Significant abuse, neglect and cruel parenting of two siblings aged 12- and 14-years by their relative carer over a period of ten years. The siblings had been removed from their parents' care in their early years because of abuse and neglect. Both siblings had a diagnosis of mild learning disabilities; Sibling A was assessed as having global developmental delay at age 6 and attended a specialist school; Sibling B attended a mainstream school. The siblings had long term involvement with specialist services from birth. The relative carer reported difficulties with both siblings' behaviour to the GP and CAMHS. There were concerns about the carer's negative and hostile approach to Sibling B; whilst in foster care Sibling B made a number of allegations of previous physical and emotional abuse. Sibling A was subsequently also placed in foster care. Findings: all children and young people deserve to be effectively safeguarded from harm; the additional vulnerability of disabled children to abuse needs to be recognised and addressed; insufficient professional recognition or challenge of the blame of children by parents/parent figures as their defence against harsh, abusive and inconsistent parenting; poor assessments and ineffective Child in Need processes leave children and young people's needs unaddressed and at risk of potential abuse and harm; fixed professional thinking which is not picked up through supervision and reflection has the capacity to undermine the ability of the safeguarding system to keep children and young people safe. Sets out key findings using a hybrid version of a systems process. There were no recommendations.
      
    Serious Case Review No:  2018/C7357  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.   1  Serious Case Review Siblings A and B  XXXXXXX       2  1. Introduction to the SCR and review process Why this serious case review (SCR) was undertaken? 1.1  This SCR has been commissioned by XXXXX Safeguarding Children’s Board (SCB) and is about Sibling A & B. When they came into Local Authority care at the ages of 12 and 14 they were found to have experienced significant abuse, neglect and cruel parenting over a 10-year period at the hands of a relative with whom they had been placed at a young age. They were both disabled children, with a diagnosis of mild learning disabilities, and despite the long-term involvement of many professionals they were not effectively safeguarded. The review reflects on the reasons for this and considers what action needs to be taken by the                 SCB to address this. The Siblings Family Background 1.2 Sibling A & B were removed from their parents care in their early years because of abuse and neglect. They were placed with a relative carer who had three teenage children who remained living at the family home into adulthood. Another relative moved to live with the family in 2012 to provide support1. The whole family is white/British.  1.3 Sibling A was assessed as having Global Developmental Delay at the age of 6 by a paediatrician and attended a specialist school for children and young people with learning disabilities. Sibling B is not assessed as having any disability, but the relative carer told some professionals that Sibling B also had Global Developmental Delay and implied to many others that Sibling B was disabled. Sibling B attended mainstream school and they provided support for what they understood to be the difficulties caused by harsh parenting and a difficult home life. 1.4 There is little available information in the records about the sibling’s day to day life, their personalities, their likes and dislikes or their friendship groups. Much of what is written about them in the assessments and records is reported directly by the relative carer with who they lived and was often negative and derogatory in nature. School reported that Sibling A was doing well at school, was a happy child and was well liked. Sibling A did not have friend’s come to the home and was said to be isolated in the family home but liked being in the bedroom with toys. Sibling B was also doing well at school, liked sports such as                                                            1 No further details about the family are provided to ensure confidentiality for the siblings. 3  Badminton, but was not allowed to go to after school clubs. Sibling B reported wanting to spend more time with friends, but this was not often allowed.  Sibling B loved the dogs at home, spent time looking after them and was responsible for cleaning up after them. Sibling B was also isolated in the home, often eating different food with Sibling A, separate from other family members. Process of the Review 1.4 This review has been undertaken using a hybrid version of a systems process. The frame of reference was set during the commissioning process. Chronologies of agency involvement with single agency reflections on practice were commissioned (see appendix 1) and interviews were conducted with most of the professionals involved with the family; it was not possible to interview all as some professionals had left their posts, but this gap was not significant to the review or data gathering process. The records, assessments and reports/email correspondence held by agencies were also reviewed. This SCR was overseen by an independent reviewer (see appendix 2) and her work has been assisted by a panel of multi-agency senior safeguarding professionals (see appendix 3) who helped with the analysis, received draft reports and made comment and revisions.  This panel met with all those professionals for a practitioner’s event where core themes were agreed and these are the Findings in Section 3.  Family Involvement 1.5 The panel discussed the sibling’s involvement and contribution to the review process. Advice was sought from those professionals currently working with them and their professional view was that the siblings were settling into the foster family and it would be unhelpful for them to talk about the recent past. This view was respected. Given this, it did not seem appropriate to include any other family member because of their continued negativity to the siblings.   4  2. Brief chronology of professional involvement  Background information 2.1 The agreed review timescale for review was from November 2014 to the time when Sibling A came into local authority care in May 2016; Sibling B was already placed with a foster family at this time. They were aged 15 and 12. The siblings had long term involvement with specialist services from birth and a summary is provided of this earlier contact. 