Death of a 3-year-old Somalian boy, Child H, and serious injury to his 2-month-old brother, in March 2013. Father has been charged with Child H's murder and his surviving siblings have been taken into care. Family had previously been separated by civil war in Somalia and spoke minimal English. Significant history of domestic abuse including an incident leading to mother spending three months in a women's refuge. Issues identified include: insufficient attention paid to past incidents of domestic abuse; professional focus on the emotional impact on children of living with domestic abuse, not on the increased risk of physical harm; lack of reassessment of the family's situation despite indicators of increased risk of harm including overcrowding and new and stressful family relationships; and inadequate range, availability and quality of interpreters. Uses the Social Care Institute for Excellence (SCIE) systems model to pose questions to Lambeth Safeguarding Children Board.
      
 Title:  Serious case review: Child H. LSCB: Lambeth Safeguarding Children Board Author: Sally Trench and Ghislaine Miller Date of publication: 2014  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.                          Lambeth SCR Child H Confidential Final Report 1   Lambeth Safeguarding Children Board  Serious Case Review Child H             Authors: Sally Trench and Ghislaine Miller SCIE Lead ReviewersLambeth SCR Child H Confidential Final Report 2 Index  Title Page 1. Introduction 4 1.1 Why this case was chosen to be reviewed 4 1.2 Succinct summary of case  4 1.3 Family composition  5 1.4 Time frame  5 1.5 Methodology 5 1.6 Reviewing expertise and independence 6 1.7 Specialist advice 7 1.8 Methodological comment and limitations 8 1.9 Structure of report 8 2. Findings: What light has this case review shed on the reliability of our systems to keep children safe? 9 2.1 Introduction 9 2.2 What is it about this case which makes it act as a window on practice more widely? 9 2.3 Appraisal of practice in this case: a synopsis 11 2.4 Summary of findings 14  Findings in detail 16 2.5 Finding 1.  A tendency among professionals in all agencies to focus on the emotional impact on children of living with domestic violence, and not on the increased probability that they will be physically harmed, impedes a full understanding of the risks to which they are exposed.   16 2.6 Finding 2.  Are the mechanisms, which are intended to pick up errors of human reasoning, functioning well and consistently in agencies?  Where they are not, inaccurate judgements are more likely to go unchallenged.   20 2.7 Finding 3.  The current range, availability and quality of interpreters is problematic; for planned work it is variable and, in emergency situations, it is so poor that it risks leaving non-English language service users without support, making it extremely difficult for professionals to make an effective assessment or diagnosis in a timely fashion.  24 2.8 Finding 4. Where there is no known recurrence of domestic violence incidents, professionals tend to 27 Lambeth SCR Child H Confidential Final Report 3 be reassured about the welfare of children in the household and/or believe their grounds for purposeful engagement with the parents are diminished. The consequence is that they get no further in understanding the causes and triggers of incidents of domestic violence, and the actual level of risk to children these imply. 2.9 Finding 5. A pursuit among social care and police staff of categorical explanations from medical professionals of the cause of physical injury to children, clashes with a norm among medical professionals of giving differential diagnoses in which anything is possible until it is ruled out. This increases the chances of miscommunication and misunderstanding about past and future risks in child protection investigations. 31 2.10 Finding 6. The low priority given by the Emergency Duty Team (EDT) to responding to requests for routine data checks relative to other demands, and the lack of a system in the Family Support and Child Protection Teams for routinely retrieving at the start of the day information logged by EDT at night, undermines timely information-sharing, even in situations where an urgent response is required. 35 3. Conclusion 39  References 41  Appendix 1: The SCR Process in detail 43  Appendix 2: Glossary 52  Appendix 3: Statistics on domestic violence 54  Appendix 4: Lessons already learnt and changes implemented to improve practice  56          Lambeth SCR Child H Confidential Final Report 4 1. Introduction 1.1 Why this case was chosen to be reviewed Lambeth Safeguarding Children Board determined to conduct a Serious Case Review (SCR) because the circumstances of this case met the following criteria:        (a) abuse or neglect of a child is known or suspected; and  (b) (i) the child has died; ... 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 to Safeguard Children, 2013:68) 1.2 Succinct summary of case The case concerns a Somali family living in Lambeth. They had previously lived in Somalia, where they had two older daughters, and later a son, Child H, who was born in 2009. The parents were separated for many years due to the civil war in their country. They were reunited in London in early 2011 when Mother joined Father in a shared house with members of his extended family. All three children remained in Africa at this time; the parents did not know where the two elder children were, and Child H stayed with relatives in Ethiopia. Professionals became involved because of the pattern of domestic violence and abuse that quickly emerged in the relationship between Mother and Father. This included supporting Mother, in late 2011 when she was heavily pregnant with Sibling 1, to leave the family home after a serious assault, and to live for three months in a women’s refuge in another London borough.   After the baby was born, professionals remained involved because the parents reconciled and Mother returned to Lambeth, where both later denied the history of domestic violence.  The baby was made subject of a Child Protection (CP) Plan based on an assessment of the risk of further violence, and professionals endeavoured to work with the parents on the implementation of that plan.  During this year, Mother quickly became pregnant again. Just before her next child (Sibling 2) was due to be born, Father brought back their three year old Child H from Ethiopia.  In January 2013, therefore, the family had grown to three children, aged three years and under.  All the children were now subject of Child Protection Plans. In early March 2013, at the age of two months, the youngest child suffered a serious injury, and was admitted to hospital in a neighbouring borough.  A week later, his 3-year old sibling died of injuries received whilst in the care of Father.     Lambeth SCR Child H Confidential Final Report 5 1.3 Family Composition Family member Age in March 2013 Father 42 Mother 40 Child H Aged 3 ½ at death Sibling 1 14 months Sibling 2 2 months The parents’ two older children did not join the family in Lambeth, and their whereabouts are unknown. 1.4 Timeframe The SCR analyses professional practice between February 2011 (Mother’s  arrival in the UK) and 11th March 2013 (date of Child H’s death).     1.5 Methodology Statutory guidance requires SCRs to be conducted in a way that:  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.  (WT 2013: 67)  The following principles should underpin 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 Lambeth SCR Child H Confidential Final Report 6 sensitively. This is important for ensuring that the child is at the centre of the process. (WT 2013: 66-67) In addition, SCR reports should  “…be written in plain English and in a way that can be easily understood by professionals and the public alike” (WT 2013: 70) To help ensure that this report is accessible to all readers, a guide to acronyms and terminology is provided as Appendix 2 of this report.   Lambeth LSCB has chosen to use the Learning Together systems model, developed within the Social Care Institute for Excellence (Fish et al., 2008) to comply fully with the requirements of Working Together 2013. The Learning Together review process is based on the following key principles: 1. Avoid hindsight bias.  In order to understand why people acted as they did, it is important to avoid hindsight bias – judging their actions from the standpoint of knowing what happened later, when it is easy to see which bits of information were significant and which were irrelevant.  Therefore this systems model seeks to understand the experience and the reasoning of the workers and managers who were working with the family at the time, in particular, to explore what sense they were making of the case, and the contributory factors in the work context that were influencing their practice at the time; 2. Provide adequate explanations.  The model requires reviewers to appraise and explain decisions, actions and inactions in professionals’ handling of the case, and to view performance as the result of interactions between the context and what the individual brings to it. 3. Move from individual instance to the general significance.  The case provides a ‘window on the system’, finding out whether weaknesses visible in the management of an individual case are widespread, and so leading to a broader understanding about what supports and what hinders the reliability of the multi-agency CP system.  4. Produce findings and questions for the Board to consider.  Some findings lead to the simple recommendation of a new rule or specific action; others may require the Board to consider how to balance identified needs with other demands on agencies’ resources.  5. Analytical rigour.  Qualitative research techniques are used to underpin rigour and reliability, alongside a very open process so that others can see how conclusions were reached.  Full details of this review process are contained in Appendix 1 of this report.   1.6 Reviewing expertise and independence Lead Reviewers The SCR has been led by two independent, experienced and accredited SCIE Lead Reviewers, Sally Trench and Ghislaine Miller. They both have extensive Lambeth SCR Child H Confidential Final Report 7 experience in writing SCRs/IMRs under the previous ‘Chapter 8’ framework, and have received training and accreditation in the SCIE Learning Together model.  Neither has any previous involvement with this case, or any previous or current relationship with Lambeth Council or partner agencies.  The Lead Reviewers have received supervision from SCIE as is standard. This supports the rigour of the analytic process and reliability of the findings as rooted in the evidence.    Review Team This comprised 9 senior managers from the multi-agency services involved with the family.  Their role was to provide a source of high-level strategic information about their own agencies, as well as professional expertise in their fields.  Together with the Lead Reviewers, they collected data about this case, including a review of agencies’ records, and produced and agreed the content of this report. Full involvement of practitioners  The second important group taking part in the case review was 25 front-line professionals and first-line managers who had worked with the family in different capacities.  They provided a detailed picture of what happened in this  individual case, and also their knowledge of the systems as a whole, to help us understand whether practice in this case had been typical or otherwise. To elicit their involvement and experiences of  this case, members of the Review Team held individual conversations with the Case Group professionals.  The Case Group also attended two multi-agency meetings to contribute to the analysis and findings from the Review Team and Lead Reviewers.    1.7 Specialist advice The Lambeth LSCB Manager arranged for specialist input about Somali history and culture to support the interpretation of professional practice in this case.  A half-day’s training was provided for the Review Team (and a shorter session for the Case Group) by the Somali Development Group, a voluntary organisation based in Bristol. This training provided an extremely useful insight into a range of historical, religious, and cultural aspects of Somali life and experiences, including    The effects of the 20 years-plus civil war and displacement of family members  The role of men/fathers in family and community life  Conversely, the often subservient role of women and children  The common use of khat as a drug and its effects The Review Team are conscious that the somewhat traditional picture that was being provided would not apply to all Somalis living in London, nor to all Somalis in their own country.  In relation to our case, it helped in bringing cultural sensitivity to how professional practice was appraised.  For example, it gave an insight into the intervention by the ‘Somali community’ regarding Mother’s reporting of domestic violence.  In particular, it suggested that Mother’s situation must have been extreme and desperate for her to flee the Lambeth SCR Child H Confidential Final Report 8 marital home (November 2011), thus seriously flouting family and community norms.  The representative from the Somali Development Group was also helpful in matters such as advising against the use of male interpreters with women in Mother’s circumstances (something which had happened uniformly in this case, due to the lack of available female interpreters).   1.8 Methodological comment and limitations 1.8.1 Participation of professionals  Child H’s death was a shock to staff who had been working with the family, and has caused them much distress and grief.  Thus, engaging constructively in the SCR process in this context has inevitably been challenging and often painful for the staff involved. Nonetheless, they have participated very responsively in individual conversations and group discussions, where they have recalled their decision-making and actions in the case. The Lead Reviewers and the Review Team have been impressed throughout by the professionalism, knowledge and experience the Case Group have contributed to the review and their capacity to reflect on their own work so openly and thoughtfully in this SCR.  Several Case Group members have remarked that it has been a positive experience to contribute to learning from the tragedy.  All this has given the Review Team a deeper and richer understanding of what happened with this family and within the safeguarding network and why, and has allowed us to capture the learning that is presented in this report.     1.8.2 Missing perspectives of the parents and children  Police have advised that the status of the parents as alleged perpetrator and witness in criminal proceedings ruled out the possibility of their participation in the SCR. This means that a critical perspective is missing from this case review. The SCR has not been able to benefit from the parents’ input regarding what worked well in their engagement with professionals, what issues made it harder for them to engage with efforts to support them in their care and protection of their children, or how they managed their interactions with the workers.  After the criminal proceedings are concluded, the parents will be asked whether they are willing to meet with the Lead Reviewers to give their views about these issues.  Should this be possible, an addendum to this report will be provided, to reflect any further learning.     Child H’s two remaining siblings are too young to make it feasible to gain their perspectives or experiences. 1.9 Structure of report The next chapter (Chapter 2) of this report begins with a summary of what happened in the case.  It identifies four distinct phases in professional contact with the family and presents judgements on the way the work was done in each phase.   This leads on to a presentation of the six priority findings.  Each finding concludes with some key questions that the finding raises for the LSCB and Lambeth SCR Child H Confidential Final Report 9 member agencies.  It is the responsibility of the LSCB to decide how best to respond to the findings, with the aim or reducing the recurrence of poor practice.  The questions are intended to support their considerations.    2.  Findings: What light has this case review shed on the reliability of our systems to keep children safe?  2.1 Introduction  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 (WT 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.’ (2013: 65) This section firstly explores the ways in which features of this particular case are common to other work that professionals conduct with children and families, and therefore how this one case can provide useful organisational learning to underpin improvement. Next, a synopsis of the appraisal of practice is provided for the reader. This sets out the view of the Review Team about how timely and effective the  interventions with Child H and his family were, including where practice fell  below expected standards. Where possible, it provides explanations for this practice, or indicates where these will be discussed more fully in the findings.  