Serious head injuries which were potentially non-accidental to a 3-month-old child in January 2017. Child BY is a twin, born prematurely at 35 weeks' gestation, discharged from hospital into a family with co-existing domestic abuse, mental illness and substance misuse and where father had just lost his brother. Family known to Child Protection Services for two older siblings; the twins were subject to Child Protection Plans at birth; various risk assessments were carried over a two year period. Family is White British. Issues identified include: the need to consider mother's full history and understand the impact of trauma, loss and ongoing abuse and coercion; severe risk of harm is most likely where there is an absence of protective factors; the need to consider male perpetrators in assessments and address or recognise their behaviour and accountability for it. Model designed and led by reviewer to enable participants to consider the events and circumstances leading up to injuries to Child BY. Learning arising: to consider the approach to domestic abuse cases where the victim expresses a wish for the relationship to continue and how this impacts on the children; to ensure that practice and supervision are influenced by an understanding of the long term impact of unresolved childhood trauma, loss and abuse and serious and chronic domestic abuse and coercion on parenting capacity; to consider how agencies currently respond to families where neglect may co-exist with domestic abuse and that neglect is responded to as a safeguarding issue and not solely as a symptom of domestic abuse.
      
 Title:  Serious case review report Child BY. LSCB: Blackpool Safeguarding Children Board Author: Clare Hyde Date of publication: 2018  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.                            Clare Hyde THE FOUNDATION FOR FAMILIES SERIOUS CASE REVIEW REPORT CHILD BY     1   Contents Key: Family Members .............................................................................................................................. 2 Introduction ............................................................................................................................................ 3 The SCR: Process and Methodology ....................................................................................................... 3 Independence ......................................................................................................................................... 6 Serious Case Review Panel ...................................................................................................................... 6 Confidentiality ......................................................................................................................................... 7 Family involvement ................................................................................................................................. 7 Staff involvement .................................................................................................................................... 8 Race, Religion, Language and Culture ..................................................................................................... 8 Summary of Family history ..................................................................................................................... 8 Overview of events and agency involvement ....................................................................................... 10 Analysis ................................................................................................................................................. 10 Summary ............................................................................................................................................... 32 Reframing our Response to Risk ........................................................................................................... 32 Learning arising from this Serious Case Review ................................................................................... 36 References ............................................................................................................................................ 39    2  Key: Family Members  Child BY Aged 3 months at date of incident Sibling 3 Aged 3 months (Child BY’s twin) at date of incident Sibling 2 Aged 3 at date of incident Sibling 1 Aged 5 at date of incident Mother Child BY’s mother Father Child BY’s father MGM Maternal grandmother    3  Introduction 1. The subject of this Serious Case Review (SCR) is Child BY. 2. Child BY suffered serious head injuries which were potentially non-accidental on 29th January 2017. Child BY was 3 months old at the time of the injuries. 3. There was a 2 year history of agency involvement with Child BY’s family in respect of domestic abuse and Father’s offending. 4. The domestic abuse (Father was the perpetrator) was serious and involved assaults, threats to kill and use of a weapon. The abuse was the primary reason that Child BY and siblings were subject to Child Protection arrangements. 