Death of a 10 month old baby who was the subject of a child in need plan, from a non-accidental head injury. The mother's boyfriend was convicted of manslaughter. The mother was 16 and living in a hostel. Considers issues around supporting young mothers and assessing the needs of the mother and the baby; disguised compliance, neglect; parenting capacity; assessing unknown men in the family; optimistic thinking; failure to take up support services offered; adolescent behaviour; substance misuse; capacity to challenge families and professional colleagues. Makes interagency and various single agency recommendations covering children's social care, housing, early childhood services; GPs and NHS Trusts and the police.
      
 Title:  Overview report on the serious case review relating to Child G - redacted version LSCB: West Sussex Safeguarding Children Board Author: Fiona Johnson Date of publication: 2013  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                       1           West Sussex Local Safeguarding Children Board  Overview Report on  The SERIOUS CASE REVIEW relating to CHILD G – Redacted version 2  1 INTRODUCTION 1.1 Background to the review  1.1.1 CHILD G information redacted was in the sole care of information redacted mother’s partner, Chris B, information redacted. On the morning information redacted he called the ambulance service as CHILD G information redacted was not breathing; following intensive medical treatment information redacted CHILD G was declared dead information redacted. Chris B was arrested and there were medical and police investigations into the circumstances surrounding the cause of information redacted death. Initial medical findings indicated that information redacted CHILD G sustained a catastrophic head injury. Police information on the known medical findings is that information redacted CHILD G had not experienced any injuries prior to being in the care of Chris B; that the injuries found were not considered accidental; and that it was believed that the use of force must have been significant.  Chris B was charged with murder but was convicted of manslaughter for which he was sentenced to 8 years in prison.    1.1.2 Following a meeting of West Sussex LSCB Serious Case Review (SCR) sub group information redacted; it was decided that the case met the criteria under para 8.9: ‘The LSCB should always undertake a serious case review when a child dies, and abuse is known or suspected to be a factor in the child’s death’ and it was recommended that a serious case review should be held. information redacted the Chair of the West Sussex Local Safeguarding Children Board made the decision to accept this recommendation and to carry out a Serious Case Review (SCR). Ofsted was notified of this decision information redacted. The Care Quality Commission and SHA were informed in writing by the Designated Nurse on information redacted. 1.2 The Terms of Reference 1.2.1 It was agreed that all agencies would address the following specific terms of reference when undertaking their reviews:-   • The key relevant points/opportunities for assessment and decision making in this case in relation to the child and family? Do assessments and decisions appear to have been reached in an informed and professional way? Specifically:  o Were the decisions made at the Child Protection Conference reasonable o In light of the Conference recommendation was the full extent of the role and responsibilities of mother’s partner in information redacted CHILD G’s life, and his ability to care information redacted assessed appropriately? o Were there any indications of potential risk at any point during the period of review, and if so were they shared or acted upon appropriately and in a timely manner?  • The actions taken following assessments and decisions and whether appropriate services were offered/provided or relevant enquiries made, in the light of assessments?  Specifically:  o Did the Children in Need plans and services provided effectively meet the child’s needs?  3  • The degree to which the child’s needs were taken into account when making decisions about the provision of children’s services, and whether this was accurately recorded? • The sensitivity of practice to the racial, cultural, linguistic and religious identity of the family and any issues of disability or other diversity issue relating to the child and information redacted family, and whether this was explored and recorded? • Was there sufficient management accountability for decision making and the involvement of managers at key points in the case?  • The adequacy of training and supervision of staff to carry out their role? • The consistency of work with each organisation’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards?  • Any organisational difficulties being experienced within or between agencies and whether there was a lack of capacity or resources in one or more organisations? • Any examples of good practice or lessons to be learned about single and multi-agency working? • Any recommendations you would make to the West Sussex Local Safeguarding Children Board regarding training, practice or procedures?  1.2.2 Initially it was agreed that the review spanned the agency involvements during the period from the information redacted; this being from the date that the Health Visitor raised concerns which led to the Initial Child Protection Conference until the date of information redacted death. Following discussion at the first SCR panel meeting it was agreed that additionally all agencies were asked to review documentation from the information redacted, when mother became pregnant and to include any relevant information in their report as well as reporting on any other relevant information outside of the time period; the time frame for the chronology was not extended.   1.2.3 Further into the review process additional information was provided by the police which became available via their criminal investigation. This information indicated that information redacted CHILD G was exposed to drugs over a period of time. As a result information redacted all agencies were contacted and asked to further review their involvement with the family to consider ‘to what extent did they consider substance misuse by any adults involved with information redacted CHILD G to be a factor – if so what actions were taken by the agency’. Agencies were asked to submit an addendum report addressing this issue and as a result the overall time-scales for the review were extended.   1.3 Review Process 1.3.1 Individual Management Review (IMR) reports were received from the following sources: • West Sussex County Council Children Social Care  (including the Child Protection Unit),  • West Sussex County Council Early Childhood (Children and Family Centre and outreach)  • Sussex Police,  • information redacted Hostel,  • Sussex Community NHS Trust  4  (Health Visiting),  • NHS Sussex Cluster (West Sussex)   (GP)  • Western Sussex Hospitals Trust  (A&E, Midwifery and Child Development Centre)  1.3.2 IMR authors were provided with a briefing session and also asked to attend the serious case review panel in order that feedback could be provided on the reports and the panel could ask questions in order to clarify any issues.   1.3.3 Additionally reports were received from a number of agencies who had limited contact with the family during the relevant period but who had information that would assist the review. Reports were received from: -  • information redacted Hospital London • South East Coast Ambulance NHS Trust  • information redacted Borough Council • information redacted (domestic violence victims advisory service)  Checks were also undertaken with Connexions and the Youth Service with regard to any involvement that they may have had. Carly attended youth clubs and received support from the Connexions service however all of this involvement was prior to the period of the review therefore it was not felt necessary for them to complete an IMR.  1.3.4 A health overview report was also produced in order to review and evaluate the practice of all involved health professionals, including GPs and providers commissioned by the PCT area.  1.4 Family Input to the Review 1.4.1 Consideration was given to involving the parents in the review process however this was not immediately possible because of the risk of compromising the criminal investigation. Mother was a witness in the criminal process. Father was thought to have had limited contact with CHILD G during the period of the review and therefore it was felt inappropriate to involve him. The parents were informed of the serious case review process and when the criminal trial was completed contact was made with mother and maternal grandmother and maternal grandfather. The independent overview author met with mother and maternal grandmother and their views are included later in the report. Numerous unsuccessful attempts were made to arrange a meeting with maternal grandfather however this was not achieved. The father was offered to see a copy of the report prior to full publication.  1.5 The Review Panel 1.5.1 The review group membership was as follows: - • Jane Browne, Surrey and Sussex Probation Trust: Chair  • Lorraine Smith, Designated Nurse • Marilyn Barton, Early Childhood WSCC • Debbie Bath, LSCB Business Manager  • Edmund Hick/Jonathan Gross, Sussex Police • Susan Ellery/Siobhan Burns/Mark Frankland, Children Social Care 5   Additionally Fiona Johnson, the Independent Overview Writer attended review Panel Meetings.  1.5.2 Dates of review Panel meetings were as follows: - information redacted 1.5.3 The Chair (Jane Browne, Surrey and Sussex Probation Trust) is from an agency that had no involvement with the family and is therefore independent with regard to this case. The independent chair of the LSCB from January 2012 is Jimmy Doyle.   1.5.4 The independent overview writer is Fiona Johnson, an independent social work consultant. Head of Children’s Safeguards & Quality Assurance in East Sussex County Council between 2004 and 2010, Fiona qualified as a social worker in 1982 and has been a senior manager in children’s services since 1997 contributing to the development of strategy and operational services with a particular focus on safeguarding and child protection. She is GSCC registered and has previously written overview reports for East Sussex, Brighton & Hove, Portsmouth, Southampton, Kent, West Sussex, Wandsworth, Surrey, Slough and Bracknell Forest LSCBs.  1.5.5 The overview report was completed based on information provided in the IMRs and the additional reports. The overview author also saw the notes of the initial child protection conference; the child in need plan and the strategy discussion notes.  1.5.6 The Panel considered at all stages how early learning could be shared with relevant agencies and staff. The recommendations and action plans will be shared with staff and implemented immediately where possible. Full publication of the findings of the review will follow on from the completion of the criminal process.  2 THE FACTS 2.1 The Family background Name1  Gender  Relationship  Date of birth Ethnicity  information redacted CHILD G information redacted Subject information redacted White British Carly G Female Mother information redacted White British Russell S Male Father  information redacted White British Chris B Male Mother’s Partner information redacted 2 Dual heritage white British/black Caribbean                                                            1 information redacted CHILD G, Carly, Chris B  etc are the names given by West Sussex LSCB to provide anonymity 2 There was some discrepancy with the police and social care recording of the dates of birth for Chris. As the GP held records for Chris from birth this was believed to be the most accurate.  6  Maureen G Female Maternal Grandmother Unknown White British Mark G Male Maternal Grandfather Unknown White British Pam B Female Chris B’s mother information redacted White British  A genogram and a full chronology covering the period the information redacted November information redacted to information redacted May information redacted   2.1.1 information redacted CHILD G and information redacted parents are white British and their first language is English; religious affiliations are unknown. Chris B is dual heritage, white British/black Caribbean, his first language is English and his religious affiliation is unknown. information redacted was the first child of Carly and Russell. Their relationship began in May information redacted and ended in August information redacted, when information redacted CHILD G was two months old, following an incident of domestic abuse. Carly started her relationship with Chris B in October information redacted when information redacted CHILD G was four months old. information redacted CHILD G and Carly were living in a hostel as a result of Carly becoming homeless during her pregnancy, following a disagreement with her mother. Prior to being pregnant Carly worked as a hairdresser; however, for the period of the review she was in receipt of benefits.   2.1.2 Chris B was said to be working as a labourer but was also receiving benefits; he had separate accommodation from Carly and during the period of the review lived at two separate addresses, both being rooms in shared houses. Chris B was reported to have a child, with whom he did not have contact, but nothing further was known about this; police investigations since the death indicate that Chris B did not have a child. Chris B has a criminal record for possession of cannabis (two counts) and has been arrested for other matters.   