Concerns about a 10-month-old girl having ingested methadone and her two siblings aged 4- and 10-years-old being exposed to drugs in January 2014. Children lived with mother and father and had regular contact with maternal grandmother. Family was known to both adult's and children's services, including children's social care. The older girls were the subject of child protection plans from May 2012. When Emily was born they were subject to child in need plans which were discontinued in September 2013. Father had abused alcohol and drugs from the age of 15. Mother had suffered post natal depression, children were often late or had sporadic attendance at school. The family are of White British heritage. The review used the Significant Incident Learning Process (SILP) model. Learning includes: professionals must assess the impact on parenting of mental health or drug and alcohol misuse; It is important to work directly with children ensuring their voices are heard; professionals should consider the possibility that parents in a drug treatment programme may be tempted to use their medication on their children. Recommendations include: social workers should consider the risk of drug using parents actively giving drugs to their children; training for social workers in order to gain confidence in working with parents who show disguised compliance and manipulative behaviour; extended family who are relied upon should be included in key child protection meetings.
      
 Title:  Serious case review: Jenny, Molly and Emily: overview report. LSCB: Middlesbrough Safeguarding Children Board Author: Nicki Pettitt Date of publication: 2017  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                               1          Serious Case Review Jenny, Molly and Emily    OVERVIEW REPORT   Lead reviewer: Nicki Pettitt Date presented to the MSCB: 18 May 2015  Publication has been delayed due to on-going criminal processes     2  Contents  1. Introduction to the case       Page 2  2. Summary of the learning       Page 3  3. Methodology        Page 3  4. Family Structure        Page 4    5. Background prior to the scoped period     Page 4  6. Key episodes         Page 6  7. Analysis by theme and lessons learned     Page 15  8. Conclusions         Page 30   9. Recommendations        Page 31       1 Introduction to the Case 1.1 The subjects of this review are 3 children. They were aged 6 years old, 4 years old and 10 months old at the time that serious concerns emerged which led to the decision to undertake a serious case review.   On 8 January 2014 Emily was taken to Accident and Emergency (A&E) by ambulance, she was unconscious. She was later diagnosed with methadone intoxication, through ingestion.  At 10 months old it is highly unlikely Emily’s ingestion was accidental.  The consultant paediatrician who treated her stated ‘I feel lucky that she is still alive.’  Emily required treatment in the paediatric intensive care unit, but has since made a full recovery. 1.2 The police investigation which commenced later confirmed through hair strand testing of the older siblings that they have also been exposed to drugs, including heroin, cocaine, cannabis and methadone.  It has not been established if the older sibling’s exposure to drugs was through ingestion or if they had been absorbed passively.   1.3 The children lived with their mother and father and had regular contact with their maternal grandmother and her family. The family had been known to both adult’s and children’s services, including children’s social care. The older girls had been the subject of child protection plans from May 2012, but the plans stopped before the birth of Emily. When Emily was born all three girls were the subject of child in need plans. They were discontinued in September 2013.  Father was known to agencies due to his long standing drug and alcohol misuse.  2 Summary of the Learning  2.1 This Serious Case Review has identified a number of learning points for the individual agencies involved and for the Middlesbrough Safeguarding Children Board (MSCB).  When considering in detail the involvement of MSCB partner agencies with Emily and her siblings it has found that:      3  ⋅ Communication was good in some areas but lacking when it came to being clear about the specific detail of concerns and in sharing concerns with children’s services about adult behaviours.  ⋅ Assumptions were made about the services being delivered and about the ability of family members to support and protect the children.    ⋅ Assumptions were made about what the wider family knew about the details of the concerns.    ⋅ There was a degree of naivety about drug and alcohol use and its impact on the children, and about false compliance from manipulative parents.  The professionals involved were working hard but often without the support and challenge they required.   ⋅ The impact of a new baby in this family was not adequately considered.  ⋅ There was a lack of direct work with the children, and although professionals described the children in detail in their recording, the children’s voices were not clearly sought or stated.   ⋅ Professionals rarely consider the possibility that parents on a drug treatment programme may be tempted to use their medication on their children. However this must be seen in the context of the circumstances in this case being unprecedented in the experience of most of those involved in this review.       3 Methodology 3.1 The MSCB agreed that this Serious Case Review (SCR) should be undertaken using the SILP methodology1. SILP is a learning model which engages frontline staff and their managers in reviewing cases, focussing on why those involved acted in a certain way at the time. This way of reviewing is encouraged and supported in Working Together to Safeguard Children 2013. 3.2 SILPs are characterised by a large number of practitioners, managers and agency Safeguarding Leads coming together for a learning event. All agency reports are shared in advance and the perspectives and opinions of all those involved are discussed and valued. The same group then come together again to study and debate the first draft of the overview report, and to make an invaluable contribution to the learning and conclusions of the review2.                                                                1 The decision to undertake an SCR into this matter was made on 9 October 2014. The delay was due to the need for the MSCB to consider the appropriateness of an SCR in a case that did not automatically meet the criteria for a review of this kind. The Reviewer appreciates the consideration given and agrees that the right decision was made in this case. Once the decision was made, the review progressed in a timely way. The only slight delay being the need to re-draft the terms of reference after additional information emerged in January 2015 in regards to the results of the hair strand testing of Jenny and Molly.  2 The SCR was planned at a scoping meeting held on 11 November 2014 with the MSCB Learning and Improving Practice Group. The Terms of Reference were compiled and the timescale for the review set. Agency reports were requested, along with a chronology of agency involvement.  A briefing meeting for Agency Report Authors was held the same day.  A learning event was held on 5 March 2015.  All the agency reports were available and had been circulated in advance with the chronology. This ensured that all staff attending were able to fully understand the multi-agency information and focus of the review. The event was very well attended by practitioners and their immediate managers. The group included a manager from a local drug agency who had not been involved with the parents but who provided helpful information on drugs and on local drug services. The level of participation and engagement in the event was extremely good.    The recall event was held on 16 April 2015. Participants who had attended the learning event considered the first draft of this report. They were able to feedback on the contents and clarify their involvement and perspective. All those involved contributed to the conclusions and the identified learning from this review.     4  3.3 It was agreed that the scope of this review would be from 24 April 2012 to 8 January 2014.  The start date is when a strategy meeting was held in respect of Jenny and Molly and the latter date is when it was known that Emily had ingested methadone 3.4 Initially the scope of the review started from the date of the pregnancy with Emily, but since more information has emerged from Cleveland Police in respect of longer term concerns about the older girls and exposure to drugs, the scope was extended.  3.5 The parents were contacted in order to meet with them to ensure their views were considered and heard as part of the review. Two appointments were offered. The first the parents did not attend. The second was cancelled following police advice after allegations that serious threats were made by Father to professionals.   3.6 Maternal Grandmother was visited by the lead reviewer and a representative of the MSCB. She provided useful information and an interesting insight into the case. Details of this will be included throughout this report.    3.7 The Department for Education (DfE) expects full publication of SCR overview reports, working to that requirement, some confidential historical family information will not be disclosed in this report.  It is written in the anticipation that it will be published, and contains all of the information that is relevant to the learning identified 3.8 The Police investigation was on-going at the time of the learning events, however the MSCB was informed in 2017 that no further action is being taken.    3.9 The children were the subject of child care proceedings and live with extended family members on Special Guardianship Orders.  3.10 The lead reviewer in this case and report author is Nicki Pettitt, an independent child protection social work manager and consultant. She is an experienced chair and author of SCRs, and is a SILP associate reviewer. She is entirely independent of MSCB and its partner agencies.   4     Family Structure 4.1 The subject children of this review are to be referred to as Jenny, Molly and Emily. The parents of the children are referred to in this report as Mother and Father. Other family members will be referred to by their family title e.g. Maternal Grandmother.  4.2 Mother and Father lived together with the children. They are thought to have been a couple since they were teenagers, although their relationship was said to be ‘on and off’. 4.3 The children and both parents are white British. Their only language is English. This information appears to have been accurately recorded on agency records. They have no known disabilities.  5 The background prior to the scoped period 5.1 Father was well known to Children’s Social Care as a child. This included a period on the Chid Protection Register (as it then was) due to his parent’s substance misuse and domestic abuse. He had issues with alcohol and drugs since he was around 15 years old. He had requested a detoxification programme from alcohol twice during 2009 and once during                                                                                                                                                                                                                       The final version of this Overview Report was presented to the Middlesbrough Safeguarding Children Board on 18 May 2015.  It has been agreed that some additions may be made to this report once the criminal investigation has been completed, including any further information that becomes available during that process and after engagement with the parents.       5  2010, but did not cooperate. He then completed home detoxification programmes in December 2010 and in February 2012 and a hospital detoxification in December 2011, but did not engage with relapse prevention appointments.  5.2 Father was said to have started abusing solvents, cannabis, valium and amphetamines when he was a child. He has been on a methadone programme since 2000 when he completed treatment for heroin and crack cocaine addiction3. He was also being prescribed Tramadol,4 a painkiller, for 10 years. In July 2012 a plan to reduce Tramadol usage was put in place with Father.  5.3 It was a common view amongst the professionals involved with the children and with Father that he was mostly managing his drug and alcohol use. However his GP notes show he had attended his GP in May 2012, that he was diagnosed with depression, was prescribed anti-depressants, and that he had made threats to self-harm. There was also information held by agencies that Father used unprescribed benzodiazepines (diazepam.) On 31 March 2012 Father was admitted to hospital having been found collapsed after heavy alcohol use. 5.4 Father was known to the police due to his use of drugs and alcohol. At the time of the start of the scope period of this review Father was put on a tag and was the subject of a curfew.  5.5 Mother was seen as the protective parent with no drug or alcohol use apparent. What was known however was that she had an addiction to Iron Bru (a soft drink high in sugar, caffeine and quinine.) Her GP records show Mother had post-natal depression after the birth of Molly and that antidepressants were prescribed. Mother was described as having a supportive family however and received help with the children from her Mother. Maternal Grandmother explained that there were periods when she was very involved in her the lives of her daughter and grandchildren, but other times when she did not see them. Grandmother stated she worked long hours and had teenage children of her own, which limited the time available. She also had a difficult relationship with Father and she worried that her daughter appeared to be ‘under his spell’. Grandmother knew he was an alcoholic and this concerned her. She did not know about his drug use.  5.6 A core assessment completed by ChSC in 2012 provides information on the parent’s childhoods, and it is noted that both grew up in homes where alcohol misuse was an issue, and Father often witnessed domestic abuse at home.   5.7 The school near to where the family lived was attended by Jenny for nursery from 2011, as she received a free place from age 2.  