5. This SCR focused upon agency involvement with Child BY’s family and in particular Child BY’s older siblings in order to identify good practice, learning and missed opportunities to safeguard all of the children which in turn could have provided an opportunity to safeguard Child BY. The SCR: Process and Methodology 6. The Local Safeguarding Children’s Board (LSCB) agreed on the 2nd February 2017 to commission a Serious Case Review (SCR) concerning the injuries suffered by Child BY. The scope of this SCR was to cover the timeframe from 3rd December 2015 to 29th January 2017 which was the date of the injury to Child BY. (It was agreed by the SCR Panel that any significant events prior to this date would also be included within the scope). 7. The Case Review Sub Group made a recommendation that the LSCB should conduct a proportionate, appropriate and participative SCR with the emphasis upon professional involvement, to address how agencies had worked together in this case, identify any learning, aggregate lessons from individual organisations and ensure that an improvement action plan was put in place.  4  8. The SCR was designed and led by Clare Hyde MBE, independent reviewer, from The Foundation for Families (a not for profit Community Interest Company). Ms. Hyde developed a review model that would enable participants to consider the events and circumstances, which led up to the injuries to Child BY. 9. This formal process allows practitioners to reflect on cases in an informed and supportive way. Documenting the history of the child and family is not the primary purpose of the review. Instead it is an effective learning tool for Local Safeguarding Children Boards to use where it is more important to consider how agencies worked together. The detail of the analysis undertaken of the case is not the focus of the reports which are succinct and centre on learning and improving practice. However, because a review has been held, it does not mean that practice has been wrong and it may be concluded that there is no need for change in either operational policy or practice. The role of Safeguarding Boards is to engage and contribute to the analysis of case issues, to provide appropriate challenge and to ensure that the learning from the review can be used to inform systems and practice development. In so doing the Board may identify additional learning issues or actions of strategic importance. These may be included in the final SCR report or in the action plan as appropriate.   10. This approach also takes account of work that suggests that developing over prescriptive recommendations has limited impact and value in complex work such as safeguarding children. For example, a 2011 study of recommendations arising from SCRs 2009 -2010, (Brandon, M et al), calls for a limiting of ‘self-perpetuating and proliferation’ of recommendations. Current thinking about how the learning from SCRs can be most effectively achieved is encouraging a lighter touch on making recommendations for implementation rather than over complex action plans. 11. An SCR Panel was convened of senior and specialist representatives from agencies involved with the family in the time covered, to oversee the conduct and outcomes of the review. All  5  panel members (apart from staff from the older sibling’s school) were independent of the family and casework. The role of the panel was to assist the Lead Reviewer in considering the evidence, formulating the recommendations and quality assuring this report. 12. There was significant agency involvement with Child BY’s family and the following agencies were asked to provide a chronology and these were integrated into a combined chronology. • Blackpool Council Children’s Services  • Blackpool Teaching Hospitals NHS Foundation Trust • Cumbria and Lancashire Community Rehabilitation Company • Lancashire Constabulary  • North West Ambulance Service • NSPCC • General Practitioners for all parties • S1’s Nursery and Primary School • Providers of Independent Domestic Violence Advocate (IDVA) and substance misuse services 13. The Lead Reviewer considered the combined chronology in order to consider in detail the sequence of events and any key practice episodes that underpinned those events.  14. The SCR Panel agreed the scope of the SCR. The SCR panel also considered key lines of enquiry which were then included in the terms of reference. These included: A. Quality of risk assessments and other assessments  B. Effectiveness and review of the Child Protection Plan including: C. Communication between agencies including information transfer, handover issues, recording events D. The voice of the children E. The views of family members and whether professionals effectively considered these.   6  15. The completion of the review was significantly delayed by a parallel police investigation regarding the injuries sustained by Child BY during which it was not possible to offer family members the opportunity to contribute to the review. Independence 16. An independent chair, from a partner agency without direct operational involvement with the family, was agreed by the Local Safeguarding Children Board to chair the SCR Panel.   