2.1.3 There is little information about Russell S as he was not involved for the significant period of this review however he is known to Sussex Police for matters including harassment of a female and is also known to have Attention Deficit Hyperactive Disorder (ADHD).  2.1.4 There was limited involvement by agencies with this family prior to the period of the review. Carly’s older sister was accommodated in her teens because of problems in her relationship with her parents; she became pregnant when she was 16. There had been police involvement with Carly and her sisters because of minor criminal matters and Carly was reported missing to the police on one occasion when she was fifteen. At that time she was reported by her father to be mixing with inappropriate older men. Carly’s parents’ relationship ended in 2009.  2.1.5 Carly became pregnant when she was sixteen and was made homeless by her mother in February information redacted following arguments about maternal grandmother’s boyfriend. It would appear that relations between Carly and her mother were acrimonious from December information redacted and Carly presented as homeless on two occasions in January information redacted and February information redacted prior to her being housed in the information redacted Hostel. 7  Throughout the period of the review the maternal grandmother provided little support; however, Carly and information redacted were supported by the maternal grandfather and his new partner. Chris B and Carly were also supported by Chris B’s mother, information redacted.  2.2 Agency Involvement with family 2.2.1 Carly reported her pregnancy first to her GP on 4th November information redacted and then booked with midwifery for her confinement on 27th November information redacted. At this stage Carly advised the midwife and GP that she was well supported by her mother and boyfriend. Carly was allocated to the teenage pregnancy midwife and on 9th February information redacted a routine safeguarding alert was raised to alert maternity staff regarding her young age as a parent.   2.2.2 In February information redacted an initial assessment was undertaken by an assistant care manager (ACM) of Carly’s needs. At that stage she was a homeless sixteen year-old who was pregnant with very limited support from her family. The outcome of this assessment was that Carly was housed at the information redacted Hostel and from March information redacted she was paid a subsistence allowance of £50.00 per week which she collected from the social work office. Social care staff did not visit the information redacted Hostel and there was no further support or assessment of her needs as a vulnerable teenager or any risk assessment of her capacity to be a parent.  2.2.3 When Carly moved to the information redacted hostel she advised the midwife on 19th February information redacted of her change of address. The midwife visited within a few days and discussed what additional support she needed. This midwife made a referral to Connexions for additional support and also updated social care and the labour ward as to the changes in Carly’s circumstances. The midwife visited on six further occasions during the pregnancy but these visits were routine and the only significant matter was a record in April information redacted that Carly had attempted to attend parent craft classes but had not continued as her partner did not like big groups. The health visiting service became involved in May information redacted and undertook an ante-natal assessment which deemed Carly to be vulnerable because of her youth, her strained relations with her extended family and Russell S’s ADHD.   2.2.4 information redacted CHILD G was born via an emergency caesarean section; following her mother experiencing an eclamptic fit information redacted 3. Carly received treatment in intensive care for the eclamptic fit but returned to the postnatal ward on information redacted; information redacted CHILD G did not need any additional care following the delivery. information redacted CHILD G and Carly were discharged from hospital on information redacted and went to stay with paternal grandmother. Following discharge Carly and information redacted CHILD G were visited by community midwives on four occasions and all clinical checks were found to be satisfactory and no concerns were raised about the baby. Care was discharged to the health visitors on information redacted.                                                            3 An eclamptic fit is seizures which can occur in pregnancy usually at any time form the 2nd trimester until up to 5 days post delivery.  It can be caused by several factors, including: reduced blood flow to the brain, caused by a combination of small clots and spasm of the small arteries; swelling in the brain (cerebral oedema), possibly as a complication of excessive fluid retention; bleeding from small arteries ruptured by the intensity of the blood pressure.  Early indications of the risk can be one, all or several symptoms including: High blood pressure, Proteinuria, generalised oedema, Epigastric pain, headaches and visual disturbances’ 8   2.2.5 Carly had her post-natal check information redacted when she self-reported that she was tired but not depressed; her physical health was seen to be normal. Carly was then seen at the hospital on information redacted for a post natal appointment because of the eclampsia. It was noted at that time that she was ‘low’ and anti-depressants were prescribed. The hospital sent the GP a letter informing of the clinic appointment on information redacted however this was not found in the GP records. Carly did not attend the GP again and received no follow-up with regard to her depression. 2.2.6 In August information redacted there was a domestic abuse incident between Carly and Russell S. The incident involved verbal and physical abuse of Carly by Russell S and also included ‘threats to kill’ being made by text. The Police were not advised by Carly of the physical abuse or ‘threats to kill’ but these were disclosed to information redacted domestic abuse victim support Services Team. They were also raised when the incident was discussed at a Multi-agency Risk Assessment Conference (MARAC) for domestic violence. Carly ended her relationship with Russell S following this incident and was provided practical and emotional support at this time by the information redacted domestic abuse victim support Services Team.  2.2.7 From information redacted Carly and information redacted CHILD G were seen regularly by the health visitor who reviewed information redacted CHILD G’s health and development and provided advice and guidance. There were no problems with information redacted CHILD G’s health or development however Carly was repeatedly reminded regarding leaving information redacted CHILD G unattended on the bed.  During this time Carly was also being supported by staff within the information redacted hostel who offered sessions aimed at improving practical skills such as cookery and money management. Carly did not engage in these support services. Carly’s physical care of information redacted CHILD G was seen to be good and information redacted CHILD G was always clean and well-dressed. There were some concerns that Carly’s verbal interaction with information redacted CHILD G was limited and that occasionally information redacted CHILD G was left unsupervised in the bedroom without all potential hazards being removed. These issues were discussed with Carly and staff considered that the issues were similar to many other tenants within this age-group. At this stage Carly was also receiving limited support from social care. Early in October 2010 Carly began a relationship with Chris B.  2.2.8 On information redacted the health visitor received a call from  information redacted who reported that Carly was not coping, was feeling low and had no milk for information redacted CHILD G. The health visitor visited the hostel later that day and found Carly with ‘made-up’ feeds that were not refrigerated and no further formula; she also said she had few clothes for information redacted CHILD G that fitted. Carly seemed low but said that she had more formula at her boyfriend’s flat which she visited regularly. information redacted CHILD G was seen and seemed well and had gained a little weight. The health visitor was concerned about the poor management of money and the lack of appropriate care regarding information redacted formula and reported these concerns to the assistant care manager (ACM), on the information redacted The ACM advised the health visitor that case responsibility was likely to move to a social worker and that consideration was being given to calling an Initial Child Protection Conference. As there is little 9  recording it is unclear why a conference was being considered. The ACM also informed the health visitor that the information redacted was in fact Chris B’s mother, Pam B. 2.2.9 Following the contact from the health visitor the ACM visited Carly and information redacted at the hostel; Pam B was also present and offered practical support to Carly around budgeting. The visit confirmed the health visitor’s concerns regarding finances. After this visit the ACM discussed the concerns with her supervisor who recommended a visit be undertaken with a Senior Practitioner. This visit took place on the information redacted and was undertaken at Chris B’s house because Carly and information redacted CHILD G were staying there. This visit raised further concerns regarding the care being provided to information redacted CHILD G as the conditions within the shared house were poor. There was evidence of cannabis use in the bedroom and it became apparent that information redacted CHILD G had spent the night in a bouncy chair as there was no travel cot despite Carly having previously told the ACM that this was where information redacted CHILD G slept when they stayed over at the house.  2.2.10 Following this visit a decision was made to convene an Initial Child Protection Conference. The process of decision-making is confused and does not appear to be reflected in the recording. There was a formal strategy discussion held on information redacted involving police and social care which identified the risks as being chronic neglect, Carly failing to prioritise information redacted CHILD G’s needs and Carly associating with people involved in drug-use. The outcome of the strategy meeting was that social care would undertake a single agency section 47 investigation and that a child protection conference would be convened. The evidence for most of the risk factors seemed limited and based mainly on the information from the health visitor and the two recent visits. Carly was formally told about the conference on information redacted when the ACM visited her at maternal grandfather’s address. 2.2.11 information redacted Carly and information redacted CHILD G were seen by the health visitor at maternal grandfather’s home. Carly said that she had moved to stay with him because she was unhappy with aspects of the regime at the information redacted hostel including cleanliness, availability of support staff and security of the home. These issues were fully discussed with hostel staff and Carly returned to the hostel on information redacted. On information redacted Carly approached the Children and Family Centre seeking support in parenting skills she was accompanied by Chis B and his mother on this visit. 2.2.12 The child protection conference was held on information redacted. Carly attended supported by her father’s partner. Staff from the information redacted hostel did not go because there was a pre-planned regional training event that they had to attend; they did send a report. The GP was also not present as he was not sent an invitation although he was aware of it happening from another source; he did not send a report. All other agencies were represented at the meeting. The decision of the conference was that there would not be a child protection plan but that Carly and information redacted CHILD G would be supported via a child in need plan. This decision was recorded as being unanimous but the record of the conference indicated that five of the eight professionals present initially recommended a child protection plan; however, the record of the final decision of the conference did not include any dissenting views. The recommendations from the conference included 10  that the core assessment should be updated and an assessment of Chris B undertaken; that Carly should attend all appointments and engage in support offered by the Children and Family Centre including a parenting course and independent life skills course; that Carly should be supported regarding housing difficulties and any recurring difficulties regarding domestic abuse from Russell; that a family group conference be considered; and finally that a contract of expectations should be drawn up which would specify the need to have a further child protection conference if Carly did not co-operate with services provided. Following the conference key worker responsibility transferred to a student social worker supervised by a qualified social worker. 