Finally, this section discusses six priority findings that have emerged from the SCR. The findings explain why professional practice was not more effective in protecting Child H in this case.  It also outlines the evidence that indicates that these are not one-off issues, but underlying patterns – which have the potential to influence future practice in similar cases.  We also consider what risks they may pose to the wider safeguarding of children.   2.2 What is it about this case which makes it act as a window on practice more widely? 2.2.1 Statutory guidance on the conduct of learning and improvement activities to safeguard and protect children, including serious case reviews (SCRs) states:  ‘Reviews are not ends in themselves. The purpose of these reviews is to identify improvements that 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)   Lambeth SCR Child H Confidential Final Report 10 2.2.2 Lambeth Safeguarding Children Board (LSCB) identified that the SCR of this tragic case held the potential to shed light on particular areas of practice:    How well are we currently working with Somali families in Lambeth, including those who have been affected by civil war and forced migration, as well as those where there is domestic violence (DV)?   How well does the system of Child Protection Plans, Conferences and Core Groups operate to keep children safe, especially when parents are resistant to this involvement?   How well do partner agencies work together, including the core CP services, in responding to suspicious injuries to small children and babies? 2.2.3 This case epitomises the difficulties that professionals face in their efforts to safeguard and protect children in situations where there is domestic violence and abuse between parents. This is relatively straightforward if the violence is admitted and the abused partner wants to separate from the violent partner with a clean break. However, it is in the nature of domestic violence that the victim often returns to their violent partner – through fear, ambivalence, and/or conflicting loyalties toward their children and the partner. Pragmatic, social and cultural issues also influence the victim’s decisions – in particular, when they are dependent on their partner for the right to remain in the UK. Despite the threat of continuing future violence, there may be other benefits to returning to the relationship: avoidance of the stigma from family and the community; an attempt to integrate in the community; the need for social companionship; and financial and practical support. Understanding these competing priorities and conflicting loyalties adequately to assess the risk of potential harm to the children involved is a complex and challenging task for professionals.  It is one made more difficult by the uncertainty about risk and danger that characterises this field of work. The available research evidence base provides indicators, but is not able to underpin absolute predictions of which partners will go on to harm their children.  Domestic violence does not happen in isolation; families are often facing other, very real challenges and disadvantages. In this case, these were associated with endeavouring to hold a family together in a context of forced migration and separation due to civil war. All these different issues compete for workers’ attention, as they bring their professional competence to bear on making sense of a situation and the implications for the safety and wellbeing of the children involved. The case therefore raises vital questions about how effectively our child protection system is working to provide a timely and effective response to children living in situations of domestic violence, in a context of migration where family members, both adults and children, have been separated by civil war and later reunited. The scenario is even more challenging for professionals to handle if, as in this case, there were no known recurrences of domestic violence incidents.   Lambeth SCR Child H Confidential Final Report 11 Specifically, this case held a number of complex challenges which safeguarding agencies working in Lambeth and other neighbour boroughs encounter regularly, in the following common areas of practice:   Working with domestic violence, with parents who either minimise or deny violence, and who resist efforts to assess risk from a violent male.  Working to address historical domestic violence, and the risk of future occurrences, during a period in which there are no known incidents.  Considering the impact of domestic violence on children – what is the nature of the risks?  Working with families from a community (in this case, Somali) characterised by a culture of family privacy and male authority.  The complexity of the work is frequently compounded by the adults’ and children’s minimal spoken English.   Responding to an urgent child protection incident in the midst of multiple competing demands, and the importance of ensuring timely and effective communication across agencies.   The dynamics at play between professionals (both in and outside formal meetings), the issues of professional practice and accountability, and the pivotal roles of supervision and management oversight.  2.3 Appraisal of practice in this case: a synopsis The response of professionals to the family falls into four distinct phases over a total period of almost two years:  1. Professional responses to the violent assaults on Mother by Father, including during her pregnancy with Sibling 1 (spring 2011 to early 2012)  2.  Professional responses after the birth of Sibling 1 when Mother returned to Father (winter 2012) 3.  The longer term work with the family that followed (spring 2012 to winter 2013) 4.  The injury to Sibling 2, the death of Child H and the response of professionals (early spring 2013) The quality of practice varied during these phases: the responses to incidents in phase 1 and the initial response after the birth of Sibling 1 were appropriate and of high quality. However, professionals appeared to struggle to a greater extent with the longer term work with the family – in particular how to address domestic violence issues during a period when there were no known violent incidents, and when both parents denied the past domestic violence which had been fully recorded and was known to have happened.   Finally, responses following the injury to Sibling 2 showed poor information transfer between teams and agencies, and the subsequent Section 47 investigation following the injury to Sibling 2 was not conducted in line with statutory guidance.   Lambeth SCR Child H Confidential Final Report 12 The different phases of involvement are discussed in more detail below and the explanations provided in the findings are signposted.   Phase 1 – professional responses to violent assaults on mother In spring 2011, before Mother’s pregnancy with Sibling 1 was known, she reported a violent assault by Father. Police dealt appropriately with the attack on Mother at home, after which she withdrew her allegations against Father.  Later in the year, when Mother was in the third trimester of her pregnancy with Sibling 1, professionals responded promptly and efficiently to the crisis situation following a further violent attack on Mother, including threats to kill Mother and unborn child, after which she fled the family home.    She was subsequently supported to separate from her partner and keep her unborn child safe. A multi-agency risk assessment conference (MARAC) was part of this planning, reflecting the very high risk of harm to Mother. Later, when Mother decided to reunite with Father in Lambeth, the cross-borough work was done well to make this return as safe as possible by continuing the protection of Mother and (now) baby.    Phase 2 – professional responses following the birth of Sibling 1 Sibling 1 was born in January 2012.  Following this, practice was initially good. Professionals made concerted efforts to equip Mother with knowledge about the risks, to support her not to return to her husband's household, as well as handling the transfer of the case from a neighbouring London borough effectively. A Core Assessment of Mother and baby was then conducted back in Lambeth, making the appropriate recommendation to hold an Initial CP Conference, with a parallel plan for a legal planning meeting (a meeting led by the Children and Young People’s Service (CYPS), with legal advisers, to consider whether there should be family court proceedings to protect a child). The fact that the legal planning meeting did not take place was a missed opportunity to explore levels of risk, and possible options for intervention.   Phase 3 - Longer term work with the family After the birth of Sibling 1 in January 2012, a period of long term work with the family began. At this point, both parents denied that the previous domestic violence incidents had occurred. During this time, the Review Team judged the response of professionals to have been less rigorous and authoritative than would have been expected. This was in large part due to professional focus being on the present rather than exploring past incidents to minimize the chance of their future recurrence. Therefore, no known current incidents of DV left professionals falsely reassured about the levels of risk to the children, and with the view they had nothing to work on. This is explained further in Finding 4.  The relevance and influence on the family of their specifically Somali experiences (e.g., of their civil war and the long separation of family members, plus the role of the local Somali community in relation to the family and the dominance of male partners) which had initially been explored, was not pursued further – despite the fact that it was reported that ‘community elders’ had taken a role in mediating between the parents regarding the domestic violence.  Lambeth SCR Child H Confidential Final Report 13 The 9-month period after the Initial CP Conference for Sibling 1 saw major changes in the family household including Mother’s pregnancy and later the birth of Sibling 2, and the arrival of 3 year old Child H from Ethiopia (where he had been staying with friends or relatives) with what appeared to be bruises to his face and marks on his body.   The changes for the family included significant overcrowding and new and stressful family relationships – not least the management of three small children aged 3 years and under.  All of these were indicators of increased risk of harm to Mother and the children. However, professionals did not undertake the re-assessment of the situation that was indicated by the family’s changed circumstances.  Father, in particular, remained an unknown quantity and did not participate in any exploration of risk or of his personal history.  The professional response was hindered by the fact that, while knowledgeable about many facets of domestic violence, those working with the family were not all sufficiently aware of the evidence base about the increased risk of physical harm to the children at this time. This is discussed further in Finding 1.  At Core Groups and CP Conferences, there was a gradual sense of things going well for the family, and an optimistic feeling that progress was being made, when in reality the CP Plans were not being fully implemented. The lack of any further known violent incidents (Finding 4) was compounded by a lack of challenge and debate about the sense that the network was making of developments in the family, either through individual professional supervision or a healthy culture of multi-agency debate and challenge. This is explored further in Finding 2.  When Child H arrived in the UK, his facial injuries were observed by various professionals, including a Health Visitor; a Social Worker, who advised that the parents should take him to be examined by the GP; and later a Midwife who contacted the family’s SW regarding her concerns.  A Section 47 investigation was not carried out, as would have been expected for a child with unexplained injuries. The Conference Chair saw this as unsatisfactory and requested an urgent CP medical.  Phase 4 – Injury to sibling 2 and professional response In March 2013, Sibling 2, who at that point was two months old, was admitted to hospital with a broken femur, an extremely serious and unusual injury in a child of that age. The subsequent child protection responses were poorly co-ordinated and, in some important respects, did not adhere to statutory guidance.   The sharing of information regarding Sibling 2 was delayed at an early, critical stage.  In A&E, the electronic ‘flag’ system for children on CP Plans was missing the relevant list of names from Lambeth, and then direct information about the family was not available from the Emergency Duty Team (EDT) for several hours.  The reasons for this are discussed further in Finding 6.  No appropriate interpreting arrangements were available which meant a significant delay in hearing the parents’ explanation for the baby’s injury. Interpreting arrangements are discussed further in Finding 3. This left A&E Lambeth SCR Child H Confidential Final Report 14 and ward staff with little information to guide their assessment of risk. Despite this, the initiative of the Named Nurse in producing a list of actions early the next morning was helpful and appropriate.  Information from social care EDT about the ‘suspicious injury’ was not picked up quickly by the social work team on the following day (Finding 6 also examines how information is handled in out of hours services).   The subsequent Section 47 investigation, led by the Family Support and Child Protection Team (FSCP), where the case was allocated, did not proceed in line with the guidance in Working Together and the London CP Procedures. The Police were not immediately contacted for a Strategy Discussion.  Instead the Social Worker (SW) visited parents in the hospital and interviewed them, with the Paediatric Registrar. The Strategy Meeting was not successfully convened until two days later, allowing the passage of time to imply a lack of urgency, and for opportunities for evidence to be contaminated or missed.  There was no consistent FSCP manager providing oversight and guidance for the investigation through the next few days.  Once Sibling 2 was admitted to a hospital ward, there was a shared view that he was in a safe place. Social and health care professionals and the police (once they became involved, at the Strategy Meeting) failed to make a link with ongoing risk to the two siblings who were now in the sole care of Father.  There was no home visit to check on their circumstances, apart from one made by the Health Visitor upon her return from leave later in the week, which found no one in.  A risk assessment was required of Father’s ability to care for the children in Mother’s absence, but this did not happen.     The delayed Strategy meeting focused on the likely cause of the injury to Sibling 2.  However the conclusions as to whether the injury was non-accidental were unclear, for reasons explored further in Finding 5.  The discrepant histories of the incident given by the parents received insufficient attention, and the necessary challenge and skepticism from the members of this Strategy Meeting were not apparent.  Consequently, the risks to all the children were wrongly downgraded, despite other evidence to suggest that risk of harm to the children was high.  Although there was significant additional evidence to suggest physical abuse and neglect, this was not acted upon in the absence of a certain medical opinion. The following day, Sibling 1 and Child H underwent CP medical examinations by a Community Paediatric Consultant.  These were conducted, although the booked interpreter did not turn up (a problem already noted in this case), using Father as the spokesperson for his children.  It was clear that the medicals needed to go ahead without further delay.  However, given that  Father was the possible ‘person of concern’ in the situation, arrangements should have been made for Child H (Sibling 1 being pre-verbal) to be spoken to alone with an interpreter at the soonest possible opportunity.  Child H was brought into A&E exactly a week after his younger sibling’s admission to hospital.  He was pronounced dead an hour later.  Lambeth SCR Child H Confidential Final Report 15 2.4 Summary of findings The Review Team has prioritised 6 findings for the LSCB to consider. They relate to four of the six categories of underlying patterns (see Appendix 1).  Finding Category Finding 1. A tendency among professionals in all agencies to focus on the emotional impact on children of living with domestic violence, and not on the increased probability that they will be physically harmed, impedes a full understanding of the risks to which they are exposed.  