17. The lead reviewer Ms Hyde was CEO of Calderdale Women Centre for 14 years (between 1994 and 2009) and developed nationally acclaimed, high quality services and support for at risk women and families. Ms Hyde contributed to Baroness Corston’s review of women with vulnerabilities in the criminal justice system which was commissioned by the Government following the deaths of several women in custody.  18. Ms Hyde is currently working with local safeguarding children boards and their partners to improve safeguarding outcomes for children and young people living with domestic violence, substance misuse and parental mental illness and to support the development of a multi-agency response to children and young people at risk of sexual exploitation. 19. Ms Hyde also designed and facilitated a multi-agency review of child sexual exploitation in Rochdale in 2012 and is currently the Independent Chair and Reviewer of several SCRs and a Domestic Homicide Review and has designed and led several Learning Reviews on behalf of local safeguarding children and adults boards. Serious Case Review Panel 20. The SCR Panel met on a number of occasions between May 2017 and September 2017. The subsequent agreement and publication of the report was delayed by a police investigation that concluded in the summer of 2018.  7  21.  The overview report was ratified at the Local Safeguarding Children Board meeting on 7th September 2018. 22. The Panel comprised of:  Clare Hyde Independent Reviewer Designated Nurse for Safeguarding (Panel Chair) Blackpool Clinical Commissioning Group Review Officer Lancashire Constabulary Named Nurse for Safeguarding Blackpool Teaching Hospitals NHS Foundation Trust Head teacher DSL/ SEND Co-ordinator S1’s primary school S1’s primary school Deputy Director Cumbria and Lancashire CRC Principal Social Worker Blackpool Council Service Manager – Duty and Assessment Blackpool Council Service Manager – Families in Need team Blackpool Council Service Manager NSPCC Designated Doctor for Safeguarding Blackpool Clinical Commissioning Group Business Development Manager Blackpool Safeguarding Children Board Confidentiality 23. Working Together to Safeguard Children 2015 clearly sets out a requirement for the publication in full of the overview report from SCRs: 24. “All reviews of cases meeting the SCR criteria should result in a report which is published and readily accessible on the LSCB’s website for a minimum of 12 months. Thereafter the report should be made available on request. This is important to support national sharing of lessons learnt and good practice in writing and publishing SCRs. From the very start of the SCR the fact that the report will be published should be taken into consideration. SCR reports should be written in such a way that publication will not be likely to harm the welfare of any children or vulnerable adults involved in the case.”  Family involvement 25. Mother, Father and MGM were all offered the opportunity to participate in this review but declined the opportunity to do so. This report is therefore limited by the lack of a perspective from family members who were in receipt of services.   8  Staff involvement 26. The staff who were involved with Child BY’s family participated in a Learning Event in July 2017. The Learning Event was attended by practitioners who had had direct involvement with Child BY’s family, in addition to the Lead Reviewer who facilitated the event and the BSCB Business Manager.  27. Following the Learning Event, the Lead Reviewer collated the outputs from the Learning Event and from the agency chronologies and began her analysis. In reviewing the findings, the panel gave consideration to what could be done differently to further improve future practice.  Race, Religion, Language and Culture 28. Child BY’s family are English White British. Whilst Mother was from a traveller family and did not live a traditional traveller lifestyle as an adult it is not known how (or if) she identified as of traveller heritage. This did not therefore inform assessments. Similarly it is not known if religion was a feature of the family’s life. The family’s first language was English. Summary of Family history    29. What is known about the family’s history is detailed below.  30. It is reported that Mother lived with domestic abuse and parental alcohol misuse as a child and also experienced the early loss of a significant family member with whom she had a very strong attachment. 31. It is believed that Child BY’s parents have been in a relationship since approximately 2008. Mother would, at that time, have been aged approximately 17 or 18 and Father 24 or 25 years old.  9  32. Mother and Father have 4 children together. Sibling 1 who was aged 6 at the time of the significant incident, Sibling 2 who was aged 2 and Child BY and his/ her twin Sibling 3 who were aged 3 months. 33. Child BY’s Father has perpetrated domestic abuse against Child BY’s mother and has been convicted of assault against her.  34. Father throughout the time scale of this SCR committed other criminal offences in addition to the domestic abuse and received further custodial sentences in 2016 (more detail given below). 35. Father had known drug and alcohol issues and was, for example, arrested for possession of cocaine and cannabis in October 2016.  