2.2 Sibling A & B moved to live with relatives at a young age. They had experienced negative and abusive experiences by their parents and it was recognised that they would need support regarding this early trauma. The available evidence suggests that the assessment of these relatives by another Local Authority was superficial and did not give sufficient weight to the type of parenting that traumatised young children might need in the long term.   Support from 2011 to 2014 2.3 In the period from 2011 to 2014 the family were provided with considerable support. CAMHS2 provided parenting support and Theraplay3 to help improve the relationship between the siblings and the relative carer. Some progress was noted, but there were concerns about harsh parenting and scapegoating of Sibling B. The school that Sibling attended was also concerned about possible neglect and harsh parenting.  2.4 These concerns were appropriately shared with Children’s Social Care (CSC). Assessments were completed and some family support work and social work support provided. The focus of attention was on the early trauma that both siblings had experienced, and the relative carer diverted professional attention by highlighting how difficult and unmanageable Sibling B’s behaviour was. This ability of the relative carer to blame the children for what was happening to them and recording of the relative carers negative perspective about both                                                            2 CAMHS stands for Child and Adolescent Mental Health Services. CAMHS are the NHS services that assesses and treat young people with emotional, behavioural or mental health difficulties. There are local NHS CAMHS services around the UK, with teams made up of nurses, therapists, psychologists, support workers and social workers, as well as other professionals. 3 Theraplay is an evidence-based child and family therapy for building and enhancing attachment, self-esteem and trust. Theraplay sessions aim to create an active, emotional connection between the child and parent or caregiver, resulting in a changed view of the self as worthy and lovable and of relationships as positive and rewarding. https://theraplay.org/index.php/what-is-theraplay-3 5  children, most of which was not evidenced, was a theme across the whole review period and is discussed in Finding 2.  2.4  The relative carer asked that Sibling B have a period of voluntary care for a period of three months. During this placement Sibling B made progress but returned to the care of the relative carer. 2.5 Sibling B disclosed physical abuse and being hungry to school and in October 2013 an anonymous referral was received regarding Sibling B being physically abused at home. There was also an allegation that an adult family member had physically abused Sibling A. These incidents were investigated by the children and family social work team, but the conclusion was that these incidents were caused by the Sibling’s complex behaviours, reported by the relative carer, and led to parenting support and advice, as opposed to an exploration of possible abuse. A theme that is evident across the period or review and which is addressed in Finding 1. Professional involvement November 2014 to May 2016 2.6 In November 2014 the children and family social work team felt that progress had been made with the parenting support and their involvement ceased. Three weeks later the relative carer made contact with the team requesting support because she could not manage what she described as the siblings difficult and challenging behaviour. This was passed to the disabled children’s team and an assessment was started, focussed on eligibility for respite care4 and support. This was despite Sibling B having no disabilities. 2.7 In January 2015 the relative carer and an adult family member went to the GP to report difficulties with managing what they described as Sibling B’s difficult and destructive behaviour. Support from CAMHS was discussed.                                                            4 Respite care is a form of short-term substitute care provided by someone other than the parents or usual carers for a child.  The 1989 Children Act provides a clear framework for the provision of short-term care known as respite care. The act requires children to be consulted about their needs, the services to be provided and if a child is using 'respite care', The Children Act 1989 was amended to include a requirement that social services authorities ‘assist individuals who provide care for such children to continue to do so, or to do so more effectively, by giving them breaks from caring. Children and Young Persons Act 2008 s25, inserting a new para into CA 1989 Sch 2 – namely para 6(1)(c).  6  2.8 In February 2015 Sibling B and the relative carer attended a routine appointment at CAMHS and the relative carer described Sibling B as having behavioural problems, lying and stealing at home and at school. It was agreed that further support could be offered to improve relationships.  The relative carer also telephoned CAMHS in the same month to report problems dealing with Sibling A’s behaviour, anger and aggression to family members. 2.9 Whilst the disabled children’s team was undertaking their assessments there were some incidents of concern. In March 2015 Sibling A (aged 13) came to school with a bruise on the nose, which was said to have been caused by an argument with the relative carer who pushed Sibling A into the wall. The relative carer reported that this was as a result of managing complex behaviours and led to no further action. There was a further similar incident a few weeks later and the relative carer reported that Sibling A was violent and aggressive and had been bruised as a result of “being contained”. This incident was again shared with the disabled children’s team who spoke to the relative carer and accepted her explanation.  2.10 There was a school meeting regarding Sibling B in March 2015. The relative carer alleged that Sibling B was stealing at home and school. The school reiterated that they had no evidence that Sibling B (aged 11) was stealing, but the relative carer said that she had asked a family friend in the police force to take Sibling B through a pretend process of being arrested for theft and taken to the cells. The relative carer said this was said to make Sibling B aware of negative actions. This was shared as a concern but led to no action.  2.11 At the beginning of April 2015 there was an anonymous call to the police regarding allegations that Sibling B was stealing at home and at school, was destroying family property and generally being destructive. A home visit by the police was undertaken, and concerns about Sibling B were shared with Children’s Social Care and passed to the disabled children’s team. This information was considered as more evidence that the relative carer was struggling to manage as opposed to concern about possible abuse. 