Although attendance was not mandatory, the school had concerns about her very poor attendance and punctuality, which continued throughout the scope of this review and after she started at the Infant School.  5.8 The children and their mother were registered at a different GP to Father. He was registered with a GP practice that was commissioned as a specialised addictions service.  The GP for the children has information in Jenny’s notes that she attended the local hospital on 27 October 2010 with an accidental ibuprofen overdose. Those working with the family during the period of child protection planning were aware of this, but it was not thought to be of significance. Jenny and Molly both received a number of their childhood immunisations late and Jenny was coded on the GP system as a ‘poor attender’.                                                              3 Methadone is used as part of a drug addiction maintenance programme. It is a narcotic pain reliever, similar to morphine; it is used to reduce the withdrawal symptoms when stopping the use of heroin without causing the ‘high’ associated with drug addiction.   4 Tramadol is a moderate strength opiate medication which is used for pain. It was reclassified after 2012 as a controlled drug. It is recognised as a drug of abuse.      6  5.9 The children’s health visitor had concerns prior to the scope of the review. The family often missed appointments, including for immunisations and developmental reviews. The health visiting service were concerned about the family’s insecure and inadequate housing, Jenny’s poor attendance at nursery, Molly’s developmental delay (delayed gross motor skills), Mother’s postnatal depression, and domestic abuse disclosed by Mother.   5.10 After the birth of Jenny four referrals were made to Children’s Social Care (ChSC) in 2008, 2009, 2010 and 2011. They undertook Initial Assessments5 in 2008 and 2010 where home visits were undertaken and discussions were held with Mother, but no further action was taken.  In 2008 the parents were drunk in charge of Jenny, in 2009 an anonymous referral was received about suspicious activity at the property, including motorbikes inside the home, and the health visitor was asked to visit, in 2010 when the health visitor raised concerns about Molly’s developmental delay, and in 2011 when they were notified that a CAF (Common Assessment Framework) was to be started after concerns about attendance at nursery were highlighted by an Education Welfare Officer and the health visitor, who were also concerned that Jenny was often tired and lethargic at nursery.  6  Key Episodes  6.1 The time under review has been divided into four key episodes. Key episodes are periods of practice and intervention that are judged to be significant to understanding the way that the case developed and handled.  The term ‘key’ emphasises that they do not form a complete history of the case but are a selection of the activity that occurred, and includes the information that is thought to be key in informing the review.  6.2 The first key episode covers from 24 April 2012 to September 2012. This includes the events leading up to Jenny and Molly becoming subject to Child Protection Plans (CPP) and the initial period of the CPPs.  6.3 The second episode covers October 2012 until March 2013, when Mother’s pregnancy with Emily was confirmed until the end of the CPPs.   6.4 The third key episode includes the birth of Emily in March 2013 until the decision to end the Child in Need Plan (CinN plan) was taken on 8 July 2013. 6.5 The fourth and last episode covers the period where there was a continuation of low level concerns despite the closure of the case to ChSC on 30 August 2013, until the incident on 8 January 2014.  Key Episode 1:  from 24 April 2012 to September 2012. 6.6 Maternal Grandmother had approached a health visitor at the clinic in April 2012 to voice her concerns for the children and their mother.  Father was said to be drinking significantly, was using drugs, carried knives, and there had been numerous domestic abuse incidents between Mother and Father, often witnessed by the children. After the health visitor made the referral to ChSC they undertook checks with other agencies and found that Jenny’s attendance at nursery was poor, that she had outstanding immunisations, that the house was in a poor state of repair, and that the children lacked stimulation and structured play at home, and that Molly had delayed gross motor skills when a baby. The family had not engaged with attempts to provide family support via the Children’s Centre or with a CAF undertaken in 2011.                                                              5 An Initial Assessment is a brief assessment of a child’s circumstances following a referral to Children’s Social Care. It will determine if a child is in need, what services would assist the child and whether a more detailed Core Assessment needs to be undertaken.     7  6.7 ChSC visited the family and were concerned at Father’s reaction and Mother’s angry denial of the concerns. Father was so agitated by the visit that the visiting social workers felt, on consultation with their manager, that the children should not remain in the home. Police assisted Mother and the children in a move to Maternal Grandmother’s home. They remained there for 2 days before Mother decided to return home as Father was ‘upset’.  6.8 This resulted in a strategy discussion held on 24 April 2012 and the decision to proceed to an initial child protection conference (ICPC).  It was agreed that the children should return to the care of Maternal Grandmother until at least the ICPC.  It was noted that Molly’s behaviour had improved while with her grandmother, however when she was taken for her outstanding immunisations she was said to be aggressive and biting.   6.9 In the meantime a referral was made for a Families Forward6 intervention. A 72 hour assessment was made but as the family were no longer thought to be in crisis they did not meet the criteria for intervention. They instead provided a list of tasks for the parents to undertake and shared their view that the children’s needs could be met by universal services and a working agreement with the family. 6.10 The ICPC was held on 15 May 2012.  The Police and Families Forward felt that a child in need plan was sufficient, however the decision was made that the criteria was met and Jenny and Molly were made the subject of a child protection plan (CPP) under the category of neglect. A secondary category of emotional harm was agreed.  The Agency Report for ChSC stated that ‘the reports to conference from various adult’s and children’s services were informative and covered all relevant issues.  The addictions nurse highlighted in her report that ‘heavy alcohol use and intoxication will of course impact on anyone’s ability to parent adequately and safely’.   6.11 A new social worker was allocated after the ICPC and the family engaged well with services in the first period of the CPP. By the first Core Group held on 23 May 2012 the children were spending increasing amounts of time at home with their parents, and then returned to their care.   6.12 The GP notes state that on 28 May 2012 Father took one of the girls to an immunisation appointment and that he was an hour late and smelt of alcohol. The practice nurse contacted the health safeguarding team and spoke to the senior nurse for safeguarding children who advised her to share the information with the social worker. Over the course of the next five weeks the practice nurse made some efforts to speak to the social worker, but did not do so until 2 July 2012. The senior nurse agreed to pass on the information to the health visitor, which she did later. There is no evidence that the health visitor informed the social worker. This information was also not included in the GPs report for the next CP Conference, and the social worker who took on the case in September was not aware of this incident. Around this time the professionals working with the children continued to have some concerns about Father’s drinking, but he insisted he just drank socially and that it was not an issue and this was not challenged rigorously. So even if the information about the visit to the GP had been appropriately shared, it was unlikely to have made a difference at this time.  6.13 Although the parents appeared to be cooperating well with services, concerns about Jenny’s attendance at nursery continued once she had returned to her parents care. The                                                             6 Families Forward are a Middlesbrough service that works with families where the adults are affected by drug and alcohol problems, domestic violence and/or mental health problems. It is an integrated, multi agency team including a Public Health Nurse, Family Support Workers, early years and pre birth support staff, Probation Officer & Clinical Psychologist.      8  parents moved to a new house in June 2012 which was very close to the school, so the continued attendance and punctuality issues were difficult for professionals to understand.  6.14 As part of the CPP both children had child protection neglect medicals in June 2012. Some minor health issues were identified in relation to Molly’s eyes (squint) and hyper-mobility in her joints.  Jenny was healthy but it was noted that she was blinking excessively and in view of a family history of eye disorders Mother was asked to consult with the family doctor.  The GP was informed of the result of the medical and need for follow-up in these areas, though a delay of some months was noted between the date of the medical and the written information being shared with the GP, the parents and with other professionals.   6.15 A Review Child Protection Conference was held on 9 August 2012.  The decision was made for the children to remain subject to a CPP. Molly was due to start nursery and Jenny to move into a full time infant class. It is important to note that Maternal Grandmother was not included in any of the child protection conferences, although she did attend the first three core groups. It would have been helpful to have her attend the conferences as she was relied on to provide support and to undertake a certain amount of monitoring of the children and their care. At the learning events it was agreed that no one really considered what Grandmother knew about the risks, and assumed she knew more than she did. It is significant that she told the lead reviewer that she was not aware that Father had a history of serious drug use and that he was on a methadone programme. She had thought that alcohol and domestic abuse were the reasons for the concerns.  6.16 This is a key practice episode because concerns were identified which lead to an assessment that the children were suffering or likely to suffer significant harm, and they became the subjects of child protection plans. There were some concerns during this period in regards to information sharing, including with Grandmother, and the missed opportunity to undertake full assessments of the parent’s use of drugs and alcohol by Families Forward.  Good practice was also identified in regards to the assessment of risk and some assertive work with the family by the social worker and health visitor.   Key Episode 2:  from September 2012 to March 2013 6.17 Mother’s pregnancy with Emily was confirmed by a midwife in September 2012. At the appointment Mother informed the midwife that ChSC were involved with the family. There is no record of this information being shared by the midwife, however Mother told the children’s social worker of her pregnancy when she visited the family on 14 September 2012.   6.18 School attendance continued to be an issue as the new academic year started. Just during September 2012 the following was noted by ChSC on their visits alone:   14.9.12 - Molly off school with an upset stomach.   19.9.12 - Both girls off with colds   24.9.12 - Both girls absent ‘ill’.  The school contacted the social worker on 26 September to state that the children were off that day and to confirm that since the start of the new term Jenny had been present for 8 days and absent for 8, her attendance was therefore just 50%. Lateness was also an issue on the days she did attend. There appears to have been an issue with professionals accepting, to a certain degree, that children are justified being off school when they are ‘unwell’. This was challenged by the staff from the school and the education agency report     9  author who stated that children should generally come to school when unwell, as long as they do not have anything contagious.  However it was confirmed that during core groups the message that the children should go to school even if the parents thought they were unwell, and that teacher would send them home if necessary, was consistently given to the parents. At the time the social worker thought that there were other issues that had an impact on the children’s attendance. These were that the children were kept up late and that Mother kept them home to meet her own needs.   6.19 The family cooperated with ChSC and the Family Resource Team who were undertaking parenting assessments at this time. A new social worker became involved in October 2012 and commenced a core assessment immediately.  