36. There is very little known or recorded about Father’s childhood therefore this was not used to inform assessment of need or risk. 37. Both Mother and Father have sought help for mental health issues during the time scale of this review.  38. Although not within the timescale of this review Mother and Father separated for 8 weeks in April 2015. During this separation Father threatened to ‘slice her throat’ with a knife. 39.  Also during the 8 week separation Mother was assaulted by a man with whom she had a brief relationship and by two women who were thought to be acquaintances of his. 40. Mother had a difficult relationship with her own mother MGM and this resulted in reported domestic abuse incidents (MGM was the alleged perpetrator) and periods of time during which Mother and MGM were estranged. 41. Sibling 1 and Sibling 2 became known to CSC in 2015 because of the domestic abuse perpetrated by Father which included assault and threats to kill Mother.  42. There were signs of neglect including the children being left alone and missed medical appointments.  10  43. In September 2015 Sibling 1 was found in the street at the age of 3 alone and partially dressed. The adult who found him discovered that 15 month old Sibling 2 was in the house alone crying in a cot upstairs. This led to a referral to Children’s Social Care and an Initial Assessment. 44. In December 2015 Siblings 1 and 2 became the subjects of Child Protection arrangements because of emotional abuse due to the ongoing domestic abuse between their parents (perpetrated by Father). 45. In April 2016 Mother’s pregnancy with Child BY and Sibling 3 was confirmed.  46. In August 2016 another family member made threats against mother. 47. In October 2016 an Initial Child Protection Conference was held in respect of the unborn twins. It was agreed that the twins would be subjects of a Child Protection Plan at birth. 48. Throughout the period covered by the review Father was supervised by the Community Rehabilitation Company in relation to his offending. Overview of events and agency involvement   49. Although the timeframe for this SCR was 3rd December 2015 to 29th January 2017 agency records held historical information which is relevant to the case and this has been considered. Analysis 50. The analysis is set out in response to the key lines of enquiry set by the SCR Panel which formed the terms of reference for the SCR.  The analysis is informed by the chronological information provided by agencies, the views and contributions of the practitioners who attended the Learning Event, by research and by analysis of other serious case reviews and domestic homicide reviews.    11  How was risk recognised and assessed in this case? 51. The risks posed to Child BY and siblings by the adults in this case were not always recognised and assessed. 52. Domestic abuse was recognised as a primary risk to the children and was the reason that they were subject to child protection arrangements.  53. However the other risks, whilst in some instances acknowledged (such as Father’s offending) were not sufficiently recognised and subsequently assessed as a risk to the children.  54. In particular the cumulative and compounding nature of multiple risks were not sufficiently recognised. 55. The potential risks to Child BY and siblings from the adults include:  Chronic and serious domestic abuse including use of a weapon and threats to kill   Attempts to separate by Mother from Father  Father’s drug and alcohol use   Father’s offending including other offenders visiting the family home.  Father’s non-compliance with his sentence conditions  Non-compliance by the adults with the expectations placed on them by the Child Protection Plan.  Signs of neglect including the children being left unattended.  Mother’s vulnerability (she was assaulted, threatened and experienced verbal abuse from 5 people other than Father during a 3 year period)  Both parent’s potential mental ill health.   Mother’s own adverse childhood experiences of loss and abuse and the potential impact of these on her parenting capacity.   The impact of prolonged coercion and abuse on Mother’s parenting capacity.  Mother’s social isolation and estrangement from and conflict with her own family.  12  56. Research consistently highlights the increased risks to children associated with domestic abuse, mental illness and substance misuse (known as the Toxic Trio –see below) and this increased the children’s vulnerability.  57. Substance misuse is a broad term encompassing the harmful use of any psychotropic substance, including alcohol and either legal or illicit drugs. Use of such substances is harmful when it has a negative effect on a person’s life, including their physical and mental health, relationships, work, education and finances or leads to offending behaviour.  58. There is no information within agency records to suggest that any one agency or any multi-agency forum recognised the higher risk of co-existing domestic abuse, mental illness and substance misuse 59. In addition to these risks poverty and debt were an issue for the family and may have caused constant stress and anxiety to one or both of the adults. 