2.12 The assessment by the disabled children’s team was concluded in April 2014. The focus of the assessment was on the relative carers reported difficulties in manging the complex behaviour of both siblings, rather than on the many incidents of possible physical abuse, emotional abuse and neglect and both siblings talking about being unhappy at 7  home.  The conclusion was that parenting support would be provided and that both siblings were assessed as being children in need5.  No Child in Need plan6 was ever developed and so progress or the lack of it was never monitored and the sibling’s own needs not outlined. The lack of a child focus in the assessment and inadequate child in need processes is discussed in Finding 3. 2.13 In mid-April 2015 the relative carer and another adult family member came into Sibling B’s school to report concerns about Sibling B’s behaviour, the impact of this on the family and “jokes” being made by other adult family members that they would hurt Sibling B. The school were concerned about the family’s negativity and asked them to leave. Sibling B was very upset by this incident and a teacher spent time facilitating to Sibling B be able to talk about what was happening at home and Sibling B disclosed recently being chained to a radiator, being treated harshly and unfairly by all family members and not wanting to go home. This support to Sibling B was good practice.  2.14 This disclosure was shared with the social worker from the disabled children’s team who discussed this with the team manager. The relative carer’s explanation regarding Sibling B being chained to the radiator was that she could not leave Sibling B alone while she had a shower because of the danger to Sibling B and others because of aggressive and out of control behaviour. This explanation was accepted as further evidence that the relative carer was struggling to cope and consequently there was no strategy discussion as would be expected and the police were not informed of this serious incident. Sibling B was not seen until several weeks later. The issue of fixed professional thinking is discussed in Finding 5. 2.15 There was a Child in Need Meeting where the incident of Sibling B being chained to the radiator was discussed. There would be further meetings in May, June and July, no minutes were produced for any of the meetings (except the school’s own record) so it is unclear exactly                                                            5 A child in need is defined in the Children Act 1989. A child shall be taken to be in need if— (a)he is unlikely to achieve or maintain, or to have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision for him of services by a local authority; (b)his health or development is likely to be significantly impaired, or further impaired, without the provision for him of such services; or (c)he is disabled.  Children’s Services decide if a child is in need by assessing their needs.  6 .  Children’s Services decide if a child is in need by assessing their needs. If they decide the child is in need they will normally draw up a plan setting out what extra help they will provide to the child and their family, focussing on how a child or young persons health and developmental outcomes can be improved. http://www.legislation.gov.uk/ukpga/1989/41/section/17 8  what was discussed and there was still no Child in Need Plan formulated (see Finding 3). 2.16 The GP and the disabled children team social worker made a referral to CAMHS for Sibling B and the family received a letter saying they would be offered an appointment in due course.  2.17 Sibling A was seen at CAMHS for the start of the assessment process with the relative carer. Sibling A was described as out of control and exhibiting violence and disruption at home. Sibling A talked about wanting things to be fairer at home. It is unclear why the siblings were to be seen separately.  2.18 In July 2015 the school noticed scratches to Sibling B’s neck and they contacted the disabled children’s team social worker. The school were informed that the relative carer had already explained that the injury was caused accidentally when Sibling B was caught stealing. The Child in Need process was to continue. The school were unhappy with this conclusion and wrote to and called the disabled children team manager. Their concerns were not taken seriously and so school staff considered how best to escalate their concerns and tried to contact the LADO7 as this had been helpful in the these past, but they were unable to make contact; the differences in opinion were not resolved and led to no change. The issue of the importance of dealing effectively with professional disagreements in a child focussed and centred way is discussed in Finding 4.  2.19 The difficulty in getting these differences addressed was in part caused by the fixed professional thinking about the cause of the sibling’s difficulties and distress. Some professionals recognised the abusive nature of the care they were receiving, but others believed that it was the manifestation of early trauma and behavioural difficulties because they were disabled children. This fixed thinking did not change, despite the available evidence; the importance of addressing cognitive biases through supervision, management oversight and opportunities for reflection is discussed in Finding 5.  2.20  In July 2015 there were also further concerns expressed by Sibling A’s school about a bruise which the relative carer had said was caused by trying to manage Sibling A’s behaviour. In August 2015 Sibling A                                                            7 The role of the LADO is set out in Working Together to Safeguard Children (2015) and is governed by the Authorities duties under section 11 of the Children Act 2004 and North Somerset Inter-Agency Policy and Procedures. This LADO role is managing allegations against people who work with children who are paid, unpaid, volunteers, casual, agency or anyone self-employed. 9  attended a further appointment at CAMHS and said that things were more settled at home.  The relative carer also went to the GP for help with filling in the Disability Living Allowance form for Sibling B who was described as difficult to manage. In September there was an assessment completed by the disabled children’s team social worker, which contained the same information as the previous assessment. 2.21  Sibling B was seen at CAMHS to start the assessment process in October 2015. An appointment had been offered in August but cancelled by the family because of summer activities and the family had been on holiday in October. At this appointment the relative carer reported that both siblings had Global Developmental Delay8 and that Sibling B’s behaviour was unmanageable with lying and stealing at home and at school. It was agreed that Cognitive Behaviour Therapy(CBT) 9 would be offered to Sibling B to help with impulse control and emotional regulation. 