2.2.13 Following the child protection conference Carly and information redacted CHILD G were seen by information redacted hostel staff on information redacted CHILD G received her third set of immunisations at the GP surgery. On the information redacted there was a child in need planning meeting attended by Carly, the social work student a Children and Family Centre outreach worker and the information redacted hostel support worker. The health visitor was unable to attend. Carly was very positive at this meeting and committed to attending ‘Solihull’ parenting classes as well as a ‘Parenting with Prospects’ course run by Connexions. Following this meeting Carly spent much of the next month away from the information redacted hostel staying with Chris B and other friends over the Christmas period. information redacted CHILD G was seen by information redacted hostel staff on information redacted however no other agency had contact with her until the information redacted The health visitor attempted three visits during the period before Christmas and received no response to messages left. information redacted the health visitor spoke on the telephone to Carly who said that she was staying at Chris B’s flat but was unwilling to give the address or to see the health visitor. The care of the health visitor transferred at the end of December information redacted. The new health visitor attempted visits in early January information redacted but was unable to see information redacted CHILD G until information redacted. 2.2.14 On information redacted, following a review of the police file by a supervising officer, Sussex Police determined that there should be an unannounced visit to Chris B’s accommodation to check regarding possible substance misuse. Sussex Police then contacted the senior practitioner involved in the earlier assessment to arrange this visit. The senior practitioner spoke to the student social worker who advised that Chris B was moving on the information redacted but that his new address was unknown. Attempts were made by the student social worker to obtain Chris B’s new address from Carly but she did not disclose it until information redacted. 2.2.15 During January information redacted Carly and information redacted CHILD G were seen at two home visits by the student social worker and she failed to engage with the Solihull parenting course being offered by the Children and Family centre. At this time Carly was thought to be spending most of her time at Chris B’s accommodation which was not seen by the student social worker as Carly was resistant to a visit being made to the home. Carly was also in arrears with her service payment on her hostel accommodation and was given a warning letter from the information redacted hostel for the arrears and because she was not residing in the hostel (there was a requirement that residents should sleep five days a week at the hostel). Carly’s explanations for her lack of co-operation were that there were mice at the hostel and that her phone had been malfunctioning. 11  2.2.16 On information redacted the health visitor visited the family at the hostel and undertook a health assessment of information redacted CHILD G who was found to have age appropriate development but could not maintain sitting position without support. Advice was provided to Carly about how she could enable information redacted CHILD G to build up information redacted upper body strength. On information redacted there was some confusion about the ‘child in need’ review meeting as the health visitor attended but was told the meeting was cancelled; shortly after the social work student arrived and the meeting took place. This was the second child in need meeting that did not have input from the health visitor. At this meeting Carly agreed ‘to fully engage with the health visitor’ but was reluctant to attend parenting classes. Following this the health visitor was requested by the social worker to provide an update health report on information redacted CHILD G. This was provided and detailed information redacted health from birth including the difficulties recently identified with maintaining a sitting position. 2.2.17 Following discussions between the social work student and Sussex Police about obtaining Chris B’s address a joint visit was eventually undertaken on information redacted. Unfortunately this visit was not unannounced because of confusion between the staff arranging the visit. The accommodation when visited was seen to be newly decorated and clean and tidy; there was no evidence of substance misuse and no smell of cannabis. Chris B appeared to be co-operative with the police and seemed to be trying to do his best for Carly and information redacted CHILD G.  2.2.18 During information redacted there was limited contact by agencies with information redacted CHILD G and Carly. The social work student visited on information redacted and undertook a budgeting exercise with Carly. She advised Carly that she would be away most of the month and advised her to contact her supervisor in her absence. The social work student also noted that information redacted CHILD G appeared to experience some distress when passing a bowel movement. Following this visit the social work student liaised with the health visitor and advised her of the date of the next child in need planning meeting and informed her about information redacted CHILD G being constipated.  2.2.19 The health visitor visited Carly information redacted at the hostel on information redacted. At that meeting Carly presented as ‘anxious’ and having a ‘low mood’; she was reluctant to see her GP as she did not want to ‘become addicted to anti-depressants’. information redacted CHILD G was seen to be ‘getting into the crawling position and weight bearing but was not pulling to stand or sitting beyond one minute’; because of concerns regarding this development the health visitor referred information redacted CHILD G to the Child Development Centre at the hospital. 2.2.20 Carly also had limited involvement with hostel staff during information redacted. Carly was very unhappy that she had not received a move-on letter and that other residents who had lived at the hostel for shorter periods had moved on. It was explained to Carly that whilst she was in arrears with her service payment; was not attending support sessions with hostel staff; and was not staying regularly at the hostel; she would not be offered further accommodation. Carly attended four support sessions with hostel staff; but did not pay off her arrears; and her residence at the hostel continued to be sporadic. As a result further warning letters were issued which advised Carly of the possibility of legal action for eviction. During information redacted CHILD G was not seen by hostel staff at all. 12  2.2.21 The CIN planning meeting held on information redacted was attended by the student social worker, the family outreach worker, the health visitor, the support worker from the information redacted hostel and Carly and Chris B. This meeting was challenging, as Carly was very angry about her accommodation situation, and walked out of the meeting. There are no minutes from this meeting, but case records indicate that Carly had failed to attend the Solihull Parenting Course and had missed appointments regarding her housing application; she still had arrears on her service payments but had done some budgeting work with the student social worker. It was noted at this meeting that information redacted CHILD G had been registered with a new doctor and that information redacted CHILD G was unwell with a gastric illness. The outcome of the meeting was to recommend continued work on assisting Carly to access permanent accommodation. Following this meeting it was agreed that as Carly would not attend the parenting group the student social worker would undertake work about child development issues on a one-to-one basis. 2.2.22 During information redacted hostel staff had contact with Carly on ten occasions and information redacted CHILD G was seen eight times; however they were not thought to be staying at the hostel and a further warning letter was sent regarding non-occupation. Carly and information redacted CHILD G were thought to be staying with her father; and on information redacted the service arrears were cleared; it is thought that maternal grandfather paid off this debt. Carly continued to make complaints about the standards in the house; complaining about mice infestation and lack of support. On information redacted there was a telephone conversation between the maternal grandfather and hostel staff where the circumstances around the decision not to provide Carly a move-on letter were fully explained. 2.2.23 The student social worker saw Carly information redacted on two occasions in information redacted; the first visit was on information redacted when Carly requested counselling as she found the experience of eclampsia to have been traumatic; she also expressed some anxiety about Russell S who has been in contact with her sister and was talking about wanting contact with information redacted. The Solihull parenting group was discussed and it was agreed that at a future session they would discuss ‘relationships, communication and atunement’. Carly also identified that information redacted CHILD G was not sleeping well and the student social worker agreed to contact the health visitor to ask for advice for Carly. The second visit was a week later when there was a discussion from the parenting programme about ‘attachment, containment and reciprocity’. This visit was followed by the student social worker and Carly visiting the Housing Office to establish her status with regard to the housing waiting list. 2.2.24 The health visitor’s only contact with Carly information redacted at this time was a telephone conversation information redacted to offer support regarding information redacted sleep problems. Carly advised the health visitor that these problems were resolved and was advised to make direct contact if there were any further problems.  2.2.25 During information redacted  the only agency to have direct contact with information redacted CHILD G was the information redacted hostel. Carly’s engagement with the hostel support services improved significantly; she attended fourteen times at Life Skills sessions and information redacted CHILD G was seen by the support worker on nine occasions and always seemed well. Carly also paid her service rent and seemed to be staying at the hostel more consistently. One explanation for this may 13  have been that she had reported to the social work student at the end of information redacted that she and Chris B had been arguing but it is also possible that Carly was being encouraged by her father to co-operate with the services in order to access permanent accommodation. By the end of the month the hostel support staff were positive that Carly would soon be receiving a move-on letter enabling her to obtain permanent accommodation from the Housing Department. 2.2.26 The CIN planning meeting on information redacted was attended by the student social worker, an hostel support worker, the health visitor, a family outreach worker and Carly and Chris B. All at the meeting were very positive about the progress that Carly was seen to have made; she had paid off her arrears and was engaging well with the hostel and so would be receiving a move-on letter. information redacted CHILD G was thought to be developing well and Carly and information redacted CHILD G were said to be attending a ‘music and play’ group. Carly was also saying that she would attend the next Solihull Parenting Group. From this meeting it was agreed that the family outreach worker would assist Carly with her housing application and that the student social worker would be recommending that the case be closed and that therefore another agency should take over as lead professional for any on-going work; this to be agreed at the next child in need planning meeting which was arranged for information redacted.  2.2.27 information redacted CHILD G was seen at the Child Development Centre on information redacted for a joint motor assessment. The outcome of this visit was that she was making ‘age-appropriate developmental progress, with motor milestones being a little slow but with no evidence of underlying disorder’. On information redacted Carly was provided with a move-on letter by the hostel staff. On information redacted Carly was seen to be very drunk at her mother’s house prior to going out with her mother and older sister. This information was provided in a child protection referral that was made regarding Carly’s younger half-siblings (there is no reference to information redacted CHILD G being present) and the link with Carly was not identified until after information redacted CHILD G  death.  2.2.28 On the information redacted Carly and information redacted CHILD G were seen by the student social worker; information redacted CHILD G was seen sitting with toys and seemed happy and well. Carly referred to her mother having been the subject of a malicious allegation and that social services were involved. Carly also said that information redacted CHILD G had recently been cared for by maternal grandfather in order to allow her to have time with Chris B. Carly referred to information redacted CHILD G having hit information redacted head on the bed headboard five days previously. information redacted CHILD G cried at the time so Carly took her to the GP however the surgery was closed. The student social worker looked at information redacted CHILD G but could find no signs of an injury. This was a positive visit and the student social worker was looking to close the case later that month. 2.2.29 Later that day the health visitor also visited Carly and information redacted CHILD G and observed positive interaction between the mother and child. The health visitor noted that information redacted CHILD G had attended the Child Development centre and no problems had been found. information redacted was seen to be ‘babbling, smiling, sitting, crawling, weight-bearing and exploring her environment’; information redacted CHILD G’s height and weight were normal and no problems were identified. There is no record that the health visitor saw a bruise and no evidence that Carly reported this incident to the health visitor. 