports of CSPRs must be published, including the Safeguarding Partnerships’ response to the review findings, in order to achieve transparency; and • Improvement must be sustained through regular monitoring and follow up so that the findings from these reviews make a real impact on improving outcomes for children. CSPRs and other case reviews should be conducted in a way which: • Recognises the complex circumstances in which professionals work together to safeguard children. • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did. • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight. Final Page | 23 • Is transparent about the way data is collected and analysed; and • Makes use of relevant research and case evidence to inform the findings. Authors will be asked to provide a detailed chronology that includes a mandatory critical analysis column for completion and a report detailing further analysis of what they deem to be critical key incidents, along with learning and action already taken to address the concern. A multi-agency Panel will scrutinise the combined chronology and identify learning. Themes will be examined, and authors are required to update on their own agency learning through the process of the review with an expectation that when the review is concluded, the majority of learning has already been addressed with processes in place to change/improve practice. There will also, and in parallel, be a process of greater collaboration through conducting conversations with the practitioners and clinicians involved and holding a multi-agency Practitioner event approximately halfway through the process in order to further identify learning and encourage reflection on their involvement; to examine the actions and decisions taken and to understand the context. When the review is concluded, a practitioner de-brief session will be undertaken to share findings and learning prior to publication of the report. Issues for consideration by Authors and the Lead Reviewer: • Professionals understanding of this family unit in terms of Child Ba’s care and safety. • Professionals understanding of Child Ba’s voice and his day-to-day lived experiences. • Professionals understanding of alcohol misuse; what was professionals’ knowledge and perception of mother’s historic alcohol misuse, the risk / level of harm this posed to Child Ba and professional understanding of mother’s pattern and consumption of alcohol. • Safeguarding concerns observed by ambulance crews: Further exploration is needed of internal safeguarding processes within EMAS and how these can be / are being improved so that safeguarding information can be shared in a timelier manner. • Analysis of the impact of children’s social care step down processes, how actions from plans were addressed and recommendations for any improvements to these. • The impact of any over optimism by professionals that, as father was in prison due to domestic violence, the risk to Child Ba had been removed without considering the risk by mother due to her alcohol misuse. • Unsafe sleeping arrangements. • The impact of the COVID-19 lockdown circumstances on assessment and decision making in this case. The time period for this Review is 1 November 2019 – June 2020. Final Page | 24 The reason for this time period is the 1 November is when Child Ba was placed on a Child Protection Plan as an unborn to June 2020, the date of Child Ba’s death. Agencies should include historic events with the family relevant to the learning aims of this Review, particularly in terms of: • Mother’s previous children and her contact with them. • Father’s involvement with Child Ba and mother, his current status and contact with mother whilst he was in prison. A template for the Chronology and Key Incident report will be provided, along with guidance for completion. Panel members: Independent Reviewer Children First Northamptonshire representative Northamptonshire Clinical Commissioning Groups representative Independent Consultant, Northamptonshire Police representative Northamptonshire Probation Service representative Northamptonshire Safeguarding Children Partnership representative Chronologies and Key Incident reports are required from: Acute Hospital involved (to include midwifery) Children First Northamptonshire GP, Northamptonshire Clinical Commissioning Groups National Probation Service Northamptonshire Police East Midlands Ambulance Service Northamptonshire Healthcare Foundation Trust Parallel Processes It is acknowledged that East Midlands Ambulance Service are undertaking an internal Serious Incident Review and the findings from that review are requested to feed into this process at the earliest opportunity. Final Page | 25 Appendix B |
NC046038 | Death of a 7-month-old girl in September 2013; inquest concluded with a finding of unlawful killing. Mother pleaded guilty to infanticide and was made the subject of a hospital treatment order under the Mental Health Act 1983. A psychiatric assessment completed during criminal proceedings described mother to be suffering from the following at the time of the incident: schizoaffective disorder for which mother had avoided treatment through her lifestyle choices and use of alternative coping mechanisms; personality disorder; and mental and behavioural disorders due to use of alcohol-dependence syndrome. Child H was living with mother, father and sibling at the time of the incident. Mother was American and had met father, a British citizen, in India before moving to the UK. Father was considerably older than mother and was receiving ongoing treatment for chronic obstructive pulmonary disease (COPD). Mother had a history of anxiety and depression and was noted to have little support in England; mother was father's sole carer. Identifies themes arising from the SCR, including: insufficient assessment with regard to the impact of mother caring for father upon her and her care of the children; focus of the discussions between agencies in relation to Child H focussing on the mental health needs of mother and physical health needs of father; recognition of symptoms of emerging mental health issues; lack of understanding and use of assessments; and lack of consideration of mother and father's self-identification as 'Spiritual Teachers' on family functioning and family culture/norms. Makes various single and multi-agency recommendations, including: revisions to the Family Support Pathway; and recognising the impact of the presentation of families on professional judgments.
| Title: Serious case review: Child H: overview report. LSCB: Nottingham City Safeguarding Children Board Author: Hayley Frame Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 NCSCB Submission Copy Serious Case Review Child H Overview Report STRICTLY CONFIDENTIAL Independent Reviewer: Hayley Frame Date: 27th February 2015 2 NCSCB Submission Copy Contents 1. Introduction 2. Methodology 3. Key 4. Summary of Information Known to Agencies and Agency Involvement in Respect of Child H 5. The Family’s experience 6. Analysis including Themes arising from the SCR 7. The experience of the child 8. Expert opinion 9. Changes in Practice and Actions Already Taken 10. Conclusions 11. Recommendations Glossary of terms Appendix 1: Terms of reference Appendix 2: Single agency recommendations Appendix 3: NCSCB Action Plan 3 NCSCB Submission Copy 1. Introduction 1.1. Serious Case Reviews are always carried out by a Local Safeguarding Children Board (LSCB), when a child dies and abuse or neglect is known or suspected to be a factor in the death. This procedure is laid out in the NCSCB Safeguarding Children Procedures and is in accordance with the expectations set out in the Government guidance, ‘Working Together to Safeguard Children’ 2013. 1.2. This report summarises the findings from a Serious Case Review that was established to consider the professional interventions in respect of a child, who will be referred to as Child H, who died suddenly at the age of 7 months whilst in the care of her mother. Her mother pleaded guilty to infanticide and was made subject of a hospital treatment order under the Mental Health Act 1983. Reason for Establishing the SCR 1.3. As a result of Child H’s death, the Nottingham City Safeguarding Children Board (NCSCB) Serious Case Review Standing Panel met on 16th October 2013 and considered her case. The Panel agreed that as abuse and neglect were suspected to have been factors in the child’s death, a recommendation should be made that a Serious Case Review (SCR) be undertaken in accordance with ‘Working Together to Safeguard Children’ 2013. This recommendation was agreed by the NCSCB Independent Chair on 29th October 2013. 2. Methodology 2.1. On 14th November 2013, the Serious Case Review Standing Panel met to consider the scope and terms of reference of the SCR. 2.2. In light of the principles outlined within Working Together to Safeguard Children 2013, a bespoke model was developed for the completion of this SCR incorporating agency reports and practitioner participation. 2.3. The model incorporated the principles of chapter 4 of Working Together 2013; namely those contained within paragraph 9 and 10: • the approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined; • reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed; • professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith; • Families, including surviving children, should be invited to contribute to reviews. They should understand how they are 4 NCSCB Submission Copy going to be involved and their expectations should be managed appropriately and sensitively. • SCRs should be conducted in a way which recognises the complex circumstances in which professionals work together to safeguard children; • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. 2.4. An Independent Reviewer, Hayley Frame, was commissioned to undertake the SCR. Miss Frame is an independent safeguarding consultant and as such is independent of all agencies contributing to the SCR. She has 19 years’ experience within safeguarding, as a practitioner and as a manager at various levels, and is a qualified and registered Social Worker. Miss Frame is experienced in completing serious case reviews and reflective learning reviews. 2.5. A Serious Case Review Panel, to be chaired by Miss Frame, was established consisting of senior managers from the agencies involved in the case. It was agreed that written material would be required from agencies, and as such a combined multi agency chronology was produced and agencies submitted a short agency report outlining the nature of their involvement and considering key issues identified in the case (see below). A briefing event was held to explain the process and the requirements of agencies. 2.6. Reports and chronologies were requested from the following agencies that had knowledge of Child H: • East Midlands Ambulance Service (EMAS) NHS Trust • Nottingham CityCare Partnership • NHS Direct • NHS Nottingham City • Nottingham City Council Children’s Social Care • Nottingham University Hospitals NHS Trust • Nottinghamshire Police • Metropolitan Police 2.7. In addition, the school of Child H’s sibling provided a chronology. 2.8. In order to ensure that the SCR considered not only what happened but why, the SCR panel agreed to adopt an approach that engaged directly with practitioners involved in the case. The aim was to ensure that the SCR process enabled an analysis of what the case might be 5 NCSCB Submission Copy telling us about the wider multi-agency system to ensure that any improvements had a wider impact and that learning was not just focused around issues that were purely case specific. As a result a practitioner panel was held, to which all practitioners and their line managers who had direct involvement in the case were invited. The practitioner panel ensured that opportunity was given to fully understand practice from the viewpoint of the individuals involved at the time. One practitioner, the Health Visitor, was seen separately due to her being on extended leave at the time of the practitioner panel. In addition, the practitioners were asked to give feedback on the overview report, which was considered and incorporated into the final draft. Serious Case Review Panel 2.9. The SCR Panel membership was as follows: Hayley Frame Independent Reviewer Head of Safeguarding East Midlands Ambulance Service NHS Trust Safeguarding Children Lead NHS Direct Detective Inspector Nottinghamshire Police Detective Inspector Metropolitan Police Named Nurse Nottingham CityCare Partnership Assistant Director of Quality Governance NHS Nottingham City Service Manager Nottingham City Council, Children and Families, Social Care Team Manager Nottingham City Council,Family and Communities (children’s centres) Named Nurse Nottingham University Hospitals NHS Trust Named Midwife Nottingham University Hospitals NHS Trust Solicitor NCSCB Legal Advisor Service Manager Safeguarding Partnerships (NCSCB) Children’s Board Officer NCSCB Administrator Safeguarding Partnerships Expert Opinion: A Consultant Perinatal Psychiatrist was invited to provide expert advice and opinion in relation to this case. The Consultant has had no previous contact with the family. The review has also taken account of the psychiatric assessments of the mother undertaken within the criminal trial, as a source of relevant expert opinion. 6 NCSCB Submission Copy The time period over which events were reviewed 2.10. The time period covered by the SCR is from 1st June 2012 (to cover the period of pregnancy) to the date of Child H’s death, 1st September 2013. Any relevant information from the time preceding the date of birth is summarised. This period was agreed to ensure learning would focus on the specific issues relating to the mother’s mental health, the impact of her pregnancy and Child H’s birth whilst allowing broader issues to be considered within summaries. Key Issues 2.11. The scoping of the Terms of Reference identified the following key issues to be examined by the SCR: 2.12. With regard to the mother: • Support received before and after the birth of Child H • Any assessments undertaken of her mental health • Her role as a carer for the father and the impact of this upon her parenting and/or mental health • Her presentation and practitioner’s perception and analysis of this 2.13. With regard to the father: • His role within the family including his occupation and beliefs • His physical and mental health and any assessment of the impact of this upon the safety and welfare of the children • His presentation and practitioner’s perception and analysis of this 2.14. With regard to the family: • Evidence of domestic stress relating to parenting, health or finances • Opportunities for early intervention, in particular during March 2013 • Quality of assessments, decision making, referral and communication • Responses to events on the weekend of Child H’s death Child H’s siblings support needs were also considered by the panel. Very little information relevant to the issues under consideration were identified and therefore, in order to deal sensitively with her confidential information and promote wherever possible her anonymity, only information already in the public domain regarding Child H’s Sibling has been included in this report. 2.15. With regard to agency involvement in the case: • How sensitive were practitioners to the needs of Child H and how equipped were practitioners to work effectively with the family? 7 NCSCB Submission Copy • Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability within the family? • What was in place to ensure management accountability for decision making and management oversight of the case? Was this effective? • Was work consistent with the agency and the LSCB’s policy and procedures? Were professional standards met? • Were staff involved trained to the appropriate level in safeguarding? • Were there any contextual issues that impacted upon work in the case i.e. staffing, capacity, sickness, organisational change, resources? • Is there evidence of positive practice? 2.16. With regard to the multi agency system: • Whether the issues identified above have resonance with other similar cases • What the case tells us about: � Any underlying patterns that either support good practice or create conditions in which problematic practice is more likely � How the wider multiagency system is operating SCR Panel Process and Timetable 2.17. The SCR Panel met on five occasions. The initial meeting was a briefing to provide an overview of the case and agree the process to be used and the expectations in relation to reports and panel meetings. Further panels considered the agency reports; discussed the case in full to analyse the information presented; considered the findings of the SCR and established the learning. 2.18. A Project Plan has been maintained throughout the SCR to ensure clear deadlines. Any changes to these, including completion and submission dates have been communicated to the NCSCB Independent Chair and the Department for Education. Parallel Processes and Investigations 2.19. Child H’s mother pleaded guilty to infanticide and following the completion of psychiatric assessments was made subject to a hospital treatment order under the Mental Health Act 1983. 2.20. The inquest by the Coroner into Child H’s death concluded on 27th February 2015 with a finding made of unlawful killing. 8 NCSCB Submission Copy Overview Report Structure 2.21. The Overview Report provides a summary of the information contained within the agency reports, ensuring that key events and issues are captured and analysed. Author’s comments are set out in bold. 2.22. The analysis includes a summary of the author’s comments, analysis of the case against the identified key issues and the themes that have emerged from this SCR. 2.23. There have been a number of developments and actions already taken and these are set out in section 9 prior to the conclusions and recommendations of the report. 3. Key: Role Key Subject Child Child H Sibling S1 Mother M Father F 4. Summary of Information Known to Agencies and Agency Involvement in Respect of Child H (Author comments are highlighted in bold) Information of Relevance prior to the Scoping Period: 4.1. M is an American woman who met F in India. They married in Minnesota USA in 2009. M declared a history of anxiety and depression when she registered with a GP in Nottingham, for which she had been taking diazepam, but did not declare any other mental illness or drug or alcohol abuse, or medical condition. She did not request any prescriptions for diazepam either. 4.2. F is an English man, some considerable years older than M, who spent some of his childhood in India and then again as an adult. F has been known under three other names. It is recorded that F was admitted to hospital in Bristol in 1995 with ‘hysteria’ and a history of heroin addiction in his youth. On registering with the GP in Nottingham, F described his occupation as an aid worker and healer and claimed to have grown up in a ‘tantric’ house, although what was meant by this is not documented. 4.3. F has had ongoing care and treatment of chronic obstructive pulmonary disease (COPD) under the care of respiratory services at since 2010. This has involved inpatient admissions and outpatient appointments. 9 NCSCB Submission Copy 4.4. There has been no prior involvement of the police or children’s social care. The family have not been known to mental health services in the UK. Summary of Information during the Scoping Period: 4.5. On 19th June 2012, M attended an initial midwifery appointment. M stated during screening questions that there was no history of domestic abuse, mental illness, or drug/alcohol misuse. It was noted that M was a full time carer for F but no discussion regarding his ill health or the impact of caring responsibilities was recorded. 4.6. A request for F to be assessed for a lung transplant was made on 12th July 2012. The outcome of this was that F was not suitable for transplant due to his age. F was admitted to hospital on 26th October 2012 with difficulty breathing, exacerbated by chronic obstructive pulmonary disease (COPD). He was discharged the following day with telephone follow up provided by community nurses. Further correspondence took place in November 2012 regarding potential procedures for F, noting a rapid decline in his condition over the last 2 years. 4.7. A home visit was undertaken by a community nurse on 29th November 2012 following contact from M stating that F was breathless. Red areas to pressure areas were noted. The following day the nurse spoke to M who reported that F was breathing more easily and that the pressure areas looked less inflamed. A referral was made for pressure relieving aids. 4.8. On 12th December 2012, an Occupational Therapist undertook a home visit in order to complete an assessment. M was documented as the carer for F, who assisted him with the majority of activities of living and personal care, including assisting F to transfer. Pressure area damage were noted to F’s elbows and wrists and an agreement was made to order an overlay mattress. On 14th December 2012, M asked that the overlay mattress and perching stool be collected as F did not want them. A visit was offered for that day to apply the mattress but this was declined by M who became upset and put the phone down. A return call was made to M to advise her of the need for the pressure relieving mattress, and M stated that F no longer had pressure sores. Arrangements were made to collect the mattress. Comment: Two days after pressure sores were noted, M was reporting that they were gone. It does not appear that direct contact took place with F regarding the pressure sores. M’s reaction to the offer of assistance with applying the mattress was one of distress, the reason for which is not explored. In addition, given that M would have been heavily pregnant, a referral for a carer’s assessment could have been considered at this stage. 10 NCSCB Submission Copy 4.9. A midwife undertook a home visit on 18th December 2012 to assess the home for suitability for a home birth. F was noted to be chronically unwell and in bed for the duration of the visit. M stated that a carer would be needed for F if she were to be transferred to hospital. There was little documented discussion regarding F’s ill health or that impact upon M of being his carer. Comment: Again this was opportunity for a referral for a carer’s assessment for M. The reason for this not being considered is explored within the analysis. 4.10. M was seen at the maternity assessment suite on 26th January 2013 with a rupture of membranes. She was still keen for a home delivery and was allowed home with advice given. Comment: It would appear that M was keen for a home birth given her caring responsibilities at home and this was reflected within her midwifery records. 4.11. The following day M contacted F’s nurse to state that her waters had broken; that she needed to go into hospital and that F needed a carer. The nurse made some initial enquiries however, M later made alternative arrangements and found someone to stay with F whilst she was in hospital. 4.12. Later on the in morning of 27th January 2013, M was admitted to hospital for induction of labour. Child H was born at 4.21pm. M stated that she could not remain in hospital as she needed to go home to care for her husband. M was advised to remain in hospital for observation due to prolonged rupture of membranes (as this increases the risk of infection to the newborn) but declined and went home at 7.00pm. Comment: M was clear that she needed to go home to care for her husband immediately after giving birth, and against clinical advice. This could have triggered a referral for a carer’s assessment to consider M’s support needs or liaison with the health visitor and community midwives regarding the home situation in addition to the routine notification regarding discharge. 4.13. M and CHILD H were visited by the community midwife on 28th January 2013 and 29th January 2013. No concerns were raised. On 1st February 2013, M and CHILD H were seen in clinic. M was feeling well and CHILD H was gaining weight. M and CHILD H were seen again in clinic on 11th February 2013. Excellent weight gain was documented. M and CHILD H were discharged from maternity care. Comment: The midwifery notes did not contain any record about M’s mental health, or consideration of the implications of her caring for her husband and children. 11 NCSCB Submission Copy 4.14. On 14th February 2013 a home visit was undertaken by the Heath Visitor. A physical examination of CHILD H was completed and no abnormalities were detected. M was recorded as being F’s full time carer. It was also recorded that M was American . M was noted to have little support in England and disclosed having experienced depression a few years previously although feeling well at present. M agreed to attend clinic and the health visitor planned to see CHILD H again at the 12 – 16 week review. Comment: It is noted within the agency report that during this visit where M disclosed previous depression there does not appear to have been any exploration by the health visitor regarding whether this had been postnatal depression or reactive depression. 4.15. On 27th February 2013, F was taken to hospital via ambulance with respiratory arrest. Whilst in hospital F spent time in intensive care. It is recorded that F was dependent upon M for care and that they had an 8 week old baby. F was transferred to the City hospital on 20th March 2013. Comment: It would appear that hospital staff were now aware of the home situation. The agency report indicates that there was minimal information in F’s records regarding his home life. 4.16. On 1st March 2013, M sent an email to S1’s school apologising for S1’s absence and explaining that F’s illness and hospital admission meant that she was unable to get S1 to school. In the email, M asked for additional support for S1 as she felt that she was being affected by the family situation. The head teacher replied, agreeing to put in extra support for S1 within school and offering to meet with M to discuss how the school could help. 4.17. On 14th March 2013, M rang the emergency services to report that CHILD H had a watering eye. The call was transferred to NHS Direct. When the nurse advisor called M back, she stated that she was really calling about herself and felt that she was having a breakdown. M reported that F was seriously ill in hospital and had nearly died 2 weeks previously. She stated that she felt paranoid, confused and was unable to remember things, and unable to get out of the house. She reported a history of anxiety and depression. The nurse advisor informed M that she would ring her GP, which she did and reported that M sounded psychotic. The GP commented that this was out of character. Comment: The nurse advisor checked that all of the family members within the household were safe. However a separate record was not created for the mother and her details were recorded on the child’s record. The agency report indicates that a record for M should have been created and a fuller and formal 12 NCSCB Submission Copy assessment of her mental state should have been carried out using assessment tools from the NHS Direct mental health training and by use of an appropriate algorithm. Had the paranoia algorithm been used, then the likely outcome would have been to attend the Emergency Department as soon as possible. 4.18. The GP rang M immediately and assessed her over the telephone. By this time M was reported as feeling settled and back to her normal self with no psychotic signs. She said that she was stressed due to F being in hospital and was struggling to cope but that she was ‘alright’. The GP recalled that S1 did go to school that day. The GP offered to visit M but she said she did not want a visit and was feeling much better. Comment: It is stated within the agency report that it is not usual for GPs to visit healthy adults at home for stress related symptoms. The call from NHS Direct stated that M was psychotic, which would have required a visit, and it was the primary concern of the GP to establish if this was the case or not. When GP had satisfied herself over the telephone that M was not presenting as psychotic, then a plan to see her in the surgery was a reasonable response. The GP offered to visit her but this was declined. It is noted that it is unusual to recover so quickly and with no treatment from a psychotic episode. This unusually sudden recovery seems to have led the GP to assume that M could not have been psychotic just an hour or so previously and thus the professional who thought she had been psychotic must have been mistaken. 