It is noted that the children had been subject to a CPP for nearly 6 months at this stage. The agency author points out that there had been some delay in the case transferring to the team that should have responsibility for children on a CPP, and temporary allocation to a worker who then left. This is why the formal core assessment was delayed. The assessments of Mother and Father’s past history, and their general mental health, were undertaken as part of the core assessment. However there was some delay in undertaking specialist assessments of the parents and no formal mental health assessments were undertaken.    6.20 It was recorded in the record of a Core Group meeting in October 2012 that the parents were asked about where Father’s methadone was stored. They stated that they had a locked box in their bedroom. This is the only record of this issue being discussed. It was not clear in recordings if any professional asked to see the locked box or if it was confirmed with parents that the drugs were always stored there. However at the learning event the social worker who was involved towards the end of the timescale of this review confirmed she had seen the locked box in the kitchen.    6.21 The Safeguarding Family Resource Team (FRT)7 were involved and were undertaking a parenting assessment covering a range of topics such as children’s basic needs, safety, emotional warmth, stimulation, guidance and boundaries. The Agency Author for ChSC states in her report that ‘the outcome of the work demonstrated that parents engaged well with the 7 sessions offered.  They had an understanding as to the importance of the emotional warmth children require and they ensured that age appropriate toys were available and had regular family outings.  The children were seen and noted to present clean and appropriately dressed but were not given any direct work as part of the programme’. The FRT involvement contributed to the focus of the case shifting to one of parenting support rather than the required risk assessment, and the initial focus and expectations from the ICPC were lost.  6.22 The next months were difficult for the family as Mother was ill with her pregnancy, with severe sickness followed by issues with her pelvis (symphysis pubis dysfunction) which was very painful and made mobility difficult. This condition did lead to a number of requests / prescriptions for codeine over the course of the pregnancy. This did not appear to have raised any concerns however with those involved in managing Mother’s condition. A pre-birth assessment was referred to at this time in professional conversations, but the ChSC author did not find a specific document completed prior to the pre-birth conference, as would be expected.                                                              7 FRT is a ChSC in-house support service providing time limited family support for families with existing social work involvement.     10  6.23 A Core Group was held on 7 November 2012. This was a significant meeting as there was a positive picture emerging of the children and the parents and no concerns were highlighted. This was despite school/nursery attendance being an on-going issue, and despite it being noted that Molly and Jenny had not been taken to appointments for their eyes. The positive nature of the information shared led to a decision being made that mental health assessments for Mother and Father were not required. This is despite the assessments being part of the CPP, and Father specifically requesting an assessment and help with his mental health before the ICPC in 2012.  6.24 The children continued to have high levels of absence from school and were often late. The parents blamed the children for the poor punctuality, saying that the children were slow, liked to take their time doing their hair, and so on.  A pattern emerged of Father often being in bed when professionals visited. The excuses were that he was ill, or that he was being kept awake at night by Mother’s sickness. This does not appear to have been challenged or the significance of this included in assessments.  6.25 At the Core Group held on 3 December 2012 it was discussed that Jenny had attended the GP in regards to the concerns about her eyes and there were no issues. This was also recorded in the GP notes but a referral was made by the school health nurse to ophthalmology anyway, as Jenny had also failed the visual test at her school entry assessment.  Jenny was not brought to the appointment when it was offered however. Molly was also referred to ophthalmology on 12.11.12 but the parents had not made an appointment through the ‘choose and book’ scheme for her to be seen.  It is significant that Jenny was not seen by an ophthalmologist until 26 November 2013. The examination showed very reduced vision in her left eye. She needed a test for cyclo refraction (an eye test to check the health of the eye). The opportunity for correction of the eyes stops at age 7, and Jenny had missed 5 appointments in over a year.  6.26 This issue was discussed at the recall event and it emerged that the school nurse had challenged the parents about the lack of attendance, but they always had an excuse. She also persuaded the ophthalmologist to give another appointment, which was subsequently offered. This should also be seen within the context of poor attendance to ophthalmology appointments across the area, with Did Not Attend (DNA) rates at around 20%.  6.27 At this time the FRT parenting assessment had been completed and was positive. The family were said to have been working ‘extremely well’ with professionals, Father had been consistently engaged with his treatment programme (methadone), the new accommodation was a positive move and the Maternal Grandmother and Maternal Aunts continued to provide support.  No further parenting work was thought to be required.  6.28 The core assessment was completed and circulated to Core Group members on 9 January 2013. It is described by the ChSC Agency Author as comprehensive and offering a good insight into the family. At this time there were no concerns for the children, they are said to be well cared for and happy. It was noted that school attendance remained an issue. 6.29 A Core Group was held on 16 January 2013. There is no evidence that consideration was given to the expected baby at this meeting. A further meeting was planned on 21 January 2013 however.  It was agreed that an ICPC for the unborn baby would be held on the same date as the next review conference for Jenny and Molly. The relevant midwife was not in attendance at either meeting. The social worker contacted them after the meeting however and verbally shared the pre-birth assessment, which had concluded that the     11  couple were preparing well, engaging with relevant professionals and showed insight into the needs of a baby.    6.30 On 31 January and 3 February 2013 Father attended hospital with abdominal pain firstly and sore ribs on the second occasion. While there Father admitted to previous alcohol detoxification and said he was continuing to drink ‘small amounts.’  The doctors questioned if he had pancreatitis, which is a serious condition which can be due to excessive alcohol consumption. There is no confirmation of this diagnosis available to the review. However when the social worker visited on 4 January Father told her he had fallen on ice and cracked his ribs.  6.31 The only issue of concern at this time, as far as the professionals involved were concerned, was school attendance. On 4 February 2013 Jenny’s attendance was 54 ‘absent’ and 36 ‘late’ from a possible 184 days. This means she had only had full days at school around 50% of the time.  The parents continued to blame illness for absences and the children for the poor timekeeping.  6.32 The RCPC on the older children and the ICPC on the unborn baby was held on 7 February 2013. During the meeting the health visitor pointed out that Father smelt of alcohol. He said that he had drunk beer the previous evening. This was dealt with during the meeting but was not included in the record of the meeting. During the learning event the chair acknowledged that it should have been. The decision was made to remove Jenny and Molly from a CPP and it was agreed that the unborn baby would not be made subject to a CPP at birth. All 3 children were to be subject to Child in Need (CinN) plans. The issues with school attendance were noted, as were the risks around Father’s ‘historical’ drug and alcohol misuse. The school had wanted the CPP to continue, but were persuaded to accept a CinN as long as supports for school attendance issues continued to be included in the plan.  6.33 This is a key practice episode because there was a lot of contact with the family and the children, and a positive view was held about the care of the children and the parent’s ability to parent despite historical concerns, particularly Father’s drug and alcohol use. Any assessment of the impact of a new baby joining the household; any meaningful engagement with the children; and any in-depth assessment of both parent’s mental health and Father’s relationship with alcohol at this time were not sufficiently pursued however. The continued concerns about school attendance were not thought to be enough of a concern to warrant a further CPP.   Key Episode 3:  from 27 March 2013 to 9 July 2013 6.34 Throughout this episode the family continued to receive support from ChSC while the children were on a CinN plan. The decision to continue involvement took into consideration the expected birth of a new baby. The parents stated their plan to continue working with agencies in the interests of the children. It had been agreed that after the birth of the baby a pre-discharge meeting would be held before the baby went home to ensure appropriate communication between professionals. Mother continued to have physical difficulties associated with being pregnant, but attended all ante-natal appointments.  6.35 Core Groups continued to monitor the CinN plan. On 13 March 2013 a meeting was held. The parents did not attend. Concerns about poor school attendance and Father’s drinking, including ‘social’ drinking during the day were discussed. On 19 March 2013 the social worker visited the family and noted the children were home from school due to vomiting.     12  The social worker noted they did not seem unwell however. It is also recorded that Father had a facial injury that he said was due to him falling from a bike. Otherwise there were no concerns about the children or the home at the visit. 6.36 The same day Father attended hospital in regards to the bike fall. A fracture was diagnosed which required surgery. While at the hospital Father disclosed that he was drinking a bottle of vodka and 8 cans of lager a day. It is not clear from the documentation that the hospital was aware that Father lived with his partner and children. The operation was undertaken two days later. The information about the extent of Father’s drinking was not shared with other professionals.  6.37 Emily was born at 36 weeks, Mother was accompanied by Maternal Grandmother and Father at the birth, although Father missed the birth of Emily. It is documented by the midwives that Father appeared to have been drinking, and was clearly intoxicated. It is speculated that this is why Grandmother was upset with him. Grandmother confirmed to the lead reviewer that father had been drinking heavily in the lead up to the birth and continued to drink on the delivery suite. He was swigging from a soft drink bottle which was filled with vodka. The following day the social worker visited the hospital and discussed with Father his drinking the day before. Father stated he had drunk 4 – 5 pints of lager but was not drunk. Mother stated that Father had appeared drunk as he had been using her gas and air. The social worker stated that Father was not to have sole care of the children while Mother was in hospital due to concerns about his drinking. Grandmother and maternal aunt agreed to look after the children. There is no evidence that Grandmother was asked about the incidents on the ward, which might have elicited the information about the extent of Father’s drinking which does not appear to have been shared.  6.38 Appropriate verbal information sharing took place around the birth of Emily. There is evidence that the ward sister shared information on the telephone with the ‘out of hours’ service which covers emergency ChSC duties on evenings and weekends8. This includes the information that Grandmother had passed on to staff on the ward that Father had drunk a litre of vodka and 8 beers the day before attending the birth and continued to drink on the delivery suite.  Grandmother had also stated that Father regularly drank excessively and spent around £190 per fortnight on alcohol. This information was not shared with the allocated social worker or any other members of the Core Group however and it has been identified that there appears to have been an issue with the level of detail recorded by the ‘out of hours’ staff which was relied on by all concerned. However the detail of the concerns was not discussed at the pre-discharge meeting held at the hospital. Dad’s drinking had been discussed, but the detail of the financial impact and the exact amount and type of drink does not appear to have been made explicit. It is also noted that the health visitor did not appear to be invited to this meeting.  6.39 The social worker visited the family the day after Mother and Emily had returned home from hospital. There was also liaison between the health visitor and social worker where concerns about the escalation of Father’s drinking were discussed. Neither was aware of the self-reported extent of the drinking however, or the detail of Grandmother’s allegations. The health visitor also discussed the case in her supervision and she voiced her concern about Mother’s ability to protect the children from the impact of Father’s drinking. 6.40 The social worker visited the following week and had no concerns. The health visitor visited the following day for the primary visit to Emily. She attempted to discuss what had                                                             8 Out of hours cover in Middlesbrough is provided by a Tees-wide Emergency Duty Service.      