Death of a three-month-old baby in 2016. An inquest recorded a verdict of death by natural causes. There were indications of drug use, poor home conditions and neglect within the family which included four other children. Children's services had been involved with the family at various times over several years. The mother was arrested and a criminal investigation initiated. Key findings: partner agencies' concerns were often not accepted by children's social care; families do not fully understand the differences between Level 2, Level 3 and Child in Need within the Common Assessment Framework; lack of openness within children's social care to escalate cases; uncertainty as to the appropriate response when the mother refused access to the health visitor and other workers; no consideration given as to why the mother was neglectful or what levels of support she had in the community. Recommendations include: the need to develop a broader agreement amongst partner agencies on the application of thresholds; to review the effectiveness of the escalation policy and its application locally; children's services should develop clear practice guidance on the use of announced and unannounced visits; professionals leading on a Level 3 Common Assessment Framework (CAF) should ensure that GPs are fully informed of CAF activity in line with existing procedures.
      
    Serious Case Review No:  2018/C7321  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.    Page | 1      Baby L Serious Case Review Findings and Recommendations Report    Page | 2    Introduction  1. This overview report was commissioned by a Safeguarding Children Board as a Serious Case Review (SCR) following the death of baby L in 2016. He was a three-month old baby who died after he was found lifeless early in the morning by an older sibling. He was taken by ambulance to hospital but resuscitation attempts by ambulance crew and hospital staff were unsuccessful.  2. The subsequent inquest recorded a verdict of death by natural causes,   3. At the time of his death there were indications of drug use in the family home, poor home conditions and neglect within the family. The family were open to children’s social care services at the time of the baby’s death and a formal child protection investigation had been initiated the previous day. Children’s services had been involved with the family at various times over several years.   4. Mother was arrested the day after baby L’s death and a criminal investigation was initiated.  5. The Safeguarding Children Board was concerned to establish whether previous contacts with services had correctly identified and assessed the risks for this family and taken appropriate action to mitigate the issues during a three year period up until baby L’s death.  6. Felicity Schofield was appointed to chair the SCR process and Daryl Agnew was commissioned as the Independent Author to complete the SCR overview report. Both are independent of any services involved in this case.  7. A panel of senior managers from each of the agencies involved was appointed to support the review process.   8. At the initial scoping meeting, a three year timeframe was agreed for the review. The SCR sub-committee also identified a number of issues for consideration by all the agencies involved. They included:   the quality of assessment;  thresholds for intervention;  family engagement and the voice of the child;  multi-agency working; and  staff supervision and management.   Page | 3    Summary and Conclusion              Thresholds 9.  The use of two levels within the Common Assessment Framework is complicated. Level 3 is similar to family support (Children in Need: Section 17) in many other local areas. Practitioners at the practitioner event expressed the view that families do not fully understand the differences between Level 2, Level 3 and Child in Need. Views were also expressed that significant efforts seem to be made by Children’s Social Care to keep cases away from children’s social care. This case also shows that partner agencies’ concerns are often not accepted by children’s social care.     10. When the case was accepted by children’s social care, the earlier work of their colleagues within the Children and Families First service went largely unrecognised so that the Child in Need plan replicated rather than built upon the work done within the earlier Common Assessment Frameworks. This is not a good use of resources and is hard for families to understand.   11. The child protection threshold was reached, but not recognised, sooner than the date when the strategy discussion was requested. This is because the concerns, which were well known to professionals, were much more significant when applied in this case to a very young baby.                Escalation 12. Practitioners understood the concept of escalation and why it was important. However, a view expressed by practitioners is that the culture within children’s social care services was not open and escalation within the lower levels of organisations had simply no effect. Practitioners with experience of working across local authority boundaries described a greater openness in neighbouring areas.               Consent 13. There was uncertainty amongst practitioners about what was the most appropriate response when the mother refused access to the health visitor and refused to let workers see parts of the family home. The LSCB should offer some practice guidance to enable practitioners to address such issues.                Assessments 14. Assessments at all levels did not consider why the mother was neglectful, her own background or the levels of support that were available to her from her extended family or within the local community.  15. GPs and other relevant partners, such as housing, were neither involved in nor advised of the outcome of assessments.  16. The lived experience of each of the children did not always feature. In particular, when the mother was pregnant with baby L the assessments did not consider either the impact on the mother in caring for a 5th child singlehandedly or the particular impact of unhygienic conditions on a new born baby.  Resources 17. There was agreement amongst all agencies at the practitioner event that there were more resources (i.e. time and capacity) available to help families within Children and Families First than when a case transferred to children’s social care.  Page | 4   Therefore it would seem, as need increases a family can actually expect less input.              Use of the Graded Care Profile 18. There has been no leadership offered to the partnership with regard to the use of the important but also intrusive and very time consuming process of a Graded Care Profile (GCP). As a result, the GCP is used in an ad hoc way and the outcomes are not used to good effect.               Unannounced visits 19. Whilst unannounced visits may be built in to either a child in need plan or a child protection plan it is difficult to understand why they would be appropriate at a Common Assessment Framework level. When the mother was not at home for unannounced visits, it seemed to be held against her. This is neither logical nor fair.    Page | 5    7.  Recommendations  The LSCB: Recommendation 1: the LSCB should offer practice guidance to enable practitioners to address the issue of the lack of parental consent within the context of voluntary family support.  Recommendation 2: the LSCB should review the multi-agency training on neglect to enable the development of a shared understanding about the cumulative impact of neglect on children and the ways in which professionals can challenge adults in such circumstances. In addition, such training should be linked to practice regarding the use of Signs of Safety and guidance on when and how to use the Graded Care Profile.  Recommendation 3: the LSCB should review the effectiveness of the escalation policy and its application within the local context.  Recommendation 4: the LSCB should develop broader agreement amongst partner agencies on the application of thresholds. This should involve commissioning follow-up work to a previous threshold audit in order to establish how effectively the thresholds are being applied.   Children’s Services: Recommendation 5: Professionals leading on a Level 3 Common Assessment Framework (CAF) should ensure that GPs (and where relevant, other partners) are fully informed of CAF activity in line with existing procedures. In addition, all multi-agency assessments should involve GPs. At Level 2 CAF, consideration should also be given to informing other agencies, where relevant.  Recommendation 6: Children’s social care staff should respect and build on the earlier work done by Children and Families First colleagues and partner agencies when a child transfers to social care.  Recommendation 7: Children’s services should develop clear practice guidance on the use of announced and unannounced visits. 