Multi-agency working in longer term work Finding 2.  Are the mechanisms, which are intended to pick up errors of human reasoning, functioning well and consistently in agencies?  Where they are not, inaccurate judgements are more likely to go unchallenged.  Human reasoning: cognitive and emotional biases Finding 3.  The current range, availability and quality of interpreters is problematic; for planned work, it is variable and, in emergency situations, it is so poor that it risks leaving non-English language service users without support, making it extremely difficult for professionals to make an effective assessment or diagnosis in a timely fashion.   Management systems Finding 4. Where there is no known recurrence of domestic violence incidents, professionals tend to be reassured about the welfare of children in the household and/or believe their grounds for purposeful engagement with the parents are diminished. The consequence is that they get no further in understanding the causes and triggers of incidents of domestic violence, and the actual level of risk to children these imply.   Multi-agency working in long term work Finding 5. A pursuit among social care and police staff of   categorical explanations from medical professionals of the cause of physical injury to children, clashes with a norm among medical professionals of giving differential diagnoses in which anything is possible until it is ruled out. This increases the chances of miscommunication and misunderstanding about past and future risks in child protection investigations. Multi-agency working in response to incidents and crises Finding 6.  The low priority given by the Emergency Duty Team (EDT) to responding to requests for routine data checks relative to other demands, and the lack of a system in the FSCP Teams for routinely retrieving at the start of the day information logged by EDT at night, undermines timely information-sharing even in situations where an urgent response is required.   Multi-agency working in response to incidents and crises Lambeth SCR Child H Confidential Final Report 16 This is a finding for Children’s Social Care.      The Review Team considered carefully whether the ineffective management of the Section 47 investigation represented a pattern of working in the individual FSCP Team, and possibly more widely.  We were reassured that it was not in two ways: 1) the team in question has been reorganized and now has new managers in place, and 2) an audit has been carried out by the Quality Assurance service, looking at the conduct of Section 47 investigations across all CSC teams.  This found that formal CP procedures are understood and followed well in teams, whilst acknowledging variations in the individual skills and experience of workers.  Lambeth CSC have said there will be a closer look at those teams where there are a low number of Section 47 investigations, to check that practice remains alert and correct in carrying out this statutory duty.  Findings in detail   This section represents the main learning from this case review for the LSCB and partner agencies. Each finding is set out in a way that illustrates:   How does the issue feature in this particular case?  How do we know it is not peculiar to this case?  What can the Case Group (those who worked with the family) and Review Team (the senior managers from each agency appointed to help with this case review) tell us about how this issue plays out in other similar cases/scenarios and/or ways that the pattern is embedded in usual practice?  How prevalent is the pattern? What evidence have we gathered about how many cases are actually or potentially affected by the pattern?  How widespread is the pattern? Is it found in a specific team, local area, district, county, region, national?  What are the implications for the reliability of the multi-agency child protection system?    The evidence for the different ‘layers’ of the findings comes from the knowledge and experience of the Review Team and the Case Group, from the records relating to this case, and other documentation from agencies, and from relevant research evidence.   Six priority findings were chosen because they represented areas of practice which were significant in how this case was managed, but which also reflected wider patterns of practice and the systems which underpin that practice.  The remainder of this section discusses the six findings. 2.5 Finding 1. A tendency among professionals in all agencies to focus on the emotional impact on children of living with domestic violence, and not on the increased probability that they will be physically harmed, impedes a full understanding of the risks to which they are exposed.   Lambeth SCR Child H Confidential Final Report 17 There is clear research evidence of the increased risk of physical harm to children from men who are violent to their female partners (e.g. Stark and Flitcraft, 1996; Bowker et al, 1998) as illustrated in the blue box below. Yet a feature of this case was how little this knowledge base informed professional practice. Concerns about physical harm focused on the mother, not the children. How did the issue feature in this particular case? The professionals involved with the family told us, and case records showed, that they did not consider there to be a risk of physical harm to the children as a result of living with a father with a recent history of violence toward his wife. This was true for all phases of the case.      When Child H first arrived in the country with what appeared to be bruising to his face and marks on his body, there was no Strategy Meeting.  The professionals who saw him shortly after his arrival did not question whether Father had caused the injuries, despite knowing that Child H had been in Father’s care for several weeks, and that Father had previously assaulted Child H’s mother.  One professional, the Midwife, after seeing Child H on a home visit, contacted the family’s SW about her concerns.  It was not until the CP Conference (almost two weeks after Child H was initially seen by the SW), that a CP Medical was requested, by the Conference Chair.  At this Conference, Child H, and then new baby Sibling 2, were made subject to CP Plans, under the category of Emotional Abuse. The history of domestic violence did not prompt professionals to ask questions about the likelihood or otherwise that Father would physically harm the children.   At a critical point in the case, after Sibling 2 was admitted to hospital, professionals in the hospital and in the FSCP Team told us they had not considered that the other two children might be unsafe left in the care of Father.  Their decision-making, including all those at the Strategy Meeting held in the hospital, assumed a benign view of Father’s ability to provide adequate care of them. No assessment of Father’s ability to look after the children adequately was conducted, including the risks he might pose to them as an adult with a history of violence.   At other key periods too, professionals focused entirely on the risks to Mother of violence from Father. This was so at the beginning of the case when Mother and baby (Sibling 1) left the women’s refuge and returned home to live with Father.  Consequently, many professionals told us that they were utterly shocked and bewildered at Child H’s death, and found it hard to believe that it had happened.   Lambeth SCR Child H Confidential Final Report 18  What is the evidence base about domestic violence and risks to children? UK: In 40-70% of cases where women are being abused, the children are being directly physically abused themselves (Stark and Flitcraft, 1996; Bowker et al, 1998). USA: In families experiencing parental domestic abuse there is an overlap of between 30 and 60% in rates of physical abuse for the children. (e.g., Barnett et al, 1997). In a national survey of over 6,000 American families, researchers found that 50 percent of men who frequently assaulted their wives also physically abused their children (Edleson, 1995).  The routine co-occurrence between adult domestic violence and both physical harm and neglect of children is underlined in a study of the characteristics of parents and partners (Hartley, 2002/2009).  Australia: Similar findings, noting significantly increased risk to children of physical abuse in homes where there is a violent male, emerge from several studies of varying sizes.  Until recent years, this was poorly recognised, and the risk of violence from adults was regarded separately from the risks of physical harm to children (Tomison, 2000).   How do we know it is not peculiar to this case?  When exploring what lay behind this lack of recognition of the risks to the children in more detail, it became clear to the Review Team that staff across agencies were unaware of the body of available research evidence on the risks to children of domestically violent parents.  In their individual conversations and discussions at the joint review meetings, members of the Case Group without exception said they made no connection between domestic violence between adults and an increased risk of physical violence to children.  This contrasts with the risk of emotional abuse, which they recognised more confidently in relation to children living in a household where there is domestic violence1.  This suggested to the Review Team that the issue was not an anomaly of professional handling of this particular case, but something that would potentially influence how professionals handled other cases where there is violence between the parents.  What numbers of cases are affected, and how widespread is the pattern: local, regional, national?                                             1 Children living in households where DV is happening are now identified as “at risk” under the Adoption and Children Act 2002.  From 31 January 2005, Section 120 of this act extended the legal definition of harming children to include harm suffered by seeing or hearing ill treatment of others.  This would include witnessing domestic abuse. Lambeth SCR Child H Confidential Final Report 19 The volume of victims and their families referred to and known to all agencies, with domestic violence as a feature of their lives, is rising year on year. Available statistics suggest this is as true nationally as it is in Lambeth2. In Lambeth alone, last year almost 400 children were estimated to be living in households affected by the most serious levels of domestic violence – which are subject to MARAC processes. The number of cases potentially affected by this finding is therefore very significant – see Appendix 3 for further details.   It is clear that domestic violence is prevalent in terms of numbers, locally and widespread around the UK.  What has been less easy to discover is exactly how widespread is the lack of professional awareness about the increased risk of physical harm to children who are living with a violent adult.  The broader experience of Review Team members locally suggests that the tendency to focus on the emotional impact on children of living with domestic violence has developed with the increased priority given to the topic and associated training within Lambeth, across London and nationally. This has generally been encouraged and considered a positive development.  The Review Team confirmed that the correlation of domestic violence with physical abuse of children is a standing feature of LSCB-delivered training in Lambeth on domestic violence. However, it has not previously been known that this aspect is becoming lost in practice. What are the implications for the reliability of the multi-agency Child Protection system? A safe system requires professionals who are knowledgeable about the research evidence base in their field, so that they can draw on this to inform their practice. Given the growing number of families known to be experiencing domestic violence from an adult male partner, it is increasingly important that professionals have an up-to-date understanding of the available evidence about this area of work.  This case has demonstrated that some aspects of the evidence base are well known, especially the potential for emotional abuse of children.  Yet the SCR process has also identified that other aspects of evidence are as yet unfamiliar: specifically, consistent research evidence about the increased risk of physical harm to children who are living with a violent adult is not informing practice. This means that physical risks to children may not be reflected in assessments and plans, increasing the chances of children being left at risk of harm.     Finding 1. A tendency among professionals in all agencies to focus on the emotional impact on children of living with domestic violence, and not on the increased probability that they will be physically harmed, impedes a full understanding of the risks to which they are exposed.  All agencies promote and expect evidence-informed practice from their workforces. The training programmes run by Lambeth LSCB aim to support                                             2 The revised Children in Need Census from April 2013 will collect this data nationally for children known to social care. Lambeth SCR Child H Confidential Final Report 20 this by equipping professionals with up-to-date knowledge about CP.  This case review has found that currently, not all professionals in Lambeth and neighbour boroughs demonstrate a confident and clear understanding of the evidence base in relation to risks of physical harm to children in households where there is domestic violence between adults.  This means that physical risks to children may not be reflected in assessments and plans, increasing the chances of children being left at risk of harm.    Without a better understanding of these risks, we can expect the possibility that professionals across partner agencies will miss the physical risks to children, which will be higher when a child is in the sole care of the violent adult.  Issues for the Board and member agencies to consider:  Is the Board surprised by this finding?  The correlation of domestic violence with physical abuse of children has been a feature of LSCB-delivered training in Lambeth on DV for a long time. Is the effectiveness of training routinely evaluated?   Are there alternative mechanisms for improving workforce awareness of the evidence base in this area?   To what extent is evidence-informed practice really supported across different agencies? Do member agencies know how it is promoted and prioritised in their work places?   How readily accessible to staff and managers are summaries of the research evidence base in this area?   Is the use of research evidence routinely reinforced and supported through the professional hierarchies and supervisions/management practices?    How would the multi-agency partnership be able to evidence a better awareness of risks in this area?  2.6 Finding 2.  Are the mechanisms, which are intended to pick up errors of human reasoning, functioning well and consistently in agencies?  Where they are not, inaccurate judgements are more likely to go unchallenged.   It is widely recognised that in working with families to safeguard children, the sense that professionals make of information they receive and how they use it will inevitably and necessarily be vulnerable to common errors of human reasoning (Munro, 1999).  As Munro (2008) notes: ‘Psychological research has shown that people are very bad at policing their own biases. Social workers need regular critical supervision to ensure that their biases are not distorting their assessments.’ Two key ‘checks and balances’ to help review judgements are professional supervision and a culture of mutual challenge in multi-agency working. The aim of supervision is to provide a fresh, and often more senior, perspective on cases, and to allow reflection and challenge of practitioners’ thinking and Lambeth SCR Child H Confidential Final Report 21 decisions where necessary. Similarly, the multi-agency network should function in such a way that thinking and decisions are challenged and tested.    However, a number of features and episodes in this case raised important questions about how well these more routine mechanisms for providing critique and challenge worked in this case and are working more generally.  How did the issue feature in this particular case? This case had a number of perplexing features for professionals, including the ongoing denial of past violence by Father against Mother – something which was known to have happened.  Added to this was the general impression received by all professionals, even those who met the parents only briefly, that these were pleasant and attentive parents.  As time went by, and there were no further known DV incidents, professionals felt reassured.   The lack of both good quality supervision within agencies and multi-agency discussion and challenge meant that these responses persisted in an unhelpful way.  