13  happened on the delivery suite but Mother was only keen to say that Father had been very helpful with the children since Emily’s birth.  6.41  In the weeks that followed the birth of Emily there were no further concerns identified about Father’s drinking. The baby appeared to be thriving, and other than on-going issues about school attendance the older girls were thought to be happy and well looked after. On 30.4.13 the allocated social worker visited and informed Mother that the case was to be reallocated as she was leaving. She explained the on-going concerns about Father’s drinking and school attendance, and reinforced to Mother the need for her to continue working with professionals.  6.42 On 3 May 2013 Emily was seen at the clinic and was described by the health visitor in attendance to be ‘jittery’. A family history of epilepsy was reported and recorded. However no further action was taken in regards to this concern. The allocated health visitor remembers discussing this when she went to the family home on 22 May, but this was not recorded.  6.43 A new social worker was allocated and visited the family on 20 May 2013. Again the two main concerns of Father’s drinking and school attendance were discussed. Father said he would drink a few pints with a family member on a Tuesday night, but that was all. The worker said there was a faint smell on Father of what could be alcohol. Father said it was prescribed mouthwash for his gums. There were no other concerns identified at the visit and all of the children seemed well and well cared for. There is no record that Father’s GP was contacted about the prescribed mouthwash. Mother’s GP confirmed during this process that it was highly unlikely that an alcoholic would be prescribed with a mouthwash with alcohol in it.   6.44 A CinN meeting was held on 4 June 2013. An issue was identified with Father taking his methadone at 6.30 am which made him drowsy unable to help with getting the children ready for school. It was agreed that the new social worker should talk to Father’s prescribers about this. School continued to be an issue, with the parents giving constant illness as an excuse for Jenny and Molly’s low attendance. An attendance management meeting was held and the school were planning to provide additional support to get the children to school, including a PSA (family support worker within the school) ringing each morning to wake up the family.  6.45 Father was admitted to hospital on 12 June 2013 after receiving severe dog bites on both arms. He told the doctors that he had been bitten at 6 am that morning trying to stop a dog biting a child. There does not appear to have been any attempt to establish who the child was, which is potentially poor safeguarding practice at the hospital. However the children’s social worker did discuss the incident with Father later, and he stated ‘what if there had been a child there?’ So there may have been a misunderstanding about what Father has said at the hospital. Father later went missing from the ward. He was readmitted the following day but was ‘wander some.’ He then left the hospital late that evening saying he was going home. He returned in the early hours ‘intoxicated’.  There is no record this information was shared with any child care professionals.  6.46 Emily was taken to A&E by both parents with a high temperature on 24 June 2013. After being observed on the paediatric day unit she was diagnosed with a viral upper respiratory tract infection and discharged home. Mother later reported it had been suspected meningitis.      14  6.47 On 9 July 2013 a call was made to Cleveland Police to state that Father had threatened an unknown woman with a knife. ‘Words of advice’ were given to Father. This information was not shared with ChSC at the time.  6.48  This is a key practice episode because concerns regarding Father’s drinking remained, although the opportunity to establish just how much he was drinking was missed. Grandmother’s report of the extent of his alcohol abuse was shared verbally with the service providing ‘out of hours’ cover for ChSC, but this was not adequately communicated to the allocated social worker or health visitor and was not put in writing by maternity ward staff. Father’s self-report to the hospital after the bike accident was not shared with any child care professional, and no professional working with the children sought information on Father’s injuries from the hospital.  Key Episode 4:  from 30 August 2013 to 1 January 2014 6.49 A plan to close the case to ChSC on 30 August 2013 was made as it appeared that Father was managing his drinking and the three children were doing well in the care of their parents. The exception to this was school attendance remaining of concern and some question about attendance at medical appointments regarding Jenny and Molly’s eyes.   6.50 The health visitor saw the family on 9 August and was informed that ChSC were closing the case. While visiting the health visitor was made aware that Emily was being given baby food, although her diet should have been just milk at 19 weeks old.  The health visitor recorded her plan to request that the case remained open to a social worker until there was a pattern of full engagement with education. The health visitor made this request, and a compromise was agreed, with the case remaining open until September when the older children returned to school.  6.51 Mother was arrested for theft of an inexpensive item of baby clothing in August 2013. She later reported it had fallen into a fold on the top of the pushchair and she had intended to pay for it. She was given an Adult Caution. At this time it is evidenced that mother was still receiving prescriptions for a relatively large amount of codeine.  6.52 In November 2013 another parent at the school shared concerns that Father was drinking heavily, taking pills, and that there was domestic violence in the household. Later in the month Molly told her teacher that Father stays in bed and drinks ‘mucky beer’. She said that her Mother had told him to stop drinking ‘but he won’t’. The school discussed the concerns with Mother who stated that Father has now stopped drinking and was doing well.   6.53 Around this time the school had concerns about Mother’s relationship with Molly, who she was often very negative to and about. On one occasion when appearing exasperated with Molly, Mum stated that children ‘need Ritalin’. All of these concerns were referred to ChSC who undertook a visit on 6 December 2013. The visit was undertaken at 9.00 am and the social workers woke the family up when they arrived. It was a very difficult visit and Mother was very angry. She left the home at one point to go to the school to complain. The social workers concluded their visit reassured that Mother had calmed down, that Father did not appear to have been drinking and that the children appeared well cared for. Molly had said during the visit that Father no longer drinks the ‘mucky beer.’ It is not clear if the concerns and conclusion of the visit were shared with other professionals working with the family, such as the health visitor.      15  6.54 On 10 December 2013 Father attended his GP surgery intoxicated with slurred speech. A week later he told the addictions nurse at the GP surgery that he had relapsed and taken some heroin the week before. This was not shared with any child care professional.  6.55 On 7 January 2014 Emily was taken to A&E with ear pain and a high temperature, she was diagnosed with an ear infection. She was admitted to the paediatric unit and later discharged with antibiotics. The following day she was brought to A&E by ambulance after being found at home unconscious and cyanosed. She was later diagnosed with methadone intoxication. 6.56 This is a key practice episode because further information was available about Father’s use of drink and drugs, this included Molly making clear allegations about what was happening at home. Although her concerns and the other allegations were discussed with the parents, they were able to reassure social workers that there were no concerns. In regards to Father’s relapse, information was not shared appropriately.  7 Analysis by Theme   7.1 From the information extrapolated from the agency reports, from the discussions at the learning events, and from the meeting with Maternal Grandmother several themes have emerged.  These can be summarised as: • Communication and information sharing • Assessments of drug/alcohol abusing parents, including their mental health • The challenge of working with parents who are manipulative or show disguised compliance  • The risks to children when a parent is on a methadone programme • Supporting staff undertaking complex case work  • Thresholds for CP Plans Viewed from a systemic perspective it is apparent how these themes influenced and impacted on each other and led to the circumstances which are the reason for this review.  Communication and Information sharing 7.2 Working Together to Safeguard Children (DfE 2013) states; ‘Information sharing between professionals and local agencies is essential for effective identification, assessment and service provision.”  This review has identified several aspects with communication and information sharing that are significant to the management, if not the outcome of the case. There are examples of good practice and areas which require improvement. 7.3 It was acknowledged at the learning event that there were a large number of people involved and that the case was relatively complex.  Information sharing between those providing services for the children was relatively good, with regular communication between the school and the health visitor, between the health visitor and the school nurse and between the social worker and the health visitor and school nurse with the exception of the, albeit received late, information about Father taking Molly for her inoculation while smelling of alcohol.  7.4 Issues were identified in the communication between the ‘out of hours’ service for ChSC and daytime professionals. While the information was shared that Father was drunk when Emily was being born, the information about the amount and type of alcohol Grandmother     16  had alleged that he regularly drank was not shared. This was a significant oversight. It is also noted that although her midwife at her booking in appointment was told by Mother that her children had a social worker, there was no communication between that midwife and the social worker or health visitor. The Agency Author states that the midwife showed little professional curiosity about the circumstances of the child protection concerns. It should also be noted that the social work and health visiting staff did not directly contact the safeguarding midwife in a timely way.  7.5 The lack of communication in regards to the information Father shared with various health professionals is also of concern. Before the birth of Emily Father told staff at A&E that he was drinking a substantial amount of alcohol on a daily basis. He also told his GP that he had used heroin shortly before the serious incident in January 2014. These facts were not shared with professionals working with the children.  Other issues were identified with the written information sharing from Father’s GP practice to the CinN meeting in May 2013.  It did not mention information received from the specialist safeguarding lead midwife and the alcohol concerns regarding Father. The GP practice specialist nurse who wrote the report stated that she had assumed that the information would have been shared with ChSC directly. This should not be assumed. The GP for Mother, when asked about the prescribing of codeine, stated that he was not aware that Father was on a methadone programme. This was of concern as full details of the children’s child protection plans were available on the GP records. At the recall event the group discussed how unrealistic it is to assume that all the GP’s in a practice will have read CPC minutes, and this needs to be taken into consideration when communicating with them.  7.6 Some of the learning identified in the agency report for the GP practice for Father was in relation to the value of staff from that agency attending CP conferences, and not just writing reports. It also identified the need for improved information sharing within both of the GP practices, and the awareness that just writing or placing something in a patient’s notes is not an adequate or effective way to share information.  7.7 Good practice was also identified with regards to information sharing from the specialist drug worker at Father’s GP practice at the time of the ICPC. A full and clear report was submitted to the ICPC which outlined all of Father’s known past and present use of substances. It included an analysis of how his parenting would be impaired by his drug use and drinking. The children’s GP did not mention in their report for a review conference that Father had attended with Molly mid-morning smelling of alcohol however.  7.8 Issues were identified with information sharing between ChSC and the IRO team which may in part be because of the difficulties with the IT system at the time. This led to the IRO who chaired the ICPC not being aware of the previous assessments undertaken on the children before the concerns emerged that led to the conference.  The IRO recognised that he relies on what information professionals bring to the meeting to ensure he gets a full picture. He remembered thinking it was unusual for a case to come to ICPC without any previous referrals/contacts.  