14  2.2.30  On information redacted the student social worker sent an email to all members of the child in need planning group distributing the minutes of the previous meeting and indicating her intention to close the case to social work with a view to another member of the child in need planning group, probably from the Children and Family Centre, picking up lead professional responsibility.  2.2.31 Carly and information redacted CHILD G spent time on information redacted at Chris B’s house and at 10pm Carly left information redacted CHILD G in Chris B’s care and returned alone to the hostel. It had been agreed that he would care for information redacted CHILD G to enable Carly to sleep as she was very tired. At some point that night information redacted CHILD G experienced a life-threatening injury that eventually lead to information redacted death on information redacted. The exact circumstances of the injury are unclear and are currently the subject of police investigation so cannot be described in more detail. (correct at time of report writing) 2.2.32 Chris B contacted the ambulance service information redacted saying that he was caring for a 10 month old child who was not breathing. An ambulance was dispatched and arrived within five minutes, resuscitation was attempted and eventually information redacted CHILD G was taken to the local hospital within an hour.  Sussex Police attended the scene and spoke to Carly (who was by then at the scene) and Chris B and then accompanied information redacted CHILD G to hospital where they were joined by Child Protection Team (CPT) officers.   2.2.33 An emergency strategy meeting was held on information redacted involving police and social care the outcome of this meeting was that information redacted CHILD G was to remain in hospital for further tests and that the police should be informed if either Carly or Chris B attempted to remove information redacted CHILD G from hospital. At this stage the police perspective was that there were no suspicious circumstances associated with the death and as a result when information redacted CHILD G was transferred from the West Sussex hospital to the London hospital information redacted CHILD G was not accompanied by a police officer. 2.2.34 information redacted CHILD G’s injuries were so severe that information redacted needed to be transferred to a specialist London hospital. Carly accompanied information redacted CHILD G in the ambulance and Chris B and other family members went to London by train; no professionals accompanied the family to London. Hospital staff in London were provided with some background information from social care and took a full social history from the family which included Chris B, Carly, maternal grandfather and his partner and Chris B’s mother. There was some confusion regarding information redacted CHILD G’s status as inaccurate information was provided indicating that information redacted CHILD G was the subject of a child protection plan; this misinformation was rectified the next day. Hospital staff advised Carly that it was unlikely that information redacted CHILD G would survive. 2.2.35 The hospital provided intensive treatment for information redacted CHILD G however information redacted injuries were too severe and at 8.00am information redacted hospital staff contacted the emergency duty service (Social Work) to advise that doctors were aiming on withdrawing care; they also expressed concern that there had been no police contact with the hospital. Withdrawal of treatment was discussed with Carly and the family at 8.40am.  15  2.2.36 On information redacted at 10.39am an EDT social worker informed the police that the London hospital had advised that information redacted CHILD G was not expected to live and had suffered a major retinal haemorrhage which would be consistent with severe shaking or a heavy fall or blow. Sussex Police then liaised with the London Police and arranged for officers to attend the London Hospital. Sussex Police then attended the London Hospital. Eventually information redacted CHILD G died at 1.10pm4 after withdrawal of ventilator support. Chris B was then arrested and escorted to West Sussex. Chris B was charged with murder and is now in prison. 3. VIEWS OF FAMILY MEMBERS 3.1 Carly was clear that in her view there was nothing that could have been done to prevent information redacted CHILD G dying, as no-one knew that Chris B would harm information redacted CHILD G; and, since information redacted the death nothing further had been identified that would have indicated that he posed a threat to information redacted safety. 3.2 Carly was also very clear that she had never seen Chris B taking drugs apart from occasionally smoking cannabis which he always did outside, away from information redacted CHILD G. Carly said that she never took any drugs, even cannabis, and would not have remained with Chris B if she knew that he was taking other drugs.  3.3 Carly was asked about the support that was provided to her, before and after information redacted CHILD G s birth. She indicated that prior to the birth she was assisted by the midwife, although she was surprised that the input was an enhanced service. After the birth she felt everything was acceptable until information redacted  contacted the health visitor and made untrue allegations about her care of information redacted CHILD G. Carly said that the child protection conference held after this was a difficult meeting; and did not enable her to express her point of view, or to tell people the truth. Particular inaccuracies were that information redacted CHILD G had not slept overnight in a bouncy chair, but in a carry-seat that was part of information redacted push-chair and was meant to be used as a travel cot for babies. Also there were plenty of toys and clothes available information redacted. 3.4 Carly agreed that after the conference she was not very co-operative with professionals as she was angry that they had not listened to her. She was also unhappy that other girls had been re-housed from the hostel ahead of her. Carly said that she did not like it at the hostel as there were mouse droppings in her room and on her bed. Carly said that this was the reason that she did not pay her rent rather than because she did not have money. Although she also said that Chris B was often short of money and that she used to feed him. Carly paid off her rent arrears independently without any assistance from her father and said that the staff at the hostel did not offer any support in enabling her to learn to manage her money. 3.5 Carly confirmed that she were unaware that there was a child in need plan and had not signed any written agreement and felt that while the social worker was visiting                                                            4 This is the time of death as recorded by the hospital – there is a discrepancy with the time recorded in the police IMR which is thought to probably be the time that the death was reported to Sussex police not the time of death. 16  she received  very little support but had to go to a lot of meetings which was sometimes unhelpful. 3.6 The maternal grandmother was able to offer little in addition to Carly’s views. She said that she had never met Chris B and had no contact with Carly for the period of the review. Maternal grandmother’s major concerns were about the effect that publication of the case review would have upon Carly who was emotionally vulnerable. 4 KEY THEMES IDENTIFIED BY THE REVIEW PROCESS  4.1 Skills in engaging families 4.1.1 A significant issue identified in this review was the extent to which any professional was able to engage and build a positive working relationship with Carly. With the possible exception of the midwife it does not appear that any professional found it easy to engage Carly and there is some evidence that she avoided contact and could be deceptive in her responses.  4.1.2 This ambivalence and unwillingness to engage was however not clearly understood by the agency system as Carly was also very adept at diverting professional attention by being critical of other professionals. This is most overt in her relations with staff at the hostel but could also be seen in some of her responses to the student social worker and health visitor. For instance there were a number of occasions when the student social worker contacted the health visitor on Carly’s behalf rather than encouraging her to take responsibility for resolving matters with the health visitor directly. Carly was also very adept at appearing to be positive about future involvement in support services which she then failed to attend. This behaviour was apparent with regard to attendance at the parenting groups and involvement with the sessions offered by the hostel.  4.1.3 Adolescents are often difficult to engage and a pattern of partial co-operation is not unusual from teenager mothers. There were aspects however of Carly’s behaviour, particularly after she became involved with Chris B, that were more representative of a pattern of behaviour observed in other serious case reviews where families show disguised compliance. This is described in research as being ‘where parents defused professionals’ attempts to take a more authoritative stance by making pre-emptive shows of cooperation… The family’s compliance was only temporary but it was sufficient to persuade workers of their apparent willingness to be more open and therefore kept them at bay.’ 5 Ostensibly the family seemed to co-operate with the professionals but in fact this was illusory and the pattern of engagement included ‘deliberate deception, disguised compliance and “telling workers what they want to hear”, selective engagement and sporadic, passive or desultory compliance.’6   4.1.4 Whilst there was significant involvement by agencies with Carly information redacted and much time was invested in helping her improve their circumstances; it was clear from the IMRs that very little was known about their day-to-day life. In particular it was very unclear to what degree Chris B was involved in direct care of information                                                            5 Reder et al (1993), 6 P 76 Understanding Serious Case Reviews and their Impact – Brandon, Bailey, Belderson, Gardner, Sidebotham, Dodsworth, Warren and Black, DCSF 2009 17  redacted CHILD G and whether it was intended that when Carly moved into independent living that Chris B would be living with her.  4.1.5 As a result of meeting with Carly and receiving her contribution to the review process the overview author considered that Carly’s lack of compliance was mainly a product of her youth. It was clear that no professional was able to engage her however this was not because she was deliberately manipulative but was a feature of her inexperience. It is possible that a greater understanding of her adolescent ambivalence by professionals might have enabled better partnership working.  4.2 Quality of supervision 4.2.1 It is clear that all staff were receiving regular supervision; however, there is some concern as to the quality of the supervision provided; in particular whether it sufficiently challenged professionals in their attitudinal perspectives. Reder and Duncan argue that front-line staff need to develop ‘a dialectic mind-set’ in which there is a constant balancing of opposing arguments, alternative hypotheses or conflicting versions of events. 7 Similarly in ‘Working together to safeguard children’ it is suggested that professionals ask themselves:  • Would I react differently if these reports had come from a different source? • What were my assumptions about this family and what, if any, is the hard evidence supporting them?8  4.2.2 The absence of clear analysis of the major risk factors in the core assessment initially undertaken by the ACM would argue that the supervision and oversight provided to her work did not provide her with sufficient challenge and scrutiny. Similarly the supervision provided to the student social worker was practically oriented and there was little evidence that it questioned the developing optimism about the apparent change that was being achieved. The role of the supervisor should be to provide independent and objective challenge and if that had been available it seems unlikely that the drift in child care planning and failure to effectively engage with Carly would have remained hidden. Despite discussion in supervision about agreeing a contract of expectations there was apparently no consideration of actions that should be taken if the contract was breached.  4.2.3 There was some evidence of challenge provided in the police oversight however the delay in arranging the follow-up visit and the move to a pre-arranged appointment would indicate that this was not sufficiently robust.  4.2.4 The health visitor was clearly receiving regular supervision and there was a child centred approach as indicated by the decision to maintain health visitor continuity when the GP changed. The supervision seemed however to be led by the health visitor and there was no evidence that the supervisor queried whether there was sufficient improvement or enabled the health visitor to challenge the student social worker perspective about the effectiveness of the child in need plan.                                                            7 Reder & Duncan Lost Innocents 1999, p98 8 Department of Health, Home Office, Department for Education and  Employment, 2006: p113 18   4.2.5 Overall the extent to which the supervision provided to professionals gave the opportunity for critical reflection is dubious given the failure by any agency to critically analyse the purpose and functioning of the child in need planning process. The exception to this would be the police supervision of the initial section 47 investigation; unfortunately the follow-up to this intervention was less effective and the delay in action influenced the outcome.  