Sexual abuse by Isobel's mother's partner from a young age; she was assaulted by him when she threatened to disclose the abuse. Isobel was referred to hospital for enuresis where a medical explanation was sought but not found. The issue was not investigated further and there was no involvement of the school or school nurse. Isobel's mother sought help when she became drug dependent and a referral was made to children's social care. The mother's partner had alcohol and drug dependencies and poor mental health but no consideration of the impact this might have on Isobel or his family was considered and no safeguarding referral was made. The family was in debt. Identifies learning points: professionals did not always recognise when they needed to ask questions, share information or follow up with colleagues about a child's wellbeing and struggled to address Isobel's thoughts "I just wanted someone to ask me"; lack of professional curiosity when faced with adults who misused drugs and alcohol; inequality in the way the mother and partner were treated following drug misuse; organisational systems were not in place to enable practitioners to see children and young people on their own. Isobel did not want the report published in its entirety, so this review sets out emerging themes and highlights the learning points. There are no recommendations included.
      
 Title:  Lessons learnt from a serious case review: BSCB 2016-17/1: “I just wanted someone to ask me” – Isobel. LSCB: Birmingham Safeguarding Children Board Author: Eleanor Stobart Date of publication: 2017  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                                                Lessons Learnt from  a Serious Case Review   BSCB 2016-17/1   "I just wanted someone to ask me" - Isobel   Independent Author:  Eleanor Stobart   2 | P a g e    CONTENTS   1. BACKGROUND ................................................................................................................ 3  2. THE REVIEW PROCESS .................................................................................................... 3  3. EMERGING THEMES ....................................................................................................... 3 3.1. Diagnosis-led models of care ....................................................................................... 3 3.2. 'Soft' signs of abuse and professional curiosity ........................................................... 4 3.3. Making space and time for children and young people .............................................. 4 3.4. The invisible man ......................................................................................................... 5 3.5. Lost histories ................................................................................................................ 5 3.6. The cumulative impact on children ............................................................................. 6  4. A PRACTITIONER LEARNING EVENT ............................................................................... 7  5. LEARNING POINTS .......................................................................................................... 8     3 | P a g e   1. BACKGROUND  Isobel lived with her mother, her mother's partner and sibling in Birmingham. Her mother's partner sexually abused her from a young age and assaulted her when she threatened to disclose the abuse.   2. THE REVIEW PROCESS A Serious Case Review was commissioned by Birmingham Safeguarding Children Board (BSCB) to examine the case in detail, to identify important learning that can be shared with relevant agencies. Isobel and her mother were consulted and helped inform the development of the terms of reference.  Agencies were required to submit reports detailing their involvement in the case.  An independent panel of experts reviewed the information reports, the overview report and a consultative practitioner learning event was held attended by professionals involved in the case, so their views could be incorporated into the review.  Isobel asked BSCB not to publish the report in its entirety. In order to respect her wishes the BSCB developed a "lessons learnt" report to be published instead. This report sets out the emerging themes from the original serious case review and highlights the learning points that were identified.    3. EMERGING THEMES   3.1. Diagnosis-led models of care When Isobel was referred to Birmingham Children's Hospital for enuresis, the focus of attention was on finding a medical explanation for her enuresis. There was no evidence to suggest that thought was given to a non-medical cause for her symptoms. There was little exploration about her life, who she lived with and no investigation into any particular stressors. The hospital did not make enquiries of any other agency or indeed contact her school or copy the school nurse into any of the letters sent to her GP. Furthermore, her GP did not investigate the issue further by involving the school nurse. Had any of these actions taken place, Isobel might have been offered support at school or via the school nurses; which in turn may not only have provided more appropriate opportunities for her to disclose the abuse that she was suffering, but also assist practitioners to identify some of the 'soft' signs of abuse that she was displaying. As it was, there was not even a mention of enuresis in her school records.  