7.9 An issue was identified in this case and others with the attendance of key people at conferences. The IRO stated ‘if we are going to spend time and money on a children protection conference, the right people need to be there’. He is right. The obvious people missing from the meetings were Grandmother, a representative from Father’s GP surgery, and a professional from drug and alcohol services who would bring specialist knowledge and challenge to the meeting. It has been identified during this process that staff made     17  assumptions about the services offered regarding drug and alcohol issues at the GP practice that were incorrect.   7.10 High caseloads also restricted the amount of time that conference chairs could spend interrogating the IT system in regards to past or on-going work with families.  Improvements in staffing levels and planned improvements to the IT system mean that this should be less of an issue in the future. This has also enabled improved systems for communication between IROs and SWs before and between conferences.  7.11 The children did not attend a number of health appointments both before the timeframe of this review and over the years that we have reviewed in detail. There were a number of DNA’s or failure to respond to requests to make appointments with the Ophthalmology Department. This information was not always reported in a timely way. In order to ensure that vulnerable children’s health needs are met information regarding missed appointments need to be shared with the key professionals (most likely to be those on the Core Group).  In the case of Jenny’s eyes, her long term heath and development may have been impacted on by the ineffective responses of her parents to the issues identified and the health appointments made.  7.12 Other issues were raised regarding the delay in sending reports, such as the neglect medical reports, and the lack of evidence that minutes/updated plans were being sent out from Core Groups.  The SCR was informed however that the newly commissioned ChSC I.T system will help to ensure more efficient recording and distribution of core group minutes and CP plans.  7.13 Lessons learned:   • Good communication and information sharing is essential in all safeguarding work, particularly between services for children and adults where there are identified potential parental risk factors.  When considering what ‘good’ looks like, it is important that staff understand that they need to share the right information and detail to ensure other services are not overwhelmed.  • Professionals need to ask exactly what services are being offered and provided to service users, and not make assumptions about what those services offer.  • For a child protection conference and subsequent plan to be effective the right people need to be present and consulted.   Assessments of drug/alcohol abusing parents, including their mental health. 7.14 Two initial assessments were completed in 2008 and 2010 after concerns had been brought to the attention of ChSC. The assessments were completed following home visits and conversations solely with mum.  These assessments were superficial and were not child focused. They did not involve Father and were limited in their consultation with other professionals, particularly adult services. The assessment undertaken in 2010 did not appear to take into consideration information from the previous referrals, and no pattern was identified. 7.15 The response to the referral from the health visitor regarding Maternal Grandmother’s concerns in 2012 was appropriate and the decision to remove the children and Mother from the house on the evening of the visit from social workers was a good and proportionate one. The Agency Author for ChSC states ‘asking Mother to move with the children would have ensured the workers had time to fully assess the situation, determine     18  the course of action relevant to family need, and afforded the children some familiarity with them going to stay with their grandmother’.  The decision to hold an ICPC after Mother returned with the children to live with Father was also appropriate and made in a timely way. The agreement made with the parents for the children to remain with Grandmother until after the conference, with any contact being supervised, was child centred and protective.  It was identified that the placement with Grandmother was not made in any formal way, and the Agency Author has reassured the review that the current legal position with regard to the Connected Person’s Policy would mean that the children were placed with Grandmother as Looked After Children.  Grandmother told the lead reviewer that she had not received any financial support and that she would not have been able to provide longer term care without such support, due to having to take time off from her work to care for the children.  7.16 The decision to make a referral of the case to Families Forward was a good one. The service could potentially have provided a structured and relevant assessment of the risks to the children in this family. However the 72 hour assessment undertaken decided the criteria for the service was not met as the family were not deemed to be in crisis. The ChSC agency author is right in saying that this was ‘a missed opportunity given the length of time Father was using substances and the addictions nurse’s assessment that it would be impacting on his parenting. It was therefore a poor and flawed assessment.’ The Families Forward work would have provided work on addictions but also on the parent’s co-dependent relationship. Mother’s loyalty to her partner was evident from the emergence of the initial concerns and their relationship and the impact on the children was never explored in detail or challenged as necessary. The agency representative for Families Forward who attended the learning event assured the review of changes to their service and said if the family had been referred at the same stage today that they would meet the criteria. 7.17 It is clear that the expectation of the IRO chairing the ICPC was that the assessment to follow the making of CPPs would include a capacity to change assessment of the parents, and that an assessment of their mental health and drug / alcohol use would be included as part of this, with specialist input. This was included in the written record of the meeting as a recommendation for the CPP. The CPP however included a parenting assessment of the parents. This is a subtle but significant difference. The assessment concentrated on care of the children, both physical and emotional, and the parents engaged. It was agreed at the learning event however that this FRT assessment was inadequate, it had no multi-agency input and it did not explore the family’s values and culture around drink and drugs. The assessment reinforced the positives and added to the general optimism that was developing about the family without providing the challenge and scrutiny of parental risk factors that was required.  7.18 The core assessment involved the analysis of information from the parents own history’s and included details of Father’s past alcohol and drug use, and his version of his current use. This was completed with an underlying positive regard for Father who was known to be in treatment and slowly reducing his methadone. His drinking, while of concern, was thought to be largely managed and on a ‘social’ level. At her visit on 8 November 2012 the social worker completed an alcohol screening tool with Father and he was said to show good insight into his previous alcohol use. This was around 4 months before Father disclosed to staff in A&E that he was drinking a bottle of vodka and 8 cans of beer a day. There was no evidence available to ChSC at this time that Father’s drinking had become a significant issue however. What was not acknowledged at the time was that with his history Father     19  should not have been drinking at all. The impact of Father drinking was underestimated and his claim to have 4 or 5 pints once a week when going out with a member of his family should have been explored further and challenged.  7.19 Mother often made excuses for Father’s drinking and minimised how much and how often he used alcohol. At other times however she alluded to the conflict between them as a result of his drinking and the impact it had on the support he was able to give with the children. This was never properly pursued with her. There was evidence, and it was confirmed at the learning event, that there was a degree of professional disbelief that Father had gone from having a serious alcohol problem to being a social drinker, but there was inadequate exploration and challenge to back up this scepticism.  Issues with information sharing in relation to Father’s drinking did not help, but the information that was shared was not used appropriately. The GP report for the RCPC in February 2012 clearly stated that Father having any alcohol intake would be of concern to the GP. To quote the agency author from South Tees NHS Foundation Trust ‘not only was Mother minimising Father’s issues with alcohol, there was evidence that so were professionals. Father smelt of alcohol at various times…including during the RCPC, and this does not appear to have made health professionals wonder what was happening day to day for the children.’   7.20 A local issue identified is the difficulty of getting an appropriate assessment of parent’s mental health and its impact on parenting without paying for this privately. The social workers reported spending hours trying to access the appropriate mental health services which are required for the parents of their clients. To find a service which will provide an assessment of the impact on parenting of mental health issues is very difficult, but much needed in the area.  This was also identified in a thematic government inspection of the relationship between children’s services and adult services for parents with mental health or substance misuse issues undertaken in Middlesbrough in 2013.9  7.21 The drug and alcohol service that Father was engaged with at the time was a GP prescribing service, not a full treatment service which helps patients shift from maintenance to recovery. The childcare professionals involved did not necessarily understand this and thought that Father’s engagement with the service was more significant than it was. The service basically provided him with his methadone and undertook testing to check he had not taken heroin in the timescale covered by the test. It does not appear to have provided any more than this.  Father did not take advantage of any other services that may have assisted him in identifying the underlying issues and worked with him on his addictions.  7.22 There was little exploration of violence within or outside of the home in the assessments undertaken. There was evidence that both parents had the capacity for violent confrontation. In relation to Father, over and above his criminal record there were allegations of domestic violence towards his partner (unsubstantiated by her) and an incident reported by Maternal Grandmother that he had picked up a fence post and threatened violence with it. In the case of Mother there were counter allegations that she had assaulted her partner and one particular incident where, in the presence of the social workers, she stormed into the children’s school and sought a confrontation with the staff. 7.23 Mother’s use of codeine did not appear to be an issue that was acknowledged at the time. With hindsight the review was made aware that this was a significant issue, as Mother has                                                             9 As part of this thematic inspection Ofsted inspected 6 local authorities looking at the links between adult and children’s services where children are living with parents with either a mental health problem or substance misuse.     20  since sought support for her codeine and other drug addictions. However it was known that she had an addiction to Iron Bru and she admitted to drinking around 2 litres a day.  7.24 While extensive assessment work was undertaken with the family, it is the view of those involved that the wrong type of assessment was completed. There had not been any concerns about the presentation of the girls; they had always gone to school well dressed. There was also evidence that the children were given affection by the parents and they appeared to be loved. There was good family support from the maternal side of the family. As reflected at the learning event, if staff were asked which of their cases were most likely to end up in a Serious Case Review, these children would not have stood out.  7.25 A disproportionate amount of credit was given to the parents for their clean home and well dressed children, their statements of commitment to the children, and their superficial willingness to work with professionals. What didn’t happen was an assessment of the parents true dependence on substances including alcohol, about the ability of the parents to change in regards to their addictions, an exploration of their co-dependent relationship, and their underlying mental health issues, all of which were likely to have a negative impact on their care of the children. It is important to not just focus on the practical care of the children, but to consider their care in a fuller sense by looking at the consistency of their care, including meeting their health needs, getting the children to school on time, and the wider impact of Father’s lifestyle on the children.  