4.3 Significance of substance misuse  4.3.1 Substance misuse was never identified as a key issue in the assessment of this family despite there being some evidence that Chris B used drugs and at one time lived in a house where it was suspected that there was drug-dealing. The significance of this issue was not recognised at the initial strategy discussion as it should have resulted in a joint section 47 investigation. This error was however identified during supervising police officer review of the work and rectified.   4.3.2 It is clear that the state of Chris B’s first flat was a significant factor in the ACM’s perspective that an initial child protection conference should be held. This issue however then became absorbed into a general concern about Carly’s neglect of information redacted CHILD G rather than focussing on what could have been the reason for the neglect. No professional linked the neglectful parenting with possible substance misuse.  4.3.3 One reason for this may well have been that there was very little evidence that Carly was involved in drug-use. She was never seen to be intoxicated by professionals and there was only one referral alleging alcohol abuse which was received after information redacted CHILD G’s death. The evidence of drug use may have been hidden as professionals had very limited access to Chris B’s accommodation and it is probable that he was the source of any drugs.   4.3.4 Since information redacted CHILD G’s death there have been two allegations by family members that information redacted CHILD G was given alcohol by adults however there is no other evidence to support these assertions and the matter is under on-going police investigation. (Correct at time of report writing).  Neither of these alleged incidents were known about by professionals prior to information redacted CHILD G’s death.   5 ANALYSIS  5.1 Did assessments and decisions appear to have been reached in an informed and professional way?  • Were the decisions made at the CP Conference reasonable? • Was the ability of mother’s partner to care for information redacted assessed appropriately? • Were there indications of potential risk, were they shared or acted upon appropriately and in a timely manner? 5.1.1 A range of assessments were undertaken with this family; and, whilst some were reached in an informed and professional way, there were others that seemed less consistent. Carly was initially assessed as a vulnerable homeless young person; this assessment identified her immediate needs for accommodation but did not address 19  her wider needs as a vulnerable young person and did not meet the requirements of the Southwark Judgement (May 2009)9. This is acknowledged in the Children’s Services IMR which is rightly critical of the initial assessment and identifies that a core assessment should have been undertaken at this time.  5.1.2 Carly was then assessed as a pregnant young woman by both the midwifery service and health visitor. These assessments were competent and addressed her needs acknowledging that she would need additional support because of her youth. The assessments were kept under review; and when Carly’s circumstances changed because of her homelessness, consideration was given to the additional support that might be required. Later when Carly experienced a difficult birth because of eclampsia she was provided with an additional follow-up at the hospital which ensured that any physical health problems were monitored. The assessment of Carly’s emotional needs following this event was less satisfactory and there is no evidence that the GP, midwife or health visitor considered the impact of the eclamptic fit on a vulnerable teenage mother and assessed whether she might need specific support or counselling. Later Carly mentioned this to the student social worker and asked for counselling but this should have been considered at an earlier point. Awareness of mental health needs is a theme in previous West Sussex Serious Case Reviews10 and it is concerning that this still remains an area of vulnerability in service provision.  5.1.3 Later assessments by the health visitor of Carly’s emotional well-being are also less effective and although there were a number of indicators that Carly was experiencing low moods there was no attempt to use formal assessment tools to establish the nature and degree of her depression. This was addressed fully in the Community NHS Trust IMR. The health visitor did however use the Brearley Risk Assessment tool to identify that Carly needed additional support as a parent. The health visitor was also fully involved in the MARAC risk assessment that identified the risks posed to information redacted CHILD G from Russell S and led to a safety plan that enabled Carly to protect her information redacted effectively.   5.1.4 The continued enhanced health visiting service input enabled the health visitor to contribute to the assessment undertaken by the ACM that resulted in the Initial Child Protection Conference held in information redacted. This assessment was limited in that it was based on very little direct contact and did not include appropriate consultation with all relevant agencies; the GP was not consulted and there was limited contact with the information redacted hostel. These issues are fully explored in the Children’s Services IMR which is rightly critical of the core assessment that was undertaken. The process was also very confusing as the strategy discussion seemed to follow from the decision to call a conference rather than initiating the process to plan the section 47 investigation. Furthermore the strategy discussion did not involve the health visitor who was the referring agency and should have been included. As the Health Overview Report identifies ensuring the right people are involved in strategy discussions and Section 47 Investigations is a theme for West Sussex LSCB that was identified in the Ofsted Report on Safeguarding.11 Another weakness                                                            9 The Southwark Judgement, made by the Law Lords in May 2009, is a piece of case law that obliges children's services to provide accommodation and support to homeless 16- and 17-year-olds. 10 SCR Family E West Sussex LSCB August 2010 11 Ofsted, Care Quality Commission (December 2010) Inspection of Safeguarding and Looked After Services in West Sussex. Ofsted. 20  in the assessment process was the decision by Sussex Police to allow a single agency assessment which led to the issue of Chris B’s possible substance misuse being inadequately investigated. Whilst this matter was picked up later by supervising officer oversight the immediate opportunity to examine this issue in more depth was lost and was never fully explored.  5.1.5 The decisions of the conference reflected the poor assessment undertaken prior to the meeting being held. It is very difficult for a chair of a child protection conference to achieve an effective outcome if the core assessment underpinning the conference process is flawed or substandard. It is clear that Carly needed to be assisted to care for information redacted CHILD G appropriately but it was less clear whether that needed to be via a child protection plan or a child in need plan; as there was insufficient evidence about Carly’s willingness or ability to co-operate without the additional challenge that a child protection plan would provide. The Children’s Services IMR clearly identified the weaknesses in the assessment that preceded the conference and concluded that the decision reached by the conference to work via a child in need plan was appropriate.   5.1.6 It is not apparent from the record of the conference how and why there was no formal dissent from this decision; given that the majority of agencies initially wanted a child protection plan. It is noteworthy that the professionals who wanted a child protection plan were largely those who had direct contact with Carly; and, it would have been good practice for the chair of the conference to have recorded more fully why those people later thought there was no need for a child protection plan. It is also unclear as to whether the chair formally invited people to record that they were dissenting from the decision. The Social Care IMR indicates that following discussion professionals’ views changed. It is certainly not positive to have such a shift in professionals’ judgement without recording why the decision was made and gives the impression that their perspective was not valued. The outline child in need plan that was formulated by the conference was however sound; and, if effectively implemented, could have provided a solid structure for working with Carly and protecting information redacted CHILD G.  5.1.7 The ability of mother’s partner to care for information redacted CHILD G was not assessed appropriately and there is very little evidence of any assessment having been undertaken. The direct contact by any professionals with Chris B was limited and was mainly concentrated in the last three months of information redacted CHILD G’s life when he attended the CIN planning meetings. There was only one visit made to his second address and that was pre-arranged and may have been deliberately organised by him to impress professionals. Certainly it affected police officer and social worker perceptions of him; and thus was viewed by the information redacted hostel staff as an endorsement that it was acceptable for Carly and information redacted CHILD G to stay there overnight.   5.1.8 In reality very little was known about Chris B and there was limited attempt made by any professional to explore further issues that could be viewed of concern. Specifically it was thought that he had a child by an earlier relationship with which he had no contact; but this was not explored more fully. There were concerns about his possible drug misuse; but these were not investigated beyond the one, pre-arranged visit. Furthermore, if there had been appropriate contact made with the GP, there 21  was some evidence of previous mental health problems as well as information that might have raised concerns about information redacted.   5.1.9 This review has identified a pattern previously recorded in serious case reviews of agencies failing to take account of the role of male carers within the family process. ‘There were instances of ‘unknown’ males in some households at the time the child was killed. There appeared to be a minimalist “need to know” attitude to sharing information about the appearance of new men in a household....these men became invisible to practitioners working with the family or child.’12 This reflects a wider issue about the lack of involvement by health and welfare professionals with men despite their significant involvement in children’s lives. The need therefore is for all agencies to ensure that relevant information about men is collected during assessment processes and to ensure that their assessment processes are adapted accordingly. In this case Russell S was seen as a negative influence and there was almost an assumption made that Chris B would be a supportive and positive factor. Certainly there was inadequate investigation of possible concerns about him. Professionals may also have been influenced in this perspective by his mother’s role as a information redacted as this may have given them a false sense of security about him.  5.1.10 There were clear examples of professionals working well together to identify and respond to indications of potential risk to information redacted CHILD G. Specifically there was sound inter-agency working to assist Carly as a vulnerable young pregnant woman and later there was effective support provided when she was the victim of domestic violence with the MARAC process providing an effective support plan. There was also good awareness of potential risks identified at the child protection conference where all agencies were clear about the need to provide an effective care plan for information redacted CHILD G even if there was dissent about the best mechanism to be used.   5.1.11 A significant flaw in this process however was the failure to explore with Chris B the issue of substance misuse; and this was never fully addressed as it was later accepted that the opportunity had been missed. There was no assessment of whether Carly was also involved in using drugs. In particular a statement made by Carly ‘that if Chris B smoked cannabis he never did it in front of information redacted CHILD G’ was one that warranted further assessment as it could be seen as an indication that Carly knew Chris B was smoking cannabis. The failure to fully address the issues of drug-use was further compounded by the child in need planning process which did not provide a framework for further assessment of the family or effective work with the family to achieve change. The professionals working with the family then became over-optimistic with regard to Carly’s capacity for change.   