This was true, even when the family’s circumstances changed considerably (with the arrival of Child H and a new baby shortly after), in a way that meant greater stress for the crowded family unit.   The Child Protection Conference Chair appeared to fulfil a significant ‘supervisory’ role, by reminding parents and professionals alike of the level of violence that had been inflicted on Mother previously.  She questioned why this evidence was not being given greater prominence, and rightly pointed out that the parents’ denial threw continuing doubt on their honesty and openness with professionals.  Thus, she represented the principal voice of caution against and challenge to the positive view of the parents.  She was supported in this within CP Conferences by the SW’s recommendation that the children continued to require CP Plans.  In contrast to this, the quality of the SW’s individual supervision meant that the need for ongoing assessment of risk was not identified and acted upon.  The Review Team would have expected professional supervision to explore the specific relationship workers form with parents and children, and how this affects what information they receive, how they interpret it and how they use it; this was particularly important for supervision of the main Social Worker.  However, the supervision of this case in the FSCP team changed hands three times during 11 months, and the amount of time allocated to it was minimal. Conversations with the Team Manager and Deputy Team Manager demonstrated that this case was regarded as low risk and going reasonably well. The formal supervision on this case in the 3 month period leading up to the death of Child H amounted to 35 minutes in total.  A similar picture held true for the Health Visitor’s safeguarding supervision, where a reassessment of risks was not considered. The Review Team would also have expected to see stronger challenge and debate among the professional network, to voice and explore differences in professional opinion. Core Group meetings, happening more regularly than Child Protection Conferences, would have been the appropriate forum for this. But as with supervision, in this case that was largely lacking.     Lambeth SCR Child H Confidential Final Report 22  How do we know it is not peculiar to this case?  As part of the case review process, the Review Team asked the Case Group about where challenge usually comes from. The answer received was: ‘Oh, the CP Conference Chair does that’. This suggests that the supervision arrangements and multi-agency discussions evident in this particular case are not atypical of usual practice. This is supported by a recent internal audit of supervision within CSC, which found that this was an area requiring further development and strengthening.  Practice was found to be variable and inconsistent, with some workers receiving good and regular supervision, and others not.  In a number of cases reviewed, there were missed opportunities for reassessment, which supervision should have picked up.  What numbers of cases are affected, and how widespread are they – local, regional, national? Supervision does not feature in the work of all professional groups.  However, for the core agencies in the field of child protection (social care, health and police), it is a critical part of their work, and so is relevant to a large number of cases. There is evidence to suggest that a lack of adequate supervision is a problem at a national level. As noted by Brandon et al. (2008) in a review of serious case reviews: ‘Scrutiny of the 47 reviews revealed a number of concerns about poor supervision to front-line workers, especially social workers. Staff in education, health and the voluntary sector were also found to need access to support, supervision and in particular to child protection advice. In some of these sectors supervision may be less of a priority than in children’s social care and therefore less likely to take place.” (2008:92)  Within the agency context of high workloads, emotionally charged work, changing organisational structures and legislative imperatives, the critical aspects of the supervisor’s role are most vulnerable. It has been demonstrated in research that in such a ‘turbulent environment’3 both supervisors and supervisees may be prone to endorse each other’s approach rather than using supervision as an opportunity to challenge and question assumptions. Such endorsements can seem like a supportive way forward in what feels like an unmanageable situation. It has been noted elsewhere (Rushton and Nathan, 1996) that, given time and resource constraints, case management aspects of supervision often supersede the important activities of reflecting on, and challenging, judgements and decisions.  There are a considerable number of multi-agency meetings, including Strategy Meetings in crisis CP work (investigations of incidents), and in the ongoing meetings (Conferences and Core Groups) for the monitoring and management of CP Plans.  This is a national structure, and is supported by statutory guidance.  The ability of these groups to fulfil the function of                                             3 Hughes and Pengelly (1997) Lambeth SCR Child H Confidential Final Report 23 respectful and rigorous challenge is relevant both locally and around the country.  We were unable to find evidence about the quality of functioning of these groups locally or elsewhere.   What are the implications for the reliability of the multi-agency child protection system? Our multi-agency safeguarding systems are intended to have checks and balances within them to guard against the known fallibility of individual judgements and decisions. In particular, individual supervision and multi-agency meetings are designed to work as mechanisms for ensuring that judgements are examined and challenged, to help ensure that individuals and groups do not get drawn into inaccurate or biased patterns of thinking.  If these mechanisms are not working well, this leaves individual professionals and the multi-agency team around the child, vulnerable to falling into well-known ‘traps’ of human reasoning such as failing to reassess judgements in the light of new evidence, or being drawn into parental versions of events (Munro, 1999). This can, in turn, lead to poor decision-making at both an individual and group level.  Finding 2.  Are the mechanisms, which are intended to pick up errors of human reasoning, functioning well and consistently in agencies?  Where they are not, inaccurate judgements are more likely to go unchallenged.   It is widely recognised that in working with families, the sense that professionals make of information they receive and how they use it will inevitably and necessarily be vulnerable to common errors of human reasoning (Munro, 1999).  We also know that we are unable to police our own cognitive biases; hence, creating safe systems requires building in mechanisms that take this into account.  Two key ‘checks and balances’ are professional supervision and multi-agency discussions about the case, each bringing fresh eyes and challenge to the process. This review suggests that these mechanisms are currently not working well enough in all cases, leaving professionals vulnerable to falling into well-known ‘traps’ of human reasoning, which in turn lead to poor decision-making. Issues for the Board and member agencies to consider:  What is known within the LSCB about the provision of supervision in agencies?  Do agencies have a structure for the regularity of supervision and a template for what it should cover?    Are agencies clear about what aspects of supervision do get prioritised and what overlooked?  How would an improvement in practice in this area be known about? Lambeth SCR Child H Confidential Final Report 24  What training is available for safeguarding supervisors, newly in role?   How well do key multi-agency meetings support respectful challenge to colleagues and respectful uncertainty to parents?  What are the chairing arrangements for key CP meetings?  Are these fit for purpose?  Are Chairs of Strategy Meetings, CP Conferences and Core Groups regularly acting as ‘devil’s advocate’, in order to challenge assumptions and views of individuals and the network of professionals working with the family?  Do they encourage respectful but open debate?  2.7 Finding 3.  The current range, availability and quality of interpreters is problematic; for planned work it is variable and, in emergency situations, it is so poor that it risks leaving non-English language service users without support, making it extremely difficult for professionals to make an effective assessment or diagnosis in a timely fashion. Gaining an accurate understanding of children’s experiences, wishes and feelings, and parents’ perspectives is a crucial task of child protection work. It is made particularly challenging when families do not speak English. Here, the availability of independent and timely interpretation services is key.  This case has highlighted difficulties in achieving timely access to interpreters, both in the long-term management of meetings and contacts, and in acute circumstances. They resulted in various episodes of inappropriate and unsafe practice.  In discussing these episodes, members of both the Review Team and Case Group were taken aback that they had occurred, and how they had impeded effective investigation of actual and potential physical injuries to the children involved. How did the issue feature in this particular case? The need to use interpreters was a key feature of this case. Both parents had Somali as their mother tongue.  Father, who had lived in the UK for some years, was able to speak and understand some English, to a ‘workable’ level.  Mother, however, knew practically no English when she arrived in London.  As time went on, she appeared to acquire some English language skills, but these remained very limited.  She required an interpreter for all interactions with professionals. Child H similarly spoke no English when he arrived in London; it was his first time in the UK.  We give just two illustrations below, the first concerning communication with Child H as a potential child victim of physical assault, the second concerning communication with his parents as potential perpetrators of an assault on his brother, Sibling 2. The first illustration relates to Child H’s arrival when he was observed to have apparent bruising to his face.  There was no Section 47 investigation, although he was considered at the Review CP Conference for Sibling 1, which Lambeth SCR Child H Confidential Final Report 25 took place two weeks later.  There, the CP Conference Chair requested that Child H should have an immediate CP medical examination.  An interpreter was booked for the medical examination but did not arrive, meaning that Father – the possible ‘person of concern’ – acted as the child’s interpreter and spokesperson. This effectively gave the child no independent voice, as would be expected in a CP medical. These circumstances were repeated at two later CP medicals for Child H and Sibling 1, when the booked interpreter again did not turn up.      The second illustration relates to the professional response to the injury to Sibling 2 in the A&E department at a hospital in a neighbour borough.  When Sibling 2 – a two-month old baby – was presented by the parents with a broken femur, medical staff needed to elicit the parents’ explanation of what had happened as quickly as possible. To do this, they used a female cousin of Father to translate for Mother, via telephone.  As with Child H, this use of a family member minimised the likelihood that she would feel able to speak openly about what had happened. While there were arrangements available for the usual telephone interpreting service in A&E at the time, the paediatric staff described two issues that deterred staff from using it.  Firstly, at that time the location of the two phones was on the busy reception desk, which afforded no confidentiality. Secondly, it was normal to experience delays in getting a service.   How do we know it is not peculiar to this case?  Input from Case Group members made it evident that the problems described above are common, rather than impinging only on this one case.  We learned from Case Group and Review Team members that all agencies, perhaps with the exception of the police, struggle to obtain consistent interpreters who can offer a high standard of service for this very complex work. There are different contract arrangements across agencies for interpreting services. Rather than a generic problem of timely access to them, however, Case Group members described how it is far easier to ensure a consistent and reliable service for planned work than for emergency or urgent work.   The reasons for this included a scarcity of trained interpreters and a lack of choice (e.g., of gender of the interpreter), particularly in minority languages.  One example given by a member of the Case Group was that there is only one Vietnamese interpreter for the whole of her borough, and this person is therefore engaged and busy for several months in advance.   Participants described the systems as operating in favour of booking interpreters for blocks of time – for example, for ongoing work with a family, CP Conferences and Core Groups. The result is that there are fewer interpreters free, and rarely at the exact time required, in matters such as urgent CP investigations – including A&E presentations, Section 47 interviews and child protection medicals, and out-of-hours activities generally.   What numbers of cases are affected, and how widespread are they – local, regional, national? How many cases require interpreters and are therefore potentially affected by this issue? Lambeth, like many London boroughs and towns and cities elsewhere in the UK, is ethnically very diverse. It is consistently in the top 10% Lambeth SCR Child H Confidential Final Report 26 for numbers of international migrants annually (see 2011 Census Headlines). Those with English as their first language in the borough have fallen from 76.2% of the population in 1992, to 51.5% in 2012. The Review Team have not been able to access data about how many child protection investigations in Lambeth involve children and/or families who require interpreters, but have estimated that these are likely to be a considerable number.  How widespread is the difficulty in accessing interpreters when needed? The Review Team have not found any hard data on this question but as described above, input from the Case Group indicated that the difficulties of access are widespread across Lambeth, including the lack of a choice in the gender of the available interpreter.  These challenges are likely to be shared by other local authorities in London and around the country where there is a high degree of diversity, but the Review Team do not have any formal data on this. What are the implications for the reliability of the multi-agency Child Protection system? Communication with children and their family members is vital to safeguarding and child protection work. In a multi-cultural borough and city, it is inevitable that communication will need to be enabled and supported by high quality, independent interpreting services for a variety of different languages.  Given the nature of the work, such services need to be accessible in a timely fashion for both planned and unscheduled, emergency work. However, this finding shows that such a situation does not always exist in Lambeth agencies, nor in the hospital where this family presented.  The current range, availability and quality of interpreters is variable for planned work, but for urgent child protection referrals and other emergency presentations, such as children with injuries to A&E, the situation is worse, with services routinely struggling to have reliable access to good quality interpreters. This makes it less likely that critical risk assessments in these circumstances, and decisions based on these, will be of an adequate quality to support this complex work.  It leaves room for poor understanding on both sides and, in some cases, for parents to mislead professionals about what has happened.  Finding 3. The current range, availability and quality of interpreters is problematic; for planned work it is variable and, in emergency situations, it is so poor that it risks leaving non-English language service users without support, making it extremely difficult for professionals to make an effective assessment or diagnosis in a timely fashion. Good quality interpreters, available in a timely way, are an essential part of a safe system for working with vulnerable families from a variety of ethnic backgrounds, especially so in a borough as diverse as Lambeth.   