4.19. Following a discussion between ambulance control, a senior clinician with NHS Direct and the NHS direct Nurse Advisor, it was agreed that the nurse advisor would make a safeguarding referral which she did that day. The referral was followed up in writing. The nurse advisor contacted M again and M informed her that the GP was not going to visit but was going to get the health visitor to ring M. The GP did not speak to the health visitor however the health visitor coincidentally rang M who described the last few weeks as a nightmare. The health visitor arranged to visit on 20th March 2013. Comment: During this contact, M did not inform the health visitor of her earlier contact with NHS Direct, however given the fact that the nurse advisor had told M that the health visitor was going to ring, it was likely that M presumed that the health visitor was already aware. 4.20. On 19th March 2013, an ambulance was called to M who reported medical symptoms of a stroke (facial twitching and right sided weakness). Although the symptoms were resolving by the time that ambulance clinicians arrived, M was accepted and transferred to NUH Stroke Unit for further assessment. At hospital, a full social history was obtained, including that M was full time carer for F and two young 13 NCSCB Submission Copy children and reported recent emotional stress and symptoms of anxiety. Both children were present with M in hospital. She was diagnosed with a migraine and sent home. The information gathered was shared with the GP via a letter. Comment: This was opportunity for discussion with the health visitor and consideration of a referral for a carer’s assessment. NUH has liaison health visitors who could have been contacted given the concerns evident from the social history provided and M’s emotional health. It was unusual for children to be on the ward with their mother and this too could have been raised with the liaison health visitors. 4.21. The health visitor visited as planned on 20th March 2013. Both children were seen and the health visitor was informed that M had been in hospital until the early hours of the morning as she had experienced numbness down one side of her body. M reported feeling helpless with regards to F whom she was visiting every second day. She reported being in a constant state of fear regarding what was going to happen to the family. M was noted to be isolated and spoke about her children going into care for a month so that she could ‘get herself together’. M reported being prescribed medication by the GP for panic attacks. Some support services were discussed, including a children’s centre and Homestart, as well as the contact number for ‘let’s talk’ wellbeing service. The health visitor documented that she felt that M was at crisis point and that the numbness experienced the previous day was a manifestation of stress. Comment: M was clearly stating to the health visitor that she was not coping. Discussion with the GP would have been pertinent at this stage as well as consideration of a CAF or indeed a referral to children’s social care. 4.22. Later that day, a Screening and Duty Family Support Worker (FSW) spoke to the health visitor, after having received the referral from NHS direct. The health visitor provided the social worker with information gained from her earlier visit. It is recorded in the health records that the FSW suggested liaison with the Family Information Service; advised that liaison with the school would occur and suggested the involvement of a family support worker. The FSW recorded the health visitor’s view that M was reaching breaking point. It was also recorded that the GP had prescribed panic attack medication and that the health visitor had provided M with information regarding support services. A telephone message was left for S1’s school by the FSW. The FSW recorded that no further action was required. Comment: The screening and duty worker appeared to be reassured by the information provided by the health visitor and by the fact that the health visitor and G.P. were aware of M’s difficulties. There is no record of contact being made with the GP 14 NCSCB Submission Copy or with M herself. There is no record of a discussion regarding the appropriateness of a CAF. 4.23. Some hours later, the FSW spoke to S1’s school who reported that she had not been seen in school since 8th March 2013 and that her attendance was 82.4%. 4.24. On 21st March 2013, the health visitor recorded that she liaised with the children’s centre who advised a referral to the carer’s federation. She then visited M to provide a leaflet and a referral form as well as contact numbers for the Family Information Service. S1 was still not in school although M reported that she was feeling much better. There was no record of a discussion with M regarding the NHS Direct referral or the health visitor’s discussion with Children’s Social Care. In interview, the health visitor recalled the contact with the children’s centre as being an informal discussion with the children’s centre worker regarding making a referral to the service (for a family support worker). She recalled that the children’s centre worker did not feel that the case would meet the threshold criteria for family support worker involvement and that they were oversubscribed. This aspect of the conversation is not recorded in the health visitor records. There is no record of the conversation between the health visitor and the children’s centre worker within the children’s centre files. The children’s centre worker in question does not recall the conversation as this was an informal chat due to the two professionals being based in the same building. 4.25. M visited the GP on 27th March 2013. Although she was stated to be much brighter, she was given lorazepam (a minor tranquilliser and benzodiazepine) for the immediate relief of stress. She was not considered to be depressed or offered antidepressants. Comment: F was still in hospital at this point. There is a discrepancy within the records as M had shared with the health visitor on 20th March 2013 that she was being prescribed medication for panic attacks but the first recorded prescription was issued on 27th March 2013. 4.26. On 27th March 2013, the health visitor received a copy of the NHS Direct Safeguarding Child Concern form. The form referred to paranoid thoughts and confusion. Receipt of the form appeared to prompt the health visitor to ring M that day; who reported that the home situation had much improved. 4.27. F was discharged from hospital on 31st March 2013. M was spoken to by a discharge co-ordinator during F’s admission and asked specifically about support needs. M stated she did not need any input and was fine 15 NCSCB Submission Copy to care for F. She was not asked explicitly about caring for the children as well as her husband. 4.28. In a telephone call from the Health Visitor on 25th April 2013, M stated that CHILD H was well and F was at home. M reported feeling well in herself. 4.29. On 2nd May 2013, F was visited by a physiotherapist for the purpose of assessment. M was documented as F’s carer. Although F reported that he was struggling with activities of living he declined the offer of referral to Occupational Therapy and the District Nurse. Comment: A pattern is emerging of the parents declining help that is offered. 4.30. The health visitor visited on 9th May 2013. M reported not being able to leave the house for prolonged periods due to F’s ill health. M stated that she was feeling well and managing home life. 12 – 16 week review of CHILD H was completed and no concerns were noted. 4.31. On 13th May 2013, M was seen by her GP who recorded that she had a ‘stress related problem’ related to her husband’s health and having a new baby. It was recorded that M ‘does everything even if [F] is able’. Medication was discussed however no prescription was issued. On 15th May 2013, F was prescribed lorazepam for his breathing difficulties. 4.32. The physiotherapist visited F again on 30th May 2013. F reported to feeling very breathless and reported having to call an ambulance twice over the weekend for chest pain. F felt that he had everything he needed therefore was discharged from the service. 4.33. On 10th June 2013, M was prescribed 12 lorazepam tablets without having been seen by a GP. The prescription was printed out by the surgery receptionist and submitted to the GP who then signed it. On 18th June 2013, M was prescribed 12 further tablets without being seen by the GP. This happened again on 21st June 2013, and on 4th July 2013, however on this occasion the number of tablets was increased to 28. It is of concern that the GP issued prescriptions for a benzodiazepine without seeing M, given the recent history of concern regarding her mental health (of which the GP was aware) and the fact that she had a young infant at home. In interview the GP stated that M would have put her requests into the surgery and they were then issued. The gap between the first prescription and the second, some 10 weeks, remains unexplained and a review of M’s health would have been pertinent prior to issuing the second prescription. There is no record of what discussions took place between the receptionist and the GP when the prescriptions were signed. 16 NCSCB Submission Copy 4.34. Further prescriptions for 28 tablets were issued by the GP on 19th and 31st July 2013, without M having a scheduled appointment with the GP. In interview the GP stated that at the end of July 2013, reception staff had noted the amount of repeat prescriptions. 4.35. On 21st August 2013, F visited the GP requesting 3 prescriptions for lorazepam. M and CHILD H were with him. It was recorded that the family were moving to the USA and that F was hoping for a lung transplant. The family were described as optimistic regarding their future in the USA and excited about the move. It is also recorded that they were ‘stock-piling’ lorazepam to take to the USA. The requested prescriptions were not issued. It is evident that the prescriptions for lorazepam were issued to M repeatedly without her being seen by the GP. In addition, the numbers of tablets prescribed increased. There is no robust trail from the GP records of the clinical decision making process. In interview, the GP confirmed that they were not following any specific guidelines with regard to the prescription of benzodiazepines. Guidance in the BNF (British National Formulary) states that benzodiazepines are indicated for short-term relief of anxiety (two to four weeks only). Whether M was requesting the medication as her mental health was deteriorating or whether the family were stock-piling the drug is not known. It is significant however that only the GP was having contact with M during this period, albeit indirectly and therefore the only one with reason to make enquires of her wellbeing. 4.36. On Saturday 31st August 2013, at 6.00am, F called an ambulance as he had chest pains and was having difficulty breathing. F informed the crew that M had run off with CHILD H leaving him with the care of S1. F was concerned that M might self harm. An immediate safeguarding referral was made by EMAS to the police and to social care. The referral is not recorded in the social care records, although reference is made to it in subsequent recordings made of the day’s events. 4.37. Police Officers attended the address at 8.20am following the report from EMAS. Whilst at the address, F informed officers that M had left the address during the night with the baby, CHILD H, in the family car. F reported that he was concerned because M suffered with anxiety. The ambulance crew at the scene informed the officers that they had already been in contact with M by telephone and that she was currently in London but would start making her way back to Nottingham once she had taken her medication for anxiety. She had informed them that 17 NCSCB Submission Copy it would take her approximately three hours to get home. S1 was taken to the police station and F was conveyed to hospital where he was admitted. 4.38. A car was later reported to the police as having been abandoned. The car was registered to M. CCTV footage later identified that M had left the car and got into a taxi at 04.30am. 4.39. At 9.50am, M approached a police officer outside Ealing police station and asked if he could help her carry her luggage to the train station. The officer could see that M was struggling and so agreed to help her, along with a colleague. Once the officers determined that M was trying to get back to Nottingham, they arranged for M to be given a lift to Kings Cross Station due to concerns that M would struggle on the tube with a young baby and all of her luggage. 4.40. By this stage, Nottinghamshire Police decided that a high risk missing enquiry be raised in respect of M and CHILD H. Nottinghamshire Police contacted M who informed them that she was in the company of Metropolitan Police Officers. M handed the phone to the Metropolitan Police Officer and the Nottinghamshire Police Officer explained that M and CHILD H were missing and there were concerns for their safety. At approximately 10.30am, both police forces then agreed to drive to Newport Pagnell Service Station which is half way between London and Nottingham; so that the Metropolitan Police Officers could hand M and CHILD H over to officers from Nottinghamshire Police. Comment: It is reported by Metropolitan Police Officers that during the time spent with M, they did not have concern regarding her mental health. 4.41. At 12.36pm, it is recorded by the social care emergency duty team that Nottinghamshire police informed them that M and CHILD H had been located in London; having travelled there by taxi after M abandoned her car in Nottingham. M was intending to travel on to Holland where she intended to live following a dispute with F. It is recorded that M had visited the police station in Ealing stating that she was suffering an anxiety attack. It is recorded that the Nottinghamshire police officer was concerned about M’s mental health given that she was unsure whether she had a passport to travel to Holland and had limited belongings. Comment: There is a discrepancy here with regard to the reported anxiety attack. The Metropolitan police reported that M approached them to request help with her luggage. However Nottinghamshire police were aware of M’s earlier conversation with EMAS where she stated that she was going to take medication for anxiety before heading back to Nottingham. 4.42. Nottinghamshire police officers collected M and CHILD H at 2.00pm. During the second part of the return journey, the two Nottingham Police 18 NCSCB Submission Copy officers found that M appeared well, both physically and mentally. She was described as calm, coherent and very well organised. Throughout the return journey she was very attentive to the needs of CHILD H who was happy and giggling. During the conversation with M she stated that she did suffer with anxiety and that she was receiving medication. When asked if she had suffered previously with any mental health problems, M informed the officers that four or five years ago whilst in America she had followed a step system recovery having been admitted to a health care facility for thirty days. She stated that she was drinking heavily at that time but not anymore. 4.43. At approximately 4.00pm, M and CHILD H arrived back in Nottingham with Nottinghamshire police officers and were taken to collect S1 from the police station. At 4.26pm, Nottinghamshire police officers spoke again with EDT with an update on the situation. The officer had been inside the family home and reported it to be clean and unlike a number of families in the area, the home had expensive household items. In relation to M’s mental health, it is recorded in the EDT records that the police officer was satisfied that M could be left with her children although the rationale for this is not recorded. The police records state that they recommended that a visit was needed by social care that evening. The police officer understood from the EDT social worker that this was not possible as there were no social workers available, but that a social worker would make contact with M on Monday morning, with a view to completing an Initial Assessment. It was agreed by both agencies that a safe and well visit would be completed by the police the following day. Comment: As a result of the Practitioner Panel it became evident that during the car journey, M informed Nottinghamshire Police Officers that she had left home following an argument with F who had asked her to leave. During the car journey, the Nottinghamshire police officers completed a full DASH RIC assessment which identified M as standard risk of domestic abuse. There had been no previous police callouts to the family in respect of domestic abuse. S1 had remained in the police station given plans for her to return to M’s care when she arrived back in Nottingham although it is noted that this was for a considerable period of time. However, Police Officers described her as relaxed and not distressed. With regard to the request for a visit to be undertaken by EDT, it has become evident that there was a degree of misunderstanding regarding this issue. Had the requested visit been as a result of child protection concerns, a visit would have been undertaken by EDT. However, at the time of the reported request, the police were not expressing concern regarding M’s ability to care for the children. 19 NCSCB Submission Copy 4.44. CHILD H died on 1st September 2013. 5. The Family’s Experience 5.1. Due to the criminal proceedings, the SCR Panel were advised by the Police that it was not appropriate to engage the parents or extended family in the process of this SCR. In addition, both parents were in receipt of support in relation to mental health issues and there was a concern that information from the SCR may impact negatively upon their health. 5.2. The decision regarding family engagement was reviewed following the conclusion of the criminal proceedings. Both parents were contacted but did not wish to contribute to the SCR. 6. Analysis including Themes arising from the SCR 6.1. Analysis of the case against the key issues: 6.2. With regard to the mother: • Support received before and after the birth of Child H • Any assessments undertaken of her mental health • Her role as a carer for the father and the impact of this upon her parenting and/or mental health • Her presentation and practitioner’s perception and analysis of this 6.3. M received routine support from midwifery and health visiting services. She was seen by different midwives and although it was recorded that she was F’s carer, there was a lack of assessment with regard to the impact of this upon her and her care of the children. 6.4. With regard to the support provided by the health visitor, at the time cases were initially classed as either being ‘Universal’ or ‘Safeguarding’. CHILD H’s case was held within the Universal caseload therefore suggesting that no additional needs had been identified regarding this family. Placing CHILD H within the Universal caseload would result in the minimum required contacts. The agency report states that a number of indicators of need were highlighted during the new birth review visit conducted on the 14th February 2013 and during subsequent contacts, which would have suggested placement within the Safeguarding caseload and therefore resulted in additional intervention and support. 6.5. Following reconfiguration of health visiting caseloads to a 4 tier model (Universal, Universal Plus, Universal Partnership Plus and 20 NCSCB Submission Copy Safeguarding), CHILD H remained in the universal caseload. The agency report suggested that as more concerns were evident, such as the history of depression; full time carer responsibilities, lack of support and isolation, plus the care of a new baby and a primary school age child, transfer to the Universal Partnership Plus caseload was indicated, which would have prompted additional contact and the consideration of initiating a Common Assessment Framework (CAF). Initiation of a CAF would have facilitated a co-ordinated approach to supporting the family and would have created an opportunity for adults and children’s services to share information and fully consider the needs of the family. 6.6. In interview the health visitor stated that she had considered initiating a CAF, but perceived the only involved agencies as being herself and S1’s school and therefore believed that a CAF would not be effective. Of course there were other agencies involved but the focus appeared to be upon agencies involved with the children as opposed to the adults in the family. 6.7. Nottingham City has a Family Support Strategy and Pathway which was launched in 2011 including guidance for practitioners. This document is currently being refreshed. Both documents were developed in consultation with key partner agencies across the Children’s Partnership. The purpose of the Family Support Pathway is to ensure children and families receive the right help at the right time and highlight the level of support that may be needed by children and families from universal through to specialist services. The CAF is integral to the effective delivery of the Family Support Pathway, to ensure that the needs of children and families are assessed and identified earlier and that coordinated multi agency action plans are produced and implemented where needed. 6.8. The current Family Support Pathway integrates the CAF process and Nottingham City’s Access to (and exit from) Social Care protocols. This is in effect the threshold for services, although the message is that services need to be joined up and work together to provide a continuum of support rather than working in isolation. 6.9. It is evident from the chronology of this case that there was opportunity for a CAF to be considered. The assumption was made, erroneously, that there were too few agencies involved to make the process effective. This should not have prevented the assessment commencing in any event given that additional needs within the family had been identified. 6.10. The health visitor made informal enquires with the children’s centre regarding the involvement of a family support worker but was reportedly told that it was unlikely that the threshold for this service would be met. In addition, she made a referral to Homestart and was told that they did not have any spaces and were struggling with funding 21 NCSCB Submission Copy issues. The health visitor shared that she felt blocked at every turn. She reflected that although she was concerned enough to want to ‘unblock’ the issues, she did not consider moving the case into the safeguarding tier or discussing the case with her safeguarding manager. This would appear to be due to the fact that the issues were deemed to be support rather than safeguarding issues. In addition, the health visitor was reassured when M informed her that the situation was much improved. When a space later came up at Homestart, the health visitor declined the service for the family feeling that it was no longer required. 6.11. With regard to M’s mental health, M disclosed a history of depression and anxiety to a number of professionals. This included during the new birth review visit undertaken by the health visitor. However this was not explored further. Health visitors are required to complete the maternal health needs assessment at the new birth review, however this was not done. Completion of this would have allowed for further exploration of maternal mental health needs. 6.12. The NHS Direct Nurse Advisor was extremely concerned regarding M’s mental health and was proactive is raising her concern. However, the agency report indicates that a record for M should have been created and a fuller and formal assessment of her mental state should have been carried out using assessment tools from the NHS Direct mental health training and by use of an appropriate algorithm. Had the paranoia algorithm been used, then the likely outcome would have been to attend the Emergency Department as soon as possible. 6.13. The GP was contacted by the Nurse Advisor and promptly spoke to M by telephone, who declined a home visit. It is recorded by NHS Direct that the GP was to liaise with the health visitor but this did not occur at this stage or at any point during CHILD H’s life. Whether the GP should have undertaken a home visit in any event given the severity of concern raised by the Nurse Advisor has been debated as part of this SCR. Given the capacity of GPs, and more importantly the telephone assessment the GP completed of M, this was an unlikely outcome. 6.14. During the visit undertaken on 20th March 2013, M disclosed to the health visitor that she was feeling lost and frightened and spoke of having her children placed into foster care for a month. The health visitor was informed of M’s admission to hospital the previous day which she assessed as being as a result of a physical manifestation of stress. M stated that the GP had prescribed her medication for panic attacks. As a result of the discussion, the health visitor provided M with the contact details for the ‘Let’s talk wellbeing’ and the family Information Service in order that M could obtain additional support. It is queried within the agency report whether M’s capacity and motivation to be able to self-refer to services and ask for support was considered given that she was presenting as being at crisis point. This was also 22 NCSCB Submission Copy further opportunity for a discussion between the GP and the Health Visitor but this did not occur. 6.15. In interview, the health visitor spoke of the difficulties she experienced in collaborative working with the GP. She felt that this was further hindered by the fact that the surgery did not have a practice manager, who might act as intermediary; the surgery had never had a linked health visitor before and she did not feel as though the role of the health visitor was embraced within the surgery. 6.16. The GP prescribed M Lorazepam for panic attacks. In interview the GP stated that M had said she had taken Lorazepam when anxious previously and this had worked for her. This discussion appeared to be the basis of the drug choice. F was also prescribed the same medication for lung disease. 6.17. Lorazepam is a benzodiazepine, a minor tranquiliser. Lorazepam is a very short acting drug, with almost immediate effect when put under the tongue, and peak effects 90-120 minutes after swallowing a tablet. This makes it the first choice for the symptoms of breathlessness and the panic that this causes in end stage lung disease. Side effects include amnesia, and paradoxical effects of increased agitation. Withdrawal can cause a long list of symptoms including anxiety, insomnia, tingling fingers and toes, and psychosis. 6.18. M was prescribed Lorazepam, in increased numbers, without being seen by the GP and for a period much longer than that recommended in the guidance issued by the BNF (British National Formulary). There were gaps in the prescriptions although it is unknown whether she was using F’s medication at other periods. It is clear that they were at one stage attempting to obtain large quantities of the drug from the GP, apparently stock-piling, to take back to America but these prescriptions were not honoured. There is no evidence within agency records of any suggestion of drug dependency however closer monitoring by the GP, given the concerns regarding M’s wellbeing and the fact that she had a young infant at home, should have occurred. 6.19. It has been suggested within this SCR that M became more stressed when F was in hospital, suggesting that he brought stability to the family and was helpful to M rather than a burden to her. Indeed, both episodes of deteriorating mental health occurred whilst F was in hospital. This does not appear to have been a factor that was considered by the professionals involved with the family during the scoping period. 