7.26 It has been identified during this review that there was a lack of direct work with the children, and although professionals described the children in detail in their recording, the children’s voices were not clearly sought or stated. It was not known what it was like for the children living with their parents. A number of professionals spent time with the children, but didn’t speak to them to explore their view of the known parental behaviours, including Father’s drinking and the amount of time he appeared to spend in bed.  7.27 The lack of a thorough pre-birth assessment in this case was noted. At the learning event it was discussed and all those present felt that if a family with children on a CPP are expecting another child, a full pre-birth assessment must be completed on that child, which also considers the impact on the rest of the family of a baby joining the household. In this case this was not entirely considered, with the families practical preparations for the new baby reassuring professionals that all would be well.  7.28 By the time the first RCPC was held the family were being seen and presented in a positive light. The IRO told the learning event that the first RCPC is seen by his team as an opportunity to take the temperature of a case. In Middlesbrough it is reported to be very rare for children to be taken off a CPP at this stage.  It was clear to the IRO that by the first RCPC that family were working with professionals and doing well, and that the care of the children was not of concern. However it was clear that no capacity to change work had been undertaken and that the core assessment had not been completed.  7.29 The reviewer was told that there is a degree of pressure to get children off a CPP after 2 reviews have been held. Local Authorities are measured on the length of time a child remains on a CPP and IROs are aware of this. In this case Jenny and Molly’s CPPs were discontinued at the second review, despite the imminent arrival of Emily. Having considered this the IRO stated at the learning event that he now always considers making an exception to this practice when a new baby was about to join the family, due to the pressure that this can place on the situation.     21  7.30 The Core Group stated that they were being pragmatic in regards to the decision not to pursue Father’s mental health assessment. With very few resources available locally, lack of knowledge in regards to the seemingly complicated pathways to access such assessments, and Father appearing more stable psychologically, the decision was made that the assessment would not be pursued. There had been a delay in receiving the medical notes from both Mother’s and Father’s GPs. The lack of any current mental health concerns emerging from the medical notes also had an impact on this decision. Soft intelligence was missed about the likelihood that users reducing methadone levels will often rely more heavily on alcohol. Father’s binge drinking, with the accompanying impact it had on his appearances at A&E, was not grasped as representing a significant setback in the families coping capacity. His drunken and abusive behaviour at the hospital at the time of Emily’s birth in January 2014 was a good indicator that he was placing his addiction before the welfare of his family. 7.31 The optimistic view of the family increasingly held by professionals had an impact on the assessments undertaken and the decisions made. Both parents were said to be likeable and professionals believed they were doing the best for the children, with the exception of the school staff who believed that the lack of parental concern about school attendance and punctuality was harmful and who struggled to work with the parents. An analysis of disguised compliance and manipulative behaviour in this case is provided below. However it should be noted here that professionals around the table spoke of the difficulty in moving from a good opinion of a family or individual when new concerns emerge. This helpful quote was provided by the South Tees NHS Foundation Trust author ‘One of the most common, problematic tendencies in human cognition…is 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.’10 This appears to have been the case here.   7.32 The learning event identified that there had been a number of different social workers involved with the family. The handover process can offer a useful opportunity for the new worker to test and challenge what has gone on before. At the learning event the social worker who took over the case from the date of the ICPC remembered being told by the previous worker that the family were nice, that they had had a hard time and were vulnerable, but that the children were doing really well. Father was also said to be stable and they said that they didn’t see the case remaining of concern for long. The fact that the case was held by predominantly newly qualified social work staff brought with it inherent dangers that the optimism of the previous worker would be transmitted to the next one. 7.33 There is no evidence that Father was asked about or tested for using any substances other than heroin and cocaine.  It is also significant to note that the tests that were undertaken would only show drug use for the previous three days, and that this was not clarified by the core group at the time. The review shows that Father, and possibly Mother, are likely to have been using other drugs (including alcohol) throughout the timeframe of the SCR. With hindsight it is clear that the substance that actually caused serious harm to the children, methadone, was never seen as a risk in this case. Father’s commitment to his treatment, his good attendance and clean tests for heroin led to a belief that drug use was not an issue for this family. Father was tested monthly while the children were on a CPP and six-monthly otherwise.                                                               10 Fish, Munro and Bairstow ‘Learning Together to Safeguard Children’ 2009      22  7.34 At the recall event it was agreed that the professional network believed, on the whole, that Father’s commitment to his methadone programme was a good thing and a protective factor for the children. There was no challenge or understanding of the length of time he had been receiving the medication, and the risks this would potentially pose to the children both directly or indirectly.  7.35 A report received for this review from the organisation that was commissioned to provide alcohol services until 2012 stated that while Father’s alcohol misuse was seen as problematic for him, the impact of this on the children in the house was not fully considered and acted on. Even when the assessments undertaken did raise concerns for the children these were not followed up with other services.  Although it was outside the timeframe of this review, this pattern continued into the period we have considered. The impact of Father’s non-engagement with the alcohol treatment service followed by his admission of increasing alcohol use over the 3 years of their involvement was never considered to be escalating the risks to the children. Action taken for non-engagement was to discharge Father from the service and inform his GP, who also did not consider the impact of this lack of cooperation with alcohol service on the children.  7.36 There are a number of examples where information in regards to Father was not shared appropriately with services involved with the children. There appears to be a lack of ‘think family’ in some key areas and a lack of consideration of Father having children, children who were living with this man with numerous issues of his own to contend with.  While reports and assessments stated that parents were engaging well, what became evident during this review was that Father was rarely seen by health professionals working with the children.   9.37 Father was more honest with professionals working with him alone, like the staff in A&E, to whom he confessed he was drinking large amounts of alcohol.  It is a challenge to put in place robust and consistent information sharing from adult focused A&E staff to professionals working with children, particularly when the question of who the patient lives with is not routinely asked.  7.38 It was not acknowledged, when talking to Mother about the children, Father and her own issues that Father was regularly upstairs. This would have had an impact on how candid she could be in regards to the impact on the children of his drinking and methadone programme. Mother would regularly minimise the concerns and say Father was doing well. There did not seem to be any attempt to meet with her alone outside of the family home to ensure she could not be overheard by Father.   7.39 Lessons Learned:   • Over optimism among some of the workers who engaged with the family led to the view that the parents had the capacity, capability and motivation to improve and maintain the quality of the care that they provided to their children. Professionals must challenge the rule of optimism and test perception against the wider information that is available. • Assessing the impact on parenting of mental health or drug and alcohol misuse is an essential requirement when working with parents with these issues. This work needs to be challenging of parents and child centred.  • Professionals need to be aware that negative drug tests do not mean that a service user is drug free, it only shows that they have not used the specific drugs that they were tested for during the previous three days.     23  • It is important to work directly with the children. Observing and describing the children is not the same as speaking to them and ensuring their voices are heard and recorded.  The challenge of working with parents who are manipulative or show disguised compliance.  7.40 ‘Disguised compliance’ is a term that can be attributed to Reder, Duncan and Gray11 It involves a parent or carer giving the appearance of co-operating with agencies to avoid raising suspicions, to allay professional concerns, and ultimately to diffuse professional intervention. At the learning event it was clear that in this case both parents had adopted this stance as a way of avoiding and placating the agencies who had voiced concerns about the children. They became skilled in manipulating professionals and were successful at avoiding any real challenge throughout the scope of this review.   7.41 In some cases parents may use anger and aggressive behaviour towards professionals so that they feel unable to carry out home visits effectively and cannot adequately check on the care and safety of children. Professionals were able to engage with the parents without challenge or hostility in the most part, however they were often described as ‘angry’ when challenged about the lack of school attendance. At the first visit in this period both parents were very angry, and Father was so agitated that the social workers feared for the safety of the children that night. Staff at the learning event said they did not feel intimidated however. It was only the school staff who had on-going concerns about his anger. They also reported that Mother was feisty, defensive and often aggressive. The social worker who took on the case and completed the core assessment reported that the previous social worker had said that she felt the school ‘had it in for the family’ and that this was not justified.   7.42 In the most part there was a reported perception that the family had nothing to hide and this feeling was reinforced by the parents’ attitudes even at unannounced visits.  The perception that the parents were seeking to comply with services and undertake positive change in their capacity to care effectively for the children was not held by professionals alone. Maternal Grandmother, who had first alerted services to the risks, is reported at Core Group meetings as describing how Mother and Father were showing positive changes in their behaviour, and that her fears for the wellbeing of the children were allayed. When the lead reviewer met her, Grandmother stated that Father was very good at playing the innocent party in all areas. She said she understood how professionals would have ‘the wool pulled over their eyes’ by him, as she had too.  She believed the children were scared of him and didn’t dare to tell anyone what was happening at home. She said that even if they were spoken to alone they would not have said anything, due to a combination of loyalty and fear.    7.43 Although he was often upstairs, the social workers, other staff undertaking home visits and the FRT workers completing the parenting assessment felt they knew Father well and that they had enough opportunity to discuss the children with him. He was said to be ‘likeable’ and appeared open about his history. With hindsight it is clear that he just engaged on his own terms and only shared the information he wanted staff to know.  He was not seen as manipulative at the time however. His disguised compliance, avoidance and use of anger and intimidation on occasion show he was skilled at deflecting and diffusing concerns.  When he was known to have been drinking he would be repentant. Mother was seen to be                                                             11 Peter Reder, Sylvia Duncan and Moira Gray in ‘Beyond blame: child abuse tragedies revisited’ (1993).        24  realistic about her partner and protective of the children. It was the view of professionals that the family were being open and honest. With hindsight it is clear they were not and it raises the very real issue in cases of this type that professionals need to keep a healthy scepticism regarding what they are told and what they observe.  7.44 A report published by ADFAM in 201412 which is extensively quoted below outlines the dilemma for staff working on cases like this one. They recognise the significant quandary for children and family support services, where staff who are motivated to work in this field by their desire to bring about positive change for families, must check themselves to test that the good they see in people is a reality.  