60. Into this context of risk Mother became pregnant with twins.  61. At the point at which the pregnancy was confirmed in April 2016 there had been 12 reported incidents of domestic abuse within a 12 month period.  62. Father was also involved in criminal offences and was sentenced in June 2016 to a 12 month Suspended Sentence Order. 63. On 19th October 2016 Child BY and his/her twin were born following an induced labour at 35 weeks’ gestation due to concerns about their static growth. Both babies were admitted to the Special Care Baby Unit (SCBU) at birth. 64. In October 2016 Father reported the tragic loss of his brother and this triggered an episode of increased or resumed drug and alcohol use. He was escorted from the Special Care Baby Unit 24th October 2016 as staff observed that he appeared to be under the influence of substances. 65. At the point at which the twins were discharged from hospital the combined or cumulative risks (including their own premature births) to all of the children were considerable.  13  66. The family as a whole and the individual family members were the focus of various risk assessments / arrangements including:  Multi Agency Risk Assessment Conference (in respect of the domestic abuse)   Domestic Abuse Stalking and Honour Based Violence Risk Assessment  OASys the offender assessment system carried out in respect of Father  Child and Family Assessments carried out by Children’s Social Care   Family in Need Assessment  67. In summary; there were various risk assessments carried out however none of these suitably assessed the combined, cumulative and increasing risks to the new born Child BY and his/her siblings.  68. The focus of the assessments carried out in respect of the whole family by Children’s Social Care remained largely on the domestic abuse and to a lesser degree upon Father’s drug and alcohol use. The outcome of this was that pressure was put on Mother to ensure that Father stayed away from the family home. (Father had refused to sign a written agreement to this effect). 69. However the biggest trigger for an abusive man to commit fatal violence (to adults and children) is separation or the threat of separation. Studies of estrangement and homicide have routinely found a very strong correlation (Stark 2007, Polk 1994). 70. Furthermore this approach did not recognise the ongoing coercive and controlling nature of Father’s abuse and the impact that this would have had on mother and her capacity to make decisions and to protect herself and the children. 71. The Serious Crime Act 2015 received royal assent on 3 March 2015. The Act creates a new offence of controlling or coercive behaviour in intimate or familial relationships. This closes gap in law around patterns of controlling or coercive behaviour in an ongoing relationship between intimate partners or family members. The offence carries a maximum sentence of 5 years’ imprisonment, a fine or both.  14  72. This offence is constituted by behaviour on the part of the perpetrator which takes place “repeatedly or continuously”. The victim and perpetrator must be “personally connected” at the time the behaviour takes place. The behaviour must have had a “serious effect” on the victim, meaning that it has caused the victim to fear violence will be used against them on “at least two occasions”, or it has had a “substantial adverse effect on the victims’ day to day activities”. The alleged perpetrator must have known that their behaviour would have a serious effect on the victim, or the behaviour must have been such that he or she “ought to have known” it would have that effect.  73. Coercive control and verbal threats are more positively correlated with homicide than violence alone, and should be taken very seriously (Liem and Roberts 2009, Stark 2007).  74. The criminal justice system’s assessments of Father included the potential risk he posed to the children as well as to Mother. (He was assessed as being of high risk to others). 75. His engagement with his Supervising Officer (SO) was inconsistent and he breached the requirement to attend statutory meetings with his SO. His SO was also aware that Father was present at the family home when the requirements of the Child Protection plan were that he should have no contact. 76. There does not seem to be any formal analysis of how this non engagement and non -compliance compounded or increased risks to the children.  77. The case was also considered by the Multi Agency Risk Assessment Conference (MARAC) on 2015 date? And 24 March 2016.  Perception of Risk 78. Some of the practitioners who contributed to the Learning Event reflected that the way in which they perceived risk in this case was influenced by their responses to Mother and Father as individual people.   15  79. Father was described by the practitioners as physically intimidating and on occasion his behaviour was aggressive and threatening. He was also known to be violent and have used weapons and threats to kill. He was also using drugs and alcohol which made his behaviour unpredictable. This would, undoubtedly, have led to practitioners being wary of him and they may also have felt unsafe in his presence. 