2.22 In November 2015 Sibling A was seen by CAMHS. The relative carer reported a difficult holiday because of the sibling’s behaviour and that she had ensured that both siblings wore special wristbands to indicate that they had special educational needs and they could be supported. CAMHS made contact with Sibling A’s school after this appointment and the school chronology of concerns regarding possible physical abuse, emotional abuse and neglect was shared. It was agreed that there would be further discussion within CAMHS about next steps for Sibling A. 2.23 In January 2016 the school noticed bruising to Sibling A’s face. Sibling A was asked about this and looked uncomfortable. School phoned the relative carer who explained that the injury had been caused by a family member needing to restrain Sibling A because of aggressive and violent behaviour. This family member admitted to slapping Sibling A. A new disabled children team social worker had recently started work with the family and was concerned about this incident and ensured a                                                            8 The term 'developmental delay' or 'global development delay' is used when a child takes longer to reach certain development milestones than other children their age. This might include learning to walk or talk, movement skills, learning new things and interacting with others socially and emotionally. https://www.mencap.org.uk/learning-disability-explained/conditions/global-development-delay 9 Cognitive behavioural therapy (CBT) is a talking therapy that can help young people manage problems by changing the way they think and behave. It's most commonly used to treat anxiety and depression, but can be useful for other mental and physical health problems. https://www.nhs.uk/conditions/cognitive-behavioural-therapy-cbt/ 10  strategy meeting10 was called. This was effective practice from a new social worker who challenged the fixed thinking. The strategy meeting decided that child protection enquiries11 (Sec 47 Children Act 1989) would commence and a police investigation.  2.24 The child protection enquiries were undertaken and both siblings were made subject to Child Protection plans12 for physical abuse. The focus remained, however, on the relative carer and the adult family member’s difficulties in managing the Siblings reported complex behaviours and the impact of early trauma. The fixed thinking that this was an issue of problems with parenting, rather than an issue of harsh and cruel parenting and physical, emotional abuse and neglect continued.  See Finding 5. The police investigation regarding this incident was discontinued because it was believed that the possible physical abuse had been provoked by Sibling A’s behaviour and that appropriate support was in place.  2.25 Over the next few weeks (January to February 2016) the social worker became concerned about the relative carers’ increasingly negative and hostile approach to Sibling B. There was a meeting in March 2016 where neglect of Sibling B and a serious incident of self-harm disclosed by Sibling B were discussed. A psychological assessment at this time recommended that Sibling B needed increased level of care and nurturing to prevent an escalation of self-harming behaviours. The relative carer was asked to consent to both siblings being placed voluntarily (Sec 20 Children Act 198913) with a foster family. She would only consent to this for Sibling B. Whilst in foster care Sibling B made a number of allegations of previous physical and emotional abuse and                                                            10 Children’s Social Care must hold a Strategy Discussion/Meeting  whenever there is reasonable cause to suspect that a child has suffered or is likely to suffer Significant Harm. This takes place between Children’s Services, the police and possibly other child care agencies at the beginning of child protection enquiries. whether any immediate. Working Together 2015. https://www.gov.uk/government/publications/working-together-to-safeguard-children--2  11 Children’s Services have a legal duty to look into a child's situation if they have information that a child may be at risk of significant harm. This is called a child protection enquiry or investigation. Sometimes it is called a “Section 47 investigation” after the section of the Children Act 1989 which sets out this duty. The purpose of the enquires is to gather information about the child and their family so that social workers can decide what action, if any, they need to take to keep a child safe and promote their welfare. http://www.legislation.gov.uk/ukpga/1989/41/section/47 12 A child protection plan is drawn up at the initial child protection conference. It says what support and monitoring will be put in place when a child is considered to be at risk of significant harm because they have suffered, or are likely to suffer physical abuse, emotional abuse or sexual abuse or neglected. When there is a child protection plan, the child will  be given a social worker who should meet regularly with the child and the parents to discuss the child's progress. The child's situation and the plan will be reviewed after three months and then every six months.  13 Section 20 of the Children act 1989 says Children’s Services should look after a child when there is no-one with parental responsibility for the child or when the person caring for the child is prevented from caring for them, for whatever reason. This is also called voluntary Accommodation. 11  legal proceedings were commenced and at the beginning of April 2016 an Interim Care Order14 was granted. 2.26 The Children’s Guardian15 met with the Independent Reviewing Officer to discuss plans for Sibling A. It was greed that the circumstances would be closely monitored and individual support be provided by a family support worker.  Sibling A had expressed a preference to remain living with the relative carer.  2.27 The individual support started, but the family support worker tasked with this work was immediately concerned about how unhappy Sibling A was and that the care provided by the family was hostile and negative. The Children’s Guardian was also concerned through her contact with both siblings and the chronology of concerns she had developed. The relative carer became more hostile and uncooperative and the plan was for Sibling A to be removed and placed with Sibling B. Initially a voluntary arrangement was discussed but the Children’s Guardian recommended Court Order as the safest and most appropriate option for ensuring security and stability for Sibling A and this was agreed. At this time the relative carer reported to the police that Sibling A had assaulted an adult family member. A police investigation started but led to no further action. 