6.20. With regard to M’s mental health on 31st August 2013, it has been reported that officers from both police forces were satisfied that M was emotionally well and that there were no indicators of concern. The officers all comment that M was loving and attentive to CHILD H who appeared well cared for. Officers spent considerable time with M and 23 NCSCB Submission Copy CHILD H, and did not have any concerns about her current mental health state or her ability to care for CHILD H. At the practitioner panel, officers shared that they spoke with M regarding what support she felt that she needed at home, and she stated that provision of child care, such as a babysitter, would allow her to return to pilates or enable her and F to spend time together. At no stage did officers feel that this was a family in crisis. 6.21. It has been raised within the SCR, including at the practitioner panel that the details of the referral made to children’s social care in March 2013 were not shared with the police on 31st August 2013. However, given that this referral resulted in no further action and there had not been any subsequent referrals, it is unlikely that this would have altered the professional views formed that day. The record of the referral has been viewed and it is clear that this did not indicate an overly worrying picture. 6.22. Given that 31st August was a Saturday; information could not have been easily obtained from health services, such as the GP and health visitor. This does highlight the limitations of provision by some agencies at weekends and out of office hours. There is a lack of clarity regarding how information is obtained out of hours and outside of the remit of the child protection process where issues of consent come in to play. Work is being taken forward to address this. 6.23. With regard to M’s role as the carer and the impact of this upon her parenting and mental health, it is clear that this was unassessed by all of those professionals in contact with the family. The chronology of this case has highlighted that there were a number of opportunities to ask further questions or enquire as to the demands upon M as a carer. Even without this exploration, the facts indicated that this was a mother with considerable demands placed upon her. There is some evidence of the parents declining support and returning equipment but there was no exploration of the reasons for this, and there appeared to be an assumption that M was coping with her caring responsibilities. Critically, consideration was never given to referring M for a carers assessment to be completed by Adult Social Care. This would have identified any support needs that M had in her role as carer for F. Those attending the practitioner panel, including staff from both adult and children’s services, as well as the health visitor in interview; all openly shared that they were not aware of carers assessments and what they consisted of; their purpose etc. It is therefore unsurprising that a referral for a carers assessment was never made. 6.24. The health visitor discussed a referral to the Carers Federation but it would appear that a referral was never made, no doubt due to M reporting an improved home situation. A referral to the Carers Federation could have provided support to M and informed her of her right to a carer’s assessment. 24 NCSCB Submission Copy 6.25. With regard to M’s presentation to agencies, she presented positively to all those agencies that had contact with her. M was described as very involved in the care and decision making around care and treatment of F, and appropriate in the care of CHILD H and S1. The health visitor described M as very caring, welcoming and child focused in her discussions. The family have been described as very together as a family unit. The school reported that M was always well presented, well groomed, attended parents evenings and liaised well with the class teacher. At the practitioner panel, M was described by the practitioners in the following terms: calm; articulate; sensible; ‘alternative’; well dressed; confident; coherent; loving; positive in attitude; a decision maker; friendly. Such positive presentations undoubtedly served to reassure practitioners that all was well. 6.26. With regard to the father: • His role within the family including his occupation and beliefs • His physical and mental health and any assessment of the impact of this upon the safety and welfare of the children • His presentation and practitioner’s perception and analysis of this 6.27. There is very little information with regard to F. Although he had a number of services involved with him in his own right given his heath needs, these services focused upon him as an elderly patient as opposed to a father with caring responsibilities. 6.28. It is not evident from the information gained from this SCR, what role F played within the family. It is known that he had reduced mobility and had a bed in the living room. He was dependent upon M for physical care. The role that he played as a parent is assumed to be minimal but this was not assessed by professionals working with the family and there is no evidence of respectful challenge to his responsibilities as a parent. There is however evidence to suggest that he was a great emotional support to M, and that she struggled when he was away from the family home due to hospital admissions. The GP’s view was that when F was seen with M and both children, he seemed to have a good relationship with all of them. 6.29. With regard to F’s occupation and beliefs, it is recorded that he was a spiritual healer but what this meant in practice was not ascertained. Health visiting paper records for S1 indicate that both parents occupation was recorded as ‘Spiritual Teacher’. F was recorded as being retired but previously working as a gambler and a spiritual leader within M’s pregnancy booking records. What this may have meant in terms of family functioning and family culture/norms is not known. 6.30. F had lung disease and as such was seen frequently by health professionals. F requested the Emergency Ambulance on a frequent 25 NCSCB Submission Copy basis for his medical condition, however, not enough to trigger action as an EMAS High Volume Service User (HVSU). Although F did not meet the criteria of HVSU, it has been suggested that calling 999 for an emergency response on numerous occasions to be treated on scene and decline hospital attendance indicated that he was potentially not managing his symptoms at home. The fact that F declined admission may have been linked to the emotional support provided to and required by M, although there is also evidence of him declining other home based support services. 6.31. There is no evidence of concern with regard to F’s mental health. 6.32. Information from the hospital indicates that assessments of F were primarily focused on his role as a patient with chronic ill health that was dependent on his wife for care. There was awareness of the pregnancy and subsequently (after the birth of CHILD H) that he had a young child but there was little focus upon him as a father. 6.33. From discussions with practitioners present at the practitioner panel, it was established that professionals would not have routinely asked a patient of F’s age about having dependent children as it is unusual in this patient group. 6.34. The health visitor described F as articulate and bright, interested in discussions and appeared involved in family decisions. She observed him to play with CHILD H. 6.35. With regard to the family: • Evidence of domestic stress relating to parenting, health or finances • Opportunities for early intervention, in particular during March 2013 • Quality of assessments, decision making, referral and communication • Responses to events on the weekend of Child H’s death 6.36. There was some evidence of domestic stress within this case, although not to the extent that a safeguarding response was felt to be required. At no stage did there appear to be concern regarding the parenting of the children. As stated previously, there was a lack of assessment of the impact of parental physical and mental health upon the parenting of the children, although the outward signs appeared to be positive. S1’s period of poor school attendance was viewed in the context of M having just had a baby and being unable to get S1 to school. Although there is some mention of financial difficulties, these were not raised as any area requiring support. It is evident that the family were isolated, and that M did not have a wide support network. 26 NCSCB Submission Copy 6.37. It has been established that there were opportunities for early intervention in March 2013, following the contact made with NHS Direct, and subsequently by the GP and health visitor, and then again, following M’s admission to hospital where it became apparent that she was under stress and had sole care of two small children. A CAF would have been a way forward to share information and coordinate support. A referral for a carer’s assessment would have been appropriate at several stages within the chronology but the professionals who had contact with the family were not aware of the process. At the practitioner panel, acute medical staff shared that they did not pick up on the vulnerabilities within the family; and felt that this was due to a lack of familiarity in dealing with social issues. 6.38. No assessments were completed of the family. With regard to referrals, NHS Direct made an appropriate referral to Children’s Social Care in March 2013. Although the screening and duty worker spoke with the health visitor and school, they did not speak with the GP or the family, although it would have been pertinent to do so. As stated within the children’s social care agency report, from the information provided the decision that no further action was required by children’s social care was an appropriate decision. However given the number of services involved and the concerns surrounding the family an assessment under the Common Assessment Framework would have been appropriate at this stage. There was no discussion of this with the health visitor. 6.39. The outcome letter sent to agencies informing them of action to be taken following their contact/referral was only sent to NHS Direct following their referral in March 2013. A copy should also have been sent to School, the Health Visitor, the GP and parents. 6.40. With regard to the referrals to children’s social care on 31st August 2013, there is no record of a referral from EMAS. Decision making in respect of the events of that day were made in conjunction with the police. The children’s social care agency report has highlighted that there was an absence of analysis recorded in relation to decisions made and highlighted that as events took place at the weekend the Emergency Duty Team and the Police would have been unable to liaise with School, the GP or the Health Visitor to ascertain their views. The Emergency Duty Team undertook Carefirst (social care database) checks for current and historical records and found two records from January 2013 (regarding potential need for a carer for F when M gave birth) and March 2013. No concerns had been raised with Children’s Social Care in the six months subsequent to the referral in March 2013. 6.41. With regard to communication, there is evidence within the chronology of communication between agencies such as between NHS Direct and social care, police and EMAS. There was robust communication between the two police forces involved on 31st August 2013. 27 NCSCB Submission Copy 6.42. However communication between the health visitor and the GP did not occur. This would have been a good opportunity to share information especially in light of the ongoing prescriptions of lorazepam to M. 6.43. Practitioners reflected upon the barriers to communication with GPs and felt that there was a physical barrier in that they are often busy in surgeries and that from this a perception has developed whereby it is hard to talk to a GP, so professionals cease trying. Although practitioners were generalising, given the knowledge that GPs have, and information to which they have access, this is an area of learning that requires further exploration. 6.44. The responses to events on the weekend of CHILD H’s death are recorded within the chronology. It is evident that the two police forces committed significant resources to ensuring that M and CHILD H returned to Nottingham safely. This was not due to concern regarding M’s mental health rather a concern that they had been reported as a high risk missing case and needed to return to Nottingham without delay as S1 was at the police station. At the practitioner panel it was discussed whether the police would have taken a different course of action had they been in possession of all of the information known about the family. The outcome of the discussion was that this was not realistic as no one agency held all of the information, compounded by the challenges of information sharing between agencies at weekends. In addition, this is a deliberation with the benefit of hindsight and knowledge of the final outcome. What is evident from the chronology is that agencies were not overly concerned regarding the family and it therefore follows that even had all the information been known to the police, the decisions made between themselves and EDT were highly likely to have remained the same. 6.45. With regard to the capacity of EDT to undertake visits to families out of hours, visits will be undertaken where there are child protection concerns. Given that EDT is operated by two workers there is no capacity to undertaken support visits. It is unhelpful to speculate in what a home visit may or may not have achieved that evening. It is clear however that requests and arrangements for visits to families out of hours, including those undertaken by the police, need to be clearly recorded, explicit and purposeful. This is an area that will require further development. 6.46. With regard to the drop in S1’s school attendance, the school decided to adopt a supportive rather than punitive approach given the family circumstances. S1 was offered pastoral care within school, including positive reinforcement. The school engaged S1 in an arts project at the local art gallery and submitted her work to competitions. 6.47. With regard to agency involvement in the case: 28 NCSCB Submission Copy • How sensitive were practitioners to the needs of Child H and how equipped were practitioners to work effectively with the family? • Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability within the family? • What was in place to ensure management accountability for decision making and management oversight of the case? Was this effective? • Was work consistent with the agency and the LSCB’s policy and procedures? Were professional standards met? • Were staff involved trained to the appropriate level in safeguarding? • Were there any contextual issues that impacted upon work in the case i.e. staffing, capacity, sickness, organisational change, resources? • Is there evidence of positive practice? 6.48. This SCR has established that there was a lack of thought given to the impact of M and F’s functioning upon the parenting that CHILD H and S1 were receiving. There were no reported concerns regarding CHILD H, who presented as a well-cared for and thriving baby. This gave professionals the impression that even in times of stress; M was able to meet the needs of the child. 6.49. The focus of the discussions between agencies in relation to CHILD H tended to be focused on the mental health needs of M and the physical health needs of F and in the main did not include an assessment or analysis of the impact of the adult issues on parenting capacity and the experiences of the children. Within this case, the large number of different professionals, particularly with the midwives caring for M and the heath professionals caring for F; may have contributed to the lack of exploration of support needs or early intervention. 6.50. With regard to whether practitioners were equipped to work effectively with the family, this SCR has prompted discussion regarding recognition of symptoms of emerging mental health issues. Student health visitors receive training on postnatal depression within their degree course, however once in practice, training in relation to the detection and management mental health issues is not included within the core training competencies for clinical staff working within the health visiting service. The health visitor in this case had not undertaken any mental health training since qualifying. Mental health training is now being rolled out to health visitors with Nottingham City Care Partnership, using the Parental Mental Health package developed by the Institute of Health Visiting. 29 NCSCB Submission Copy 6.51. There was opportunity for more robust monitoring of M by her GP but this did not occur, even when it would seem probable that her mental health was a continued concern or indeed deteriorating. 6.52. With regard to whether practice was sensitive to the racial and cultural identity of the family, it would appear that M’s nationality was not given a great deal of attention. As stated in the agency report for the CCG, her fluent English and white ethnic group may have led practitioners to minimise her non-British cultural background and whether this impacted upon her willingness to disclose any previous mental health problems. It would appear that practitioners were influenced by the positive presentations of the family, including material presentation such as the home conditions within which the family lived. 6.53. With regard to management accountability, it has been established that the health visitor did not escalate her concerns to her supervisor. The NHS Direct Nurse Advisor did seek guidance from a senior clinician; however despite being advised to open a separate record for M she did not do so. The initial contact completed by the children’s social care screening and duty team worker was not signed off by a team manager, as was the requirement although this was unlikely to have made any material difference. Relevant senior officers from the two police forces were involved in the decision making on 31st August, although the children’s social care EDT worker did not raise the case with an on call manager, probably due to the fact that action was not taken by EDT and there was no need to provide alternative accommodation for S1 given M’s return to Nottingham. 6.54. The SCR has not indicated that there was a failure to comply with policy and procedure and professionals involved were all trained to the appropriate level of safeguarding. 6.55. The SCR has not indicated that agencies, apart from the health visitor, were impacted upon by any contextual issues such as staffing, capacity, sickness or organisational change. The health visitor however was managing 200 cases yet working only 2 days a week. This meant that she spent 1.5 days on her caseload as 0.5 was spent in clinic. In interview the Health Visitor spoke of being very busy and that although her team were supportive she had minimal contact with them given her working hours. 6.56. With regard to examples of positive practice, the efforts of the two police forces on 31st August 2013 are to be commended. The decision to transport M and CHILD H to Nottingham would have had a significant resource implication. In addition, the NHS Direct Nurse Advisor made great efforts to seek support for M. 6.57. With regard to the multiagency system: 30 NCSCB Submission Copy • Whether the issues identified above have resonance with other similar cases • What the case tells us about any underlying patterns that either support good practice or create conditions in which problematic practice is more likely 6.58. There have been a number of cases where the understanding and use of the Common Assessment Framework has been an issue of concern. This has been taken forward as part of the refresh of the Family Support Pathway. Practitioner understanding of early help needs to be improved, and the re-launch of the Family Support Pathway is the ideal opportunity to achieve this. Within this case, the practitioners shared that the barriers to undertaking a CAF included a lack of peer support from colleagues in other involved agencies and that the CAF was not perceived to add value. This is important learning to be taken forward. It has also been raised that there is a lack of a coherent CAF training programme within agencies which no doubt impacts upon professional confidence in completing a CAF. 6.59. In addition, a lack of understanding of carer’s assessments has featured in SILPs and a Domestic Homicide Review undertaken locally. Despite there being a carer’s strategy within Nottingham City, practitioner understanding of this would appear to be extremely limited. 6.60. Within this case, the practitioners identified that they were not aware that carer’s assessments existed, what they were or how they could access one, the exception being at the Acute Hospital who deal with mainly elderly patients who have elderly spouses or partners. Even in the knowledge of carer’s assessments, these practitioners still wondered if they would have considered a referral in the case of M as she was young and fit in outward presentation. The definition of a carer plus understanding of additional responsibilities, especially those of caring for dependent children, is learning that needs to be taken forward. 6.61. With regard to underlying patterns that create conditions in which problematic practice is more likely, this SCR has explored the barriers to a whole family approach. It was felt by practitioners involved in the case that the focus upon their primary client group had the greatest impact. For example, community adult services will hold information on file about others living in the household but this information is not used to ask wider contextual questions given that their role is very task focused and has a narrow remit. However, acute services working with adults could not see any major blocks to asking about the family context in routine paperwork, including any dependants or triggers for additional need. 7. The experience of the child 31 NCSCB Submission Copy 7.1. There has been considerable discussion regarding the experiences of the children, especially during the weekend of CHILD H’s death. Although CHILD H appeared well cared for and content in her mother’s care, the circumstances within which she arrived in London were unusual. Professionals focused upon the presenting situation, rather than the context within which events were occurring and the perspective of the child within that. 7.2. The SCR panel has deliberated whether contact with emergency health professionals in London might have been an appropriate consideration although it is noted that given M’s presentation at that time, this would have been unlikely to alter the sequence of events. A discussion involving health rather than one held just between social care and the police would have been a sensible approach however, and potentially might have brought a greater focus upon the experience of the child and allowed opportunity to gather information in order to better understand the antecedents that led to the situation within which Child H and M found themselves. 8. Expert Opinion 8.1. Dr Margaret Oates, Consultant Perinatal Psychiatrist, has considered all of the agency information provided to the SCR and submitted her written comments. These comments have helpfully enabled the SCR panels to fully consider the issue of M’s mental health and whether professionals involved should have been more alert to concerns. Dr Oates has identified key events where a mental health assessment would have been a pertinent consideration, such as following admission to the Stroke Unit and when arriving in London with CHILD H. It is recognised however that M did not present to non medical professionals as mentally unwell. With regard to the interventions of the GP, Dr Oates’ view is that the fact that M appeared to be fluctuating and free from evidence of symptoms when seen, was taken to be evidence that she was not seriously mentally ill. Indeed, Dr Oates found that all the professionals involved appeared to make their judgements upon the cross-sectional evaluation of M’s current presentation and functioning. 8.2. On the basis of the written information made available to Dr Oates, her expert opinion is that is very unlikely that M was suffering from a postpartum onset depressive illness often referred to as postnatal depression. Her view is that it is more likely that M had a more longstanding serious mental illness, possibly a chronic psychotic state which she was able to contain by her unusual lifestyle, which might have merely seemed eccentric to others, except at moments of great stress. Dr Oates has suggested that this would explain her fluctuating presentation and the fact that on occasion of contact with professionals she appeared to have none of the symptoms that a non-32 NCSCB Submission Copy specialist would regard as indicative of a psychosis i.e. she did not appear to have hallucinations or thought disorder. Any evidence of delusional thinking or unreasonable beliefs would only have been evident if the reasons had been explored and then probably only by an experienced mental health practitioner. Dr Oates’ expert opinion is that it is probable that M was psychotic at the time that CHILD H died and probable that she had been for some time. 8.3. The author has had sight of the psychiatric assessment of Dr M di Lustro, Consultant Forensic Psychiatrist, completed in respect of M during the criminal proceedings. The assessment details that M was guarded in the information that she would provide and was adept at containing her symptoms, having done so when she was mentally unwell and seeing professionals including her own GP after the birth of CHILD H and with police officers who escorted her back to Nottingham from London and were in her home just a few hours before she killed CHILD H, believing her fit to care alone for her children. 8.4. It was outlined that M has previously sought to avoid acquiring a label of having mental health problems and chosen not to report her previous history to community services. 8.5. The psychiatric assessment has described a diagnosis of: a) Schizoaffective disorder, for which M had avoided treatment through her lifestyle choices and the use of alternative coping strategies, such as meditation and mindfulness skills. b) Personality disorder c) Mental and behavioural disorders due to use of alcohol-dependence syndrome. M has denied excessive alcohol use in recent years, although she was described to be intoxicated following CHILD H’s death. 8.6. It is the expert opinion of Dr di Lustro that M was suffering from symptoms of this mental illness and personality disorder at the time of CHILD H’s death. 9. Changes in Practice and Actions Already Taken How is the wider multi-agency system operating now? 9.1. The following bullet points outline the many changes in practice that have now occurred. 