This review has found that an overall scarcity results in a general booking-up of good interpreters, and a lack of availability in emergency or urgent matters such as CP interviews, CP medicals, and Lambeth SCR Child H Confidential Final Report 27 presentations to A&E.  This significantly undermines the reliability with which we can expect the multi-agency child protection system to function, representing a barrier to the ability of professionals  to communicate effectively with children and parents alike and leaving children therefore potentially at greater risk of harm.  Issues for the Board and member agencies to consider:  Is the Board aware of these areas of difficulty in interpreting services?  What does the Board think about the impact on CP work, especially urgent CP work?  Is this an acceptable situation?  What are the obstacles to improving this situation (including funding)?  Is there any London-wide action which might be helpful – e.g., commissioning across boroughs?  Is the Board aware of how needs assessments for interpreting services are carried out and whether they are adequate?   Have Board agencies previously shared information about how their various contracts and interpreting services are working – and how they are monitored?   What are the options for tackling the deficits found in this case review?  How well does contract monitoring identify when things are going well, need improvement, or have made improvements?   Is change needed to the information collected and analysed?  Language Line is used by a number of agencies on a regular basis.  Is there guidance about those circumstances when this would not be sufficient – e.g., when it is important to get other cues from a child or adult by a face-to-face interaction?  2.8 Finding 4.  Where there is no known recurrence of domestic violence incidents, professionals tend to be reassured about the welfare of children in the household and/or believe their grounds for purposeful engagement with the parents are diminished. The consequence is that they get no further in understanding the causes and triggers of incidents of domestic violence, and the actual level of risk to children these imply.   Child protection work requires that professionals attempt to predict the future, gauging the current harm and risks to children. In cases of domestic violence, this involves working with parents to explore previous incidents in order better to understand the causes and triggers of violence and their significance for minimising ongoing risks and potential future incidents.  This case has highlighted a tendency among multi-agency professionals to give greater weight to whether domestic violence is known to be currently occurring, than to what historical incidents of domestic violence reveal about risk now and in the future.  This creates difficulties for maintaining professional Lambeth SCR Child H Confidential Final Report 28 confidence and skills to implement  aspects of child protection plans that concern domestic violence, when the main issue of concern appears to be ‘absent’ or have ceased.  The result may be a false perception of decreased risks when, without professionals achieving an understanding of the causes and triggers of the violence, actual levels of risk may still be high.  Even where workers are aware that risk is still present, cases can become ‘stuck’, with professionals unclear about how to effect change.   How did the issue feature in this particular case? Sibling 1 was placed on a CP Plan, which was later amended to include the two other children. This was designed to protect the children via two parallel approaches: family support to both parents, and actions to address the domestic violence in the family. There was a requirement for Mother to engage with and receive protective advice from the specialist DV service, GAIA. It was also stipulated that ‘There should be no further DV or argument that gets physical at all, and not around Sibling 1’. The contingency statement in the Core Group records suggested that, should the family not comply, legal action would be considered. The family engaged well with the family support elements of the plan, but not with the actions relating to domestic violence. For example, Mother refused to attend the GAIA service as required. During this time, there were no further known incidents of domestic violence. As the immediacy of the previous incident receded, and no further incidents came to light, most professionals were reassured and felt that there was a declining basis for taking robust action with the family, and maintaining a focus on domestic violence within the multi-agency group. As more time elapsed since the original domestic violence incident, increasingly those working with the family were of the view that there was no reason to keep the children on CP Plans – even though little was actually known about the parental relationship and father’s propensity to violence. This case had a feature which proved particularly difficult for professionals to manage: the parents’ contention that there had never been any violence between them.  Professionals knew that this was untrue, given the history recorded by Police, hospital and the women’s refuge staff, but were unsuccessful in engaging either parent in a more open exploration of past history and future risk.  In exploring what lay behind the insufficient and ineffective engagement with the history of domestic violence and ongoing risk for the family, the Review Team discussed the difficulty posed by the parents’ complete denial of past or present violence.  Input from CSC highlighted how this denial, and refusal to discuss DV, was compounded by the fact that no further violent incidents came to light after the parents had reunited.  This is a common circumstance in working with DV cases, where further real or potential incidents of violence remain a secret kept by both perpetrator and victim (and sometimes their children as well).   All this suggests why it became more difficult, and perhaps seemed less relevant, to challenge the parental denial of the original violent incidents, or Lambeth SCR Child H Confidential Final Report 29 indeed the ongoing issue of risk.  As more time passed from the incident of Mother fleeing DV, the impact of this event reduced.  The reaction of professionals suggests that, rather than relating simply to a skills deficit, the underlying issue related more to how violence was being conceptualised (as incidents or process) and the implications for how risk was understood.         How do we know it is not peculiar to this case?  The Review Team and Case Group recognised a familiar pattern in how professionals had responded to this case in relation to assessing the risk of domestic violence.  Any number of SCRs have demonstrated how difficult it is for professionals to challenge parents who appear compliant (‘deceptive compliance’).  Where there is, added to this, an ongoing denial of current domestic violence, workers struggle to maintain an active and alert assessment of potential future incidents, their causes and triggers, and thus the ongoing risk to parent/victims and children.  Participants in this review explained how such a focus on known current DV is encouraged by the courts who gauge levels of risk relative to actual rather than potential occurrences. Where there are no further reported incidents, the evidence for insisting on completion of required actions by the parents, or moving into the court arena, is perceived by CSC and partner agencies as becoming weaker with every passing Conference.   Over time, professional partners tend to feel reassured when there is no further known domestic violence, and when children are seen to be doing well and parents appear to be caring. In the absence of known incidents of violence, the basis for enforcing the plan or any contingency actions appears to diminish – even though actual levels of risk are unknown and can remain high.  Indeed, options for formal intervention (e.g., via court proceedings) become increasingly limited.   The Review Team considered carefully how well professionals’ skills and experiences prepare them for working effectively in this complex area, and we acknowledged that there are different levels of skill among staff.  But it seems that the common circumstances of denial in DV cases – combined with no further known incidents – continue to present a challenge very widely to workers and their managers, as to how to engage parents and assess risk appropriately.  As noted above, there was an additional complicating factor in this case, which was the Mother’s recanting of her original experience of DV.  There are some similar features in the work with chronic neglect cases, where purposeful intervention can be difficult to sustain – until a current ‘incident’ occurs, to which protective action by organisations can be attached.      What numbers of cases are affected, and how widespread are they – local, regional, national? This finding relates to the professional tendency to assess levels of risk to children as being determined by whether domestic violence is known to be occurring currently in a family, rather than on understanding of whether and how it may happen in a potential future scenario. As discussed in Finding 1, domestic violence is prevalent and widespread in the UK (see figures in Lambeth SCR Child H Confidential Final Report 30 Appendix 3). In Lambeth, last year almost 400 children were estimated to be living in households affected by the most serious levels of domestic violence. This suggests a relatively large number of cases may be affected by this issue. We have not been able to ascertain how widespread the tendency is for professionals to focus on actual current domestic violence incidents, rather than the causes and triggers of past and potential future incidents.   What are the implications for the reliability of the multi-agency child protection system? A safe child protection system needs to deal proficiently with risk and probability; it is not enough to respond reactively after an incident of harm has been caused to a child. However, this finding draws attention to the way in which professional responses to domestic violence in families are functioning less well to act pre-emptively on behalf of children.   Whether domestic violence is known to be currently occurring in a family tends to determine the perceived levels of risk to children and the need for purposeful engagement with parents, leaving the causes and triggers of past and potential future incidents poorly understood. This case suggests a common bias in professional handling of domestic violence cases whereby the present is given more weight than the past. So domestic violence cases in which there is no known recurrence of incidents tends to lead to a perception of decreased risk and diminishing need for the implementation of domestic violence-related interventions.    Finding 4.  Where there is no known recurrence of  domestic violence incidents, professionals tend to be reassured about the welfare of children in the household and/or believe their grounds for purposeful engagement with the parents are diminished. The consequence is that they get no further in understanding the causes and triggers of incidents of domestic violence, and the actual level of risk to children these imply.   A safe child protection system needs to deal proficiently with risk and probability; it is not enough to respond reactively after an incident of harm has been caused to a child. However, this finding draws attention to the way in which professional responses to domestic violence in families are functioning less well to act pre-emptively on behalf of children.  Whether domestic violence is known to be currently occurring in a family tends to determine the perceived levels of risk to children and the need for purposeful engagement with parents, leaving the causes and triggers of past and potential future incidents poorly understood. This case suggests a common bias in professional handling of domestic violence cases whereby the present is given more weight than the past, and parents’ denials are insufficiently challenged.  So domestic violence cases in which there is no known recurrence of incidents tend to lead to a flawed perception of decreased risk and a scaling-down of concern and appropriate action.    Lambeth SCR Child H Confidential Final Report 31 Issues for the Board and member agencies to consider:  Does the Board recognise this as a familiar pattern?  How can professionals be supported to maintain a focus on domestic violence when there is no known recurrence during professional involvement?  What kind of information needs to be collected to let the Board know whether improvement has been made in this area?   What is the ‘minimum’ kind of risk assessment of a perpetrator which is needed to support an effective CP Plan?  And how should this be expressed in CP Plans in a consistent way?  How can the multi-agency network be helped to move ‘stuck’ cases on in a way that reduces risk of harm to children?   2.9 Finding 5 – A pursuit among social care and police staff of categorical explanations from medical professionals of the cause of physical injury to children clashes with a norm among medical professionals of giving differential diagnoses  in which anything is possible until it is ruled out. This increases the chances of miscommunication and misunderstanding about past and future risks in child protection investigations. The multi-agency safeguarding network needs to be able to work and communicate together effectively in response to acute child protection incidents.  The process for managing and conducting Section 47 inquiries and criminal investigations involves social care, police and medical professionals (and possibly others, depending on the case).  Together, they must plan and undertake the tasks required to investigate how and when the injuries might have occurred, who might have caused them, and to ensure the children’s immediate and longer term safety. This is a complex exercise, given that different professionals bring their own skills, experience and specialist knowledge to the table, with the lead child protection agencies (children’s social care and Police) in charge of directing the Section 47 process.  How the investigation was conducted following the presentation of Sibling 2 to A&E has drawn attention to norms related to communication between health, social care professionals and police that provide the latent conditions for errors and mistakes to occur in this critical process.  How did the issue feature in this particular case? Following Sibling 2’s presentation at A&E with a serious physical injury, a delayed Strategy Meeting was held. The purpose of the meeting was to share information and views about risk and to determine what further investigation needed to be carried out. Yet in the event, the focus was predominantly on the medical view of the physical injury to Sibling 2.   Lambeth SCR Child H Confidential Final Report 32 Input from the Case Group highlighted that practitioners involved in the meeting were left with very different ideas of what had been said and meant by colleagues.  Critically, those from health and those from children’s social care and police left the meeting with discrepant understandings of whether the causation of Sibling 2’s injury was accidental or non-accidental (NAI). The baby’s Consultant Orthopaedic Surgeon thought he had articulated that the cause of the injury remained uncertain. However, non-medical colleagues took the surgeon’s input to mean that ‘on balance the injury was accidental’. Yet at the time neither ‘side’ was aware of the discrepant understanding.   The emphasis placed on the medical view of the injury in the meeting also distracted from other important areas of risk assessment that should have been discussed, including the inconsistent explanations by the parents, progress in corroborating their explanations, and ongoing risks to the other children. How do we know it is not peculiar to this case?  It became an important part of the Review team’s Task to get underneath this issue. Discussions within the Review Team and Case Group confirmed the view that, within CYPS and the Police, the quest for certainty from medical colleagues about how a physical injury has occurred is very strong.  This is understandable, as their possible options to protect a child at risk in such circumstances rely on the clarity and precision of evidence which can, for example, be produced in court.  Participants felt this was more so in relation to physical injuries, than in relation to cases featuring suspected sexual abuse or unacceptable levels of care. Discussion among the Review Team also confirmed the clash between this need for categorical explanations from medical colleagues on the part of social care and police staff, with the norms of medical professionals themselves. Input from participants shed light on the way the medical view was articulated by the surgeon in this case, and how this is standard. The baby’s Consultant Orthopaedic Surgeon had explained that ‘the injury could be consistent with the parents’ story’.  