The issue of a diagnosis-led model of care also occurred in her mother's partner's case. For example, both his GP and the staff within the intensive care unit at the hospital focused on his  4 | P a g e   health problems without wider consideration to the impact that his dependence on drugs and alcohol might have on those around him.  3.2. 'Soft' signs of abuse and professional curiosity Isobel's mother felt that both Isobel and her sibling showed signs of distress during the period under review. Undoubtedly, the sibling was displaying aggressive behaviour (described by the GP Practice Nurse); the sibling was clinging towards the mother (described by the school); and often sought attention (described by the social worker). Indeed, Isobel's behaviour at school was described as attention-seeking and disruptive. Furthermore, as the hospital never found a medical cause for Isobel's enuresis, other causes should have been considered. Despite all these potential signs of abuse, no professional gave Isobel the opportunity or space to describe what was happening in her world. Professionals should have been more curious and we know from Isobel herself that she simply wanted someone to ask her because she felt too afraid to disclose.  The National Institute for Health and Care Excellence (NICE) has recently (February 2017) produced draft guidance for consultation suggesting that professionals should be alert to abuse and neglect if a child displays signs such as:1   Low self-esteem  Wetting and soiling  Recurrent nightmares  Aggressive behaviour  Withdrawing communication  Habitual body rocking  Indiscriminate contact or affection seeking  Over-friendliness towards strangers  Excessive clinginess  Persistently seeking attention.  3.3. Making space and time for children and young people  It was obvious from reading Isobel's medical records that she was rarely seen alone. She described being unable to discuss the sexual abuse she was suffering in front of her mother because her mother would be hurt. There were a couple of occasions when doctors asked Isobel whether she was sexually active but it was not clear from the records how the question had been phrased. If she was asked whether she was sexually active, had a                                                       1 For further information see http://www.bbc.co.uk/news/education-39038529 – accessed online 22 February 2017  5 | P a g e   boyfriend or could be pregnant, it would not necessarily have elicited information from her about sexual abuse.  There was another occasion when Isobel appeared to try to tell a professional about life in her family. She told a social worker that her mother and her mother's partner argued a lot but this was not explored further. She told staff at her school that a boy had touched her inappropriately – it is not clear, but she may have done this to see if anyone would take such allegations seriously.   Being professionally curious is not simply about asking the question. It is about the language used, creating a trusting relationship, a safe space in which to disclose and giving time to children and young people so they do not feel pressured. Professionals would have needed to be much more enquiring to help Isobel to articulate what was happening to her, especially as her mother's partner said he would kill her if she told anyone what was happening.   3.4. The invisible man There was clearly a disparity in the way in which professionals regarded Isobel's mother compared to the way they viewed her mother's partner. For instance, when Isobel's mother took an overdose of cocaine, a referral was (rightly) made to Children's Social Care. Nevertheless, when her mother's partner presented at hospital having collapsed at a party, it was known that he drank over 300 units of alcohol a week in addition to taking cocaine daily. Despite this, little consideration was given to his home circumstances (his records simply stated that he lived with his wife) and no safeguarding referral was made.  At various times, her mother's partner spent around £400 a week on drugs and alcohol; whilst at the same time Isobel's sibling was being described by Children's Social Care as "underweight and small" and the school had concerns about the sibling's "poor appetite". Agencies such as the drug and alcohol service allayed their concerns by viewing Isobel's mother as a protective factor for Isobel and her sibling.  Indeed, the partner's GP also never explored his home situation despite the Practice's knowledge of his poor medical health and his dependence on substances.  3.5. Lost histories  The partner's GP Practice described him as a "fairly pleasant and docile" man, who during consultations was "pleasant and placid and did not come over as a controlling individual". In fact, the GP went as far as expressing surprise (when interviewed for the serious case review) that he had committed such a crime. Therefore, it is a concern that as far back as 1999 the same GP Practice had referred him to the Birmingham and Solihull Mental Health Foundation Trust because of his violent outbursts. His anger was clearly an on-going concern because he was again referred to mental health services by his GP in 2003. It  6 | P a g e   appeared that his history of violence towards his then partner and their 4-month-old child did not 'travel' with him and was not overtly flagged on his records. Thus, over time this information became 'lost' in the background of his records and he became viewed as a "fairly pleasant and placid" man.   3.6. The cumulative impact on children  It was notable that this case featured domestic abuse, parental mental ill-health and parental substance misuse. These three facets in family life are often referred to as the 'toxic trio' and are indicators of increased risk of harm to children and young people. Yet professionals from health, education, Children's Social Care, and drug and alcohol services failed to recognise the cumulative impact these issues might have on Isobel and her sibling's life at home.  