9.2. Within NUH: • Recommendation with regards to staff making enquiries with regards admission documentation incorporating a question on Carer responsibilities. Responsibility for this action has been allocated to the NUH Documentation Group and will become part of the admission documentation (timescales to be confirmed). Safeguarding Champions within NUH have been informed of the 33 NCSCB Submission Copy importance of asking this question and the Champions will disseminate to ward areas • The letter from Midwives to GPs following an antenatal booking includes all relevant history and safeguarding information • Paediatric Liaison Health Visitors have attended Safeguarding Champion Meeting April 2014 to Staff on role their and function within NUH. 9.3. Within Social Care: • As of October 2013 all Initial Contacts must be authorised by a Team Manager. Before the Manager will authorise the form they will need to see that checks have been undertaken with the appropriate health agency (GP, Health Visitor, School Nurse, and Mental Health Midwife), School, probation and housing services. The Manager will want to know when the child was last seen, whether the parents have been spoken to and that all concerns raised within the contact have been followed up and that it includes information on previous contacts, referrals and interventions by Children’s Social Care. • A step by step guide has been developed for Screening and Duty practitioners outlining information that needs to be obtained and from whom when managing a contact/referral. Furthermore each screener has a prompt guide outlining the things that they need to take into account. This includes how many referrals there has been in the last twelve months, previous Child Protection Plans and concerns, family support, mental health, learning disability, domestic abuse, alcohol and or drug misuse, whether there is a CAF in place and views of other professionals. • A system has been established that when a contact/referral has been made and contact has not been possible with either a parent (as there are no telephone details) or an agency (due to school holidays) a note will be placed in the diary as a prompt to contact the parent and school when they reopen. Furthermore a letter will be sent to the parent requesting that they contact Children’s Social Care. This system is currently a paper diary system the possibility of this becoming an electronic system is being explored. • In January 2013 the Local Authority began rolling out a workforce training programme on Signs of Safety; alongside the training programme changes are being made to processes and documentation to support the roll out. The framework of Signs of Safety supports practitioners and referring agencies to analyse complex information focusing them to be clear about; what they are worried about (danger/risks) what’s going well (safety and strengths) what needs to happen and how safe is the child on a scale of 0 - 10, with 0 being no signs of safety immediate action required by Children’s Social Care and 10 being high levels of 34 NCSCB Submission Copy safety no further action needed. Referrers and workers are required to provide a rationale for their concerns. • In December 2013 the Contact and Referral Form, Initial and Core Assessments and CAF forms (used by Family Community Teams) were revised to include the Signs of Safety framework, which focuses the referral concerns to be about the impact to the child. The new single assessment documentation implemented on 1st April 2014 also reflects these changes. Supervision case discussion records have also been revised to include Signs of Safety, thus allowing practitioners and Team Managers to monitor if change is happening and whether or not safety is increasing. These changes keep the voice of the child at the heart of practice. • In November 2013 the new service Children and Families Direct was launched. All new calls relating to children and families go to this service, which directs callers to the most appropriate service for their query/need. In relation to cases involving safeguarding concerns, these are referred straight onto the Screening and Duty Team. It is anticipated that the volume of calls to Duty and Screening will reduce as a result of this new service. 9.4. Within Nottingham CityCare Partnership: • Nottingham CityCare have invested in improving both the number of CAF’s initiated and practitioner knowledge regarding its use. In addition to the development of a CAF policy, guidance and training, the CityCare safeguarding team have performance management systems in place with regard to CAF. • A two day training course is being delivered to all band 6 and 7 health visiting staff. To date, 3 sessions have been delivered resulting in 25 staff attending. The programme is delivered by a small team who have been trained to use the Parental Mental Health package developed by the Institute of Health visiting. CityCare are using the Edinburgh Postnatal Depression Scale tool, along with the Wooley questions as a precursor if required. • A pathway for strategy discussions between Health, Police and Social Care which is concordant with Working Together to Safeguard Children 2013 has been developed. • A Serious Incident Review group has been developed within CityCare, chaired by the Named Nurse for safeguarding, whose primary task is to embed the learning from Serious Case Reviews and Serious Incident Learning Processes and ensure that recommendations and action plans progress in a timely manner. In light of the learning from this review, all services are required to 35 NCSCB Submission Copy implement routine questioning regarding caring responsibilities and a pathway for the referral for Carer’s assessment. • CityCare have introduced a new model of strengths based working with families (based around the ‘Signs of Safety’ model) which will facilitate discussions with children, parents and carers in a child focused way by the usage of a number of tools that are developed to capture the child’s thoughts and feelings. All Health Visitors and School Health Nurses are to receive this training in line with the implementation plan. • CityCare has reviewed and transformed the Safeguarding supervision model within the organisation. At the beginning of the safeguarding supervision, the Universal Partnership Plus caseload is reviewed to ensure that all families within the caseload have a CAF in place and where there is not a CAF, a rationale is documented. 9.5. Within NHS Nottingham City: • The review has not been able to provide an explanation or understanding of the clinical rationale for the decisions made in relation to the prescribing of Lorazepam for M during March – July 2013. As this matter has not been resolved, a referral has been made to the Medical Directorate of the Derbyshire and Nottinghamshire Area Team of NHS England in order that it can be addressed. 10. Conclusions: 10.1. It is evident that this was a family who experienced periods of stress and M in particular, had considerable demands placed upon her. The impact of this family environment upon the children was unassessed and as such there is little sense of the child’s experience. Outward signs were that there were no concerns regarding CHILD H and only minor concerns regarding S1 which were being addressed by school. 10.2. It has been suggested that the nature of M’s mental illness; with such a seemingly rapid recovery on two occasions (March and August 2013) served to mislead professionals regarding its severity. The expert psychiatric opinion has indicated that M was suffering from a long standing psychotic illness and had become adept at concealing her symptoms. 10.3. There were opportunities to provide early intervention and support to this family. This would of course have been reliant upon their cooperation and there is evidence of the family declining support and not acting upon advice given. There was also opportunity for closer monitoring of M by her GP. 36 NCSCB Submission Copy 10.4. Even with the benefit of hindsight, and in the knowledge of all of the agency information, it is unlikely that this case would have reached the threshold for safeguarding activity during CHILD H’s short life. However key learning has been established that is relevant to families, such as the barriers to completing a CAF, the lack of understanding of carer’s assessments and the perceived barriers to engaging effectively with GPs. In addition, the interface between the police and the Social Care emergency duty team has highlighted the need for greater clarity regarding requests for visits undertaken by both agencies out of hours. 10.5. This learning will be taken forward as part of the recommendations arising from this SCR. 11. Recommendations 11.1. Each agency that has completed an agency report has developed recommendations for their agency. These are attached as Appendix 2. The implementation of these recommendations is monitored through the NCSCB. 11.2. The following recommendations have been made for Nottingham City as a result of learning from this Serious Case Review. They reflect the analysis and learning points, taking into account progress already made. A Strategic Action Plan has been agreed to implement these actions and ensure that services are developed as a result of the learning from this case. This is attached at Appendix 3. This action plan will be monitored through the SCR Standing Panel, with further assessment of the evidence and impact on practice being undertaken by the NCSCB Quality Assurance Group. Recommendation 1: The revisions to the Family Support Pathway need to address: • the barriers to providing early help including specific guidance on how to initiate early help • guidance to adult services in contact with families • the role of GPs in the context of family support and safeguarding • whether early help processes are robust enough to encompass a whole family perspective • specific reference to the impact of parental health factors upon the parenting provided to dependent children. Recommendation 2: The Nottingham City Carer’s strategy needs to be meaningful to practitioners working with families and as such, awareness needs to be greatly improved. A referral pathway for carers assessment should be cascaded amongst agencies. Recommendation 3: NCSCB need to be assured by agencies that practitioners are equipped, in accordance with the nature of their role, to work 37 NCSCB Submission Copy confidently with cases where there are a number of issues of concern. The Excellence in Safeguarding tool developed by the NCSCB is an ideal mechanism to ensure this. Recommendation 4: Heath visiting services should ensure that any concerns regarding a parent’s mental health are routinely shared with the GP. Recommendation 5: NCSCB need to be assured by the relevant agencies that arrangements and requests for information exchange and visits to family out of hours are robust, clearly recorded, explicit and purposeful. Recommendation 6: Practitioners working with families need to recognise that the presentation of families can influence judgement and present an overly optimistic or positive picture. Practitioners require skills to be able to unpick what may lie behind the presentation and focus upon the child’s experience. A culture of professional curiosity needs to be embedded. Glossary of Terms Term Definition LSCB Local Safeguarding Children Board NCSCB Nottingham City Safeguarding children Board SCR Serious Case Review DASH RIC Domestic Abuse, Stalking and Honour based Violence risk identification checklist EDT Emergency Duty Team NUH Nottingham University Hospitals NHS Trust 38 NCSCB Submission Copy COPD chronic obstructive pulmonary disease EMAS East Midlands Ambulance Service Appendix 2: single agency recommendations Nottingham CityCare Partnership 1. Health Visitors should write a clear summary on SystmOne of any concerns relating to a child or a carer/parent before they temporarily leave or transfer to another caseload. The HV should record on SystmOne that they have given a formal handover to the new HV. 2. Regular review of caseloads within children’s services, by the caseload holder, should occur to ensure that children, young people and families are receiving the right level of intervention according to their needs. 39 NCSCB Submission Copy 3. Mental health awareness training should be included within the core training competencies for clinical staff working in health visiting teams. 4. All health assessments undertaken within Nottingham CityCare Partnership should enquire about caring responsibilities and potential issues relating to this role, as standard. 5. The role of carers and a carer’s assessment requires strengthening across Nottingham CityCare Partnership. All staff should be aware of when to offer carers assessment and how to achieve this. A Nottingham CityCare Partnership strategy for carers should be developed. 6. All clinical staff working with individuals living with long term conditions should be confident and competent in assessing the impact of the long term conditions on emotional wellbeing. Enquiry regarding the emotional wellbeing should be included in assessments as standard. EMAS No recommendations were made Metropolitan Police No recommendations were made NHS Direct The recommendations relate to the individual Nurse Advisor who has subsequently left the organisation. No wider learning or action has been identified. Nottingham University Hospitals NHS Trust 1. Staff should explore wider family issues, obtaining and documenting a clear history, considering the impact of this information on the welfare of the family including any children or other dependents and taking actions as appropriate. NHS Nottingham City 1. Information and a reminder to be issued to all GP practices in relation to the use of Benzodiazepines for managing anxiety 2. An audit to be undertaken in Primary Care of postpartum woman, up to one year post delivery, when anxiety /depression medication are being prescribed to assess compliance with guidelines for managing anxiety and depression. 40 NCSCB Submission Copy 3. To include “Think Family” strategies within GP training sessions. The effectiveness of the input will be monitored within the GP leads meetings on a quarterly basis by exploring case histories and discussing solutions to use in practice. Nottingham City Council Children’s Social Care 1. Where a Contact or Referral results in there being no further action required by Children’s Social Care and it is felt that a CAF is needed this option box is ticked in the outcome letter sent to key agencies not just the referring agency 2. Parents and agencies must be contacted when gathering information for a Contact or Referral. 3. The protocol for the Children’s Assessment needs to outline practice expectations in responding to Initial Contacts and Referrals. 4. Children’s Social Care records need to include the rationale for decision making including planned follow up actions. For EDT this should include the rationale for safe and well checks not being conducted by EDT 5. This recommendation is for the consideration of the Overview Report Author. Given that there might have been a number of adult health services involved with F, it would be helpful if there was consideration for a strategic recommendation that those providing adult services should consider the needs of children, including whether parenting is impacted in situations where additional support has been required. Ideally this would include guidance on factors that may increase domestic stress or vulnerability. Nottinghamshire Police 1. If there is any doubt or concerns around the mental health of an individual then an expert medical assessment should be sought in all cases particularly where there are safeguarding concerns around the capability to care for a child. 2. Improved safeguarding and vulnerability training for front line staff. In August 2013, Nottinghamshire Police commenced a new one day training delivery to all frontline police officers and police staff (Response and Neighbourhood Policing Teams). The subject matter is ‘Vulnerability’ and aimed to support a holistic frontline approach to safeguarding and vulnerability, taking full consideration of mental health, substance misuse and domestic violence in both adults and children. This training has commenced and is on going. The training covers safeguarding adults and is the main focus of the training – it 41 NCSCB Submission Copy details what vulnerability looks like and includes the vulnerability triangle and the referral process in both the County and the City. 42 NCSCB Submission Copy DRAFT Appendix 3: DRAFT - NCSCB Strategic Action Plan Recommendations Each agency that has completed an agency report has developed recommendations for their agency. The implementation of these recommendations is monitored through the NCSCB. The following recommendations have been made for Nottingham City as a result of learning from this Serious Case Review. They reflect the analysis and learning points, taking into account progress already made. A Strategic Action Plan has been agreed to implement these actions this is attached below. This action plan will be monitored through the SCR Standing Panel, with further assessment of the evidence and impact on practice being undertaken by the NCSCB Quality Assurance Group. • The revisions to the Family Support Pathway need to address the: o Barriers to providing early help including specific guidance on how to initiate early help o Guidance to adult services in contact with families o The role of GPs in the context of family support and safeguarding. o Whether early help processes are robust enough to encompass a whole family perspective o Specific reference to the impact of parental health factors upon the parenting provided to dependent children. • The Nottingham City Carer’s strategy needs to be meaningful to practitioners working with families and as such, awareness needs to be greatly improved. A referral pathway for carer’s assessment should be cascaded amongst agencies. • NCSCB need to be assured by agencies that practitioners are equipped, in accordance with the nature of their role, to work confidently with cases where there are a number of issues of concern. The Excellence in Safeguarding tool developed by the NCSCB is an ideal mechanism to ensure this. • Heath visiting services should ensure that any concerns regarding a parent’s mental health are routinely shared with the GP. • NCSCB need to be assured by the relevant agencies that arrangements and requests for information exchange and visits to family out of hours are robust, clearly recorded, explicit and purposeful. • Practitioners working with families need to recognise that the presentation of families can influence judgement and present an overly optimistic or positive picture. Practitioners require skills to be able to unpick what may lie behind the presentation and focus upon the child’s experience. A culture of professional curiosity needs to be embedded. 43 NCSCB Submission Copy Outcome Recommendation Action By Whom Timescale (to be determined by SCRSP) Evidence 1 Barriers to families receiving early help will be removed Adult services and family GPs will have a clear reference point within the Family Support Pathway as to their role in family support and safeguarding. Parental health factors and the impact of these on dependant children will be effectively identified, considered and acted upon. The revisions to the Family Support Pathway need to address the: • Barriers to providing early help including specific guidance on how to initiate early help • Guidance to adult services in contact with families • The role of GPs in the context of family support and safeguarding. • Whether early help processes are robust enough to encompass a whole family perspective • Specific reference to the impact of parental health factors upon the parenting provided to dependent children. Revised Family Support Pathway to be completed CPB/NCSCB Impact evaluation of Family Support Pathway Quality assurance of CAF 2 Carer’s will be provided with appropriate support The Nottingham City Carer’s strategy needs to be meaningful to practitioners working with Review of dissemination and implementation of Carer’s strategy NCC Adult Assessment The number requests for carer’s assessments will 44 NCSCB Submission Copy Outcome Recommendation Action By Whom Timescale (to be determined by SCRSP) Evidence families and as such, awareness needs to be greatly improved. A referral pathway for carer’s assessment should be cascaded amongst agencies. Referral pathway available to practitioners including on line increase. Source of referrals for carer’s assessments will be reflective of the wider workforce. 3 Families will be in receipt of assessments that are holistic and inclusive of all of their identified needs NCSCB need to be assured by agencies that practitioners are equipped, in accordance with the nature of their role, to work confidently with cases where there are a number of issues of concern. The Excellence in Safeguarding tool developed by the NCSCB is an ideal mechanism to ensure this. Review of the implementation and usage of the Excellence in Safeguarding tool NCSCB All workers will apply the practice principles within the excellence in safeguarding tool in case management. 4 Parental mental Health needs are being appropriately identified and addressed within primary health Heath visiting services should ensure that any concerns regarding a parent’s mental health are routinely shared with the GP. Guidance is issued to health visitors and GPs reinforcing the need for communication City Care Partnership Early identification of parental mental health issues in evident within early help assessments 45 NCSCB Submission Copy Outcome Recommendation Action By Whom Timescale (to be determined by SCRSP) Evidence 5 Families in crisis are responded to effectively outside of office hours NCSCB need to be assured by the relevant agencies that arrangements and requests for information exchange and visits to family out of hours are robust, clearly recorded, explicit and purposeful. An information sharing protocol between the key agencies out of hours is established A protocol for safe and well visits is established Ratified by NCSCB Protocols established and embedded 6 Workers will look beyond the presentation of families in order to avoid making judgments that could unduly influence their assessment Practitioners working with families need to recognise that the presentation of families can influence judgement and present an overly optimistic or positive picture. Practitioners require skills to be able to unpick what may lie behind the presentation and focus upon the child’s experience. A culture of professional curiosity needs to be embedded. Partner agencies to ensure that relevant assessment skills training encompasses the learning from this SCR and explores the barriers to effective assessment of the parent NCSCB partner agencies Assessment skills training materials are quality assured by NCSCB 46 NCSCB Submission Copy |
NC043838 | Abduction of a 15-year-old girl in 2012, by her teacher, Mr K. Child G was involved in a sexual relationship with Mr K, which began around her 15th birthday. Mr K was found guilty of abduction and admitted a number of charges of sexual activity with a child under 16-years; he received a custodial sentence of 5-and-a-half-years. Concerns relating to Child G and Mr K's relationship were raised seven times with the school prior to the incident. Identifies serious concerns relating to school's actions, including: failure to identify the abuse and exploitation of Child G; optimistic assumptions and fixed thinking in relation to Mr K's behaviour; failure to hear concerns raised by students; failure to involve Child G's mother; insufficient recognition of Mr K's inappropriate use of Twitter to communicate with Child G; serious concerns with the ways in which information was recorded, stored, retrieved and provided for the review. Identifies procedural failings in police handling of allegations relating to inappropriate images of Mr K on Child G's phone. Makes various interagency and single agency recommendations covering: East Sussex Local Safeguarding Children Board, children's services, school and police services.
| Title: Child G a serious case review LSCB: East Sussex Safeguarding Children Board Author: Kevin Harrington Date of publication: 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. This report is the property of the East Sussex Safeguarding Children Board. Page 1 of 46 Kevin Harrington Associates Limited CHILD G A SERIOUS CASE REVIEW Kevin Harrington JP, BA, MSc, CQSW Date of publication: 16 December 2013 This report is the property of the East Sussex Safeguarding Children Board. Page 2 of 46 TABLE OF CONTENTS TABLE OF CONTENTS ............................................................................... 2 1. INTRODUCTION ...................................................................................... 3 2. ARRANGEMENTS FOR THE SERIOUS CASE REVIEW ....................... 3 3. METHODOLOGY USED TO DRAW UP THIS REPORT ......................... 5 4. A BRIEF CHRONOLOGY OF KEY EVENTS .......................................... 6 5. THE FAMILY ............................................................................................ 9 5.1 Child G ...................................................................................................... 9 5.2 Ms C .......................................................................................................... 9 6. THE AGENCIES ...................................................................................... 9 6.1 The General Practitioners ....................................................................... 9 6.2 East Sussex Healthcare Trust (Community Services) ........................ 10 6.3 East Sussex Healthcare Trust (Acute Services) .................................. 11 6.4 Sussex Partnership NHS Foundation Trust......................................... 11 6.5 Hastings & Rother Clinical Commissioning Group - Health Overview Report ........................................................................................................... 11 6.6 East Sussex County Council – Children’s Social Care Services ....... 12 6.7 Sussex Police ......................................................................................... 16 6.8 School D ................................................................................................. 20 7. KEY ISSUES .......................................................................................... 30 7.1 Why these events have led to a Serious Case Review. ...................... 30 7.2 The information provided to this review by School D ........................ 30 7.3 Recognising abuse ................................................................................ 31 7.4 Listening to young people .................................................................... 32 7.5 Working with parents ............................................................................ 33 7.6 Record-keeping ...................................................................................... 34 7.7 E-safety ................................................................................................... 35 8. GOOD PRACTICE ................................................................................. 36 9. SERIOUS CASE REVIEW PROCESS ................................................... 36 10. CONCLUSIONS: KEY THEMES, MISSED OPPORTUNITIES AND LESSONS LEARNED ................................................................................ 37 11. RECOMMENDATIONS FROM THIS SERIOUS CASE REVIEW ........ 40 11.1 Introduction .......................................................................................... 40 11.2 Recommendations to the East Sussex Local Safeguarding Children Board ............................................................................................................ 40 APPENDIX A: Composition of SCR Panel .............................................. 41 APPENDIX B: Details of the Chair of this review and the author of this report ......................................................................................................... 42 APPENDIX C: Terms of Reference for this Serious Case Review ........ 43 APPENDIX D: Recommendations from the agencies’ management reviews ...................................................................................................... 44 APPENDIX E: References ........................................................................ 46 This report is the property of the East Sussex Safeguarding Children Board. Page 3 of 46 1. INTRODUCTION 1.1 During 2012 a girl, Child G1, became involved in a sexual relationship with a teacher at her school, Mr K. Anticipating that this relationship would come to light, they left the country together. After just over a week they were detained by police. Child G returned to her family and Mr K was brought back to this country in custody. Child G was fourteen years old when the relationship began and fifteen when they left the country. Mr K was subsequently imprisoned as a result of criminal charges arising from these events. 1.2 These matters came to the attention of the Local Safeguarding Children Board (LSCB) in East Sussex, where the girl lived. The Independent Chair of the Board, Ms Cathie Pattison, decided in January 2013 to initiate this Serious Case Review (SCR). 1.3 The purposes of SCRs are set out in “Working Together2”. They are to establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and improve intra- and inter-agency working and better safeguard and promote the welfare of children. 2. ARRANGEMENTS FOR THE SERIOUS CASE REVIEW 2.1 A number of key steps needed to move the SCR forward could not be taken until criminal proceedings had been completed. Consequently, although the SCR was formally initiated early in 2013, it was not completed until December of that year, when those proceedings had been concluded and relevant people who had given evidence in the trial were able to contribute to this review. 