80. Mother was described by the practitioners who contributed to the Learning Event as ‘warm’, ‘nice’, ‘a good mum’, ‘vulnerable’ and ‘socially isolated’. She was not ever considered to be a source of risk to Child BY and the siblings and practitioners felt empathy towards her. 81. It is only by taking into account Mother’s own childhood experiences of loss and abuse and the transition from being a child living with domestic abuse to being a young adult and parent and becoming a victim of prolonged and serious domestic abuse and the other stresses that she was enduring that we might consider that her capacity to parent may have been compromised.  82. The birth of premature twins into a family where there were already several serious pre-existing risks to children was a further significant and compounding risk and placed additional strain on Mother in particular. 83. The limited research which exists on the increased risk of childhood abuse for twins shows that large families and inadequate spacing of children increase the risk of abuse. Twin births incorporate both of these factors, yet the association of twinning with subsequent abuse has not been widely explored. In one U.S. study 48 families with twins were compared with 124 single-birth families, matched for hospital of delivery, birth date, maternal age, race, and socioeconomic status. Three control (2.4%) and nine twin (18.7%) families were reported for maltreatment (P less than .001). Mothers of twins experienced greater previous parity than did control subjects (P less than .001). Twins also had significantly longer nursery stays (P less than .001), lower birth weights (P less than .001), and lower Apgar scores at one (P less than .01) and five (P less than .05) minutes. A regression analysis incorporating all of these  16  variables, however, showed that twin status was most predictive of subsequent abuse. (Increased child abuse in families with twins. Groothuis JR, et al 1982) 84. A further study showed that close spacing of children may be a significant risk factor for subsequent abuse in some families. Twin births are an extreme example of close spacing. Therefore, the authors hypothesized that twin births may predispose to an increased incidence of child abuse. Thirty-eight families with twins were compared with 97 single birth families and matched for birthdate, maternal age, race, and socioeconomic status. Families with twins experienced a significantly higher incidence of child abuse and neglect than did those with single births (p less than .003). (Increased child abuse in families with twins. Robarge JP, Reynolds ZB, Groothuis JR. 1982) 85. In summary there is cumulative risk of harm to a child when several risk factors are present in combination over periods of time. The 2011 to 2014 National Triennial Analysis of SCR’s qualifies this “ We previously noted this particularly in relation to domestic abuse, parental mental ill-health, and alcohol or substance misuse, but it also includes other risks such as adverse experiences in the parents’ own childhoods, a history of violent crime, a pattern of multiple consecutive partners, acrimonious separation, and social isolation. When presented with any of these risk factors, practitioners should explore whether there may be other cumulative risks of harm to the child, as well as any protective factors. The impact of all domestic abuse is harmful to children and a step-change is required in how we understand and respond to domestic abuse. There is a need to move away from incident-based models of intervention with domestic abuse to a deeper understanding of the ongoing nature of coercive control and its impact on women and children, and also on men”.      17  How was the voice of the child/ren heard and how is this evidenced?  86. Because Child BY and the siblings’ ages ranged from 3 months to 5 years (at the time of the injuries to Child BY) any efforts to hear their voices should have focused on their likely daily lived experience as well as direct work with the two older siblings. 87. In the case of Sibling 1 regular and repeated efforts were made particularly by the FIN workers to engage her/him and to see and speak to her/him alone.  88. However Sibling 1 was often reluctant to speak to workers and there was evidence that s/he may have been coached or coerced by Mother and/ or Father and consequently expressed fear that Sibling 2 would be taken away and that Father would be ‘locked up’. S/he also referred to ‘those nasty ladies’ when speaking about the professionals who were working with the family. 89. Coaching and coercing such a young child who would not have been able to process what was happening to her/him emotionally or intellectually was in itself an abusive act and left her/him fearful for her/his family members. 90. We know from the agency chronologies that Sibling 1 and Sibling 2 witnessed abuse and experienced neglect and that life for them before Sibling 3 and Child BY were born was likely to have been difficult and dangerous at times. 91.  In September 2015 Sibling 1 at 3 years of age was found partially dressed and barefoot in the street at 8am by a member of the public. Sibling 1 managed to take the adult to the home address and told her that “little brother/ sister” was upstairs.  