He, like Health members of the Review Team, would understand this statement as leaving the causation of the injury open.  They would see it as a step in the process of ‘differential diagnosis’ – a principle of which is that ‘anything is possible until it is ruled out’.  However, non-medical colleagues took the surgeon’s statement to mean that ‘on balance the injury was accidental’.   A Review Team member from Health summed up the clash neatly:  “In my experience, this is quite a common pitfall in strategy meetings and is a generalisable finding. It arises because doctors don’t fully understand that social workers and police are listening for a clear opinion on which to plan the rest of the investigation (and if they don’t hear it they may feel unable to proceed) and because social workers and police don’t appreciate they may be listening to a discussion of ideas rather than a finished opinion. In practice, getting to an opinion is an iterative process – that involves some people checking out the history, others requesting more specialist help or further investigations. It’s about tolerating (and planning for) uncertainty to allow this process to happen”. Lambeth SCR Child H Confidential Final Report 33 The experience of Review Team members was that the more experienced health professionals are in the field of child protection, the better they are at bridging the gap in expectations, by explaining the steps in a differential diagnosis and advising caution as appropriate.   What numbers of cases are affected, and how widespread is the pattern – local, regional, national? It is likely that numerous cases present the problem of assessing whether injuries raise child protection concerns or not. Child protection referrals coming into CYPS and CP work involving partner agencies are very high, and have risen significantly over recent years.  The table below refers to the number of S47 investigations (many of which are a response to ‘incidents’ of physical harm) in Lambeth and nationally for the last three years of available statistics.    Year Lambeth UK UK rate per 10,000 children 09/10 402 89,300 81.1 10/11 561 111,700 101.1 11/12 729 124,600 109.9 Source: Department for Education  We also have indicative evidence that the confusion between medical and other types of evidence regarding the existence of abuse is not restricted to Lambeth.  Recent SCRs around the country have identified similar practice, where alternative explanations of physical harm have either been misleading or too readily accepted (e.g., Daniel P, Keanu W, Victoria C).  This and another Learning Together review, in a different part of the country, have identified exactly this issue: a tendency for the multi-agency team to await a certain judgement of non-accidental injury before taking protective action.  In these systems reviews, we have been able to go further by exploring the underlying patterns and reasons for how professionals from different agencies approach such tasks in different ways and with different understanding.  What are the implications for the reliability of the multi-agency child protection system? Physical injuries to children which are known from the outset to be non-accidental are the exception rather than the rule. It is more common that the causation of physical injuries is open to a range of discrepant explanations. A safe system therefore requires reliable means whereby different professionals can bring their respective expertise to bear on planning and undertaking the tasks required to investigate how and when the injuries might have occurred, who might have caused them, and to ensure the child and siblings’ immediate and longer term safety. A pattern whereby a quest for certainty from social care and police runs alongside a norm among health colleagues of keeping all possibilities on the table until they are discredited, without either side realising the difference, creates potential accident opportunities. It represents a barrier to effective communication and collaboration in this challenging and critical area of work. Lambeth SCR Child H Confidential Final Report 34   Finding 5.  A pursuit among social care and police staff of categorical explanations from medical professionals of the cause of physical injury to children clashes with a norm among medical professionals of giving differential diagnoses in which anything is possible until it is ruled out. This increases the chances of miscommunication and misunderstanding about past and future risks for a child in child protection investigations. Child abuse does not come ready labelled as such. This is as true for physical injuries sustained by a child, as it is for the presentation of emotional or behaviour problems. It is usual that there are different but equally plausible explanations for the causes which can include non-accidental injury inflicted on a child. A safe system therefore requires child protection investigations that bring the knowledge of different professions to bear on this challenging task.  This finding highlights a pattern that affects the reliability with which child protection investigations will function, due to a mismatch between social care, police and medical professionals’ expectations about the process of communication. Social care and police staff look to medical staff to provide categorical explanations of the causes of physical injury, while it is standard for medical professionals to provide a more nuanced account of possibilities.  All parties remain unaware of the mismatch, increasing the likelihood that past and future risks for the children concerned will be poorly understood and acted on.  Issues for the Board and member agencies to consider:  Is this a known problem to the Board?  If so, how widespread is it considered to be?  Is this an area of practice which is addressed in any current training/policies/procedures?  What might the role of the Chair be in Strategy Meetings and CP Conferences to support improvement (e.g., at the end of the meeting, summing up what has been understood and agreed, and listing the consequent decisions)?  What might the role of the hospital and/or community Named professionals be to support improvement?  Should the named nurse and doctor have a particular role to play where there is i) uncertainty about causation of a suspicious injury and/or ii) disagreement among medical and nursing staff about the causation of a suspicious injury?   Does the Board think there might be any particular constraints in trying to improve practice in this area?  How would the Board know if there had been improvement in this area of multi-agency practice? Lambeth SCR Child H Confidential Final Report 35 Some thoughts about training: Use of role play – e.g., of Strategy Meeting in such cases Examples of cases where there is/remains uncertainty about the causation of an injury Presentations by nurses/doctors to other professionals regarding what constitutes uncertainty about an injury and why Presentations by Social Workers and Police to medical colleagues regarding the full range of risk factors which can lead to decision-making in a case (and vice versa).    2.10 Finding 6.  The low priority given by the Emergency Duty Team (EDT) to responding to requests for routine data checks relative to other demands, and the lack of a system in the FSCP Teams for routinely retrieving at the start of the day information logged by EDT at night, undermines timely information-sharing even in situations where an urgent response is required.   This is a finding for Children’s Social Care.    In all cases, but particularly in urgent child protection matters, the timely and accurate exchange of information, within and across agencies, is essential for safe working in this complex area.  At nights and week-ends, different systems are in operation and there are generally fewer staff to handle the work. It is vital that the systems for requesting and passing on information are as efficient and reliable as possible.  This case has highlighted two particular weaknesses in how the out-of-hours processes are routinely working. These relate to  a) norms about how requests for information are prioritised; and  b) processes whereby day time staff pick up messages from the previous night.  How did the issue feature in this particular case? In this case there were two distinct instances of the vulnerabilities referred to in this finding.  When Sibling 2 presented at A&E with a serious physical injury, the system that would usually have worked to inform A&E staff that the child was on a Child Protection Plan was temporarily missing an up-to-date electronic list of Lambeth children’s names.  This was a brief gap, but in this instance it had the effect of slowing down the momentum in identifying risk to the children.  In this instance, this was particularly significant because the parents had (falsely)  told hospital staff that they were not known to CSC. The Review Team noted the vital role played by such information and flagging systems, given that decisions about safeguarding children (e.g., to send them home from hospital with parents) often have to be taken urgently.    A request for information was therefore sent to the Emergency Duty Team in Lambeth. Given the acute nature of the presentation, this information was required very promptly.  Instead, there was a delay of six hours before EDT’s Lambeth SCR Child H Confidential Final Report 36 reply was received. This meant that Sibling 2 had moved from A&E to the orthopaedic ward before details about the family and the existence of a CP Plan for the children were provided to the hospital. This first instance was compounded the following morning when the record of the EDT Social Worker’s discussion with the hospital was not picked up by the allocated Social Worker in the daytime team, or anyone else in her team in a timely way. This meant that the SW was unaware of the advice that this was a child protection matter, to be shared urgently with the Police Child Abuse Investigation Team (CAIT).  She first learned about Sibling 2’s injury and the concerns of the doctors at midday the day after he had initially presented at A&E.   How do we know it is not peculiar to this case?  As part of the case review process, those involved explored the extent to which these two instances were unique to this case, or representative of more routine processes and practices.  In relation to the delay in responding to A&E’s requests for information, the Case Group and Review Team members, including members of the EDT, confirmed that lengthy delays in response to requests for information out of hours are common.  The telephone operator who answers the initial request for a data check is unable to supply information herself.  She/he is based in a call centre and does not have access to CYPS’s electronic database so is unable to ascertain whether a client is known or whether a child is subject of a CP Plan.  She/he must pass the request to the sole EDT social worker on duty. This gives the first indication of the underlying nature of this issue, and therefore the likelihood of its reoccurrence. As well as shedding light on the process of response of EDT, input from the Case Group and Review Team also helped explain norms about how different information requests are prioritised by EDT workers. Working alone, the EDT social worker must prioritise between referrals that come in throughout the night.   Input from participants gave a picture of a reasonably standard hierarchy of urgency that is used, whereby an adult mental health assessment or the emergency placement of a child, take precedence over requests for ‘routine data checks’ – which is how the first call from the hospital was regarded. As the former often require a long time to complete, this can then leave a response to a request for data checks waiting for several hours, as we saw in this case, regardless of the severity of the injury to a child. The standard use of this hierarchy of response will therefore make it less likely that physical injuries to children will routinely be treated as a matter of urgency.   In relation to the delay to the daytime staff picking up messages from the previous night, participants in the case review process also described what lay behind this delay and therefore the likelihood of the problem recurring in other cases. Participants explained that the EDT passes information to the daytime team by loading its record of what occurred during the night or week-end directly onto Framework, the service’s electronic database – as happened in this case.  Lambeth SCR Child H Confidential Final Report 37 The system vulnerability arises from the fact that in the FSCP Teams there is no routine and reliable system to ensure that the EDT records on Framework are picked up at 9am every day.  Social Workers do not always come to the office first thing; they may be out on a home visit, or at a meeting; indeed, they may be sick or on holiday, and whose responsibility is it to check Framework on behalf of the whole team every morning is unspecified.  The result is poor reliability in how emergency information gets received into the team.  This leaves the only safeguard in place being the possibility that either the EDT worker or the other participant, such as the hospital in this case, will follow up with a phone call to the day time team, which does not happen routinely.   What numbers of cases are actually or potentially affected?  Participants in the case review process considered that the number of cases where the timeliness of information-sharing and response following a presentation to services out of hours is likely to be significant both in Lambeth and beyond. We were unable to identify any formal data in the timeframes but anecdotally A&E departments in hospitals are very busy places at night and week-ends, and thus the potential need for information regarding children and their safety can be correspondingly high.   Anecdotally too, the flow of information from the EDT into the daytime FSCP teams happens on a regular basis and in considerable volume.  Allocated clients – children and families – form a large proportion of the out of hours workload, and all these EDT transactions have to be provided to the daytime teams at 9am Monday to Friday. We have not been able to ascertain absolute numbers.  How widespread is the pattern – local, regional, national? Here too, hard data have proved hard to access but the Review Team thought it is common for EDTs in inner-London boroughs to experience heavy demand and be staffed by a single worker on duty out of hours, and thus to be forced to prioritise some requests and deprioritise others. We have not found any research that would shed light on whether the logic used by EDT staff in Lambeth of giving low priority to responding to requests for routine data checks relative to other demands, is common. The Review Team would hope and expect that requests for data checks concerning the presentation of a baby with physical injuries would automatically rank as high priority, but has not been able to ascertain whether across London or nationally this is indeed the case.  Input from Children’s Social Care has indicated that the lack of a system for routinely retrieving at the start of the day information logged by EDT is not a feature of all social care teams. The Review Team were told that in the Referral and Assessment Team, the ‘front door’ of the CYPS service, unlike in the FSCP Teams, there is an established system for retrieving all EDT referrals every morning.  This is done by a duty worker whose job it is to do this at 9am promptly.  Where the referral concerns a family already known, the information is passed on to the allocated worker in the appropriate team.    Lambeth SCR Child H Confidential Final Report 38 What kind of risk does this pattern introduce to the safe and reliable  functioning of our system?  A safe system for protecting children needs as reliable a response out of hours as during the normal working week. Yet, at nights and week-ends, CP Police and CYPS emergency services operate on a fraction of the staff who carry out their duties during the working week.  At the same time, they regularly work with risky and urgent situations, and they must be able to refer information onwards in a timely and effective way.   The two systems vulnerabilities found in this pattern demonstrate how relaying and picking up EDT information can be affected a) by the lower priority given to responding to ‘normal data checks’ and b) the unreliable practice in retrieving urgent EDT information at the earliest moment – 9am on the next working day.     These vulnerabilities mean that important information about children and families may not be shared in a timely way, and therefore will not inform crucial professional responses.     Finding 6.  