5.1.12 The strategy discussion initiated after information redacted CHILD G suffered information redacted injuries did not immediately identify Chris B as a possible perpetrator. On the information redacted it was known that information redacted CHILD G had experienced a life threatening event while in the sole care of Chris B however the reasons for the event were not clear. He was therefore allowed to attend the London hospital with Carly and her family. There was limited communication with the hospital about how to manage his contact however information redacted CHILD G’s medical condition meant that it was unlikely he would have unsupervised contact                                                            12 P52 Understanding Serious Case Reviews and their Impact: Brandon et al DCSF 2009 22  with the child. The process of managing parental contact after a life threatening event, and where exact cause is not known, is always difficult; the strategy discussion allowed the contact on the basis of the medical information available at the time.  5.2 Were the actions taken following assessments appropriate? Did the children in need plans and services provided meet the child’s needs?  5.2.1 Services provided following the earlier assessments were in the main appropriate and proportionate. Accommodation was provided for Carly that was suitable for her needs as a young and vulnerable person who was soon to be a mother. There was suitable support and advice available and a range of support systems were established to provide her with skills required to move towards fully independent living. Carly’s willingness to take up the services offered was limited however this ambivalence was within the normal range of responses by adolescents of her age. Consideration was not given in the assessment as to whether Carly was emotionally and socially vulnerable and therefore should have been accommodated as a ‘looked after child’ in accordance with the Southwark judgement. It is probable however that even if that assessment had given greater consideration to these factors the accommodation that would have been provided in those circumstances might well have been similar. It is clear that Carly was very eager to move into fully independent accommodation and it is unlikely that she would have wished to have been placed in foster-care or supported lodgings.  5.2.2 Similarly the support provided by the health visitor was broadly appropriate in that she provided enhanced support and information redacted CHILD G was visited fairly frequently. The only area were there could have been greater consideration to support needs was regarding provision of counselling or similar services with regard to the birth experience which appears to have been a difficult and traumatic period for Carly and which she later identified as a need.  5.2.3 Service provision after the child protection conference was mixed. A clear ‘outline child in need plan’ was developed at the child protection conference; however, there was some delay before key components of this plan were established. In part this was because the conference was just before Christmas. It was also because Carly was not co-operative with the student social worker; and was very adept at avoiding other professionals. Another factor that may have influenced Carly’s engagement with services is the range of options that was being discussed and the lack of clarity about how they related to proposed outcomes. The initial conference identified neglect as a key issue and indicated that Carly was failing to prepare feeds for information redacted CHILD G appropriately; and was not budgeting effectively. As the early childhood service IMR indicates these issues would most appropriately be met by the Parents with Prospects course; which whilst offered to Carly was not pressed strongly. The course that was emphasised was the Solihull Parenting course which focussed on ‘containment, reciprocity and behaviour management’; and which did not obviously address issues identified in the core assessment. Neither of these courses addressed the significant factor which was identified in the conference, which was the role that was being played in information redacted CHILD G’s life by Chris B nor did they consider substance misuse or its possible impact on the child.   23  5.2.4 During the five months after the child protection conference there was significant evidence that Carly was not co-operating with the child in need plan. She failed to attend the Solihull Parenting Group; refused to provide Chris B’s address where she and information redacted CHILD G were regularly staying; failed to budget effectively and remained in arrears for most of the period; and often avoided contact with professionals. It is probable that her eventual co-operation in information redacted was purely driven by the desire to access permanent accommodation and it is possible that the apparent improvements would not be sustained. There was no evidence that any of the professionals involved with Carly and information redacted CHILD G at this time identified that her ambivalence was an indication of possible risk to information redacted CHILD G and a rule of optimism seemed to predominate in the latter stage of the CIN plan.  5.2.5 Although there is mention of a contract of expectations in the social care IMR, it is not clear when this was developed; and if so, it was not shared with other agencies. It was decided that the Family Group Conference should not be taken forward which meant that an opportunity to establish the full nature and type of support provided by both Chris B’s mother and Carly’s father and his partner was missed. There was a lack of a clear outcome focus in the implementation and practical administration of the plan that subsequently led to drift. This process was compounded by poorly chaired and administered meetings and it is clear that no agency had full records from the meetings or a copy of the child in need plan or contract of expectations.   5.2.6 There was however, no evidence that any agency requested these documents, or raised concerns about the planning. The main responsibility for ensuring a child in need plan is effective lies with the key worker however, it is a multi-agency responsibility; and, if it is clear that the plan is not being successfully implemented, all agencies have a responsibility to take action. The outline ‘child in need’ plan agreed at the initial child protection conference clearly stated that if Carly did not co-operate, or there were further concerns, that a further child protection conference should be convened. This could have been requested by any of the professionals. That it was not called would imply that none of the other professionals was more concerned than the key worker about the failure of Carly to co-operate with the ‘child in need’ plan and the potential risk this posed to information redacted CHILD G. This would suggest that all the professionals involved with the family became committed to a perspective that there was improvement despite limited evidence to support that view. ‘The vulnerability lies not in the initial assessment, but in whether or not the revision process breaks down and practitioners become stuck in one mind-set or even become fixated on an erroneous assessment, thus missing, discounting or re-interpreting discrepant evidence’.13    5.3 Were the child’s needs taken into account when making decisions about the provision of children’s services, and was this was accurately recorded? 5.3.1 During the period of the review information redacted CHILD G was a very young baby with very limited capacity and ability to make information redacted needs known. Recording by agencies about information redacted CHILD G that could identify information redacted possible wishes and feelings was limited. There is recording to indicate that information redacted CHILD G was usually very clean and well-dressed.                                                            13 (Woods and Hollnagel, 2006: 75) (Munro 2008): 53 quoted in Piloting the SCIE ‘systems’ model for case reviews: learning from the North Westhttp://www.scie.org.uk/children/learningtogether/files/NWPIlotsReport_a.pdf 24  There is also recording about the physical risks that information redacted CHILD G could be exposed to, such as, being left unsupervised on the bed. information redacted physical health and development was also documented and indications of delay in sitting were identified. There is less recording about the nature of the relationship between Carly and information redacted CHILD G and the extent to which Carly was able to develop a fulfilling relationship with information redacted; although the health visitor did report good bonding. The recording from the information redacted hostel indicated vulnerabilities in this area but there is limited evidence from the other IMRs. There is some evidence in the information redacted hostel IMR that this was not the only time that Chris B had sole care of information redacted CHILD G and that report indicates other occasions when Carly put her own needs ahead of those of her information redacted. This may be nothing more than a teenager mother coming to terms with the challenge of caring for a dependent child. It could however also be an indication of an absence of a strong bond between Carly and information redacted CHILD G which may be relevant in that it may have influenced Carly’s decision to leave information redacted CHILD G in Chris B’s care. A mother with a limited or ambivalent attachment to her child may be more likely to leave information redacted with risky carers.   5.3.2 The failure to fully assess Chris B or know or understand his role in information redacted CHILD G’s life was very significant when considering information redacted needs. It is now clear that he was significantly involved and on occasions provided unsupervised care for information redacted CHILD G. It is apparent that this was not fully known to all the professionals working with Carly however if they were taking information redacted CHILD G’s needs into account this should have been considered.   There is no evidence that Carly was withholding this information as there is little evidence that she was ever asked. This is particularly important in view of information redacted CHILD G’s age and vulnerability; very small children cannot tell professionals about the adults in their lives so it behoves involved professionals to ask the questions.  5.3.3 A factor that has been identified in a number of serious case reviews is the extreme vulnerability of very young babies who because of their total dependency on their carers are at greatest risk of abuse, particularly physical assault. In the most recent research on serious case reviews just under half of all serious case reviews concern a baby under one year of age. That research identified that ‘there were three main ways in which the youngest babies aged under six months died or were harmed. These were primarily physical assault.’14  All professionals working with young babies should establish early who is involved in the care being provided to the child in order that appropriate assessments can be made as to whether they are suitable carers.    5.4 The sensitivity of practice to the racial, cultural, linguistic and religious identity of the family and any issues of disability or other diversity issue relating to the child and her family, and whether this was explored and recorded. 5.4.1 The professionals involved with the family identified that information redacted CHILD G’s parents were white British and that their first language was English. None of the professionals recorded their religious affiliation. Chris B’s ethnicity was poorly                                                            14 Building on the learning from serious case reviews: A two-year analysis of child  protection database notifications 2007-2009 Marian Brandon, Sue Bailey and Pippa Belderson 25  recorded by most agencies however the GP noted that he described himself as ‘mixed white and black Caribbean’. There is no recording of his religious affiliations and no evidence that any agency considered his ethnic origins and background in their assessments. information redacted CHILD G was the first child of Carly, who was 16. Her boyfriend Chris B was nine years older. This was not highlighted as an issue; although all professionals did identify Carly’s youth as a risk factor and provided her with additional support.  5.4.2 Both information redacted CHILD G s parents were unemployed at the time of information redacted CHILD G’s death. Carly had previously worked as a hairdresser and Chris B had worked as a labourer. Carly had problems managing her finances throughout the period of the review and was regularly in arrears with her rent. It is unclear whether these financial difficulties were associated with drug-use and whilst she was offered support with managing her money there is no evidence that any professional discussed why she was finding this difficult.  5.4.3 Russell S was known to have ADHD and this was considered by the health visitor when assessing the family’s needs. A number of professionals discussed with Carly her emotional needs, and she was prescribed anti-depressants post-natally by hospital staff; however, this was not followed up in the community and further assessment could have been undertaken. Chris B was not identified as having mental health difficulties during the period of the review but had experienced emotional difficulties earlier. Neither Carly nor Chris B were identified as having any communication difficulties.   