2.2 The LSCB constituted a panel (the Panel) to manage and oversee the conduct of the review. The membership of the Panel is set out at Appendix A. In line with the guidance in place at that time two independent people were appointed in connection with the review: Mr Ron Lock, to lead the review, and 1 Despite the fact that this case attracted a great deal of publicity the SCR Panel judged that it would be inappropriate that this public document should identify the individuals involved. 2 Working Together to Safeguard Children (2010) – referred to in this report as “Working Together” – is a government publication containing statutory guidance on how organisations and individuals should safeguard and promote the welfare of children and young people, in accordance with the Children Act 1989 and the Children Act 2004. It has been revised while this review has been in process and replaced by Working Together to Safeguard Children (2013). Most of the agencies completed their submissions to this review before Working Together 2013 was in place. This Overview Report has taken account of the revised guidance but there are no specific implications from the revision for the content of the report. This report is the property of the East Sussex Safeguarding Children Board. Page 4 of 46 Mr Kevin Harrington to write this Overview Report. Further details are at Appendix B. 2.3 It was determined that the agencies listed in the table below should contribute to the review. Agencies with substantial contact were required to submit full Individual Management Reviews (IMR) whereas agencies with less significant or less recent involvement provided reports for background information. The most important IMRs were those submitted by police, children’s social care services and Child G’s school. AGENCY NATURE OF CONTRIBUTION Sussex Police Individual Management Review (IMR) East Sussex County Council, children’s social care services, referred to as CSC IMR Child G’s school, referred to as School D IMR The family’s General Practitioner IMR East Sussex Healthcare Trust (Community Services) IMR Hastings & Rother Clinical Commissioning Group Health Overview Report East Sussex Healthcare Trust (Acute Services) Background report Sussex Partnership NHS Foundation Trust Background report 2.4 The government has introduced arrangements for the publication3 in full of Overview Reports from Serious Case Reviews, unless there are particular reasons why this would not be appropriate. This report was written in the anticipation that it would be published. It will still be appropriate that some confidential information is not disclosed. Consequently the information in the report is limited so as to: 1) take reasonable precautions not to disclose the identity of the child or family. 2) protect the right to an appropriate degree of privacy of family members. 3) avoid the possibility of heightening any risk of harm to this child or others. 2.5 Anonymised Terms of Reference for this SCR are attached at Appendix C. They are drawn from the statutory guidance contained in Working Together. The period covered by this review is from September 2010, when Child G came to the notice of some of the agencies involved in this review on an unrelated matter, until September 2012, when she returned to her family. 3 See Working Together 2013 This report is the property of the East Sussex Safeguarding Children Board. Page 5 of 46 3. METHODOLOGY USED TO DRAW UP THIS REPORT 3.1 This Overview Report relies on The agency IMRs, background information submitted and subsequent Panel discussions and dialogue with IMR authors. The report from a “Safeguarding Review”, an independent exercise carried out by School D after these events came to light. The views of Child G’s mother, discussed in section 5 below. Some information emerging from the trial of Mr K. 3.2 It is now clear that School D did not keep any formal contemporaneous records of the events under review. Information was initially submitted to this review on a tabular timeline document, which was drawn up soon after the abduction of Child G. This was accompanied by three documents, pro formas headed “Child Protection Incident / Welfare Concern Form”. This review was at an advanced stage when it became clear that these pro formas were not contemporaneous – although they were dated variously in March, May and July 2012. The Panel noticed that they were inaccurate, in particular referring to the outcome of an event in April on a pro forma dated in March. 3.3 This was raised by the SCR Chair with the school and further investigations were carried out. It was confirmed by the school that all the documentation had been completed after Child G was abducted. One of the school’s two teachers with particular responsibility for safeguarding (ST1) told the SCR that the decision to backdate the forms was made jointly by herself and her colleague (ST2), the Deputy Head Teacher (DHT), the Head Teacher and the Executive Head Teacher4 . The Executive Head Teacher described this, in a letter to the Chair of the SCR, as a misunderstanding arising from the fact that they had not been asked to provide contemporaneous records. 3.4 It is a matter of concern that the school should have provided its evidence to this review in the way that has come to light. It is a fundamental and obvious premise that the accuracy and propriety of records will be a cornerstone of an exercise such as this. This is discussed further below. 3.5 This report consists of A factual context and chronology. Commentary on the family situation and their input to the SCR. Analysis of the part played by each agency, and of their IMR. Closer analysis of key issues arising from the review. Conclusions and recommendations. 3.6 The conduct of the review has not been determined by any particular theoretical model. However the review has been carried out in keeping with the underlying principles of the statutory guidance, set out in Working Together 2013, detailed below: The review 4 A Head Teacher with responsibility for more than one school. This report is the property of the East Sussex Safeguarding Children Board. Page 6 of 46 recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight5; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. 4. A BRIEF CHRONOLOGY OF KEY EVENTS 4.1 This section of the report briefly describes the events under review and the background to those events. Further detail is then provided at appropriate points throughout the report. 4.2 Child G lived with her mother, Ms C, her mother’s partner, and other children of the family. Throughout the period under review Child G was in full time education at School D. The family have no significant history of contact with police, health or social care services outside the matters detailed in this report. 4.3 In 2010 Child G came to the attention of some agencies involved in this review because of a matter unconnected to these events. A supply teacher from another school had made inappropriate remarks to a number of pupils, and in particular Child G. He had asked pupils including Child G for their addresses, and, at another school, had made drawings of pupils, one of which contained an explicitly sexual reference. This situation was managed under formal child protection arrangements, led by the Local Authority Designated Officer6 (LADO). It did not lead to any further action by police, health services or CSC but the school followed up, using the appropriate employment procedures and national regulatory arrangements, with the employment agency which had provided this supply teacher. 4.4 In February 2012 Child G went on a school trip to America. Mr K was one of the members of school staff leading the trip. It was during this trip that evidence first emerged which was suggestive of an inappropriate relationship between Mr K and Child G. Mr K denied this to senior staff. No other agency was informed. Some information was given to Child G’s mother who was said to be satisfied with the way the school had dealt with the situation. There is no record that Child G was spoken to although ST1 has reported doing so. The Head Teacher was made aware of the concerns at the beginning of March. 5 This review does not rely on hindsight, and tries not to use hindsight in a way that is unfair. It does use hindsight where that promotes a fuller understanding of the events and their causation. 6 The LADO is an officer (or officers) in every local authority with responsibility for acting and advising on safeguarding concerns in respect of people whose employment brings them into contact with children. This report is the property of the East Sussex Safeguarding Children Board. Page 7 of 46 4.5 On the same day that the school contacted Ms C about this, she and Child G consulted the family GP about a number of issues relating to Child G’s health and emotional well-being. Mr K was not mentioned. The GP suggested that the school counsellor might be able to assist but did not feel any further action or treatment was indicated. 4.6 A school nurse also saw Child G around this time and made a referral to Child & Adolescent Mental Health Services (CAMHS) in respect of a possible medical condition. CAMHS offered an appointment to Child G but she did not attend. CAMHS notified the School Nurse of this and wrote to the family inviting future contact but there was no further CAMHS involvement. 4.7 During March there were two incidents of Child G truanting from the lesson she should be attending and making her way to Mr K’s classroom. The Deputy Head spoke to Mr K about this. In May senior school staff became aware of Mr K and Child G using Twitter to communicate with each other. The content of those communications was clearly indicative of an unprofessional relationship. School staff discussed this with the LADO who, on the basis of the information shared, advised that it was not a matter of child protection, requiring a multi-agency response, but something which the school could deal with. 4.8 There were two meetings between Mr K and senior school staff during June, in which they discussed how Mr K could be supported in dealing with Child G’s interest in him. In July two former students came to the school and raised concerns about the relationship between Mr K and Child G. Mr K denied to school staff that there was any truth in these allegations and no further child protection action was taken. It was agreed that Mr K himself should contact Ms C to reassure her and he did so. 4.9 Two months later the father of another pupil contacted police, reporting that Child G had an inappropriate photograph of Mr K on her phone. A number of other children were said to have seen this. This led to an investigation under formal child protection procedures. Child G and her mother were interviewed. Child G denied the allegations. Her phone was seized and an initial inspection revealed no cause for concern. Ms C said she did not believe the rumours. Mr K was not interviewed. 4.10 The following day Ms C understood that Child G was staying overnight with a school friend. However she did not come to school the morning after that. In the late morning Ms C was routinely notified by the school of her daughter’s absence. It transpired that Child G had only stayed with her friend until the early evening of the previous day and that her whereabouts thereafter were not known. Ms C reported her missing to police. 4.11 Police made extensive enquiries and established that Mr K and Child G had left the country together. Child G had used Mr K’s wife’s passport. They were identified and detained in Europe just over a week later. Police enquiries revealed further evidence indicating that there had been a continuing sexual relationship between them, at least from soon after Child G’s 15th birthday. This report is the property of the East Sussex Safeguarding Children Board. Page 8 of 46 4.12 Mr K was brought back to the UK in custody and charged with the abduction of Child G (taking a child without lawful authority). He denied the charge so that she and other witnesses were required to come to court and give evidence. He was found guilty of that offence and received a prison sentence of 12 months. He then admitted a number of charges of sexual activity with a child under 16 years of age and was further sentenced to 54 months in prison – a custodial sentence of five and a half years in total.This report is the property of the East Sussex Safeguarding Children Board. Page 9 of 46 5. THE FAMILY 5.1 Child G 5.1.1 Child G was offered an opportunity to meet with the author of this report while it was being drawn up but did not wish to do so. She did come to a meeting with her mother to discuss the key findings from the review. 5.2 Ms C 5.2.1 Ms C was keen to contribute to this review and met the author of this report, and a Panel member, to do so. She was able to describe in detail what and when she knew about the events under review. As described throughout this report there are some key issues and events where her account cannot be reconciled with evidence provided by the school to this review. 5.2.2 Ms C wanted to emphasise how grateful she was for the support she received from police, from the point at which it became clear that her daughter had been abducted. She told us that she appreciated not just all that had been done but the way in which it was done – “they really care”. She also commended the support provided by the social worker from the local authority. 5.2.3 She was outspoken in her dissatisfaction with School D, and her comments were measured and thoughtful. She was deeply concerned by the specific mistakes made, the many missed opportunities to protect her daughter and by the reliability of some of the information provided by school staff to this review. However, her greatest regret was that she felt undermined as a parent by the school’s management of this situation. They had not adequately informed and involved her. The consequence of the school’s approach was that “they didn’t allow me the opportunity to intervene”. 5.2.4 When discussing the outcomes of the review Ms C indicated a willingness to be directly involved in action which agencies might be taking to follow up the lessons learned. 6. THE AGENCIES 6.1 The General Practitioners 6.1.1 Prior to the events leading to this review Child G had little contact with her GPs. She saw the GPs once during the period under review. The GP did not feel she needed onward referral at that stage, except that it was suggested that she might contact a school counsellor. The IMR concludes that “Concerns regarding physical and emotional health were appropriately assessed and actioned. There were no child protection concerns”. This report is the property of the East Sussex Safeguarding Children Board. Page 10 of 46 6.1.2 This account fits the pattern reported by other services, of Child G’s health and conduct raising no significant cause for concern before the events leading to this review. 6.2 East Sussex Healthcare Trust (Community Services) 6.2.1 The involvement of this Trust arises from Child G seeing the School Nurse during the period under review. This was on one occasion in March 20127, soon after the school trip to the USA. Child G was referred to the School Nurse by ST2 in the aftermath of the first concerns about a relationship with Mr K. Child G had spoken to ST2 and mentioned matters which might indicate emotional disturbance or unhappiness. 6.2.2 The referral from ST2 made no specific reference to any concerns about the relationship with Mr K but described the matters mentioned by Child G. The School Nurse saw her the day after she was referred and noted that she “presented as clean and tidy, she did not appear overly nervous and was open in sharing information regarding (the reasons for referral)”. 6.2.3 The School Nurse nonetheless, with the consent of Child G and her mother, made a referral to Child and Adolescent Mental Health Services (CAMHS). An appointment was offered about a month later – not an unusual or inappropriate delay in responding to low level concerns - but was not kept. CAMHS wrote to the family inviting further contact if they felt that would be helpful. The School Nurse was informed of this but did not take any further action. That would again not be unusual in the circumstances – the concerns were not urgent and, since the first contact, there had been no further involvement by the School Nurse. 6.2.4 The only other issue arising from this review for the school nursing service relates to a Strategy Discussion8 held in September 2012, following the discovery of inappropriate photographs of Mr K. No representative from health services was invited to that meeting. 6.2.5 At that time in East Sussex health professionals would only be invited to such a meeting if it were known that the situation to be discussed involved specific health needs. In this case it would in fact have been appropriate to invite the School Nurse because of her earlier direct contact with Child G, which may have been significant. However the School Nurse was not contacted and her brief involvement only emerged subsequently. 6.2.6 In any event this situation has changed with the implementation of the 2013 Working Together guidance, which states that “A local authority social worker and their manager, health professionals and a police representative should, as a minimum, be involved in the strategy discussion”. 7 School D has reported an earlier referral but this appears to be an error. 8 Strategy Discussions are part of the national arrangements for determining how agencies - principally police and the local authority - should respond to child protection concerns. This report is the property of the East Sussex Safeguarding Children Board. Page 11 of 46 Local agencies are now making arrangements to ensure that there is compliance with the new requirement, so that health professionals are routinely involved in such meetings. 6.2.7 Overall then the involvement of the school nursing service in these events was minimal and no particular issues arise from it. However the IMR notes that since these events there has been an improvement in the relationship between the school nursing service and School D: “(There had been) problems in…accessing suitable rooms for health assessments and …difficulties in offering a drop-in service and sexual health advice to pupils. Opportunities to inform the staff and pupils about the school nursing service…were blocked. However, since the incident, there have been several improvements in the communication processes between school staff, SENCO9, welfare staff and the School Nursing Team”. 6.3 East Sussex Healthcare Trust (Acute Services) 6.3.1 This agency did have some contact with family members during the period under review and has reported that contact to the SCR. It is not relevant to the events under review. 6.4 Sussex Partnership NHS Foundation Trust 6.4.1 This agency manages CAMHS and has submitted a brief report confirming the facts of the referral to them in March 2012 and the appointment consequently offered but not kept by Child G. 6.5 Hastings & Rother Clinical Commissioning Group - Health Overview Report 6.5.1 Arrangements in place when this review was initiated required that all SCRs should include a Health Overview Report – a report prepared by the organisation responsible for the commissioning of health services locally. In this case the Health Overview Report was submitted by the Hastings and Rother Clinical Commissioning Group. 6.5.2 The Health Overview Report comes to the same conclusions as those reached separately by the various health services in their IMRs. “All health agencies appeared to have positive professional working relationships with Child G and her family. The services offered were in the context of a universal service which was wholly appropriate”. 9 Special Educational Needs Co-ordinator – a teacher with particular responsibility for co-ordinating and developing a school’s provision for children with special educational needs. This report is the property of the East Sussex Safeguarding Children Board. Page 12 of 46 6.6 East Sussex County Council – Children’s Social Care Services 6.6.1 Children’s social care services (CSC) were first aware of Child G in 2010 when she was one of the girls targeted by a supply teacher, an event quite separate from the matters leading to this SCR. The CSC involvement was that the LADO chaired the Strategy Discussion which decided how the agencies should respond to those events. 6.6.2 There were some weaknesses in the way in which this matter was dealt with. There was insufficient detail in the actions agreed. There was a lack of emphasis on exploring the consequences for the young people involved of what had happened, and any treatment or support that they might need. There was no effective co-ordination after the Strategy Discussion and it was left to one agency – the school – to conclude the agencies’ response to the referral. There was then no action to confirm that the school had followed up in the way that had been agreed. This is mentioned here because there are similarities with the agencies’ actions in relation to Child G in 2012 – a lack of detail in planning and follow-up and a failure to consider the broader implications of the concerns raised. 6.6.3 The local authority’s first involvement in the events under review here was in May 2012, when the LADO was approached for advice by School D after the concerns relating to Mr K’s use of Twitter. On the basis of the information provided the LADO judged that this was an internal matter for the school to deal with rather than something requiring a co-ordinated approach under child protection arrangements. The young person’s name was not given to him, or sought by him (so that no connection could have been made with the 2010 incident).The LADO made no record of this consultation. 6.6.4 CSC’s operational involvement commenced as a result of the report to police in September. CSC were contacted by police on the Monday, a Strategy Discussion was held the following day and a joint visit made to the family the day after that. CSC then terminated their involvement, re-opening the case when it became clear that Child G was missing. 6.6.5 The Strategy Discussion was attended by a Detective Constable (DC1) from the police Child Protection Team (CPT), a social worker (SW1), the LADO, who chaired the meeting, and, from the school, the Head Teacher, ST1 and a personnel officer. The meeting was informed by the school staff about the incidents in February, May and July and how the school had responded. The meeting also heard from ST1 and the Head Teacher that Mr K’s marriage was in difficulties and that as early as January 2012 (before the trip to America) he had been known to have slept in his car. 6.6.6 The notes of the Strategy Discussion refer to the Deputy Head having told Mr K “that he should not seek support from a young girl”. ST1 told the meeting about a pupil refusing to go to Mr K’s class as the pupil said he was a “pervert”. The notes of the meeting also state that This report is the property of the East Sussex Safeguarding Children Board. Page 13 of 46 “The Head Teacher said there had not been any previous concerns about Mr K”. The notes make no reference to events in March, nor to Mr K having been seen holding hands with Child G, although ST1 had told Child G’s mother about this in March. These matters are significant and are discussed further below. 6.6.7 The actions agreed at the meeting were: ST1 would identify the two ex-pupils who had raised concerns in July and seek further details of the issues relating to the “Twitter incident”. Head Teacher to try to ascertain Mr K’s current address and pass it to DC1. Police and social worker to make a joint visit to Child G’s home, that day or the following day, to seize her phone and computer and speak with her and her mother Mr K and other staff at the school were not to be informed of these matters until police agreed to this. Personnel Officer to make contingency arrangements in the event of action against Mr K. A further Strategy Discussion would be held in a week’s time. 6.6.8 The CSC IMR notes that the meeting (and the meeting held in 2010) did not consider the safety or welfare of any young people other than Child G. There was evidence that the teacher in the 2010 incident had approached or considered approaching a number of young people. In 2012, although there was only evidence of Child G being targeted by Mr K, it was alleged that other pupils had seen inappropriate images of him. 6.6.9 It would have been appropriate for the meeting to think more broadly about the situation, the effect on other pupils and on the school community as a whole – not to make any detailed plans at that stage but to begin to draw out the possible wider implications of the concerns raised. As the IMR points out, not only was this a safeguarding weakness, it was also a missed opportunity to consider “how the group of students could be supported and educated in relation to these issues in order to ensure they were all managing the situation and to build resilience in them and open up discussions between staff and students about these sorts of issues”. 6.6.10 The interview subsequently conducted by DC1 and another social worker (SW2) was not carried out in compliance with standard safeguarding requirements. Child G and her mother were not interviewed separately. That is a routine expectation in child protection enquiries of this nature and there was no good reason not to do so here. It seems that the investigators were swayed by what they felt was a relaxed and open relationship between mother and daughter. 6.6.11 Child G is described as follows: “She did not appear anxious or as if she were hiding anything and the social worker reports having no concerns about her presentation”. This report is the property of the East Sussex Safeguarding Children Board. Page 14 of 46 Child G denied having any sort of relationship with Mr K. She denied that there had ever been physical contact between them. 6.6.12 Ms C said that she knew about what was said to be Child G’s “crush” but that she did not believe anything improper had happened. She confirmed that she had spoken directly to Mr K who had reassured her of this. Ms C also said that she routinely checked the content on her daughter’s phone and had once seen inappropriate pictures of Child G. Child G had told her that this had been a trivial incident she and some other girls had been involved in. 6.6.13 The investigating social worker has reported that she was influenced by considerations arising from Child G’s involvement in the situation in 2010. On that occasion Child G was “able to recognise the appropriate boundaries between staff and students”. The social worker has reported that this contributed to her view that Child G could be interviewed in the presence of her mother. 6.6.14 This is surprising. CSC had not been directly involved in the previous matter and this member of staff had no detailed knowledge of what had happened then, or in the family subsequently. In fact this social worker had not attended the Strategy Discussion the previous day, but had been briefed by a colleague who had attended. If a reliance on what happened in 2010 really had been such a determining influence on how to conduct this interview, that would be a matter of concern. It seems more likely that this reflects a rationalisation, after the event, of the failure to conduct separate interviews. 6.6.15 Following the interview and the completion of routine checks with all agencies it was judged by the social worker and her manager that there was no continuing role for CSC at that stage. Police had further enquiries to make, but no immediate actions for social workers had arisen from the initial investigation. The IMR suggests that “it may have taken some time for the forensic information to have become available and there were no identified immediate risks… There was no role for a social worker at that time. This is consistent with expected East Sussex practice that cases are closed when there is no current social work role or active intervention and re-opened if new information comes to light”. 6.6.16 In general it will be preferable to maintain the momentum of a joint investigation until it is clear that a joint approach is no longer necessary. That provides greater continuity and stronger continuing lines of communication between agencies. 