One of the difficulties for agencies working with domestic abuse, parental mental ill health and parental substance misuse is that they are working with the adults in a household. Sometimes adults choose not to engage with services, and this was certainly the case with Isobel's mother's partner. Furthermore, services that provide support to adults are designed around adults and they do not always come into contact with their children and so fail to consider them.   Professionals did not explore more widely and 'think the unthinkable' even though (with hindsight) the signs were there. Isobel said her mother and her partner argued and her mother described her relationship with her partner as "fractious". Despite this, she was never referred to a specialist domestic abuse service that could provide support to her and her children.  Both Isobel's mother and her partner were referred to mental health services. The partner's anger was never really assessed or addressed. Research2 shows that a third of perpetrators and victims of domestic abuse disclose mental health issues and/or substance misuse.  The partner openly discussed his dependence on drugs and alcohol and Isobel's mother actively sought help when she became dependent on cocaine. It was known that the family were in debt. Isobel's mother told professionals it was because her partner spent the family money on drugs and alcohol. Again, professionals did not enquire further to understand how this affected the rest of the family even in basic terms such as how did Isobel's mother manage to provide her children with food, housing, heating and clothing.                                                            2 See www.safelives.org.uk In plain sight: The evidence from children exposed to domestic abuse, CAADA Research Report February 2014 – accessed online 23 February 2017  7 | P a g e    4. A PRACTITIONER LEARNING EVENT A practitioner learning event was held to specifically address some of the issues raised in the course of the review and those raised by Isobel and her mother. It was attended by 27 managers/practitioners from a range of agencies including:  Birmingham and Solihull Mental Health Foundation Trust   Birmingham and Solihull Women’s Aid   Birmingham Children’s Hospital  Birmingham Clinical Commissioning Group  Birmingham Community Health Care NHS Foundation Trust  Child and Adolescent Mental Health Service (CAMHS)  Children’s Social Care  Community Mental Health Team   Drug and alcohol services – Change Grow Live  Birmingham City Council Education Services   GP Practice  Heart of England NHS Foundation Trust  School  Solihull Clinical Commissioning Group  West Midlands Police  It was clear from the event that the children and their mother were viewed separately to the mother's partner by the majority of agencies i.e. most agencies either worked with the partner and did not consider his family; or they worked with the children and their mother and did not explore the partner's influence on the family dynamics. Health practitioners were focused on the health issues that family members presented and little thought was given to the wider context of their lives. For example, Birmingham Children's Hospital did not consider non-medical reasons for Isobel's enuresis and the partner's GP did not consider the impact of his health and alcohol use on the family.  All agencies struggled to address Isobel's thoughts – "I just wanted someone to ask me". This was for a number of reasons:   Practitioners felt uncomfortable insisting that young children should be seen alone   Organisational systems were not in place to enable practitioners to see children and young people on their own   8 | P a g e    Practitioners had difficulties "thinking the unthinkable"   Practitioners felt they did not have the skills to ask searching questions Although practitioners recognised a range of signs of abuse, these signs were not seen as a whole and therefore when taken in isolation did not raise concerns.   5. LEARNING POINTS  Professionals did not always recognise when they needed to ask questions, share information or follow up with colleagues about a child's wellbeing   There was a lack of curiosity when faced with adults who used significant amounts of drugs and alcohol. Professionals did not establish their domestic circumstances or the implications for children living in the household and did not consider compromised parenting capacity.    There was an inequality in the way in which professionals treated Isobel's mother when she overdosed on drugs compared to the way they treated her mother's partner when he presented with high levels of drug use i.e. in Isobel's mother's case a referral was made to Children's Social Care whereas no one asked whether the partner had (or lived with) children   No professional gave Isobel the opportunity or space to describe what was happening in her world. They did not have the confidence to ask difficult questions – "I just wanted someone to ask me".    Professionals felt uncomfortable asking to see children on their own    Little consideration was given to home circumstances and family composition – i.e. adult services tended to focus on adults (to the detriment of children)   Agencies did not routinely have systems that could flag an individual's history   