The theme of optimism and disguised compliance generated a useful discussion at the learning event. Police and Drug Treatment representatives described a more cynical approach in their willingness to trust individuals they come into contact with. This cynicism was often borne out of considerable experience of clients being dishonest or evasive. There is therefore a delicate balance to be drawn between being overly cynical and recognising the potential in individuals to make positive life changes. It is important that families experience optimism from workers who support them to help them to believe that they can tackle the complex problems they face in their chaotic lives. However, this should not be at the expense of a naive trust. Professionals must draw upon all the information that is available to them to challenge themselves and others to ensure that children are living in caring and safe environments.  7.45 It was acknowledged at the learning event that the parents had been skilled at ensuring that professionals were not aware of the drug and alcohol use in the home, the domestic abuse and the general lack of routines. The fact that Families Forward, who are experienced drugs workers, did not recognise the degree of disguised compliance used by the parents is significant. Many of Father’s stories and explanations that were accepted at the time are suspicious now that we are aware of the on-going use of drugs and alcohol. The amount of accidents he had, and how unlucky he seemed getting injuries from slipping on ice, falling off his bike, and being bitten by dogs. All should have made professionals question his lifestyle and sobriety. The family were seen as unlucky and victims rather than chaotic and manipulative.  7.46 The signs of disguised compliance were there at the time. The indifference displayed by the parents in getting the children to school either at all or on time served as an indicator that parents were not making the progress that was required of them, and that they were not heeding professional advice. The school showed tenacity in challenging the parent’s behaviour in this key aspect of their children’s lives, but it was not enough to effectively change the perceptions of others. Father would also often not come downstairs when professionals visited, and as he was not asked to come and join the meeting how he appeared was not considered. When he was seen he was engaged and appeared well. As pointed out in the ChSC report, ‘this could imply that he was choosing when to make an appearance and therefore mask his true behaviours’.  What was missing was a consistent robust challenge between professionals to test out beliefs and perceptions, with the mechanism in place to detect key changes in behaviour and the consequent implications for the wellbeing of the children.                                                                12 Adfam is a national umbrella organisation working to improve the quality of life for families affected by drugs and alcohol.     25  7.47 Lessons Learned:   • Professionals need to be curious and not accept things on face value.  • Professionals must be prepared to challenge their own as well as others’ views, and need support to regularly review cases in a way that encourages staff to question if over-optimism, disguised compliance or avoidance of issues is playing a part.  • IROs have the potential to provide an essential independent view to consider if professionals are over optimistic, or if parents are being manipulative and disguising their lack of compliance. To provide this crucial role they need the right information available, including up to date chronologies.  • All professionals working with children and families need to be trained and supported, to include the provision of reflective supervision, in the identification and challenge of parents who use manipulation and disguised compliance, to ensure the needs of the child remain the priority.  • Schools generally know the children well and their views should always be listened to and considered in assessments and planning. • In order to have the required time to reflect and analyse professionals need effective administrative support, manageable caseloads and effective supervision.   The risks to children when a parent is on a methadone programme. 7.48 In 2003 it was estimated that between 250,000 and 350,000 children in the UK were affected by parental drug use. By 2009, a reported 120,000 children were living with a parent currently engaged in treatment and data collated in 2011-12, indicated that 60,596 adults with an opiate problem had parental responsibility and were receiving a prescribing intervention13. Information received from Public Health in Middlesbrough shows that 2600 people are in drug and alcohol treatment in the town and 50% of them have children.  7.49 This SCR has been helped by close reference to a study entitled ‘Medications in Drug Treatment: Tackling the Risks to Children’ which was published by ADFAM in 2014.  The report is an in depth study of a number of cases where children have died or been harmed from ingesting Opioid Substitution Treatment (OST) medicines, including methadone. The report includes a consideration of the 17 Serious Case Reviews involving the ingestion of OST drugs by children in the five years from 2009 until 2014.  7.50 The report is very clear that there are risks to children if they are living in households where methadone is used and stored. It states that Methadone is ‘toxic, powerful and a clear danger to children when stored or used incorrectly by their parents and carers’. The report is clear that methadone in particular, ‘poses a significant risk to children and other opioid naïve people’. 7.51 There have been at least 17 fatalities and 5 non-fatal ingestions of OST medication by children during the period looked at in the ADFAM report, the majority of which were methadone ingestions. They state that ‘these figures are of necessity underestimates and exclude ‘near misses’ or incidents that failed to culminate in a serious case review for which there is no data publicly available’. Most of the cases were thought to involve the accidental drinking of methadone by children able to help themselves to the drug. In five of the cases however it was clear that the parents had intentionally given the drug to the                                                             13 Chandler et al (2013) ‘Substance, structure and stigma: parents in the UK accounting for opioid substitution therapy during the antenatal and postnatal periods’     26  child. In six other cases it was not ascertained how the child had ingested the drug.  7.52 A number of the serious case reviews undertaken into cases like this one have analysed the practice of giving children low doses of methadone or other drugs with the aim of sedating or pacifying them. The ADFAM report states that ‘parents may have a number of ill-informed or incorrect motivations or beliefs relating to this practice, for example that children can cope with smaller doses of a prescribed medication which is used widely and safely by adults’ and that ‘it is a similar principle to other poor parenting practices which use substances to pacify children, like dipping a baby’s dummy in whisky to help them sleep.’ It is noted in this case that Emily had been seen the day before her overdose at the hospital with an ear infection which would have made her fractious and hard to settle.  7.53 The ADFAM report found that in cases where parents deliberately gave their children drugs, ‘professionals involved with the family are unlikely to account for this possibility.’ At the learning event professionals who knew the family said that it did not occur to them that either parent would give drugs to the children. Their shock and disbelief that this may be the case was evident and understandable.  7.54 Other SCRs considered in the ADFAM report have noted the following findings which may be relevant to this case: - ‘Whilst all agencies were vigilant in monitoring for neglect or harm in respect of the child, no assessment had been carried out to mitigate the risk of him actively being given prescription drugs’ (Bradford LSCB)  - ‘None of the professionals involved with the family had foreseen the possibility of either child being given methadone by one or other of their parents’ (Bristol LSCB Child K) - ‘It is suggested that practitioners acknowledge to themselves and service users that there are occasions when parents deliberately administer drugs, including methadone, to their children’ (Bristol LSCB Child K) 7.55 As well as studying the relevant SCRs the ADFAM report undertook group interviews with a large number of practitioners in the fields of drug misuse and children’s safeguarding. They found that staff tended to be aware of the risk to children of them ingesting drugs accidentally and where child neglect was an issue. They were less aware of the risk of parents deliberately giving drugs to their children, and the groups found the finding of the SCRs surprising. One said they “couldn’t have dreamed” their clients would engage in this practice. The report stated that professionals did not routinely discuss the dangerous use of using methadone as a pacifier within assessments or key working interventions due to the lack of belief and understanding about this practice. In this case this issue was never considered or discussed amongst professionals or with the family.   It was clear from the learning event that such a practice was ‘unthinkable’ to those involved.    7.56  An SCR undertaken by Gloucestershire LSCB engaged with the Mother in the case who informed the review that she believed the practice of administering methadone to small children was not uncommon amongst some substance-misusing parents.  This is not something that the local drug agencies in Middlesbrough have considered, however the learning from this review will help to raise awareness of this an issue.  It should be noted that without Emily presenting with an overdose of methadone, the possibility of the use of drugs on the children in this family would have been unknown to the professionals involved. There may be a number of other cases where this is an issue.       27   7.57 Lessons learned:   • Professionals need to keep a healthy scepticism and always consider the possibility that parents on a drug treatment programme may be tempted to use their medication on their children, perhaps thinking that it will not harm them.  • Professionals need to feel confident in addressing with parents the deliberate administration of methadone and other drugs to children.  Thresholds for CP Plans. 7.58 A large number of Serious Case Reviews have highlighted issues with inconsistency in the application of thresholds in regards to neglect and poor understanding by professionals of neglect14. A theme that emerged during the learning event was the need for a clear understanding of the thresholds for a CP plan in neglect cases. In many ways this case did not meet the usual and expected criteria for a CPP with the category of neglect. The children appeared to be well looked after. They were clean, well dressed, had age-appropriate toys, and lived in a home that was largely well looked after. Their parents gave the impression that they had their children’s best interests at heart and that they were willing to engage with agencies in order to improve their children’s care. They also had extended family support.  7.59 As shown above however, the parent’s cooperation was on their own terms, and they were able to manipulate staff and show a compliance with services that was false. The identified school attendance issues and poor punctuality, and the missed medical appointments and inoculations were clear symptoms of neglect. This was a family who were not prioritising the needs of their children above the parents own issues. The neglect that Jenny, Molly and Emily were suffering was underestimated.  7.60 The children’s health needs were not attended to as they should have been, with Jenny potentially having long term issues with her eyes due to lack of attendance at appointments for this issue. It is noted that both parents attended all appointments for their own needs however, for example Mother’s health issues during pregnancy. There was a degree of chaos however in Father’s reliance on A&E to meet a number of his health concerns during the time we considered.  This is also another indicator of a family in crisis without the ability and commitment to maintaining their children’s care.   7.61 In neglect cases the use of a chronology to reflect on and analyse the care of the children and the significant events in regards to parental risk factors is essential. Although historic concerns were not particularly significant in this case, it would be helpful to build a tool which enabled a shared understanding of the children’s history by incorporating all of the information held on the family across the agencies involved. If a multi-agency chronology which included a focus on lack of compliance was drawn up, including the numerous excuses given for the children to miss school and health appointments, the issues and on-going neglect of the children would have been seen more clearly.  7.62 Without direct work being undertaken with the children it was also hard for professionals to establish the true extent of their neglect. Although there is no guarantee that Jenny or Molly would have told social workers or the FRT workers about what happened behind                                                             14 Learning Lessons from Serious Case Reviews, Ofsted.      28  closed doors, some work with them on their life experiences may have provided a valuable insight into their lived experience.  7.63 There was little questioning of how often the children appeared to be ill, and how often professionals noted the girls seemed pale, lethargic or tired.  