5.4.4 Comparatively little was recorded about the social background of the extended family of either parent. Carly was seen to have intermittent support from her family. information redacted. It is apparent that there was some confusion by professionals about the role played by Chris B’s mother information redacted. This was particularly apparent in her contacts with the health visitor prior to the initial child protection conference. It is clear however that staff at the Children and Family Centre were very clear that when she attended there with Carly information redacted she was not attending as a professional. It is not known if this confusion about role affected how professionals responded to Chris B but there is no explicit evidence that there was a serious intention to deceive.  5.5 The management accountability for decision making and involvement of managers at key points in the case. 5.5.1 All of the IMRs are clear that there was appropriate management involvement and accountability throughout the period of the review. There is certainly evidence that practice was reviewed and that actions were taken when there were concerns that appropriate interventions had not been undertaken. An example of this would be the police management oversight of the child protection investigation which led to a joint visit by police and social workers to Chris B’s home address.   5.5.2 The Sussex Community NHS IMR identified that the child in need plan was not fully discussed in supervision and that practice regarding child in need plans had now changed with awareness of the raised thresholds and increased vulnerability of children subject to such plans.   26  5.5.3 There were however limitations in the management input as much of it was reactive and dependent on upward reporting by frontline practitioners. This may have been why the management scrutiny did not identify the drift in the child in need planning and was not robust in challenging practitioners about Carly’s capacity to improve. Clearly this is linked to the quality of the supervision provided to professionals as discussed earlier. ‘Child protection ….. managers need to establish the systems, ethos and context in which constant testing and revision of hypotheses and assumptions can underpin practice, as well as creating a working environment where professionals are actively encouraged to question their judgements and to invite alternative opinion – one in which it is acceptable and safe to simply change their mind.’15  5.6 The adequacy of training and supervision of staff to carry out their role. 5.6.1 Most of the professionals from the agencies who were permanently employed had received appropriate child protection training and most were considered to be experienced staff with relevant safeguarding knowledge. Within social care the ACM although undertaking work beyond that which is usual for unqualified staff had undertaken appropriate training and was considered to have sufficient experience and knowledge to undertake the work. The quality of the assessment undertaken would raise questions about the validity of that assumption and it is noted that unqualified staff no longer carry out initial or core assessments in West Sussex.   5.6.2 The social work student who was key worker for a significant period was supervised by a qualified social worker who was in the process of completing her specialist award; it being a requirement of this training that student supervision is undertaken. Similarly the social work student was in the last year of training and was undertaking a final placement and there is the expectation that this should include some experience of statutory work. The nature of the case was not such that it would be inappropriate for a student social worker to act as key worker. It must be acknowledged however that this worker’s personal experience of this case will have been very difficult.  5.6.3 As has been indicated earlier in the report the quality of the supervision provided to staff was variable and did not provide sufficient challenge and opportunity for professionals to re-evaluate their assessment of this family. There was an assumption that Chris B was an acceptable partner because ostensibly he appeared more suitable than Carly’s previous boyfriend however this was not based on a robust or assertive assessment. Many of Carly’s actions were considered to be usual adolescent behaviour and there was insufficient consideration of other causes for her financial problems and inability to co-operate with hostel staff. There was not a thorough exploration of the issues of substance misuse despite some indications of this as a risk factor early in the assessment process. The assumption that progress was being made was not questioned in supervision and managers and supervisors did not challenge the plan to ‘step-down’ the child in need plan.  5.7 The consistency of work with policy and procedures for safeguarding and with wider professional standards.                                                             15 Munro, E. (1999) ‘Common errors of reasoning in child protection work’, Child abuse and neglect, 23, 8, 745–758. 27  5.7.1 During the period of the review the multi-agency Sussex Child Protection and Safeguarding Children Procedures (2006) were in place and available to staff, either as a hard copy or electronically. The main areas where there were questions of consistency with procedures were around the organisation and administration of the child protection conference and the systems and processes around section 47 inquiries, particularly strategy discussions.   5.7.2 A number of the IMRs discussed the issue of dissent at child protection conferences and it would appear that some professionals were not clear about their responsibilities to identify formally when they are not in agreement with the conference decision. The recording of the conference should also indicate where there is dissent; and, if it is resolved, how that resolution has been achieved. A number of agencies also indicated there were concerns about the mechanisms for distribution of invitations and reports for child protection conferences and it is clear that these were not in accordance with the standards as detailed in the procedures.   5.7.3 The processes around joint and single agency investigations by police and social care are issues that were highlighted in the Ofsted inspections and have been subject to significant levels of scrutiny since then. As a result of audits of these systems major changes in practice have been achieved.  5.7.4 There is no specific information in the procedures about the management of child in need plans or agencies’ responsibility within this integrated model. It is clear, however, that there were aspects of the inter-agency child in need planning that were not consistent with good professional practice. Any such joint working requires all agencies to be fully involved and to have access to joint documentation such as the child in need plan and contract of expectations.   5.8 Organisational difficulties experienced within or between agencies and any lack of capacity or resources in one or more organisations. 5.8.1 The IMR from Sussex Community NHS Trust identifies throughout the report the significant organisational and structural changes that were occurring during the period of this review. The IMR also identifies that health visitor caseloads were high and that the health visiting team was 0.65 down due to long term sickness. It was  felt however that this would not have impacted on the care that information redacted CHILD G and Carly received as they were receiving an enhanced health visiting service and were prioritised. The GP report does suggest that work pressures for health visitors meant that there was less opportunity for joint working but this was not evidenced specifically with regard to work with Carly and information redacted CHILD G. The Health Overview report does not support it as a significant issue and in fact states that it was clear that supervision and training for health visiting staff were maintained despite these changes.  5.8.2 The social care IMR identifies that there were organisational changes within the service in March information redacted and that the Ofsted Safeguarding Inspection took place between information redacted. Whilst it would be expected that these events could be seen to be pressures that could have affected practice in fact the staff interviewed did not identify this to be a problem. None of the staff interviewed considered that they were working beyond capacity and they were clear that this 28  case was allocated to the social work student because it was felt to be appropriate to her learning rather than because of allocation pressures.  5.9 Examples of good practice.  5.9.1 Commentary about good practice has been provided throughout the report but it is noteworthy that in general there was good communication between agencies and there was significant evidence of professionals working closely together within the child protection and child in need planning process. There were however no examples of practice within this case that were significantly better than the norm which require specific mention.   5.10 Recommendations regarding training, practice or procedures. 5.10.1 Any specific recommendations regarding training, practice or procedures are included in Section 7 and then followed through to Section 9.   5.10.2 The specific recommendation from the Sussex Community Trust regarding the provision of multi-agency training on Child in Need planning was incorporated into recommendation 9.3. Similarly the recommendations from the Health Overview Report regarding involvement of professionals in child protection conferences and notification and distribution of conference minutes are included in recommendation 9.7.   5.10.3 The information redacted hostel made a number of recommendations for the LSCB; two of them are incorporated into 9.3 and 9.7; one of them will be acknowledged within the next review of child protection procedures; and one, ‘Request a report from Adult Social care and Supporting People Commissioners on whether general service specifications in contracts involving services to households including children make sufficient provision for adequate direct support time to be spent on dealing with Safeguarding issues.’ was felt to fall outside of the remit of the LSCB.  6 ASSESSMENT OF AGENCY MANAGEMENT REVIEWS  All of the IMRs were considered by the panel to be of an adequate standard and provided useful descriptions of events as they occurred. There was less focus on the explanations as to why things happened in the first drafts and in the main this was the area that required further elaboration when IMR authors were interviewed by the panel. The Serious Case Review Panel reviewed all of the recommendations and the action plans. A number of agencies’ recommendations were not sufficiently smart, measurable, achievable, relevant or time-bounded and so the agencies were asked to re-draft them.   6.1 West Sussex County Council Children’s Social Care 6.1.1 This report addresses the key terms of reference and clearly identifies the failures in the assessment processes undertaken by the ACM. The report identifies that the conference provided a sound ‘child in need’ plan but is possibly too positive that this was the only possible outcome. The report is also less critical of the ‘child in need’ planning processes and fails to identify drift as a key factor in the failure to progress the plan.  6.1.2 This IMR was reviewed by the panel three times and some amendments were suggested. The panel considered that the authorship was sufficiently independent; 29  the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust.  6.2 West Sussex County Council Early Childhood (Children and Family Centre and outreach)  6.2.1 This IMR reported on the comparatively limited involvement that the service had with the family. It appropriately identifies that the services suggested for Carly and information redacted CHILD G may not have been most appropriate but seemed to have been offered largely because they were available. It also raises legitimate questions about the nature of the child in need planning and the absence of any commissioned work regarding Chris B.  6.2.2 This IMR was reviewed by the panel and some minor adjustments were suggested but broadly the report was unchanged. The panel considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust.  6.3 Sussex Police 6.3.1 This IMR identified the key points when the police were involved with the family; specifically around the joint working around domestic abuse prior to the initial child protection conference; the limitations in the assessment regarding substance misuse by father; and the joint intervention after information redacted CHILD G sustained information redacted injuries.  6.3.2 This IMR was reviewed by the panel twice and some amendments were suggested. The panel also noted the discrepancy in the time of death as recorded within police records as opposed to the hospital report. The panel considered that the authorship was sufficiently independent; the recommendation was appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust.        6.4 information redacted Hostel,  6.4.1 This IMR examined the intervention by staff from the information redacted hostel and identified weaknesses in administrative arrangements associated with the conference process. The report also identified improvements that could be implemented with regard to the safeguarding arrangements within the hostel around recording and management systems. 6.4.2 This IMR was reviewed by the panel who considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. This was particularly noteworthy given that this organisation is not often involved in work of this nature.    