2.28 In June 2016 Final care Orders were granted for both Siblings and they remain living with their foster family where they are making good progress.                                                                14 A Care Order is a court order which places a child in the care of Children’s Services. It lasts until the child is 18 unless the court ends it before then. When there is a care order, Children's Services share parental responsibility for the child with the parents. Children's Services must find out the parents’ wishes about any decision they make about their child, but they always have the final say and can make plans for the child even if the parents don't agree with them. 15 A children’s guardian is an independent and experienced social worker who is an officer of the court. Their job is to make enquiries about the child’s circumstances and make a recommendation about what is best for the child in the future. Children's Guardians are organised by a service known as CAFCASS. The court will automatically appoint a guardian for the child for an Emergency Protection Order or a Care Order.  12  3. The Findings 3.1 The review of these children’s circumstances has highlighted a number of issues or Findings regarding the effectiveness of safeguarding processes for them, with implications for other children. The aim of a serious case review is to use a single case as a ‘window on the system’, to uncover more general strengths and weaknesses in the safeguarding system and to try and understand what was influencing the professional response. At the heart of this review is the importance of a skilled and prepared workforce who are supported to effectively safeguard children and young people, particularly those who are disabled. This is covered in Finding 1, but all the other Findings are connected to this core issue.  3.2 Some professionals in this case developed fixed thinking about the sibling’s circumstances which was not addressed or noticed, these professionals relied too much on the relative carers distorted and biased views and accepted uncritically the blaming of children for the abuse they were experiencing. Disclosures of abuse were not dealt with appropriately and poor assessments and child in need processes meant that the right support was not provided and action not taken. Those professionals in schools that knew the children best advocated for them but were not heard and the struggle to get these professional disagreements addressed meant safeguarding action was not taken.   The Findings  1. All children and young people deserve to be effectively safeguarded from harm; the additional vulnerability of disabled children to abuse needs to be recognised and addressed. 2. There is insufficient professional recognition or challenge of the blame of children and young people by parents/parent figures as their defence against harsh, abusive and inconsistent parenting. 3. Poor assessments and ineffective Child in Need processes leave Children and young people’s needs unaddressed and at risk of potential abuse and harm. 4. Addressing intra and inter professional disagreements and disputes is essential to promote the well-being of children and protect them from harm. 5. Fixed professional thinking which is not picked up through supervision and reflection has the capacity to undermine the ability of the safeguarding system to keep children and young people safe.  13  Finding 1: All children and young people deserve to be effectively safeguarded from harm; the additional vulnerability of disabled children to abuse needs to be recognised and addressed.  3.3 There was significant evidence over time of neglect, physical abuse and emotional abuse of Sibling B and Sibling B. Both reported being hungry, and there were fluctuating concerns about them being low weight. They were given different food from the rest of the family. They were both observed to be unkempt. Sibling A was observed to have bruises of concern, which Sibling A confirmed were caused by an adult hitting or restraining.  The adult children of the relative carer were said to be resentful of the siblings and discussed causing them harm and bullying them on a number of occasions.  3.4 Child protection processes were instigated on some occasions, but there were incidents where a strategy meeting/discussion should have been held and was not. An example is when Sibling B was chained to radiator where the action was to ask the relative carer not to repeat this or behaviour or when the relative carer admitted slapping Sibling B and parenting support was suggested, but not accepted. It is clear that some professionals made assumptions about these circumstances based on a false understanding of the impact of disabilities and early trauma. 3.5 Sibling A was known to have Global Developmental delay and mild learning disabilities, attended a specialist school and was provided with specialist support at that school. Sibling B had no diagnosed disability but was often represented by the relative carer as having a disability.  The relative carer claimed Living Disability Allowance for Sibling B. In December 2014 both siblings were assessed by the Disabled Children’s Team. This perception of the disability being the key issue became an influencing factor in the effective safeguarding of the siblings, where evidence of possible physical abuse was described by the relative carer as difficulties in managing children with complex needs and behaviours. 3.6 Research has found that disabled children are three to four times more likely to be abused and neglected than non-disabled children (Jones et al 2012i; Sullivan & Knutson 2000ii); are more likely to experience multiple types and occurrences of abuse (Sullivan and Knutson 2000) and have a prevalence rate of 20% for experiencing physical violence, 14 % sexual violence, 18% emotional abuse and 9.5% for neglect (Jones et al 2012iii). Disabled children have an equal right to protection, yet 14  researchiv shows that there are a number of barriers to effective practice in this area. There can be reluctance on the part of professionals to believe disabled children, the indicators of abuse can be mistakenly understood to have been caused or exacerbated by their impairments and there has been a reluctance to challenge parents – or to see them as “heroic carers” dealing with children who make demands on them.  There was evidence of this for the siblings. 3.7 The circumstances of Sibling A and Sibling B echo that of the national research and concerns emerging from other Serious case reviews. Locally there has been work in this area to address the safeguarding response to disabled children and the Board will need to be satisfied that this is having a positive impact. Finding 2: There is insufficient professional recognition or challenge of the blame of children and young people by parents/parent figures as their defence against harsh, abusive and inconsistent parenting. 