With hindsight there is a possibility it was due to the substances they may have been ingesting. However even at the time there were questions to answer about why the children were so often ill and tired, and why the parents seemed to find it so hard to get them to school and medical appointments. There was also no exploration of whether the children needed any further medical assessments regarding the reoccurring illnesses. This was probably because professionals did not believe the children were ill.    7.64 It is a dilemma, when things seem to be going well otherwise, to decide to keep children on a CPP plan when school attendance appears to be the only significant factor in a case. However it has been established that had there been an analysis of the families lack of compliance, which went back to their early lack of engagement with the CAF and refusal to engage with family support provided by the Children’s Centre, along with the on-going missed health appointments and school issues, the threshold for a further period of CP planning may be have been met.  There was also limited exploration of how the care of the older children would be impacted on by the birth of a new baby.  7.65 The IRO who chaired the conference where the decision was made to take Jenny and Molly off the CPP was influenced by the positive regard for the progress made by the parents in the previous 9 months. He was also aware of the need to ensure dynamic CP planning by not allowing children to remain on a CPP for a long period. He did not have time, with a large caseload, to explore the case recordings, and took what was presented to the conference at face value. It was understandable, in light of the positive assessments and effective disguised compliance from the parents, that Jenny and Molly‘s cases were stepped down to CinN plans that were supposed to be used to continue to work with the family on the school attendance issues.  7.66 The recall event discussed the focus on neglect in Middlesbrough since 2014. A neglect strategy has been written and it is comprehensive. Training has been extensive and widely offered and there has been a good uptake. The impact of this would not have been embedded at the time that the work was undertaken in this case. Those involved in the review felt that practice was improving in this crucial area.  7.67 Lessons learned: • Poor school attendance and punctuality and a pattern of missed health appointments, constitute child neglect.  • Staff should not accept assertions and reassurances about taking children to key appointments without checking that that they have happened.  • When a new baby is expected in a family, consideration needs to be given to extending the period of the CPP to allow for the impact of the baby to be assessed and monitored. Supporting staff undertaking complex case work.  7.68 It is clear that staff working with families with complex difficulties and child protection or safeguarding concerns require the time to undertake the role, on-going training, support, and the opportunity to reflect on their work. A number of issues have been identified which     29  provide a context around the work undertaken on this case. These include high caseloads, limited management capacity and staffing issues.  7.69 At the time the children were made subject to a CPP the health visiting service was under a lot of stress with a new and complicated IT system (SystmOne) to work on. They were also very short staffed, with around 1/3 of the team off on long-term sick leave. Managers had to move staff across the town to try and provide adequate cover. At this time the health visiting and school health nurse services in Middlesbrough were seen as ‘at risk’ and were the subject of an incident report. However it should be noted that the social worker stated at the learning event that she always felt well supported by the health visitor and school nurse in this case.  7.70 It was shared that community midwives are expected to see one woman every 20 minutes, and during the relatively short appointments no concerns for Mother or the family were evident.  7.71 Father’s GP surgery had a number of key members of staff leave during the period of this review which had an impact on the management of the work and the level of experience within the practice. 7.72  The ChSC agency report informed the review that 2012 ‘saw an unsteady year for the children’s workforce.  Agency staff were being recruited, retention of staff was at a critical point and caseloads were high.  Providing consistency for families was difficult to maintain and team managers had to work with these inconsistencies on a regular basis’. The staff at the learning event agreed with this analysis and stated that as newly qualified staff they felt they could have had more support.   The three social workers that had involvement in the case during the scope of the review were newly qualified. None of their managers had been working in a managerial role for more than 2 years. The agency report and learning event both highlighted the lack of management oversight and decision making in this case and an absence of regular supervision.  The social workers did not have the required number of supervision sessions set out in policy. This allowed the social workers, through lack of experience, to begin again when the case was allocated to them, and to maintain their over optimism in regards to the parents.  7.73 It was evident from this review that the MSCB had not been made aware at the time of the difficulties faced by front-line staff due to staff sickness, shortages and demands such as IT systems and reorganisations.  7.74 Staff need help and support to challenge other professionals. A lack of professional challenge was evident in this case.  Supervision was also inadequate in regards to providing challenge to staff about the assumptions they were making and the conclusions they reached about this family. The school provided some challenge by questioning the assessments being made and by stating their disagreement in regards to the decision to remove the children form a CPP.  However they did not formally escalate their concerns.  7.75 There was a lack of analysis evident across and between agencies. Professionals at the learning event recognised the need to regularly take a step back when working with families to really think about what is happening, to consider the child’s world, and to question their assumptions. They could see the value of regular skilled supervision in helping them to identify their over-optimism and whether clients are exhibiting disguised compliance. They felt that multi-agency group supervision would enable a culture of respectful challenge which could also consider professional dynamics without the     30  presence of children and families.  Some changes have been made in Middlesbrough since the time this review considers, and they are noted below at 10.4.  7.76 Lessons Learned: • Regular and effective supervision is essential in giving professionals the opportunity to reflect on their work, and in ensuring that the work undertaken is child centred.  • Issues of capacity should always be escalated to senior managers as soon as they become an issue. The MSCB should also be informed of these issues. This is likely to be more of an issue as demands increase and resources are more stretched. 7.77 Good Practice  There were a number of examples identified in this case of good practice across all the agencies involved. They include: • Good communication between the health visitor and school, including some joint visiting.  • The School regularly and assertively voicing their concerns and keeping a focus on the needs of the child. • Meetings happened on time and visiting was regular, and often unannounced, which is good, particularly when seen in the context of low staffing levels and high caseloads in both ChSC and health visiting services.  • A GP practice chased information that was missing from a conference. • The investigation into Emily’s methadone ingestion and the swift actions taken to safeguard Emily and her siblings on the day she was admitted to hospital. • Record keeping was largely good. • The ICPC was well attended, reports were written and the recommended plan was robust.  Conclusions  8.1 The potential for parents to deliberately give their children drugs was unprecedented in the experience of all the professionals involved in this case at the time and to those involved in the SCR.  It was hard for staff to ‘think the unthinkable’ when they had not been made aware of the potential for such a form of abuse. It is hoped that the learning from this review will alert all professionals in Middlesbrough and beyond, to the potential for children to be given dangerous substances by their parents.  8.2 The review has attempted to avoid hindsight bias which “oversimplifies or trivialises the situation confronting the practitioner and masks the processes affecting practitioner behaviour” (Woods et al15).  The learning has been identified in each section above, and the recommendations links to this learning.  8.3 Even without the benefit of hindsight there was evidence available that Father or Mother might pose a risk to children before the incident in January 2014. It is not known if either parent deliberately put Emily’s life at risk, or indeed whether they underestimated the impact of such an action.  The ADFAM report quotes a service user who said that ‘opiate users often feel they know more about the use of opiates than practitioners, through their                                                             15 David D Woods et al. Behind Human Error. 2010.     31  own lived experience: they may feel relatively confident in administering a small amount to a child, and having begun the practice of using it as a pacifier, may become increasingly bold in doing so’.   8.4 A number of changes have taken place in Middlesbrough since the serious concerns about Emily, Jenny and Molly emerged in January 2014.   This reflects the fact that some of the “best learning from serious case reviews may come from the process of carrying out the review” 16 • IRO caseloads are now 50% lower allowing them more time to ensure they have all the required information for a meeting and to ensure child protection plans are robust.  • The GP agency report states that the specialist nurse at the practice has started to place more emphasis on safe storage in her consultations, be more specific regarding documentation of alcohol and opiate use and increased the education regarding alcohol use and methadone in combination.  • Middlesbrough ChSC has embedded the ASYE, approved supported year of employment and therefore newly qualified social workers are now offered additional support and guidance from a dedicated training and development officer as well as increased supervision from their direct line managers.    • Adult practitioners with experience of substance misuse are now aligned with Safeguarding Front of House services and provide the necessary guidance support and training to both managers and social workers alike.  They are also developing a new model that will bring together a think family approach to assessment and intervention where substance misuse is a factor within families.  • In 2014 ChSC implemented a system for creating electronic records for all children open to Safeguarding Services.   Manual files have been systematically archived via a roll out programme and the workforce has undergone training on how to fully record on the Integrated Children’s System.  9 Recommendations 9.1 It is recognised that actions have already been made in relation to some of the individual agency's identified learning. In addition agency reports included some recommendations which this review endorses. They are attached as an appendix.  9.2 It is acknowledged that the ADFAM report of 2014 that has been extensively quoted in this report and the serious case reviews it studied have made some excellent national recommendations. They include the recommendation that ‘consideration should be given to a short and powerful social media campaign to tackle a culture where administering methadone to children is perceived as acceptable’. This SCR would welcome this action.   9.3 The purpose of providing additional recommendations is to ensure that the MSCB and all professionals in the partner agencies of the Board are confident that the areas identified as of concern in this review are addressed.                                                                 16 Brandon et al.  Lessons from Serious Case Reviews.  2012     32  Recommendation1  The MSCB to request that Middlesbrough Recovering Together (MRT) reviews all information for service users and professionals regarding drug treatments. They must ensure that leaflets and posters make it clear that giving an OST to a child is extremely dangerous and can be fatal.   Recommendation 2  The MSCB to include the risk of drug using parents actively giving drugs to their children is covered in all relevant MSCB training. Consideration should be given to including the request that relevant staff routinely ask parents who misuse substances if they have ever given their children illicit substances.  Training could also include the signs and symptoms in children of drug ingestion, and clarity about what professionals should do if they suspect this is happening.  Recommendation 3  That the MSCB consider piloting a model of reflective supervision for core groups, to ensure professionals gain confidence in working with parents who are manipulative and show disguised compliance.   Recommendation 4  The MSCB should inform all partner agencies of its expectation that all relevant staff working with children should attend MRT drug and alcohol awareness training.  Recommendation 5 The MSCB to communicate to ChSC its expectation that consideration should always be given to sharing information with extended family that are being relied on to assist in the safeguarding of children. This should include them being invited to key meetings such as child protection conferences and them receiving information in writing about the concerns and risks.  Recommendation 6 That the MSCB undertakes a multi-agency case file audit to consider if there is adequate evidence of the following in agency records: • Reflective supervision • The voice of the child  ……………….   