6.5 Sussex Community NHS Trust (Health Visiting), 6.5.1 The community trust had significant involvement with information redacted and information redacted family and the IMR clearly identifies areas of good practice that included the intervention during pregnancy; the support after information redacted birth and the positive response after the incident of domestic violence. The report highlights the issues around the conference and the multi-agency working around the child in need plan. The report is legitimately critical of the administrative arrangements around the conference and child in need meetings but also 30  acknowledges that the health visitor had a responsibility to challenge when practice did not meet expected standards.  6.5.2 This IMR was reviewed by the panel and some minor adjustments were suggested but broadly the report was unchanged. The panel considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust.  6.6 NHS Sussex Cluster (West Sussex) (GP) 6.6.1 GP involvement with this family was limited and the contact was with a number of surgeries as information redacted CHILD G’s doctor was changed half way through the period of the review. The IMR details the contacts with the family and highlights the weaknesses in the assessment prior to the child protection conference when no formal contact was made with the GP. The GP also raises some concerns regarding the inter-disciplinary working between GP and health–visiting services that are addressed in the Health Overview report.  6.6.2 This IMR was reviewed by the panel twice and some amendments were suggested. The panel considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust.        6.7 Western Sussex Hospitals Trust (A and E, Child Development Centre) 6.7.1 The hospitals trust had limited involvement during the period of the review however the IMR provided useful information regarding the assessment and support provided to Carly during her pregnancy and after information redacted CHILD G’s birth.  6.7.2 This IMR was reviewed by the panel and some minor adjustments were suggested but broadly the report was unchanged. The panel considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust.  6.8 Health Overview Report 6.8.1 This very comprehensive and detailed report appropriately reviewed the key themes from the health IMRs and identified any relevant matters of concern for commissioners. These were the problems regarding administrative arrangements for conferences, the difficulties in engaging adolescent mothers; the importance of effective child in need planning; and positively improved recording and communication between agencies. The panel considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust.        7 LESSONS LEARNED FROM THE REVIEW 7.1  The importance of effective engagement of families and the need for assertive and inquiring interventions that include all adults, particularly men in the assessment process. Alongside this the review identified the difficulty of working with teenaged mothers; and the problems of distinguishing between ‘usual’ adolescent behaviour, and more problematic, ‘passive resistance’. A key factor for professionals working with families is their capacity to challenge and confront when outcomes are not achieved; regardless of the underlying causes. 31   7.2   The need for challenging and empowering supervision that enables professionals to review their work effectively. This needs to engender sceptical review and the capacity to re-evaluate existing presumptions. The challenge for supervisors is to be sufficiently aware of progress in work with families whilst still maintaining a degree of independence and scrutiny. It is crucial that supervisors do not solely rely on the supervisee to raise issues.  7.3  The need for improved child in need planning processes. These systems need to have multi-agency involvement and ownership and must ensure that there is sufficient capacity and capability to review the effectiveness of the child in need plan. This evaluation needs to include an on-going consideration of the assessment process which allows for re-assessment as time progresses and enables an evidence–based approach to casework planning.  7.4 The importance of greater awareness and consideration of substance misuse and the ways in which it may influence and affect parents and carers’ abilities to provide safe and consistent care for children particularly the more vulnerable babies. This understanding requires that professionals move beyond outward signs such as direct use of drugs and alcohol and consider other factors such as money management and availability as other indicators of possible substance misuse.  7.5 The importance of ensuring that all appropriate persons are invited to conferences and receive minutes within reasonable time frames.   8 CONCLUSIONS 8.1 Even with the benefit of hindsight there has been no evidence identified that Chris B presented a risk of physical harm to information redacted CHILD G. It must be acknowledged however that very little was known about him or about the level and nature of care that he was providing to information redacted CHILD G. If the work undertaken with agencies had been significantly different there would be no guarantee that information redacted CHILD G’s death could have been avoided. The reality is that there was limited information held by any agency to indicate that Chris B posed a risk to information redacted CHILD G and the review has not been able to identify any information that could have been accessed that would have shown that he was unsuitable to be caring for information redacted CHILD G. 8.2 With hindsight it is clear that information redacted CHILD G was exposed to drugs during information redacted life. The issue of substance misuse was not fully addressed in any professional assessment of information redacted mother. It is possible that if there had been a more thorough investigation of this issue when it was first raised then the risks to information redacted CHILD G might have been identified. 8.3 It is possible that if an effective assessment had been undertaken investigating the concerns regarding substance misuse that this would have identified further information about Chris B but it is equally possible that this would not have provided any additional knowledge.  It is therefore not clear how this death could have been prevented.  32  9 RECOMMENDATIONS   LSCB  9.1 That the West Sussex LSCB ensures that the learning is shared with all relevant staff.  9.2 That the West Sussex LSCB ensures that the recommendations in all of the completed IMRs are implemented by regular review of individual action plans.  9.3 That the LSCB ensures that all relevant member agencies are engaged with and fully understand the child in need planning processes including the use of ‘contracts of expectation’.  9.4 That all relevant agencies should satisfy the West Sussex LSCB that assessment processes include due consideration of the involvement of fathers  and/or partners in the child's life. Where possible this should include their effective involvement in the process.  9.5 That the LSCB request all agencies examine their supervision of professionals who work with children in need. Agencies to report on whether supervision arrangements are sufficiently robust and capable of challenging and sceptical review.  9.6 That the LSCB undertake a review of multi-agency working with families where substance misuse is considered; following the launch of the ‘Think Family’ protocols  9.7 That the LSCB requests the Children’s Safeguarding Unit to review the processes regarding invitations to and distribution of minutes from child protection conferences.  see Integrated Action Plan  WSCC CHILDREN’S SOCIAL CARE 9.8 To ensure agency checks are completed and recorded on Framework I within all Section 47 enquiries (7.5.9)  9.9 A review of the quality of Child in Need Plans arising from an Initial Child Protection Conference (7.5.4)  9.10 Improve the quality of assessment in relation to the following;  • children alleged to be suffering from neglect. (7.2), • parenting capacity of teenage parents (7.1) • the role and impact of new partners in relation to the child (7.5.2) • ensure all CIN plans include a contract of expectations (7.5.4).  9.11 Improve the quality of student supervision in relation to casework practice, analysis and planning, allocation of cases and understanding of working in a multi-professional context.   9.12 Raise awareness of the value of Family Group Conferences or family meetings in Children in Need plans.  (7.5.7)  SUSSEX POLICE 33  9.13 That any changes to the existing Police processes for the way information is shared and recorded are subject of post implementation audit and review.   WSCC EARLY CHILDHOOD  9.14 Establish a single strategic oversight for Safeguarding and Family Support activities within ECS - - (reference paragraph 10.1 in Section 10 ‘Learning Points’.)   9.15 The implementation of a case file structure for Family Outreach Worker Service – to ensure consistent practice across the service - (reference paragraph 10.2 in Section 10 ‘Learning Points’).  9.16 Ensure consistent practice for casework supervision with related record keeping – (reference paragraph 10.3 in Section 10 ‘Learning Points’.)  9.17 Family Outreach Service to have clear and consistent care planning requirements which ensure focus on children’s needs and related improved outcomes  - reference paragraph 10.4,  10.5 and 10.6 in Section 10 ‘Learning Points’.  9.18 To ensure that diversity issues are routinely considered in all contacts with children and their families – (reference paragraph 10.7 in Section 10 ‘Learning Points’.)  information redacted HOSTEL,  9.19 Improve record keeping.  9.20 Align Hostel ISP and CIN Plan reviews and Safeguarding processes.  9.21 Review Visitor Time procedures to ensure robust risk assessment of visitors to vulnerable tenants.  9.22 Revise Hostel Safeguarding policy and procedures to make more comprehensive.  9.23 Revise Confidentiality and Data Protection policies.  9.24 Develop Trustees understanding of Safeguarding.  9.25 Improve management and sharing of key information.  9.26 Increase manager involvement in Safeguarding cases.  9.27 Review all Safeguarding cases.  SUSSEX COMMUNITY NHS TRUST (HEALTH VISITING), 9.28 Sussex Community Trust to ensure that HV assessments meet the required Core Service Standard.  9.29 Sussex Community Trust to ensure that practitioners who attend child protection conferences are fully conversant with the process.  34  9.30 Sussex Community NHS Trust Child Protection and Safeguarding Children Procedures to include clear guidance on the roles and responsibilities of health professionals within integrated working on a CIN plan.  WESTERN SUSSEX HOSPITALS TRUST  9.31 Where there are vulnerabilities recognized at clinic consultations, letters should be copied to relevant parties such as the health visitor, with the consent of the individual  9.32 Although the A & E visit information redacted appears to imply a minor illness, it is unclear that there was any regard taken of her social situation. This should be reviewed using the new paediatric A&E flow chart to trigger the assessment of vulnerabilities.  9.33 Although safeguarding training and the hospital procedures provide clarity on how the safeguarding team can be accessed to support staff and help with progressing safeguarding concerns, this should be strengthened.  9.34 There are not any copies of the PICU retrieval documentation in the notes; this should be remedied by the provision of an HDU/PICU retrieval pathway, or copies of PICU documentation should be added to the medical notes.  NHS SUSSEX CLUSTER (WEST SUSSEX) (GP) 9.35 That NHS Sussex Cluster (West Sussex) advise all GPs in West Sussex that when the GP hears of a child protection conference being scheduled, they ensure that they have been invited and if they are unable to attend they send a report and also advise GPs that the GP contacts the social worker if they do not receive a report after the conference.  9.36 That the NHS Sussex Cluster (West Sussex) advises GP surgeries in West Sussex to ensure that their practice nurses document which adult attends with a child for vaccinations and whether they have parental responsibility and they document why a vaccination has been given later than advised if this has happened.  9.37 NHS Sussex Cluster (West Sussex) requests that the Acute Trusts that are commissioned by them ensure that their Accident and Emergency Discharge Summaries are legible so that GPs and Health Visitors and others are able to identify any concerns from the records.  9.38 NHS Sussex Cluster (West Sussex) commission future midwifery services to include a requirement for midwives to document antenatal and postnatal consultations within the GP medical notes.  9.39 Recommendation that NHS Sussex Cluster (West Sussex) carry out an audit of all West Sussex GP Surgeries to discover which GP surgeries hold a regular multi-disciplinary child safeguarding meeting (to include GPs, practice staff, health visitors (HV), school nurses (SN) etc) and to encourage those surgeries that do not hold such meetings to introduce them.  35  SUSSEX COMMUNITY NHS TRUST & WESTERN SUSSEX HOSPITALS NHS TRUST 9.40 Sussex Community NHS Trust and Western Sussex Hospitals NHS Trust to review the system for receiving and processing Child Protection Conference invites and documentation, to ensure there is a clear audit trail of receipt of information and that non receipt of expected documentation is followed up appropriately.    Fiona Johnson January 2013 36  Appendix one Genogram information redacted   