The low priority given by the Emergency Duty Team (EDT) to responding to requests for routine data checks relative to other demands, and the lack of a system in the FSCP Teams for routinely retrieving at the start of the day information logged by EDT at night, undermines timely information-sharing even in situations where an urgent response is required.   This is a finding for Children’s Social Care.    The need for timely and effective help to children is not restricted to office hours of the working week. A safe system therefore needs the out of hours services to work reliably for children who present at nighttimes, weekends and over holiday periods. This case has highlighted two patterns that undermine the reliability with which information is provided to and received from the Emergency Duty Team in Lambeth. These are  a)  by the lower priority given to responding to ‘normal data check’ requests by the Emergency Duty Team and b)  the lack of a system in the FSCP Teams for routinely retrieving, at the start of the day,  information logged by EDT the preceding night.   Both have the effect of inhibiting the timely flow of urgent information, leaving professionals in various services (but often health settings) less able to make proper assessments of risk, and children remaining in potentially unsafe situations. Issues for the Board and CYPS to consider   Is this a known problem – within CYPS?  Within the LSCB? Lambeth SCR Child H Confidential Final Report 39  Does the Board/CYPS agree that these are critical systems flaws?  Is it acceptable that out of hours services have to wait several hours for a simple piece of information, such as the existence of a CP Plan?   What has been done already to consider how to improve a timely and effective flow between out of hours and daytime services?  Can we learn from good systems in EDTs and CYPS teams in other London boroughs?  Are there particular problems getting in the way – e.g., lack of access to the CYPS database by the operator taking requests for information?  Would it be possible for the EDT operator to be able to answer simple questions such as ‘subject to CP Plan’ – without recourse to the social worker on duty?  What would constitute an improvement in both these vulnerabilities and how would the Board know there had been an improvement?  Are there any resource issues which come into play?  3. Conclusion The tragic death of three-year old Child H has resulted in a number of legal steps.  His father has been charged with his murder, and his trial is scheduled for early 2014.  His surviving siblings have been removed into the care of Lambeth Council.   This review has identified a number of factors which affected the work of the professional safeguarding children network with Child H’s family.  It has analysed the judgements and actions of those involved in the case, and the reasons for these. It has also analysed what this case has told us about weaknesses and vulnerabilities in the multi-agency child protection system. A key part of this story remains unknown. The perspective of the parents, who remained secretive about many things in their contact with agencies and professional staff, has not been captured.  Unfortunately, the ongoing criminal justice process has meant that there has not yet been an opportunity to interview Mother and Father.  Without their insights and information, the understanding of the family and how they worked with professionals remains incomplete.  It is not known yet whether the parents will be willing to contribute to the review in some way after the criminal trial has concluded.  In a ‘systems’ case review, the individual case acts as a window on the local systems, so that broader learning can emerge. Through this case, six priority findings have been identified, relating to:  Professional understandings of the risk of physical harm to children living in families where there is domestic violence between partners   The role of supervision and multi-agency groups in reflecting on and challenging judgements Lambeth SCR Child H Confidential Final Report 40   The quality and availability of interpreters, particularly in emergency situations  The challenge of tackling domestic violence when it has occurred in the past and there is no reoccurrence  Differential understandings between health and social care of the role and meaning of medical opinion in determining likely cause of injuries, and subsequent actions, and  Information sharing between Emergency Duty Teams and other teams and agencies. The LSCB is presented these findings and associated questions to consider as they decide how best to respond, as a way forward to strengthen and develop the work of the multi-agency network in Lambeth and hospitals in neighbouring authorities.     Lambeth SCR Child H Confidential Final Report 41 References Barnett, O., Miller-Perrin, C., Dale, R.D., Family Violence across the Lifespan: An Introduction, Sage Publications, 2010 Bowker, L. H., Arbitell, M., McFerron, J. R., ‘On the relationship between wife beating and child abuse’, in K. Yllo & M. Bograd (Eds.), Feminist perspectives on wife abuse (pp.90-113), Sage Publications, 1988. Brandon, M., Thoburn, J., Lewis, A., Way, A., Safeguarding Children with the Children Act 1989, London: The Stationery Office, 1999 Brandon, M., Bailey, S., Belderson, P., Gardner, R., Sidebotham, P., Dodsworth, J., Warren, C., Black, J., Understanding Serious Case Reviews and their Impact: A Biennial Analysis of Serious Case Reviews, 2005 – 07, University of East Anglia/DCSF, 2009 Edleson, J.L., Peled, J., Jaffe, P.G. (Eds), Ending the cycle of violence: Community responses to children of battered women, Sage Publications, 1995 Farmer, E. and Owen, M., Child Protection Practice: Private Risks and Public Remedies, London, HMSO, 1995 Fish, S., Munro, E., Bairstow, S., SCIE Report 19: Learning together to safeguard children: developing a multi-agency systems approach for case reviews, Social Care Institute for Excellence (SCIE), 2008 Fish, S., Munro, E., Bairstow, S., SCIE Guide 24: Learning together to safeguard children: developing a multi-agency systems approach for case reviews, Social Care Institute for Excellence (SCIE), 2009 Hartley, C.C., ‘The Co-occurrence of Child Maltreatment and Domestic Violence: Examining Both Neglect and Child Physical Abuse, Child Maltreatment, 2002; 7; 349, and Sage Publications 2009 (http://www.uk.sagepub.com/pricefamchnge4e/study/articles/06/Hartley.pdf) Hughes, L., and Pengelly, P., Staff supervision in a turbulent environment: managing process and task in front-line services, London: Jessica Kingsley   London CP Procedures, 3rd Edition, 2007  Lord Laming, The Victoria Climbie Inquiry Report, The Stationery Office Limited, London, 2003  Munro, E., ‘Common Errors of Reasoning in Child Protection Work’, Child Abuse and Neglect, Vol 23, No 8: 745-758, 1999 Munro, E., ‘A systems approach to investigating child abuse deaths’, originally published in The British Journal of Social Work, 35 (4), pp. 531-546, Oxford University Press, 2005  Munro, E., ‘A systems approach to investigating child abuse deaths [online]’, London: LSE Research Online, 2007 Munro, E., ‘Lessons learnt, boxes ticked, families ignored’, The Independent,   16th November 2008 Lambeth SCR Child H Confidential Final Report 42 Ofsted, Learning Lessons, taking action: Ofsted’s evaluation of serious case reviews 1 April 2007 – 31st March 2008,  Reder, P., Duncan, S., and Gray, M., Beyond Blame: Child Abuse Tragedies Revisited, Routledge, 1993 Reder, P., and Duncan, S., Lost Innocents: A Follow-up Study of Fatal Child Abuse, London: Routledge, 1999 Regan, L., ‘Children and Domestic Violence: Its Impacts and Links with Woman Abuse’ paper presented at the Impact of Domestic Violence on Children Conference, London, October 2001 Rushton, A., and Nathan, J., “The Supervision of Child Protection Work”, The British Journal of Social Work, Vol 26 (3): 357-374 SCIE At a Glance 01: Guide to Learning together to safeguard children: developing a multi-agency systems approach for case reviews, Social Care Institute for Excellence (SCIE), 2008 Stanley, N., Children Experiencing Domestic Violence: A Research Review, Dartington: Research in Practice, 2011 Stark, E., and Flitcraft, A., Women at risk: domestic violence & women’s health, Sage Publications, 1996 Tomison, A., ‘Exploring family violence: Links between child maltreatment and domestic violence’, Issues in Child Abuse Prevention, no. 13: Melbourne: Australian Institute of Family Studies, 2000 Topping, A., “Domestic violence figures are disturbingly high, says charity”, The Guardian, 7th March 2013 www.womensaid.gov.uk: Home/Domestic Violence A-Z/Children  Working Together to Safeguard Children, DCSF, 2010 Working Together to Safeguard Children, DfE, 2013  Lambeth SCR Child H Confidential Final Report 43 Appendix 1 – Methodology  1. This SCR has used the SCIE Learning Together model for case reviews. This is a ‘systems’ approach which provides a theory and method for understanding why good and poor practice occur, in order to identify effective supports and solutions that go beyond a single case.  Initially used as a method for conducting accident investigations in other high risk areas of work, such as aviation, it was taken up in Health agencies, and from 2006, was developed for use in case reviews of multi-agency safeguarding and CP work (Munro, 2005; Fish et al, 2009).  National guidance in the 2013 revision of Working Together to Safeguard Children (2013) now requires all SCRs to adopt a systems methodology.   2. The model is distinctive in its approach to understanding professional practice in context; it does this by identifying the factors in the system that influence the nature and quality of work with families.  Solutions then focus on redesigning the system to minimise adverse contributory factors, and to make it easier for professionals to practice safely and effectively.  3.  Learning Together is a multi-agency model, which enables the safeguarding work of all agencies to be reviewed and analysed in a partnership context. Thus, many of the findings relate to multi-agency working.  However, some systems findings can and do emerge which relate to an individual agency.  Where this is the case, the finding makes that explicit.   4  The basic principles – the ‘methodological heart’ – of the Learning Together model – are described in summary form below:   a.  Avoid hindsight bias – understand what it was like for workers and managers who were working with the family at the time (the ‘view from the tunnel’).  What was influencing and guiding their work? b. Provide adequate explanations – appraise and explain decisions, actions, in-actions in professional handling of the case. See performance as the result of interactions between the context and what the individual brings to it c.  Move from individual instance to the general significance – provide a ‘window on the system’ that illuminates what bolsters and what hinders the reliability of the multi-agency CP system.  d. Produce findings and questions for the Board to consider. Pre-set recommendations may be suitable for problems for which the solutions are known, but are less helpful for puzzles that present more difficult conundrums.  e.  Analytical rigour: use of qualitative research techniques to underpin rigour and  reliability. 2.4  Typology of underlying patterns 2.4.1 To identify the findings, the Review Team has used the SCIE typology of underlying patterns of interaction in the way that local child protection Lambeth SCR Child H Confidential Final Report 44 systems are functioning.  Do they support good quality work or make it less likely that individual professionals and their agencies can work together effectively?   They are presented in six broad categories of underlying issues: 1. Multi-agency working in response to incidents and crises 2. Multi-agency working in longer term work 3. Human reasoning: cognitive and emotional biases 4. Family – Professional interaction 5. Tools 6. Management systems Each finding is listed under the appropriate category, although some could potentially fit under more than one category.   1. Anatomy of a finding For each finding, the report is structured to present a clear account of:  How the issue manifests itself in the particular case  In what way it is an underlying issue – not a quirk of the particular individuals involved this time and in the particular constellation of the case?  What information is there about how widespread a problem this is perceived to be locally, or data about its prevalence nationally?  How the issue is usefully framed for the LSCB to consider relative to their aims and responsibilities, the risk and reliability of multi-agency systems. This is illustrated in the Anatomy of a Learning Together Finding (below).  Lambeth SCR Child H Confidential Final Report 45   1.5 Review Team and Case Group 1.5.1  Review Team The Review Team comprises senior managers from the agencies involved in the case, who have had no direct part in the conduct of the case. Led by two independent Lead Reviewers, they act as a panel working together throughout the review, gathering and analysing data, and reaching conclusions about general patterns and findings.  They are also a source of data about the services they represent: their strategic policies, procedures, standards, and the organisational context relating to particular issues or circumstances such as resource constraints, changes in structure, and so on.    The Review Team members also have responsibility for supporting and enabling members of their agency to take part in the case review.   The two Lead Reviewers in this SCR are both accredited to carry out SCIE reviews, and have extensive experience in writing SCRs/IMRs under the previous ‘Chapter 8’ framework.  Neither has any previous involvement with this case, or any previous or current relationship with Lambeth Council or partner agencies.    Lambeth SCR Child H Confidential Final Report 46 Ghislaine Miller, SCIE independent Lead Reviewer Sally Trench, SCIE independent Lead Reviewer Interim Assistant Director Looked-after Children and Corporate Parenting Lambeth Children and Young People’s Service (CYPS) Consultant Paediatrician and Named Doctor for CP and Safeguarding St. George’s Hospital (SGH) Nurse Consultant, Designated Nurse CP NHS Lambeth Clinical Commissioning Group (CCG) Consultant Paediatrician and Designated Doctor for Safeguarding, NHS Lambeth CCG Trust Named Nurse, Safeguarding Children Guy’s and St. Thomas’ NHS Foundation Trust Head of EYFS and Childcare Early Intervention and Targeted Lambeth CYPS Review Officer Band L SC&O 21(2) Crime Academy & Review Group Metropolitan Police Quality Assurance Officer Lambeth CYPS Head of Service for Quality Assurance and LSCB Board Manager Lambeth CYPS     1.5.2 Case Group The Case Group are the professionals who were directly involved with the family.  The Learning Together model offers a high level of inclusion and collaboration with these workers/managers, who are asked to describe their ‘view from the tunnel’ – about their work with the family at the time and what was affecting this.     In this case review, the Review Team carried out individual conversations with 25 Case Group professionals, and received transcripts of 3 further conversations which were held with members of the dental practice.     Lambeth SCR Child H Confidential Final Report 47 Health: GPs (x2) Consultant Paediatrician (Emergency Medicine), SGH Paediatric Registrar, SGH Consultant Orthopaedic Surgeon, SGH Consultant Community Paediatrician, Guy’s and St Thomas’ NHS Foundation Trust Named Nurse, SGH Midwife, Guy’s and St. Thomas’ NHS Foundation Trust  Health Visitor, Guy’s and St Thomas’ NHS Foundation Trust Health Visitor, Guy’s and St Thomas’ NHS Foundation Trust CYPS: Head of Service, CPFS Teams, CYPS Lambeth Deputy Team Manager (x2), CP&FS Team, Lambeth Team Manager, CP&FS Team, Lambeth Social Worker, CP&FS Team, Lambeth Deputy Service Manager, Locality Team, Westminster Senior Safeguarding Coordinator, Lambeth Adult and Community Services CP Conference Chair Team Manager, EDT Sessional Social Worker, EDT Early Years and Education: Head Teacher, Primary School Outreach Worker, Children’s Centre Nursery Teacher Metropolitan Police: Police Constable, Child Abuse Investigation Team (CAIT) Police Constable, Community Safety Unit Police Constable, Domestic Violence and Hate Crime Unit (by telephone) The case review received copies of conversations undertaken by NHS London, with:  Dentist  Receptionist, dental surgery Practice Manager of the dental surgery Lambeth SCR Child H Confidential Final Report 48   1.6 Structure of the review process A Learning Together case review reflects the fact that this is an iterative process of information-gathering, analysis, checking and re-checking, to ensure that the accumulating evidence and interpretation of data are correct and reasonable.    