6.6.17 Moreover at this point it was also decided by CSC managers that the Strategy Discussion would not now be re-convened as originally planned. The rationale for this is unclear. The LADO, who had led the original meeting, had gone on holiday, so was not consulted. Nothing had arisen from the interview which could not have been anticipated. It seems a premature decision, particularly as the agencies were all said to accept that there was substance to the allegations made: This report is the property of the East Sussex Safeguarding Children Board. Page 15 of 46 “The LADO’s first comment upon interview for this report that there was a shared agreement between all the professionals involved at the strategy meeting on 18/09/12 that this was serious and the information was such that they considered that the allegations were likely to be true”. The decision to cancel the follow-up meeting suggests that, following the interviews, professionals had become less convinced that the concerns had substance. However, even setting aside subsequent developments, it will have been more appropriate to have kept to the original plan whereby the agencies, represented by those who had actually been involved in the investigation, would re-convene to agree a way forward. 6.6.18 The absence on leave of the LADO may have been a factor in the changed arrangements, although there are well established cover arrangements. He has subsequently indicated that his preference would have been to stick to the original plan. He has suggested that he would have expected at least a telephone conversation on his return from leave, if the plan were to deviate from his original recommendations. The CSC IMR accepts that it would have been preferable to proceed as originally agreed. 6.6.19 This then is a second example of an investigation being left for one agency (on this occasion police) to follow up and conclude, with no clear arrangements for the other agencies to be informed, the LADO to be advised of the outcome and the LADO to determine that the matter had been dealt with appropriately. The LADO and his employing organisation cannot be responsible for doing what the individual agencies and organisations should have done. Equally they must accept the responsibilities which sit with their central role in this network of duties and obligations. 6.6.20 The issue of recording of events and communications between agencies is discussed below, with reference to School D. It is a subject that arises also in respect of the LADO and it is agreed that the LADO made no record of his involvement in this case when he was contacted in May about the use of Twitter. 6.6.21 It is in the nature of the LADO’s role that there will be numerous occasions when schools and other agencies seek to “sound out” the LADO about matters which might require further action. It will often be the case that those making enquiries will wish to do so in a way that does not trigger any formal procedures – these can be delicate situations where agencies want to avoid causing unnecessary problems for a colleague, or generating an investigation which might subsequently be seen as an over-reaction. 6.6.22 The LADO told this review that his normal practice when asked for advice would be to have a discussion and then ask the enquirer to send an email confirming the contact. He would then reply so that there was a written record of the communication. This is unsatisfactory. No professional should rely on someone who consults them to make a record of that consultation. The IMR advises that a working group has been established to assist the LADO in developing more reliable recording systems. That may be necessary but the underlying issue here is not a procedural one – the LADO is This report is the property of the East Sussex Safeguarding Children Board. Page 16 of 46 personally and professionally responsible for ensuring that consultations are conducted and recorded appropriately. 6.6.23 The review considered the possible factors underlying the concerns around the involvement of the LADO in these events. It is a demanding role, often an isolated one, with responsibility for advising and guiding large numbers of individuals and organisations on a wide range of potentially problematic and difficult decisions. Many of the requests for advice will be made “on the hoof” rather than as formal referrals. Often the advice needed and provided is straightforward, which can make it more difficult to identify those cases which are more complex. However, in this case it is recognised that there were weaknesses, both in professional practice and in administration, which meant that the independent leadership of this investigation was not as thorough as it might have been. 6.6.24 As with a number of the comments about agencies’ actions in this report, it is accepted that a different approach to the planning of the investigation and the way it was followed up may not have made a difference to the subsequent developments in the case. It is possible that Mr K may still have abducted Child G once he realised that formal investigations were underway. However the principal aim of this review is to identify issues that would help agencies in comparable situations in the future, which is why these matters are highlighted. 6.7 Sussex Police 6.7.1 Police first knew of Child G as a result of the events during 2010. The police IMR is concerned that the overall management of the allegations at that time was not sufficiently thorough. There were a number of specific steps which could have been taken by police to ensure that the decisions on how to proceed would be better informed: “the strategy discussion did not agree a plan to establish if any criminal offences had been committed or were likely to be committed” 6.7.2 There is no evidenced link between the events leading to this review and these concerns from 2010. However the police analysis does highlight a lack of appropriate curiosity across the agencies, which is in keeping with evidence emerging from the events leading to this review. 6.7.3 Police were the first agency to learn of the events which brought matters to a head in 2012. The concerns about the inappropriate photograph of Mr K were passed to the police Child Protection Team (CPT) who asked local police to carry out initial investigations. They received this information on a Friday afternoon, visited and interviewed the informant immediately. (The informant was in fact the father of the young person who had actually seen the images, as had two other students: police should ideally have spoken to the young person herself). The officer then passed the information to the police school liaison officer, requesting that further enquiries be made and the CPT informed. The school liaison officer would not be at work until Monday. This report is the property of the East Sussex Safeguarding Children Board. Page 17 of 46 6.7.4 In order to comply with the Sussex Police Child Protection Policy, all investigations into allegations against persons working with children should be carried out directly by the CPT. Some officers interviewed for this review have said that this is impractical, as the CPT is a relatively small unit. It may be appropriate that “mainstream” officers can undertake those initial enquiries but Sussex Police need to resolve this gap between what is procedurally required and what can happen “on the ground”. They are following this up as a consequence of this SCR. 6.7.5 In any event the initial information gathered did not indicate that Child G was at immediate risk and the decision to gather further information was reasonable. However the reason for delaying feedback to the CPT until the following week is unclear. The CPT could have been contacted on the Saturday. While they would probably not have taken immediate investigative action, there was no reason to delay informing them of the allegations made until the Monday. 6.7.6 On the Monday the liaison police officer for the school immediately recognised the potentially serious nature of what had been described and spoke to the CPT. That team then followed up swiftly and liaised with other agencies so that the Strategy Discussion was convened the following day and the interview of Child G and her mother was carried out the day after that. In relation to the nature of the allegations, this was a satisfactory timescale. 6.7.7 Police were represented at the Strategy Discussion by the Detective Constable, DC1, who went on to interview Child G and her mother. This was again a procedural breach of the force’s policy, which is that police should be represented at such meetings, when there are concerns about abuse by a professional, by a CPT Detective Sergeant. Officers interviewed for this review reported that this was also an unrealistic expectation for a small team. Again, if procedural requirements are honoured more in the breach than the observance, it is appropriate to reconsider those arrangements, and the police IMR confirms that this is being followed up. 6.7.8 The IMR details a number of weaknesses in the conduct and outcomes of the Strategy Discussion, which “did not agree contingencies to be considered based on the outcome of the joint visit…or of any criminal investigation …(and) failed to provide any direction as to what should happen if any images were found on Child G’s phone, what should occur if any images were not obviously on her phone or if she had made any disclosure about Mr K. Nor did it discuss what action would be taken against Mr K if offences were disclosed”. 6.7.9 The Strategy Discussion also failed to draw together and evaluate all the evidence that was held by the agencies. The school described the incidents of ex-pupils reporting their concerns about the nature of the relationship between Child G and Mr K, and the fact that a pupil had referred to Mr K as a pervert. However these reports were not considered and analysed in detail, indicating, as the police IMR suggests “an apparent lack of professional curiosity by …all agencies” This report is the property of the East Sussex Safeguarding Children Board. Page 18 of 46 6.7.10 Subsequently, as described above, the interview of Child G and her mother did not meet routine requirements in that they were not seen separately. The police IMR explains why, from a police perspective, this should have been done, even if it were anticipated that Child G would not make a full disclosure: “There was a history of … inappropriate contact…during which time Child G had been spoken to about it by her mother and denied the relationship. It was therefore important to provide Child G with an opportunity to talk without having to lose face in the presence of her mother. It is unlikely that Child G would have disclosed the full circumstances but (she) may well have inadvertently provided additional information to enable a better risk assessment to be made”. 6.7.11 During the course of the interview DC1 was told by Ms C that she had looked at Child G’s phone and found inappropriate images of her daughter. Child G had “laughed this off”, explaining it in terms of harmless fun with female school friends. The IMR comments that “This provided a further concern. The explanation provided to her mother by Child G may have been true but (was) improbable, the more likely reason having regard to the history … was that she and Mr K were exchanging inappropriate images of each other.” This was significant new information from the interview which was not given sufficient weight in the continuing investigation. 6.7.12 The interview provided some evidence which eased the concerns of the investigators. Child G was bright and personable and absolutely denied any abuse. Her mother was clear that she did not believe the story. Although they were not seen separately they came across well in the interview, both individually and together. There was certainly no indication that Child G was at risk of significant harm, such that urgent action was needed. However no explanation for the current and continuing allegations had emerged and there were still clear lines of investigation for police to pursue. 6.7.13 The next step was to ascertain whether indeed there were inappropriate photos of Mr K on Child G’s phone. Child G made no objection to her phone being removed by police, another reassuring factor at that point. The procedurally correct approach would then be to submit the phone to the police “Hi Tech Crime Unit” (HTCU). The HTCU can examine mobile phones to extract current and deleted images if they have not been written over. They would have had a completion target of doing this within approximately a week from the date of submission to them. They can respond immediately but what was known at that stage would not have indicated that degree of urgency. 6.7.14 In fact CPT officers did not do this. DC1 discussed the situation with a Detective Inspector (DI1) and they decided to view the phone themselves. The officers examined the phone and found nothing of concern. On that basis the police investigation took what proved to be an inappropriate turn. The phone was still to be sent to the HTCU for a full examination but, the following This report is the property of the East Sussex Safeguarding Children Board. Page 19 of 46 day, police advised ST1 that they would not at that point be interviewing Mr K, or seizing his phone and that “it was for the school to instigate their disciplinary procedures (as) no criminal offences had been disclosed by Child G and … it was a third party complaint at that time”. In fact, subsequent examination of Child G’s phone has revealed that it did contain inappropriate images. For an appropriately trained investigator these were not difficult to find. 6.7.15 Although procedurally incorrect, because it potentially compromised any future evidential trail, the decision taken by DI1 to inspect the phone was understandable and has been explained as follows: “he considered the legal implications and decided it was appropriate and in the best interests of getting to the truth as soon as possible to view the photos immediately rather than wait for the mobile phone unit to produce an evidential report”. 6.7.16 The IMR goes on to suggest that “DI1’s decision to examine the phone had no impact on Mr K abducting Child G - to the contrary had the image been found it may have resulted in further police activity that may have prevented (the abduction)”. This is correct although it might equally be the case that Mr K, learning of the seizure of the phone, anticipated that the incriminating material would be discovered more promptly and the abduction was accelerated. 6.7.17 In any event the learning point is that police, and CSC allowed themselves to be falsely reassured by the apparent absence of incriminating evidence. Although the phone was still to be sent to the HTCU, what had been a problem requiring a multi-agency approach was now being left with the school for any immediate follow-up. This was despite the knowledge that the school had consistently avoided or been dilatory in dealing with concerns about this relationship since February. 6.7.18 The school was not notified of the outcome of the interviews and the decisions taken by police and CSC, an error arising from a lack of detail in the plans agreed at the Strategy Discussion. As the police IMR comments “the school would have needed to know the result of the joint visit before Child G attended school to facilitate proper management of the pupil and staff member concerned”. Arrangements should have been made for either CSC or police to feed back to the school. However the situation was not clarified for the school until ST1 contacted police in the middle of the morning on Thursday, the day after Child G and her mother had been interviewed. 6.7.19 Police were not then told by the school that Mr K had called to say that he was unwell and would not be coming to work. The IMR identifies the implication: “reporting sick following a joint visit… was indicative that he had been made aware of the police involvement”. This report is the property of the East Sussex Safeguarding Children Board. Page 20 of 46 If police had been aware that he was not at school it may be that they would then have investigated further and identified the preparations being made for the abduction of Child G. 6.7.20 Child G was reported missing to police by her mother on the Friday and the IMR describes how this report was appropriately assessed and dealt with: “When Child G was reported missing (the Duty Inspector) took control from the outset… When the Inspector had reasons to suspect that Child G and Mr K may have gone missing together he raised her to being a High Risk Missing Person at the appropriate time…A Detective Inspector took control of the Criminal Investigation alongside the Missing Person Investigation. The school and local authority Head of Safeguarding were kept informed of developments appropriately”. This was a comprehensive response which reflected the serious nature of the matter reported. 6.8 School D 6.8.1 This review has identified serious concerns about School D’s management of the situation involving Mr K and Child G. Over a period of some seven months there were a number of missed opportunities by school staff to recognise or acknowledge that there was a significant problem arising from Mr K’s conduct, and that child protection intervention was necessary. Then, the process of confirming what happened and why it happened has not been straightforward. There are conflicting accounts of the facts of some aspects of the case. In all the circumstances the Panel has agreed that it is appropriate that this report should describe the events, and the evidence received by the Panel, in greater detail than might otherwise be felt necessary. 6.8.2 The first evidence of cause for concern about Mr K came to light in February following the trip to the USA. Two pupils approached the Head of the Upper School (HUS) on 24/2/12 and reported rumours that Child G had a “crush” on Mr K since the trip to America. HUS spoke to Mr K and gave him advice about maintaining professional boundaries. HUS told ST1 about this and she is said to have also spoken to Mr K about professional boundaries the following week. 6.8.3 There is no record of anyone speaking to Child G although the IMR author was subsequently told that ST1 did speak to her in the presence of senior (male) members of staff. As the IMR comments “This situation might not have been conducive to Child G being able to express herself given the sensitive nature of the issue”. 6.8.4 HUS is said by the school to have referred Child G on 24/2/12 to be seen by the School Nurse. The reason for the referral is recorded as being to discuss health issues and “how she is feeling”. There is no record of the School Nurse receiving any referral at this time or seeing the child. There is then a record, on 28/2/12, of HUS contacting Child G’s mother, Ms C, This report is the property of the East Sussex Safeguarding Children Board. Page 21 of 46 apparently principally to discuss Child G’s health. During that conversation he spoke to her about the issue of Mr K. Ms C is recorded as viewing this as a “typical teenage crush” and not feeling concerned about it – it was noted that she “did not want it blown out of proportion”. 6.8.5 Ms C says that HUS did not contact her but that she did receive a call from ST1. Ms C says that ST1 told her that there had been rumours of an inappropriate relationship between Mr K and Child G. She remembers ST1 telling her that there had been an incident in which Mr K had taken Child G’s hand, to reassure her when she had become distressed about a medical issue. Ms C reports that she was told that the rumours had been investigated and that they were found to be untrue. 6.8.6 On 28/2/12, after the reported conversation with ST1, Ms C took Child G to see their GP, where they discussed a number of issues relating to Child G’s health. The GP noted that she reported feeling “emotionally very stressed” and suggested that they might contact a counsellor at her school, but the GP did not feel that any further action was necessary. 6.8.7 A school Child Protection Incident Form10 (which we now know was completed after Child G’s abduction) then includes a record that on 8/3/12 (a Thursday) ST1 liaised with the Head Teacher who was “made aware of incidents to date”. The form does not refer to anything else happening on 8/3/12 and that section of the form is closed, dated 10/3/12. 6.8.8 However it is known from other records that on 8/3/12 a teacher, Teacher 1, emailed ST2. The email advised ST2 that Teacher 1 had heard students saying that Mr K and Child G had “got close during the trip to (America) and had been caught holding hands”. ST2 told Teacher 1 that she would follow this up and, that day, she emailed ST1 and HUS. The email recounted what she had been told and also said that Mr K had taken Child G out of a class, claiming that this was so that he could provide additional maths tuition. Notes presented to this review in September 2013 by ST1 referred to a Senior Management Team meeting on Thursday 8th March 2012, which was also mentioned on the time line provided by the school to this review. Present at this meeting were the Head Teacher, Head of Year (HOY) and ST1. HOY talked about ‘Child G [being taken)] out of (a lesson) to Maths class’ and ‘discussed crush/rumours’ 6.8.9 The school has been unable to provide adequate information about the provision of additional tuition. The IMR reports that “staff were unable to state precisely if Child G had been formally offered Maths booster lessons by Mr K, who had requested these, how many had been held, how long the sessions had lasted until and whether there had been any parental agreement”. 10 The local authority’s guidance to schools states that “The use of a standard “Child Protection Incident / Welfare Concern” form for all staff irrespective of their role in school / educational establishment… is required”. This report is the property of the East Sussex Safeguarding Children Board. Page 22 of 46 Setting aside any child protection issues it must be a matter of concern that a school should be so unable to account for how staff and students were using their time. 6.8.10 ST1 reported to this SCR that she had met with Mr K on 9/3/1211 and again discussed the need to maintain professional boundaries. On the following Wednesday, 14/3/12, HUS emailed ST2 to ask if arrangements had been made for Child G to see the School Nurse. ST2 contacted the School Nurse that day and the nurse saw Child G the following day,15/3/12. That contact is discussed above in section 6.2. 6.8.11 On 29/3/12 HUS emailed the Deputy Head Teacher and ST1 to advise that there had been two incidents (recorded on CCTV) of Child G not attending her class but going instead to the room where Mr K was teaching. The chronology submitted to this review by the school states that this was “despite Mr K being warned about the need to keep professional boundaries”. That comment implies that Mr K was in some way complicit in her not being in her class or, perhaps, that colleagues feared that he might not be able to conduct himself in a professional way. In any event it clearly reflected a concern about his conduct rather than that of the child. 6.8.12 That concern emerges similarly from notes, presented to this review by ST1 in September 2013, of a discussion between her and Mr K. Those written notes are as follows: “Why did he ask for Child G from (her lesson)”. Mr K’s response was that they “needed to do revision session in class”. ST1 responded by commenting on “how this fuelled further gossip”. (This incident appears to have taken place after Child G had already taken the exam but that does not appear to have been identified as a concern at the time). ST1 then spoke about “hand holding on plane” to which Mr K said that he was “Not holding hand but tapped her hand on his shoulder”. Finally they “went over professional boundaries again”. Two people holding hands is very different from a girl tapping a teacher’s shoulder. That comment was a significant discrepancy in accounts of events but this inconsistency was not identified or followed up in any way. 6.8.13 On 30/3/12 the Deputy Head Teacher met with Mr K and subsequently sent an email confirming their discussion in which it had been agreed that Mr K would send Child G away if she tried to approach him in his classroom. keep his classroom door open at all times. not be alone with Child G 6.8.14 Following the meeting, adjustments were also made to Child G’s school timetable so that she had a different maths teacher. However, as with 11 There is a discrepancy about when this meeting took place. The school’s “time line” states that the meeting took place on 8/3/12. There is no reference to it on the Child Protection Forms. ST1’s notes place the meeting at 9/3/12. This report is the property of the East Sussex Safeguarding Children Board. Page 23 of 46 the issue of extra tuition, the school’s record keeping on this matter is inadequate: “there was some discrepancy surrounding the precise dates that Mr K ceased to be Child G's Maths tutor. No exact date was known by the school. One senior manager stated that this had been shortly after the Easter break, but ST1 stated clearly that this did not take place until June 2012”. It is a further cause for concern that, on the basis of ST1’s recollection, the school allowed this continuing opportunity for Mr K to promote the abusive relationship. 6.8.15 The Child Protection Incident Form, first dated 8/3/12, is concluded with a section noting that the Deputy Head Teacher had met with Mr K “to agree supportive strategies for Mr K to manage Child G’s behaviour”. This section of the form is dated 30/3/12 and also includes a note that Child G had not attended an appointment at CAMHS made for her by the School Nurse. However the appointment offered by CAMHS was not until 18/4/12. After this inconsistency was identified by the SCR Panel, demonstrating that the form could not be a contemporaneous record, the Executive Head Teacher, in a letter to the SCR Chair, confirmed that this form and all other records offered by the school had been filled in after the abduction, and that this had been known by the whole Senior Management Team. This is discussed further below. 6.8.16 The overwhelming concern arising from the matters detailed above is the lack of alertness to child protection implications. There was one very significant piece of evidence – that they were reported to be seen holding hands – which clearly indicated inappropriate conduct by the teacher. Indeed ST1 had spoken to Child G’s mother about the pair holding hands. That evidence was supplemented by the account of Mr K taking Child G out of a class she should have been attending. These matters were known to a number of members of teaching staff, including the most senior staff and staff with particular child protection responsibilities. Mr K was advised about “professional boundaries”, implying that in some way he had breached or was in danger of breaching those boundaries. 6.8.17 Yet the response to the situation appears to have been determined entirely from the perspective of a teacher at risk of false allegations. This sort of “fixed thinking” is repeatedly identified as a factor in situations which lead to SCRs: “Once a view had been formed there was a reluctance to revise a judgement”12 What was known by the end of March clearly constituted cause for concern sufficient that school staff should have at least raised the matter with the LADO. That is not a judgment which relies on hindsight. 6.8.18 On 22/5/12, for the fifth time, school staff were alerted to evidence indicating an improper relationship between Child G and Mr K. Again this evidence was raised by other students. A student in the same year as Child G 12 Biennial analysis of Serious Case Reviews 2005-2007, Brandon et al UEA 2009 This report is the property of the East Sussex Safeguarding Children Board. Page 24 of 46 told ST1 that she had seen correspondence between Child G and Mr K on Twitter. ST1 made no formal written record of this meeting but has provided copies of handwritten notes, apparently detailing what the student reported seeing, including three specific comments: “marriage falling apart”, “separate rooms” and “miss you”. 6.8.19 ST1 contacted the school’s IT services to enlist their support in accessing Child G’s Twitter account, where they found nothing of concern. Again this was an inappropriate response to the reports received. It immediately locates the cause for concern with the child rather than the teacher, despite the nature of his comments detailed in the previous paragraph. The child was therefore the focus of the investigation, rather than the teacher. The three quotes detailed above, particularly “miss you”, unequivocally indicate an inappropriate relationship. ST1’s notes indicate that the Head Teacher was informed of these matters. 