3.8 There were a number of occasions where Sibling A & Sibling B made disclosures about abuse and neglect, and when either a member of the family or the relative carer was asked about it, they said the incident had happened, but that the actions had been necessary because of the complex and destructive behaviour of the siblings; in effect the adults blamed the siblings for the harm they had experienced. This constantly sent a message to the siblings that they somehow deserved the neglect and abuse and were actually responsible for it. This had the potential to be extremely damaging for them but was not acknowledged or noticed by the majority of professionals.  3.9 For example, Sibling B reported wanting to eat the same food as everyone else and to be allowed to eat food with the family. The relative carer reported that this could not happen because the siblings were “messy eaters” and it put the rest of the family off their food.  3.10 It is striking the extent to which the negative views of the siblings made by the relative carer and other family members were accepted by most professionals at face value and reported as facts, despite evidence to the contrary. In one of the many assessments completed it is reported that Sibling B was “stealing food” and “being over controlling” (aged 12) and that Sibling A was out of control and waking the whole house up at night. These were the views of the relative carer and there was no evidence to suggest that they were true. They should have been recorded as the views of the adult, which were not supported by any objective evidence. This build up a picture that the 15  children were unmanageable was something that was not evident when professionals interacted with the children. When an allegation of physical abuse and restraint was made by Sibling A, the relative carer provided a picture of her responding calmly and kindly, helping an unmanageable child and the relative carers views are reported verbatim in the assessment report “the relative was speaking in calm voice, asking her to calm down and they would leave her quietly”. 3.11 Professionals must be supported to remain in a position of “respectful uncertainty” and display “healthy scepticism” which in practice means checking the validity of information provided by parents/adults by cross referencing/triangulating with other sources and testing out the level of parental care and concern for children and the extent to which parents feel a sense of responsibility for their children and their well-being. 3.12 If young people are to develop and grow successfully into adulthood they need and deserve sensitive caregiving, where secure and loving attachments are fostered, where love and care is provided and they are enabled to experience empathy and are treated fairly and justly.   3.13 Parental blame has the potential to undermine helpful interventions because of parental denial of their own responsibility to change.  It is a self-reinforcing process whereby young people who have already experienced harm and abuse, which has undermined their self-esteem and resilience, are now held responsible for that poor-quality care.  This is something like a cognitive “catch 22” or a “no win” situation which has the capacity to cause great emotional damage and impact on moral development.  Ultimately the message here is that these young people do not warrant or deserve appropriate and loving care.  3.14 Parental/carer attitudes to young people which are about blame, harsh and critical care and scapegoating must be recognised as a key indicator of emotional abuse and addressed appropriately.   Finding 3: Poor assessments and ineffective Child in Need processes leave Children and young people’s needs unaddressed and at risk of potential abuse and harm. 3.15 There were many single assessments completed by Children’s Social Care regarding Sibling A and Sibling B. Some were never written up, and those that were, were largely descriptive, focussed on the views of adults and did not represent the voice or perspective of the children. They lacked any professional analysis or judgement about the needs or circumstances of the children. Commonly the sections on parenting 16  capacity, an essential part of the assessment, were not filled in nor was the social workers summary.  3.16 This lack of analysis meant that the children’s circumstances were not well understood and therefore was a lack of proposals for action to address them. For example, the assessment completed for the child protection conference which took place around the time that Sibling B came into care noted the incident of self-injurious behaviour. The comment about what needs to happened said “Sibling B needs to live a healthy lifestyle”  and “ concern…Sibling B stealing at school….Sibling B reports hunger” the comment on what needs to happen was that “ Sibling B needs to attend school”. Overall all the assessments quoted the views of the relative carer without commentary and without expressing a view about the care being provided.  3.17 Good assessment mattersv vi; they are key to effective intervention and to improving outcomes for children. Conversely, research has shown that poor or inadequate assessments are associated with unclear plans to meet children’s needs, poor outcomes and drift.  Poor assessments without professional judgement also undermine the ability of professionals to keep children safe and to address their needs and circumstances. 3.18 Between April 2015 and January 2016, the siblings were assessed as being Child in Need. Child in Need meetings were held, but there was never a child need plan developed. This meant there was a lack of clarity regarding what the siblings needs were understood to be, and therefore no goals or objectives were outlined, progress or the lack of it unknown and overall there was a complete lack of clarity regarding what the purpose of this process was. It meant that the children were not safeguarded and core issues remained unaddressed.  3.19 The Children Act 1989vii defines Children in Need (CIN) as those children whose vulnerability is such that they are unlikely to reach or maintain their health and development milestones without the provision of services to them and their families. This is a serious issue for all children. The emphasis placed on good quality assessment to determine the level of need is reflective of the potential risks for a child’s future. Once an assessment is undertaken and needs identified it is expected that a child focused plan is formulated which addresses those needs, there is a clear outline of the outcomes expected, services to be provided and the reviewing mechanisms identified. The reviewing mechanism are important to ensure that the needs of 17  children are being addressed, that there are positive changes to their circumstances and the right support is being provided. The lack of this focussed approach means that children’s needs and outcomes are not improved, and there is a potential waste of resources with services being provided but being ineffective or not creating change. Without a plan, and goals, and reviews this will not be identified.  