The Review Team form the ‘engine’ of the process, working in collaboration with Case Group members who are involved singly in conversations, and then in multi-agency ‘Follow-on’ meetings.   The sequence of events in this review is shown below. Date Event 23.04.13 Scoping meeting between Lead Reviewers, LSCB Chair and Manager 13.05.13 Introductory meeting for the Review Team  23.05.13 Introductory meeting for the Case Group – to explain the Learning Together model/method, and the case review process which they will be part of.  14, 17, 18 and 28.06.13 Four days’ conversations with members of the Case Group (individual sessions of about 1.5 hours with each member of the Case Group; normally conducted by two members of the Review Team) 26.06.13 1) Half day training for the Review Team, provided by the Somali Development Group 2) Review Team analysis meeting (1) 01.07.13 Review Team analysis meeting (2) 15.07.13 First Follow-on meeting (Review Team and Case Group) In this meeting, the group works together on  identifying Key Practice Episodes (KPEs) in the case which affected how the case was handled and/or the outcome of the case  appraising the practice in these KPEs  considering what was affecting the work/workers at the time (the ‘view from the tunnel’) NB, In the spirit of learning, the Designated Nurse and Designated Doctor from SGH were invited to this and the second Follow-on meeting as observers. 24.07.13 Review Team analysis meeting (3) 29.07.13 Lead Reviewers’ updating presentation to LSCB Executive Group Lambeth SCR Child H Confidential Final Report 49 09.08.13 Second Follow-on meeting (Review Team and Case Group) At this meeting, the group are provided with a draft report which sets out the emerging underlying patterns and findings, and are asked to consider whether these are specific to this individual case or pertain more widely and form a pattern. 09.08.13 Review Team analysis meeting (4) 15.08.13 Quality Assurance: supervision session for Lead Reviewers with SCIE (Dr. Sheila Fish) 06.09.13 Review Team meeting (5) – to consider the draft final report 10.09.13 SCR Sub-Group meeting – to consider the draft final report 26.09.13 Meeting with LSCB Board Chair, DCS, and (previous) Interim DCS. Request for report to be revised and to then agreed by Review Team.  DfE informed by LSCB Chair of delay in completion of report. 6.12.13 Final meeting of the review team TBC LSCB meeting – to consider the draft final report TBC Final report, fit for publication, to be submitted to Department for Education (DfE)  1.7 Scope and terms of reference 1.7.1 Taking a systems approach encourages reviewers to begin with an open enquiry rather than a pre-determined set of questions from terms of reference, such as in a traditional SCR. This enables the data to lead to the key issues to be explored.     In this SCR, we noted and explored the questions (Para 1.1.2) which Lambeth SCB had posed as of particular interest.   1.7.2 The time frame for the SCR was decided as follows:  February 2011 (Mother’s arrival in the UK) to 11th March 2013 (date of Child H’s death)  1.8 Sources of data 1.8.1 Data from practitioners  Conversations, as described above, with members of the Case Group; these were recorded and discussed by the whole Review Team.   Two Follow-on meetings in which members of the Case Group responded to the analysis of the case and gave feedback about accuracy and fair representation of their views.  In relation to the emerging findings, the Case Group were asked to comment on whether Lambeth SCR Child H Confidential Final Report 50 these were underlying and widespread/prevalent.  In other words, could we draw conclusions about whether, and in what way, this case provides a ‘window on the system’?    Members of the Case Group have also helpfully responded to follow-up queries and requests from the Lead Reviewers and the Review Team for clarification or further information, where this has been needed.  1.8.1.1 Key Practice Episodes and Contributory Factors The data from the conversations with the Case Group translates into their ‘view from the tunnel’ and thence into a selection of Key Practice Episodes (KPEs) which enable us as reviewers to capture the optimum learning from the case.  These KPEs are significant points or periods in relation to how the case was handled or how it developed. Case Group members are also an invaluable source of information about the why questions – an exploration of the Contributory Factors which were affecting their practice and decisions at the time.  1.8.1.2 Participation   The Lead Reviewers and the Review Team are grateful for the willingness of the professionals to reflect on their own work, and to engage so openly and thoughtfully in this SCR.  The tragic circumstances of the child’s death have meant that the process has been a very painful one for most if not all members of the Case Group.     Nonetheless, they have participated very responsively in individual conversations, which have recalled their role in the child’s story, and in group discussions which have at times been very difficult and challenging.  Several have remarked that it has been a positive experience to contribute to learning from the tragedy.  All this has given the Review Team a deeper and richer understanding of what happened with this family and within the safeguarding network, and has allowed us to capture the learning which is presented in this report.     2 Data from documentation The Lead Reviewers and members of the Review Team reviewed the following documentation:  The records of the agencies in the case, which were then translated into an integrated chronology  Referral and information records (CYPS)  Transfer summary (CYPS)  Minutes of meetings: CP Conferences, Core Groups, MARAC  Reports for CP Conferences  CP Plans and Written Agreements  Core Assessment (CYPS)  Detailed records of CP home visits (CYPS)   CP Medical report for MA (6th December 2012) Lambeth SCR Child H Confidential Final Report 51  Record of outcome of S47 Enquiries March 2013  Record of Strategy Discussions March 2013  Detailed records from EDT, 4/5 March 2013  Detailed records of Brother 2’s hospital admission and care  Email correspondence of CYPS managers regarding the incidents in March 2013  CP Medical reports for MA and Brother 1 (8th March 2013)   In addition, the Lead Reviewers read the SCR Panel minutes of 26.03.13, and a briefing document drawn up for consideration at that meeting, including draft Terms of Reference.   1.8.3  Data from family, friends and community 1.8.3.1 As in traditional SCRs, the Learning Together model aims to include the views and perspectives of family members as a valuable element in understanding the case and the work of agencies.     In this review, the status of the parents as perpetrator and witness in criminal proceedings has ruled out the offer of conversations with them at this time.  It is hoped that at a future point, it will be possible to engage both parents in a dialogue about their experience of working with agencies.    Lambeth SCR Child H Confidential Final Report 52 Appendix 2 – Guide to terminology Acronyms used and terminology explained 1. 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.’ (2013: 70) Writing for multiple audiences is always challenging.  An appendix (Appendix 2) on terminology aims to support readers who are not familiar with the processes and language of safeguarding and child protection work.  2. Lambeth LSCB and SCIE are both keen to improve the accessibility of SCR reports and welcome feedback and suggestions for how this might be improved. 3.  Acronyms A&E Accident and Emergency Department (hospital) CSC Children’s Social Care CYPS Children and Young People’s Services DTM Deputy Team Manager DV Domestic violence  ED Emergency Department FSCP Family Support and Child Protection Team GSTT Guy’s and St. Thomas’ Hospital Trust HV Health Visitor IDVA Independent Domestic Violence Agency LSCB Local Safeguarding Children Board LT Learning Together MARAC Multi Agency Risk Assessment Conference  SCIE Social Care Institute for Excellence  SGH St. George’s Hospital SW Social Worker TM Team Manager 4.  Terminology   Children Act 1989: When local authority social care services work with a family, the principal legislation underpinning their powers and duties is the Children Act, 1989. One particular section of the Act is referred to throughout this report: section 47.    Lambeth SCR Child H Confidential Final Report 53 S47: This sets out the duties of Police and CYPS to respond to any report that ‘a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm.’  Under these circumstances, enquiries must be made to decide on action needed to safeguard or promote the child’s welfare.  Strategy Meeting: This is the meeting (or sometimes telephone discussion) which initiates the s47 process.  The first action after a child protection referral has been received is for CYPS to make contact with the Police and to set up a Strategy Meeting to plan who will do what in carrying out the enquiries for this child/ren.  Formal Child Protection Procedures: Child Protection Conferences, Core Groups and Child Protection Plans are ‘regulated’ by statutory guidance (Working Together, all editions).  They are the multi-agency formal procedures for identifying, assessing and planning for the protection of children who reach the threshold of ‘at risk of significant harm’.  Under the umbrella of the LSCB, the CYPS service is responsible for convening and supporting these arrangements.  The CYPS social worker is designated as the ‘key worker’ for the children on Child Protection Plans. Court orders: The act gives other powers to the courts – to make protective orders of various kinds, including an Emergency Protection Order (s44) – and powers to the local authority to apply for such orders.  Police have the power (Police Protection) without an order to remove a child who is in immediate risk of significant harm to a place of safety.   Details of how a S47 investigation, or enquiry, is to be carried out are found in Working Together, all editions. Lambeth SCR Child H Confidential Final Report 54 Appendix 3 - Statistics on domestic violence  National data: Figures reveal that  ‘…13,500 people – 80% of them women – reported domestic violence to Citizens Advice last year. There were 3,300 reported incidents between October and December 2012, an 11% increase on the same period the previous year.’ (Topping, 2013) In the same Guardian article, Home Office figures are quoted which state that last year 1.2 million women experienced DV, including sexual violence, from their partners.    Women’s Aid.org.uk: Research shows that domestic violence can affect one in four women in their lifetimes, regardless of age, social class, race, disability or lifestyle. Domestic violence accounts for between 16% and one quarter of all recorded violent crime, and for 10% of emergency calls. In any one year, there are 13 million separate incidents of physical violence or threats of violence against women from partners or former partners. (Home Office, 2004; Dodd et al., 2004; Dobash and Dobash, 1980; Walby and Allen, 2004)  Statistics about domestic violence: Incidence and prevalence of domestic violence: General  In 2011/12, 7.3% of women (1.2 million) and 5% of  men (800,000) report having experienced domestic abuse.   31% of women and 18% of men have experienced domestic abuse since the age of 16 years.  This amounts to 5 million women and 2.9 million men.   In 2011/12, the police reported nearly 800,000 incidents of domestic violence.   There has been a 65% increase in the number of domestic violence prosecutions between 2005/06 and 2010/11 and a corresponding 99% increase in number of defendants convicted.   Despite this, domestic violence conviction rates in the five years to 2011 stood at just 6.5% of incidents reported to police – though a much higher proportion of around 70% of those charged.   Women are much more likely than men to be the victim of multiple incidents of abuse, of different types of domestic abuse (partner abuse, family abuse, sexual assault and stalking), and in particular of sexual violence.  Lambeth statistics: include various indicators that reflect the level of DV:   Referrals to CYPS with DV as a factor: 19%  Number of CP plans with DV as a factor: 61%  Total number of calls in the past year to national DV helpline from Lambeth residents: 1,696 calls (30,424 calls from London as a Lambeth SCR Child H Confidential Final Report 55 whole). Calls from Lambeth were the third highest in London after Croydon (1747) and Lewisham (1699) The table below gives the Lambeth MARAC referrals from 2007 to the present. These show a continuing rise in the numbers of referred victims who are regarded as ‘at high risk of serious harm or death’, and who have become the subject of protection plans formulated at the MARAC meetings.  Date Period No of victim referrals Number of associated children Apr 07 – Mar 08 47 59 Apr 08 – Mar 09 156 171 Apr 09 – Mar 10 307 328 Apr 10 – Mar 11 341 400 Apr 11 – Mar 12 286 361 Apr 12 – Mar 13 396 388 Rolling 12 month Aug 12 – July 13  408  391  Lambeth SCR Child H Confidential Final Report 56 Appendix 4 - Lessons already learnt and changes implemented to improve practice across agencies This Appendix details actions already taken which are relevant to four of the six priority findings. Finding 1: A tendency among professionals in all agencies to focus on the emotional impact on children of living with domestic violence, and not on the increased probability that they will be physically harmed, impedes a full understanding of the risks to which they are exposed.    LSCB: Has endorsed and rolled out the Barnardo’s risk assessment tool which does specifically look at the risks to the children of direct physical abuse.   CYPS: Since this review, the CP Conference Chairs have been asked to review the categorisation of children on CP Plans and stress the correlation.between DV and physical abuse in the conference and risk assessment.  GSTT: GSTT have undertaken training for community practitioners re routine enquiry and use of Barnardo’s risk assessment in March/April 2013.  SGH: An action plan was developed following a Learning Improvement process in response to this case.   This included the following changes: o Risk assessment tool introduced to A&E for use when NAI is one possible explanation for the presenting complaint (more detail in action plan). o Lead consultant for child safeguarding, particularly for the more medical aspects, e.g., interpretation of injury, for each specialty identified. o Lead consultant to be identified and notified on admission whenever child safeguarding concerns are raised. o Ward team to assess risks in respect of the child’s safety on the ward when NAI is a possibility and implement appropriate measures, e.g., positioning child close to nursing station, restricting visitors. Finding 3: The current range, availability and quality of interpreters is problematic; for planned work it is variable and, in emergency situations, it is so poor that it risks leaving non-English language service users without support, making it extremely difficult for professionals to make an effective assessment or diagnosis in a timely fashion.  SGH: Phones used for Language Line (and other confidential purposes) in the A&E department have been moved into two side rooms.   Finding 4: Where there is no known recurrence of domestic violence incidents, professionals tend to be reassured about the welfare of children in the household and/or believe their grounds for purposeful engagement with the parents are diminished. The consequence is that they get no further Lambeth SCR Child H Confidential Final Report 57 in understanding the causes and triggers of incidents of domestic violence, and the actual level of risk to children these imply.  CYPS: Is moving towards the full-scale implementation of the Signs of Safety model which will strengthen the quality of risk assessment, make concerns more easily understood by parents, and will frame CP Plans in a way that is more outcome-focussed.  Finding 5: A pursuit among social care and police staff of categorical explanations from medical professionals of the cause of physical injury to children, clashes with a norm among medical professionals of giving differential diagnoses in which anything is possible until it is ruled out. This increases the chances of miscommunication and misunderstanding about past and future risks in child protection investigations.  CYPS: Following the incident, guidance has been reissued within CYPS to social work teams about the requirement to record on the day the key findings and actions arising from a Strategy Meeting, and give those to the attendees on the day. This was audited and found to be happening in the cases seen. SGH: An action plan was developed following a Learning Improvement process in response to this case.  The changes are outlined above, under Finding 1.        