6.8.20 Even without the context of the previous concerns the school’s response to this evidence of conduct which clearly flouted professional boundaries was subdued. ST1 met with Mr K the following day and advised him to adjust his Twitter account so that pupils could not use it to communicate with him. There is no formal record of this meeting but ST1 has provided a handwritten note, dated 23/5/12, which might be a record of a meeting with Mr K. It contains the comment “No (heavily underlined) Twitter messages with Child G”. 6.8.21 The IMR author takes a clear view: “It was evident … that the specific incident relating to the Twitter message did indicate a likely relationship … which was well beyond a teenage crush and therefore should have triggered a more detailed and urgent investigation by the school”. I agree with that except to add that any investigation should not now have been carried out by the school but as a formal investigation under child protection procedures. The IMR also suggests that, even setting aside the subsequent events, this situation might have prompted disciplinary action under employment procedures against Mr K. That may have been difficult to pursue in the absence of any clear “e-safety” policy which would serve to protect both students and staff. That is discussed further below. 6.8.22 There is no formal note of any discussion of this situation with Child G. However the author of the school’s IMR was told that ST1 spoke to Child G and that a meeting took place in which ST1, the student who had raised the concerns and Child G were all present. This did not allow Child G the opportunity to talk openly but the content of the interview is of even greater concern than the way it was conducted. Although there is again no formal record ST1 has provided copies of hand-written comments made on a sheet of paper from her diary on which she has written “Discussed with Child G to stop hounding Mr K in corridors…Find own-age boyfriend”. This report is the property of the East Sussex Safeguarding Children Board. Page 25 of 46 This starkly illustrates how blinkered the approach to this situation was, and how, in the face of mounting evidence to the contrary, the child continued to be identified as the problem. 6.8.23 The significance of this incident is heightened because there had been a previous problem in this school, in 2008, when a member of staff used social media to “groom”13 a student. The IMR comments “It does seem highly unlikely given the high profile nature of the incident in 2008, that the school would not have had at least a greater understanding and heightened awareness of the use of social media as a means to groom children and young people. Any potential lessons learnt from previous experiences do not appear to have been embedded within the school”. 6.8.24 There is contradictory evidence in relation to the other two aspects of following up this reported concern – contacting Child G’s mother and taking professional advice. The school has reported that, between 1/6/12 and 12/7/12 seven calls were made to Ms C. None was answered and the school reports that messages were left for her on each occasion. This account is supported by the school’s automated telephone log in that there is a record of seven calls to Ms C, each lasting some 30 seconds. Ms C recalls only that a message was left on her phone on 11/6/12 - she can be clear about that date because of other significant events in the family in June. Ms C did not return the call immediately but did so three days later, leaving a message for ST1. Ms C reports that they then each made one more unsuccessful attempt to make telephone contact, after which no further action was taken. The school did not attempt to contact Ms C in writing until, by their account, 12/7/12. This was more than six weeks after these aspects of the case came to light and appears to have been prompted not by the concerns about the teacher’s inappropriate use of Twitter but, as described below, by a further report of an improper relationship. Setting aside the discrepancies in the detail it is agreed that there was never any direct contact between Ms C and the school and that she was not made aware of the concerns relating to Twitter at this time. 6.8.25 In respect of taking professional advice, the school report that between 23/5/12 and 25/5/12 ST1 made “repeated attempts to call the LADO for advice on how to proceed” but that “telephone calls and messages left for the LADO were not responded to in a timely manner”. The LADO, by the nature of his job, is often away from his desk. However he has reviewed his records from that time and has found no emails or messages from the school. The school has records of three telephone calls to the LADO’s number but it is not clear that any messages were left. The LADO’s administrative support staff have no record of taking any messages. 6.8.26 Neither the LADO nor the school have made any formal record of what happened when the LADO did speak with ST1 which is most likely to have 13 Child grooming refers to action deliberately undertaken with the aim of befriending and establishing an emotional connection with a child, to lower the child's inhibitions in preparation for sexual exploitation of that child, This report is the property of the East Sussex Safeguarding Children Board. Page 26 of 46 been on 25/5/12 (a Friday). The school’s timeline states that there was a telephone conversation in which the LADO advised that “if there was no tangible evidence of grooming there were insufficient grounds for external intervention”. The IMR from CSC reports, on the basis of the interview with the LADO for this review, that “The LADO advised that it was an internal matter for the school as no allegation had been made and that they should meet with Mr. K and set clear expectations and boundaries with him”. There is an email dated 28/5/12 from the DCPT to the LADO thanking him for his advice. 6.8.27 So, there are no reliable records but it seems that the immediate concern, the use of Twitter, was not put to the LADO as something that had happened in a context of other concerns about an inappropriate relationship. In any event, the failure to draw together all the facts known at this stage was a significant missed opportunity to understand that there was mounting evidence of a continuing, improper relationship between a teacher and a pupil. 6.8.28 On 12/6/12 the Deputy Head Teacher “met with Mr K to catch-up with concerns about home-life and review previous action points”. There are no notes of this meeting but subsequently “ST1 and other members of staff continued to monitor including on 22nd June 2012 Mr K’s Head of Department talked to Mr K to see if any department support was needed in light of the rumours”. 6.8.29 As these quotes illustrate, these steps were focussed on Mr K’s perceived needs, including concerns about his situation outside school – school staff were aware that his marriage was in difficulties. Child G appears to have been viewed as an aggravating factor for a colleague under pressure. The continuing support offered to Mr K by the school is impressive but entirely informal - there is no evidence of awareness of how procedures can and should be used to protect staff who may be falsely accused. There is also no evidence of any support or appropriate concern for Child G. 6.8.30 The IMR refers to the school’s response to Mr K’s conduct and lack of professionalism: “(the Twitter issue) did constitute a significant breach of professional boundaries by Mr K and at the very least should have initiated the first stages of disciplinary proceedings against (him) by the school as evidence showed that he had been spoken to on at least three occasions prior to this incident about the need to maintain professional boundaries with Child G, which had clearly been ignored”. This is an important comment. According to the Child Protection Form (B) the Head Teacher and Executive Head Teacher were aware of these events. Even if there had been no substance to the deeper concerns about the relationship with Child G, there appears to have been a complacency about such unprofessional conduct by a member of staff. This report is the property of the East Sussex Safeguarding Children Board. Page 27 of 46 6.8.31 The school did take one initiative in response to Child G’s perceived needs – she was referred by the Deputy Head of the Upper School to ‘Safe Around Sex’ workshops that were being run in School by the Targeted Youth Support (TYS) service. This information was initially provided to this review by the TYS and is not mentioned in the timeline prepared by School D. The TYS was not given any specific information about the reason for referring Child G. The Deputy Head has subsequently explained that his decision to make this referral was “based solely on wider welfare concerns that the school had about Child G, not as a direct result of continuing rumours about her crush on Mr K”. 6.8.32 But there was no substantial evidence of “wider welfare concerns” for Child G. There was certainly no evidence of promiscuity or that Child G was at risk because of any sexual activity apart from the rumours of the relationship with Mr K – which the school had dismissed as untrue. It is difficult to understand the thinking which prompted this referral: the school has reported that Child G fitted a “profile” of young women who had become pregnant soon after leaving school, in that she was vulnerable, quiet and naïve. She was certainly vulnerable but this response continued to locate any continuing problem with Child G rather than the teacher who was abusing her. 6.8.33 On 11/7/12 two ex-pupils came to the school and spoke to a member of staff, Teacher 2, expressing concern that there was an improper relationship between Child G and Mr K. No formal record was made of this but ST1 has supplied cursory notes which include the comment “Picking her up after work experience”. Again, this is highly suggestive of a relationship being promoted by the teacher, not a teacher being pursued by a child. ST1 saw Mr K the following day. There is then a record by ST1 in the “response / outcome” section of the second Child Protection Incident form stating that “ST1 met Mr K who denied everything and was visibly distressed that Child G telling (sic) lies about him and that the same historic rumours were being brought back up”. 6.8.34 The action said to be taken in response to this was that a letter was sent by ST1 to Ms C on 12/7/12 and the Head Teacher was kept informed. There is no record of how the Head Teacher was kept informed or by whom. There was no discussion with Child G. Ms C denies ever having received such a letter but the school file which she has been given does contain a letter dated 12/7/12 from ST1 which states that ST1 has made “numerous attempts to contact you” and asks that she contact the school “as a matter of urgency”. 6.8.35 In any event, this was the sixth indication of cause for concern about the relationship between Child G and Mr K. The matter was raised by ex-pupils with no reason to make a false allegation. The report of Mr K picking her up from work experience cannot be explained in terms of inappropriate conduct by Child G. Yet the staff involved, including the Head Teacher, appear to have been oblivious to the possibility that Child G was indeed being abused by Mr K. This report is the property of the East Sussex Safeguarding Children Board. Page 28 of 46 6.8.36 ST1 has reported that she subsequently spoke to Mr K and suggested that he contact the two ex-students to discuss why they had made these allegations. This suggestion flies in the face of common sense but the fact that it was made by a teacher with a particular responsibility for child protection is a matter of even greater concern. 6.8.37 In fact Mr K told ST1 that he would contact Child G’s mother instead and Ms C has confirmed that Mr K did so. She describes him telling her that Child G was pursuing him to such an extent that he was worried that this would damage his career. At one point in the conversation he became tearful. This contact can now be understood in terms of Mr K’s “grooming” of her family to conceal the truth about his relationship with Child G. Ms C has reported that she entirely accepted what Mr K was telling her and subsequently rebuked her daughter for behaving in such a way. 6.8.38 The IMR author refers to recent research by the NSPCC14 to illustrate the extent to which “early warnings” can be seen in this case. These included: A pupil receiving special attention or preferential treatment or additional help – Child G was receiving additional booster lessons in Maths by Mr K Excessive time spent alone with pupils – Child G had recently been on a school trip with other pupils to Los Angeles with Mr K (and they were seen holding hands) Frequently spending time with a pupil in private or isolated areas – Child G had been caught truanting in school and found in Mr K’s classroom Using texts, telephone calls or other social media networking sites to communicate inappropriately – they were communicating via Twitter Other pupils are suspicious – concerns were repeatedly disclosed by pupils at the school Yet, as the IMR comments “at no point does any evidence point to staff within the school re-evaluating the initial assumptions they had made in the context of additional information being brought to them”. 6.8.39 On Monday, 17/9/12, the school became aware of the allegation to police that there was an improper photograph of Mr K being circulated by pupils and that this was linked to the allegation of an improper relationship with Child G. The following day the Head Teacher, ST1 and the school personnel officer represented School D at the Strategy Discussion. 6.8.40 The minutes of the meeting contain information from the school which has not been recorded anywhere else. Firstly ST1 reported that another child had refused to be taught by Mr K, calling him a “pervert”. ST1 also reported that at one point, after the concerns about use of Twitter came to light, the Deputy Head Teacher spoke to Mr K 14 Safeguarding in Education, NSPCC (2013) This report is the property of the East Sussex Safeguarding Children Board. Page 29 of 46 “offering him support over his marriage breakdown, and told him that he should not seek support from a young girl (my emphasis)”. 6.8.41 These matters are significant. The fact that another pupil was known to have called Mr K a pervert indicates that school staff were aware that there were wider rumours about Mr K’s sexual conduct, not just about inappropriate behaviour by Child G. This knowledge did not lead to any action, and does not appear to have been taken into account by any member of staff in deciding how to respond to the issues involving Child G. Then, the fact that the Deputy Head rebuked Mr K for looking to Child G for support also indicates some acceptance that Mr K was behaving inappropriately, despite advice given to him about professional boundaries. 6.8.42 Following the Strategy Discussion the school effectively became an observer of the unfolding events and played no active part. Indeed, as described above, a lack of detail in planning the investigation meant that they were not kept adequately advised of events. 6.8.43 As mentioned above, School D responded proactively to the concerns arising from this case and from other events and situations with safeguarding implications by proactively commissioning a “safeguarding review”. This was led by professionals external to the school with specialist, relevant experience. It was an intensive exercise, carried out over a period of months, and culminating in April 2013. It may be significant that, for understandable logistical reasons, it did not involve students or their parents. 6.8.44 That review, which considered the situation in the school after the events leading to the Serious Case Review and the consequent publicity, was generally positive about the school’s safeguarding arrangements. It noted that “This review did not find evidence of any significant or systemic failings in safeguarding ... There were areas for further development and learning identified in order for the school to achieve best practice and recommendations have been made accordingly. There was wider learning identified for inter-agency working to achieve best practice within East Sussex and recommendations have been made accordingly”. 6.8.45 That review did not consider the specifics of this case because this SCR was in the process of doing so. However the judgment quoted above does not sit easily with the key issues arising for the school from this SCR. Clearly the SCR is about only one young person and one relatively unusual set of events, but it has investigated those circumstances in great depth. Some of the failings identified in this SCR are both significant and systemic. There is accordingly a recommendation from this report that the findings of School D’s safeguarding review are re-visited, with specific reference to the key issues emerging from this SCR. This report is the property of the East Sussex Safeguarding Children Board. Page 30 of 46 7. KEY ISSUES 7.1 Why these events have led to a Serious Case Review. 7.1.1 There has been a great deal of media coverage of the events leading to the imprisonment of Mr K. Some of that coverage has been sensitive to the effects of these matters on the family of Child G, though much of the publicity has sensationalised the events. One theme in the coverage has been a sanitisation of what happened, presenting this as a story of true but thwarted love. 7.1.2 It is right to challenge that presentation. Child G was 14 years old when Mr K first sought to form an unprofessional relationship with her. This should not be seen as a relationship based on mutual consent – it was founded in an abuse of the power he had as a result of his age and status. Child G was then sexually exploited and the sexual exploitation of children is child sexual abuse. She was abducted – that is, she was illegally removed from her parent. The abduction was perpetrated by a member of a respected profession. Mr K took opportunities afforded to him by his professional position as a teacher to abuse a child, despite the consequences for her, her family, the school, the teaching profession and indeed his own family. The judge, summing up in the criminal trial, remarked that "I have seen nothing in the evidence which shows that at any stage you tried to provide proper boundaries between yourself and her, to discourage her, or let other staff deal with the matter appropriately… you subjected her family to appalling distress and concerns for her safety. You made no attempt to think of their welfare or let someone know she was safe”. 7.1.3 These matters are unusual and do not immediately fit with the guidance on circumstances which should lead to a SCR being conducted. But the decision to carry out an SCR was carefully considered and the LSCB Chair took that decision while recognising that the statutory requirement at the time was not necessarily met. She acknowledged that Ms C felt that there should be an open investigation into what had happened. She further noted that there had been a great deal of media coverage and public interest in what had happened. She felt that it was right that a full and transparent review should be carried out, to demonstrate publicly that the agencies involved had thoroughly considered these events and were responding appropriately to the issues arising. Even though the events under review are unusual the review has identified broad themes and learning points which can assist the promotion of good safeguarding practice. 7.2 The information provided to this review by School D 7.2.1 This review has identified serious concerns about the ways in which information was recorded, stored, retrieved and provided to us by School D. Those concerns are detailed in the previous sections of this report. They emerged gradually during this review and were substantiated when it was well advanced. There may have been no intention to mislead but the Child This report is the property of the East Sussex Safeguarding Children Board. Page 31 of 46 Protection Forms were submitted to this review without any indication that they were not contemporaneous records. It was through the SCR’s investigations that it became clear that these were not contemporaneous records, that they were the only documentation of the events and that they had not been compiled until after the abduction. There has been no adequate explanation of why that was not made clear at the outset other than, effectively, to say that “we were not asked”. 7.2.2 It was at best naïve not to realise that the review needed to see original documentation. Significant time was wasted before realising that there were no contemporaneous school records. It then became difficult to trust the records which were provided when they were found to contain errors and omissions. This became a particular concern when hand written notes taken at the time of events were eventually seen and it was established that critical information – for example, that Mr K was picking Child G up from work experience - had not been included in the Child Protection Forms. 7.2.3 The Chair of Governors of the school has commissioned an independent enquiry to inform a decision as to whether any action should be taken under the school’s disciplinary procedures. That enquiry has confirmed many of the matters set out in this report. 7.2.4 In summary it is the clear view of the SCR Panel that the school’s recording has been inadequate and fed in to this process in a way that was unhelpful. Nonetheless the SCR Panel has agreed that it has been possible to draw together a sufficiently accurate account of events to inform this report and the judgments it contains. 7.3 Recognising abuse 7.3.1 The failure of staff to identify the abuse and exploitation of Child G was a wide-ranging one. The review has not brought to light any evidence at all of any staff who had any clear concerns about Mr K’s conduct. All the specialist and senior staff in the school seem to have reconstructed the events into misconduct by Child G. Mr K became the victim. Even when reporting to this review after Mr K’s imprisonment, there was evidence of some school staff failing to recognise the child protection implications in some of the earlier events. 7.3.2 This is a matter of concern in itself, and one this school must address, because, as demonstrated above (and taking account of further information arising from the criminal proceedings) the evidence of the developing relationship was substantial and widely known or suspected in the school community. 7.3.3 Understanding how professionals responded to the emerging evidence in this case may be assisted by an analytical approach referred to by the Social Care Institute for Excellence (SCIE) in their work on SCRs. The “garden path syndrome” describes the way in which people accommodate new and developing information within the assumptions they have already This report is the property of the East Sussex Safeguarding Children Board. Page 32 of 46 made about a situation. Here the general mindset from the outset was that a student was behaving inappropriately towards a teacher and the accumulating information to the contrary was dismissed or not recognised. 7.3.4 This set the parameters for the way in which new information was evaluated. It was underpinned by a broader set of assumptions about the way young people behave, the way in which teachers conduct themselves, the vulnerability of teachers to false allegations, and sympathy for an apparently engaging teacher who was known to be experiencing personal difficulties outside school. Yet the possibility that there might be cause for concern for Child G’s safety was never considered. 7.3.5 That “garden path” hampered any critical evaluation of events. In particular it did not provide a context for individuals with demanding responsibilities to share concerns or, if they did not have concerns, for that to be challenged. This developing situation was not known to only a few staff. Many teachers, at the most senior level, had some awareness of what are now recognised as causes for concern but failed to reflect on that. 7.3.6 There was no formal supervision structure in place for staff with safeguarding responsibilities. Such an arrangement would have provided an opportunity to critically challenge or re-evaluate assumptions and decisions taken, and identify the growing body of evidence which clearly showed that child protection thresholds had been reached. 7.3.7 It is significant that the first recommendation from the school’s safeguarding review, commissioned and completed before this review and before the criminal proceedings were concluded, is that it should “promote a more positive culture of challenge and professional curiosity within the staff group, in order to achieve the ability to consider and proffer a differential hypothesis for presenting concerns”. That recommendation is heavily underlined by the issues arising from this SCR. 7.4 Listening to young people 7.4.1 Safeguarding concerns were raised or came to light seven times, including the final report to police. On five of those occasions concerns were raised initially by young people – the only exceptions were the instances of Child G being seen on CCTV in locations where Mr K was teaching. 7.4.2 The fact that none of these reports led to investigation is of concern. Despite corroborative evidence the reports were dismissed, even though there was no indication that any of them were malicious or sensationalist. There is no suggestion that the reports were made by students with any reason for causing trouble either for Child G or Mr K, nor from students with any “track record” of making unwarranted claims. There was not any context at that time of Child G being bullied or harassed by other young people. There does not seem to have been any attempt to understand why concerns were This report is the property of the East Sussex Safeguarding Children Board. Page 33 of 46 being repeatedly raised, beyond a “knee jerk” reaction of blaming the child for harassing a teacher. 7.4.3 Serious Case Reviews frequently identify failures to listen to the “voice of the child” and explain those failures in terms of organisational culture, inadequate training, manipulative parents and a range of other contributory causative factors. The child in this case may have been so caught up in this particular situation that she would have been unlikely to disclose any cause for concern. But if the young people who were raising concerns had been heard, there were a number of opportunities for interventions which might have prevented the events leading to this review. 7.4.4 The emerging concerns were not raised appropriately with Child G herself. In fact, even when there was a formal child protection investigation by experienced police and CSC officers, Child G was not seen alone. In school there was never an occasion when a member of teaching staff sought to talk to her privately, and without accusing her of wrongdoing, about her broader health and well-being. Even if all the incorrect assumptions made by school staff were true – that this was an immature young person with a “crush” on a teacher – one might have expected that someone could have tried to explore this and assist her. 7.4.5 One cannot extrapolate from this one case to conclude that there is any structural weakness in the communications between staff and students at this school, or in the school’s pastoral care. In fact there is much evidence to the contrary, set out not least in the safeguarding review commissioned by the school and completed earlier this year. Equally though school staff need to reflect on how they were deceived and misled over a period of months, by an unsophisticated and careless abuser, who did little to cover his tracks. 