3.20 It appears that the perception that both siblings were disabled children impacted on the robustness of the response. In 2012, Ofstedviii undertook a thematic inspection on “Protecting Disabled Children Ofsted (2012) found that for disabled children the children in need (CIN) work was not always well co-ordinated; many plans were not detailed or focussed on outcomes. In a small number of cases children had no plans or reviews were not held. In other cases, the reviews did not always include other professionals working with the children. Ofsted concluded that the lack of rigour nationally in the management of children in need work increased the likelihood of child protection concerns not being identified early enough. This was evident for the siblings. 3.21 There is no data about how widespread an issue this is likely to be locally, but the lack of robust child in need plans impacted on the wellbeing of the siblings and the national picture and serious case reviews suggest this is an area around which the safeguarding Board  Finding 4: Addressing intra and inter professional disagreements and disputes is essential to promote the well-being of children and protect them from harm. At no time must professional disagreement detract from ensuring that the child is safeguarded. The child's welfare and safety must remain paramount throughout16. 3.22 This Finding is about the way in which professionals are able to manage and resolve professional differences and disagreements in the best interests of children and young people. Professional disagreements and differences are inevitable given the complexity of safeguarding children and young people, the propensity for human bias and fixed thinking.  Establishing a culture of openness to change, to constructive challenge and self-criticism is fundamental to addressing these issues.                                                             16  18  3.23 Reder and Duncanix as a result of their review of Serious Case Reviews nearly twenty years ago argue that professionals need to develop ‘a dialectic mindset’ in which there is a constant balancing of opposing arguments, alternative hypotheses or conflicting versions of events. It is not the disagreements that matter, but whether there is a culture and openness in the way in which they are addressed.  3.24 Researchx and Serious Case Reviewsxi highlight that significant professional differences about the needs of children suggest that those needs are not well understood by any one part of the multi-professional network. The              safeguarding procedures17 make clear the importance of addressing disagreements at an early stage in the best interests of children, putting professional rivalries and myths about roles and perspectives to one side. This did not happen for Sibling A and Sibling B. 3.25 The schools that the siblings attended became increasingly concerned about their welfare and the attitude of the relative carer to them. They consistently reported those concerns, but their views were dismissed and they were led to believe that they were incorrect in their analysis. This was in part influenced by the relative carer who sought to split professional, complaining of having been treated unfairly by school.  The school did try and address these issues with front line managers but they were unsuccessful and were not then clear about what they should do next. As part of this review it became clear that not all professional groups are aware of the existing escalation policy. 3.26 There were also professional disagreements within the disabled children’s team about what needed to happen for these children. These also remained unresolved and were exacerbated by existing pressures on the team and a management style characterised by autocracy. This has changed, but the concern remains that this issue is not just about knowledge and compliance with the escalation process. It raises the point about what do professionals do regarding differences in the analysis of a child’s circumstances; what are the opportunities for debate and reflection in a multi-agency context? There will always be debate about the complex area of safeguarding practice, and parents/carers can make use of these differences to distract attention from their own abusive or neglectful parenting. This happened for                                                            17 19  siblings and is a known danger for future practice locally and nationally.  3.28 There was evidence that professionals did act on disagreements. The Chair of the Review child protection conference challenged the Disabled Children Team Leader about a lack of proactive action for the siblings and the Children’s Guardian appropriately questioned the best options for both siblings when they cam into the care of the Local Authority.  3.29 This review has highlighted the importance of an awareness of existing escalation processes and professionals finding ways to address professional disagreements in the best interests of children and young people.   Finding 5: Fixed professional thinking which is not picked up through supervision and reflection has the capacity to undermine the ability of the safeguarding system to keep children and young people safe. “our failure to review judgements and plans – once we have formed a view on what is going on, we often fail to notice or to dismiss evidence that challenges that picture.’ (Fish, Munro and Bairstow 2009xii)  3.30 This Finding focusses on the impact of fixed thinking on professional practice. It is linked to the previous finding on professional disputes, but as a concept has been recognised as a significant issue in the ability of professionals to safeguard children effectively.  3.31 There were high levels of fixed thinking by some professionals regarding the circumstances of Sibling A and Sibling B. There was significant and growing evidence that they were being abused, neglected and being subjected to harsh and cruel parenting. However, the narrative remained for some that this was a family/carer who were struggling to cope with difficult and damaged children. The belief was that this behaviour was a manifestation of their early trauma, which had taken place many years earlier.  