7.5 Working with parents 7.5.1 As Ms C has described in her contribution to the review, there was little evidence of the school seeking to involve her in tackling a problem, even in the way that they had defined it, a teacher being harassed by a student. There is conflicting evidence about attempts made to contact her but it is clear that Ms C was only spoken to by a member of teaching staff two or three times in the seven months that her daughter was being abused – and on one of those occasions the person who spoke to her was the abuser. It is also undisputed that some of the evidence of cause for concern – again, even if that were only seen as concern that her daughter was behaving inappropriately – was never shared with Ms C. 7.5.2 It does not seem that senior and specialist staff ever discussed the emerging concerns and agreed how they should be tackled. That may be to do with the specifics of this situation - this review has not heard from any other source that parents are not appropriately included in the life of the school. The school was subject to an Ofsted inspection in November 2012 and its overall effectiveness was found to be good, as was the behaviour and safety of its pupils. This report is the property of the East Sussex Safeguarding Children Board. Page 34 of 46 7.5.3 However the review has identified that School D makes almost no use of the Common Assessment Framework15 (CAF) arrangements. The IMR reports that “Despite there being a small number of pupils at the school with a CAF, these were all initiated by other outside agencies. During the previous two academic years (2011-12 & 2012-13) the school was one of only three secondary schools across East Sussex who did not initiate a single CAF”. 7.5.4 The CAF would have offered structured processes for starting to work with Child G and her mother, based on the school’s premise, worrying enough in itself, that a child was seeking to promote an inappropriate relationship with a teacher. One would then expect that this structured approach would have enabled all those involved to identify the real areas of concern and escalate their interventions accordingly. 7.6 Record-keeping 7.6.1 This review has brought to light concerns about routine record-keeping both in CSC and at School D. For CSC the LADO did not have a reliable system for recording enquiries from schools. That has been recognised as a weakness and arrangements are being made to address this. For School D the concerns are different. There are processes in place but, in this case, they were not followed, either by those with key safeguarding responsibilities or by senior staff. It was, the IMR tells us, “acknowledged that they did not routinely record or note discussions or meetings that they had with pupils”. 7.6.2 To differing degrees the heart of the problem lies in the failure to identify that this was a safeguarding situation in the first place, but systems should be robust enough to accommodate that possibility. For the protection of all concerned the use of good quality, standardised recording arrangements needs to be an automatic response to any concern involving a relationship between a teacher and a young person which may be improper. 7.6.3 The use of forms which are headed “Child Protection” may not promote that standardised practice – the implication that a child is being abused may be counter-productive. It may be more useful to have recording and evaluation arrangements which are specific to issues relating to relationships between teachers and young people. 15 The CAF was established by the former Department for Children, Schools and Families. It is described as “a standardised approach to conducting assessments of children's additional needs and deciding how these should be met…The CAF promotes more effective, earlier identification of additional needs, particularly in universal services. It aims to provide a simple process for a holistic assessment of children's needs and strengths; taking account of the roles of parents, carers and environmental factors on their development”. This report is the property of the East Sussex Safeguarding Children Board. Page 35 of 46 7.6.4 In any event a recommendation from this review will highlight the importance of maintaining accurate written records of any internal meetings which relate to child protection concerns and of any contact with statutory agencies such as LADO and the police. 7.7 E-safety 7.7.1 Mr K used “social media” – specifically, Twitter – to communicate with Child G. This was not “grooming” in the more commonly recognised reference to the process by which an adult with a sexual interest in children will approach a child online, with the intention of developing a relationship with that child. However it was part of the way he promoted the abusive relationship which led this SCR to consider issues around “e-safety”. 7.7.2 The Department for Education’s website16 sets the scene: “Technology enhances learning, and schools and colleges can do much to ensure students get the most from it, by encouraging responsible online behaviour. Involving children and young people in the development of their school’s e-safety policy can minimise risk and embed important principles such as keep personal information private consider the long-term implications of any content posted online do not upload or post inappropriate, offensive or illegal content to their own or other online spaces read and adhere to any website’s terms of conditions of use – including those around age restrictions.” 7.7.3 Those broad principles can serve as the basis for the development of more detailed arrangements which will include guidance on how teachers should conduct themselves. There are many exemplars17 easily available that can be used to develop that guidance. It is necessary here because, as the school’s own safeguarding review found, “the school lacks a comprehensive policy or a whole school approach and accountability for e-safety. . It is right that the focus must be on raising staff awareness to keep themselves safe and to avoid any suggestion of wrongdoing which at the same time would make investigating breaching such professional boundaries a clearer exercise. However the main focus must be on a sophisticated approach to conversations and education of pupils to ensure that they understand the complexities of safe relationships, what constitutes an unsafe relationship and how to manage this within and post school”. 7.7.4 The guidance will also need to include a policy on mobile phones, which covers searching and confiscation - the intuitive reaction of ST1 in seizing 16 http://www.education.gov.uk/schools/pupilsupport/pastoralcare/b00198456/principles-of-e-safety 17 For example, the South West Grid for Learning Trust, an educational trust with a reputation for supporting schools with online safety has developed the following: Z:\SWGfL-School-E-Safety-Template-Policy-(without-appendices)-Oct-2013.docx This report is the property of the East Sussex Safeguarding Children Board. Page 36 of 46 Child G’s phone in May, and engaging the school’s IT services in investigating it, may not have been supported by such a policy. 7.7.5 The school’s safeguarding review is right to conclude that “a more robust response across the school to staff/student contact via social media…might not have interrupted the course of events which followed (but) it might have led those around Child G who may have had knowledge of the relationship to question the relationship and challenge Child G on her actions or report concerns to staff”. 7.7.6 Having said all that, the need for a coherent e-safety policy should not mask more basic failings. Being “friends” with a student on Twitter is as clearly inappropriate for a teacher as being friends in any other sense. There was compelling evidence of inappropriate conduct before the Twitter issue came to light. In a sense the emergence of the inappropriate use of Twitter became another way in which staff rationalised and failed to recognise the evidence of sexual abuse. 8. GOOD PRACTICE 8.1 Under previous arrangements for evaluating SCRs OFSTED18 suggested that the “best” reviews will identify “Good practice… with… potential for wider implementation”. This review has not identified any professional practice, during the period under review, which would meet that expectation. However it is right to reiterate that Ms C was very grateful for the diligence and commitment of police and CSC in their work with her after the abduction. 9. SERIOUS CASE REVIEW PROCESS 9.1 As explained above this review was necessarily delayed for criminal proceedings to be completed. The verification of information supplied by School D also led to some extensions to the timescale for the review. Otherwise the process has been straightforward and efficient. 18 OFSTED SCR Descriptors January 2009 This report is the property of the East Sussex Safeguarding Children Board. Page 37 of 46 10. CONCLUSIONS: KEY THEMES, MISSED OPPORTUNITIES AND LESSONS LEARNED 10.1 This review is unusual in that it arises solely from the abuse of Child G by her teacher. Child G was not abused or neglected within her family – quite the opposite. There are no key issues arising from the minimal involvement of health services. There are matters for police and CSC, and it is right that those matters are addressed, but the lessons to be learned arise, in the main, from the way in which staff at School D repeatedly failed to see the evidence of Mr K’s misconduct or to hear the concerns raised by students. 10.2 It is striking that it was, overwhelmingly, young people who raised concerns about this situation. Those concerns were repeatedly dismissed. Serious Case Reviews have often commented on agencies’ failures to hear the “voice of the child” but this has generally been a reference to the abused child. Here the very nature of the abuse, grooming and exploitation, made it unlikely that the victim would raise concerns. Yet agencies, and particularly the school, were too ready to dismiss the reports received from other children. That should lead those agencies to re-consider how they respond, individually and together, to concerns raised by young people. 10.3 This review has tried to identify and understand the factors which contributed to the agencies’ inadequate response to the mounting cause for concern. There was, in the school, a sort of “default position” of intuitively supporting a colleague with a corresponding reluctance to believe that the colleague might be an abuser. The most senior staff had some knowledge of the situation: the fact that they did not recognise the safeguarding implications will have sent a signal to other staff, as will the similar position taken by staff with particular child protection responsibilities. 10.4 That judgment on “who to believe” needs to be located in a broader set of professional and societal assumptions about the way young people behave, the way in which teachers conduct themselves, the vulnerability of colleagues / teachers to false allegations and unfounded concerns, a fear that child protection agencies will over-react to concerns, and a sympathy for an apparently promising teacher who was known to be experiencing personal difficulties outside work. 10.5 Most significantly there was no evidence of any attempt by school staff to talk to Child G in a way that was supportive. She was never offered a private discussion with any member of staff after she was seen by the school nurse. She may not have disclosed abuse but she was not given an opportunity to do so until the abusive relationship was firmly established. 10.6 The failure by the school to involve Child G’s mother in responding to these events is equally a cause for concern. Even if her daughter were not being abused but was behaving in a way that was damaging to herself and to a blameless member of staff, Ms C needed to know that. She is absolutely right to identify that she was denied the opportunity to assist her daughter. This report is the property of the East Sussex Safeguarding Children Board. Page 38 of 46 10.7 It is not suggested that Ms C was deliberately left out of the loop. Nonetheless the failure to involve her was something more than carelessness. It was linked to the reluctance to acknowledge the increasing evidence of an improper relationship, and the tendency to re-formulate that evidence into something more routine, such as an unprofessional (but not seriously harmful) use of Twitter. While there was a significant and mounting weight of evidence of abuse there was a lack of adherence to any formal process within the school for identifying, analysing and responding to the emerging concerns. 10.8 The review has identified some weaknesses in “routine” child protection work in this case, once matters reached that stage. Initial enquiries by police should have been carried out by the Child Protection Team. The Strategy Discussion was not sufficiently thorough and did not plan against potential and predictable contingencies. The subsequent interviews did not comply with procedural requirements in that Child G and her mother were not seen separately. A decision to reconvene the meeting was inappropriately overturned. CSC may have terminated their involvement too speedily. Police may have compromised evidence by examining Child G’s phone without recourse to specialist staff. It is right that these matters are identified as learning points even if they may not have affected the course of subsequent events. 10.9 The scope of the agencies’ response to the events, once concerns became explicit, was limited. They have all said that the evidence of abuse by Mr K, as considered in the Strategy Discussion, was persuasive. Yet this did not lead to any discussion of the consequences of this for the school more generally. They could not have foreseen the extreme nature of subsequent events but they could have anticipated that the abuse of a child by a teacher would become known and that the consequences of that would need to be carefully managed with the collaboration of all the agencies. 10.10 The review has identified weaknesses in the agencies’ arrangements for recording information – a specific issue for the LADO and a much broader range of concerns for the school. There was no contemporaneous recording of any of the emerging concerns for Child G. This is despite the fact that schools have been provided with comprehensive and accessible guidance19 by the local authority. That guidance, in its introductory comments, notes that there has been a problem, identified in previous Serious Case Reviews, concerning record keeping by schools. This review indicates that at School D lessons had not been adequately learned. The reasons for this are inextricably linked with the continuing failure to recognise that this was an abusive relationship, but the weaknesses identified fall well below the threshold of reasonable practice in relation to record-keeping. 10.11 There is a further concern, which must be recognised, about the reliability of information the school has supplied to this review, and the fact that some matters cannot be reconciled. It was, at best, an unnecessary impediment to the process of the review that the school did not make it clear 19 Record Keeping in Maintained Schools.doc This report is the property of the East Sussex Safeguarding Children Board. Page 39 of 46 that no records had been kept, nor that records had been made retrospectively but were supplied in a way which led the Panel to believe that they were contemporaneous. 10.12 This section of the report started with an acknowledgment that this was, in some ways, an unusual Serious Case Review. Yet the “headline” issues emerging from the review are not unusual – they are about listening to young people, talking to children who may be victims of abuse, involving their parents purposefully, recording and sharing information reliably and planning interventions more carefully across the agencies. This report is the property of the East Sussex Safeguarding Children Board. Page 40 of 46 11. RECOMMENDATIONS FROM THIS SERIOUS CASE REVIEW 11.1 Introduction 11.1.1 These recommendations to the LSCB reflect the key issues arising from this review. Some matters - for example, the level of seniority at which police are represented at meetings – are specific to an agency and have been addressed in the agencies’ individual responses to the review. The recommendations arising from the individual agencies’ reports are attached in Appendix D. There are no substantial matters arising from this review for NHS agencies and, accordingly, no recommendations. 11.1.2 Agencies have not awaited the completion of this review in order to tackle issues arising from these events. Some of these recommendations, or aspects of them, have been identified and addressed already, as part of an Action Plan. 11.2 Recommendations to the East Sussex Local Safeguarding Children Board 11.2.1 The Board should work with School D, re-visiting the findings of the school’s safeguarding review, to ensure that the school can demonstrate an appropriate understanding, at all levels of seniority, of safeguarding issues and how to respond to them, including appropriate parental involvement. arrangements for the support and supervision of staff with specialist child protection responsibilities. compliance with arrangements for the recording of safeguarding concerns and actions taken in response to such concerns. 11.2.2 The Board should develop initiatives which promote the ability of young people in schools to raise safeguarding concerns, and the capacity of schools and other agencies to hear and respond to such concerns. 11.2.3 The Board should use this report and the outcomes of this review in training and development opportunities, particularly for school staff with safeguarding responsibilities: “What would stop this happening in our school?” 11.2.4 The Board should promote the development of robust “e-safety” arrangements in schools 11.2.5 The Board should require the Local Authority, with input from schools and other relevant agencies, to review the arrangements for the LADO service, with reference to the key issues arising for that service from this SCR. This report is the property of the East Sussex Safeguarding Children Board. Page 41 of 46 APPENDIX A: Composition of SCR Panel Name / Designation Organisation Role Mr Ron Lock Independent Panel Chair Head of Children’s Safeguards & Quality Assurance East Sussex County Council Children’s Services Panel Member Child Protection and Safeguarding Manager, Protecting Vulnerable People Branch Sussex Police Panel Member Behaviour and Attendance Co-ordinator East Sussex County Council Children’s Services Panel Member Designated Doctor for Safeguarding Hastings & Rother Clinical Commissioning Group Panel Member Designated Nurse for Safeguarding Hastings & Rother Clinical Commissioning Group Panel Member Manager East Sussex Safeguarding Children Board In attendance Mr Kevin Harrington Independent Overview Report author This report is the property of the East Sussex Safeguarding Children Board. Page 42 of 46 APPENDIX B: Details of the Chair of this review and the author of this report Independent Chair of the Serious Case Review: Mr Ron Lock Ron Lock is a qualified social worker who has spent all his career in the field of child protection, for most of that time with the NSPCC, finishing in their employment in 2001 as a Regional Head of Child Protection Services. Since then Ron has been an independent consultant in safeguarding children, and has specialised in Serious Case Reviews, to date being involved in more than 70, either as independent chair or overview author. Whilst much of this work has occurred for a number of LSCBs across the South of England, Mr Lock has not previously worked in East Sussex and has not been involved in any earlier Serious Case Reviews which they may have undertaken. Independent Author of Overview Report; Mr Kevin Harrington Kevin Harrington trained in social work and social administration at the London School of Economics. He worked in local government for 25 years in a range of social care and general management positions. Since 2003 he has worked as an independent consultant to health and social care agencies in the public, private and voluntary sectors. He has a particular interest in Serious Case Reviews, in respect of children and vulnerable adults, and has contributed to around 40 such reviews. He has not previously worked in East Sussex. Mr Harrington has been involved in professional regulatory work for the General Medical Council and for the Nursing and Midwifery Council. He has served as a magistrate in the criminal courts in East London for 15 years. This report is the property of the East Sussex Safeguarding Children Board. Page 43 of 46 APPENDIX C: Terms of Reference for this Serious Case Review The Serious Case Review considered events in the period from September 2010, when there were concerns about the conduct of a supply teacher at School D, until the date when it was confirmed that Child G had been abducted. The agencies were asked to draw up their Individual Management Reviews around the key issues specified in Working Together, to be considered in all SCRs, namely: Were practitioners aware of and sensitive to the needs of the young person in their work, and knowledgeable both about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare? When, and in what way, was the young person’s wishes and feelings ascertained and taken into account of when making decisions about the provision of children’s services? Was this information recorded? Did the organisation have in place policies and procedures for safeguarding and promoting the welfare of children and acting on concerns about their welfare? Did your agency consider that the threshold was reached for any relevant legal intervention at an earlier stage? What were the key relevant points/opportunities for assessment and decision making in this case in relation to the Child G and family? Do assessments and decisions appear to have been reached in an informed and professional way? Were concerns about this young person shared between the relevant agencies in a timely manner, with appropriate communication and analysis? Should communications be reviewed between agencies, in order to identify if there were issues of concern that were not shared? Did actions accord with assessments and decisions made? Were appropriate services offered/provided, or relevant enquiries made, in the light of assessments? Were there any issues, in communication, information sharing or service delivery, between those with responsibilities for work during normal office hours and others providing out of hours services? Was practice sensitive to racial, cultural, linguistic and religious identity and any issues of disability? Were senior managers or other organisations and professionals involved at points in the case where they should have been? Was the work in this case consistent with each organisation’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards? Were there organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? Was there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case? Was there sufficient management accountability for decision making? This report is the property of the East Sussex Safeguarding Children Board. Page 44 of 46 APPENDIX D: Recommendations from the agencies’ management reviews East Sussex Children’s Services, Social Care Full compliance with the Child Protection procedures around children and young people being seen on their own as part of a Child Protection Investigation, should consistently be adhered to. During investigations and ongoing assessments, where communication through mobile phones and computers are an issue, staff should be challenged on their knowledge of the use of social media and advice and assistance should be sought The LADO needs to complete the piece of work to ensure that recording of the work is always completed and stored appropriately and this should be agreed in consultation with senior managers. In light of Working Together 2013, CSC must identify the most appropriate health professional to be invited prior to convening a Strategy Discussion East Sussex Children’s Services, Education Re-issue their E-safety and Social Media Guidance to all schools (including primary, secondary, special schools and academies) so that all parties (students, parents and teachers) are aware of the potential pitfalls and dangers when using social media. Review the Designated Child Protection Teacher training to ensure it includes information about multi-media technologies including social media as a means of grooming children and young people. School D The school should update its existing Safeguarding Policy (dated May 2012) detailing all safeguarding procedural changes implemented since May 2012. The Safeguarding Policy should also make explicit any future procedural changes with a clear time line of their implementation. This document should be ratified no later than December 2013 and reviewed every two years. Undertake an independent and bi-annual file audit of their child protection cases in line with the school and LSCB’s expectations and standards and the findings of these file audits shared with the LSCB. Be reminded of the importance of their responsibility of maintaining accurate written records that reflect communication and decisions in the assessment process. This should include emphasis on written records of any contact with statutory agencies such as the Police and Children’s Social Services. This report is the property of the East Sussex Safeguarding Children Board. Page 45 of 46 Be reminded of the importance of ensuring that the wishes, feelings and experiences of the child is at the centre of all assessments and ensure that children’s wishes, feelings and experiences are routinely recorded as part of all safeguarding concern. Arrange Child Exploitation and Online Protection training to all Designated Child Protection Teachers and wider IT staff about e-safety issues and possible safeguarding concerns related to the use of social media and potential for grooming. Arrange child protection training for the Senior Management Team, Designated Child Protection Teachers and all pastoral care staff on the application of child protection thresholds. When making a referral to outside agencies share all relevant information relating to the young person being referred. Sussex Police Protecting Vulnerable People Branch to perform an audit, in the next 6 months, to establish if CPT officers generally carry out the first response to allegations made against people working with children. This will enable a decision to be made whether to amend the child protection policy. Head of Protecting Vulnerable People Branch to review, in the next 6 months, the requirement and capability for a CPT Detective Sergeant to attend all Strategy Discussions for allegations made against people working with children. This report is the property of the East Sussex Safeguarding Children Board. Page 46 of 46 APPENDIX E: References Footnotes have been used to indicate specific quotations from or references to research, practice guidance and other documentation. This Overview Report has been generally informed by the following publications Working Together to Safeguard Children (2013) Working Together to Safeguard Children,(HM Government 2010) The Victoria Climbie Inquiry (Lord Laming 2003) The Protection of Children in England: A Progress Report ( Lord Laming 2009) Improving safeguarding practice, Study of Serious Case Reviews, 2001-2003 Wendy Rose & Julia Barnes DCSF 2008 Analysing child deaths and serious injury through abuse and neglect: what can we learn – A biennial analysis of serious case reviews 2003-2005 Understanding Serious Case Reviews and their Impact - a Biennial Analysis of Serious Case Reviews 2005-07 DCSF 2009 Learning together to safeguard children: developing a multiagency systems approach for case reviews. ( SCIE 2009) The Munro Review of Child Protection: Final Report (HMSO May 2011) The Munro Review of Child Protection: Interim Report (HMSO February 2011) Publication of Serious Case Review Overview Reports: Letter from Parliamentary Under Secretary of State for Children and Families 10th June 2010 Social Networking: a guide for trainee teachers and newly qualified teachers (Childnet International 2011) Professional Guidance on the use of electronic communication and social media – General Teaching Council, Scotland Keeping Children Safe in Education – consultation documents (DfE 2013) Child Sexual Exploitation and the response to localised grooming (House of Commons Home Affairs Committee, June 2013) Executive Summary, Serious Case Review, Teacher X – Hillingdon Safeguarding Children Board, 2011 Out of mind, out of sight – Child Exploitation & Online Protection Centre (2011) SCR, Daniel Pelka, Coventry LSCB, September 2013 |
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