3.32 There was no objective analysis that the children had been living with the relative carer since they were 17 months and 3 years old, and therefore the likely influence was currant parenting and circumstances.  In one report to the case conference it was reported that “Sibling B will damage property, scream, shout, and threatens to run from the house” and that “Sibling A keeps the whole family up by running around at night” yet the children are described as showing the person undertaking the home visit for this report around their bedrooms and 20  their favourite toys. The observation of the children was different to the descriptions provided by the relative carer and family. The school consistently addressed this with the relative carer and other family members. The fixed thinking did not change with challenge from other professionals or the observations that the children often looked nervous. 3.33 Child protection inevitably involves working with uncertainties and making difficult decisions and complex judgements on the basis of incomplete information in rapidly evolving, often hostile and highly stressful contexts. There is a substantial body of research evidence that has clearly identified the unconscious tendency for early evidence bias in human decision making; that is, an initial summing up of a situation strongly influences the analysis of subsequent or new information leading to fixed thinking and faulty conclusionsxiii.   3.34 Serious Case Reviewsxiv have repeatedly found that professionals were either unwilling or slow to revise their judgements in the face of new or contradictory evidence and that this selective interpretation of information, only using that which confirmed their preferred view about a particular case, became a “pervasive belief” which influenced the professional response.  These pervasive beliefs were found to remain, even where there was considerable evidence of lack of progress or success in interventions and services offered. As Munro notes, “the single most important factor in minimising errors in safeguarding practice is for professionals to be enabled to admit that they might be wrong”xv.  3.35 Practitioners must be willing, encouraged and supported to challenge, and where necessary revise, their views throughout the period of any intervention.  To achieve this, practitioners and their managers should routinely play their own ‘devil’s advocate’ in considering alternative actions, explanations or hypotheses.  Supervision should provide a safe but challenging space to oversee and review cases with the help of a fresh, experienced, pair of eyes and to systematically guard against either rigid adherence to a particular view.      21  Appendix 1 Chronologies were sought from and received from:                  Police                  Children’s Services CAFCASS GP and              Health Trust                  Community Partnership Schools attended by the siblings      22  Appendix 2: About the Independent Reviewer and overview author:              , is accredited in systems learning and the SCIE “Learning Together” model, and is an experienced independent investigator and safeguarding lead who has undertaken many Serious Case Reviews nationally over the last 15 years.              has a professional background in social work, training and policy development.               has never worked for any agency in               and is completely independent.   23  Appendix 3:  Review Panel Organisation Title  Independent Author  Independent Chair              Council Assistant Director, Support and Safeguarding Children              Council Service Leader, Strategic Safeguarding and Quality Assurance               Council Principal Social Worker                Council Safeguarding in Education Training Officer  Head of Children’s Safeguarding (Designated Nurse)  Designated Nurse                CCG Designated Doctor for Child Protection                 Police DCI               , Investigations CAFCASS Service Leader     24  References: i Jones, L., Bellis, M.A., Wood, S., Hughes, K., et al. (2012) Prevalence and risk of violence against children with disabilities: a systematic review and meta-analysis of observational studies. The Lancet July 2012. ii Sullivan P.M., and Knutson J.F. (2000) Maltreatment and disabilities: a population based epidemiological study. Child Abuse and Neglect 24, 10, 1257–1273 iii Miller, D. and Brown, J. (2014)’We have the right to be safe’: protecting disabled children from abuse NSPCC. https://www.nspcc.org.uk/globalassets/documents/research-reports/right-safe-disabled-children-abuse-report. pdf iv  https://www.nspcc.org.uk/services-and-resources/research-and-resources/2014/right-to-be-safe/  v Barlow, J. & Scott, J. (2010) Safeguarding in the 21st Century -Where to Now. Dartington: Research in Practice. vi Turney, D et al (2011) Social work assessment of children in need: what do we know? Messages from research; DfE https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/182302/DFERBX-10-08.pdf vii http://www.legislation.gov.uk/ukpga/1989/41/contents viii Ofsted (2012) Protecting Disabled Children: Thematic Inspection. London: Ofsted. www.ofsted.gov.uk/resources/ protecting-disabled-children-thematic-inspection ix Reder, P and Duncan, S (2003) Understanding communication in child protection networks. Child Abuse Review. Volume12, Issue2 March/April 2003 x Burton S (2009) The Oversight and Review of Cases in the Light of Changing Circumstances and New Information: How do people respond to new (and challenging) information? Safeguarding: Briefing 3. London: Centre for Excellence and Outcomes in Children and Young People’s Services. xi Sidebotham et al (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014; Department for Education  https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/53382 6/Triennial_Analysis_of_SCRs_2011-2014___Pathways_to_harm_and_protection.pdf    xii Fish et al (2008) SCIE Report 19: Learning together to safeguard children: developing a multi-agency systems approach for case reviews                                                            25                                                                                                                                                                                       xiii Broadhurst et al ( 2010) Ten pitfalls and how to avoid them What research tells us; NSPCC https://www.nspcc.org.uk/globalassets/documents/research-reports/10pitfalls-initial-assessments-report.pdf   xiv Sidebotham et al (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014; Department for Education  https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/53382 6/Triennial_Analysis_of_SCRs_2011-2014___Pathways_to_harm_and_protection.pdf    xv Munro, Eileen (2010) Learning to reduce risk in child protection British Journal of Social Work, 40 (4). 1135-1151. ISSN 1468-263X 