The adult found Sibling 2 upstairs in a travel cot, crying. It is not clear how long the children had been left alone. This incident was reported to CSC.  92. Sibling 1’s behaviour was of concern to professionals and to Mother as s/he was aggressive towards Mother, Sibling 2 and towards practitioners. S/he also swore and was disobedient. 93. Practitioners focused on improving Mother’s parenting skills to enable her to manage and improve Sibling 1’s behaviour.   18  94. It was noted by a FIN worker that Sibling 1’s behaviour improved when Father was in prison i.e. out of the family home. This did not however shift the focus of interventions from Mother’s parenting skills to interventions which could have focused upon the cause of Sibling 1’s distress and provided therapeutic or other input. 95. It is particularly striking that Sibling 2 is mentioned very rarely in the multi-agency chronologies other than by his/ her nursery school who report that s/he found it very difficult to settle in nursery and was still very distressed one month after having joined. 96. Sibling 2 is also mentioned in his/ her own right in April 2016 when a FIN worker carried out a home visit. The worker recorded that Sibling 2 presented with a burn on his/ her right hand, between the thumb and fore finger; this was approx. the size of a 20p piece. Mother showed the FIN worker the cooker in the kitchen and stated that as she had open the oven door when the grill was on Sibling 2 had put his/ her hand inside and caught it on the hot grill.  97. The FIN worker gave advice to seek medical attention if the injury began to weep or become sore and updated the Social Worker. This was not further considered as a potential non accidental injury and was not discussed at the following Core Group meeting. 98. It was noted that Sibling 1’s behaviour improved when Father’s access to the family ceased due his imprisonment. It was also noted that Mother’s engagement with services improved. This observation was reflected back by the FIN practitioner to Father who became angry and aggressive. 99. Some practitioners who attended the Learning Event also reflected that mother seemed to ‘favour’ Child BY and tended to his/ her needs ahead of his/her twins’. Practitioners had partially explored this with Mother who explained that Child BY had been born first. Suggestions were made to Mother than she alternated her attention between the twins so that Sibling 3 would sometimes have his/ her needs met first.  19  100. The lived experience of Child BY and Sibling 3 as new born, premature twins is difficult but not impossible to imagine by considering their daily lives. Were their emotional and physical needs met immediately? How did Mother form attachments with them as individual babies (see comments above) and how did this inform assessments? Was the house warm, peaceful, calm? This does not seem to have been formally considered and reflected upon in a multi-agency forum such as core groups.  How effectively were child protection and other processes used in this case? 101. The focus of multi-agency child protection arrangements was to support Mother to end the relationship and ensure no contact with Father. This approach did not recognise the extreme difficulty for any woman living in a situation of domestic abuse to effect any change, including the difficulties of moving out of a controlling and coercive relationship nor did it acknowledge the increased risk of any attempt to end the relationship. 102. Sibling 1 and Sibling 2 became subject to Child Protection arrangements in December 2015 because of emotional abuse. At that point Father was asked to sign a written agreement to stay away from the family home and to have no contact with the children until a risk assessment had been carried out. Both adults stated that they wanted the relationship to continue. 103. It is noted that whilst Mother reiterated her wish to continue her relationship with Father this was not explored with her by any practitioner and did not appear to influence decision making or risk assessments. 104. The outcome of the risk assessment is not clear from agency records however Father did continue to visit and stay at the family home and there was evidence that both he and Mother lied about his presence there.  20  105. Between December 2015 when Sibling 1 and Sibling 2 were made subjects of Child Protection arrangements until October 2016 when Child BY and his/ her twin were also made subjects of Child Protection arrangements there was a pattern of:  Non-compliance with or refusal to sign a written agreement to restrict contact with the children by Father ( such written agreements are no longer used in Blackpool as part of child protection arrangements)  The confirmed presence of Father in the family home which was, on occasion, denied by both adults.  Information to suggest that Sibling 1 had been coached and coerced.  A deterioration in Sibling 1’s behaviour.  Reported incidents of domestic abuse.  Fluctuating engagement with supporting agencies by Mother.  Non -attendance for ante natal care with the twin pregnancy.  Fluctuating engagement by Father with his CRC officer.  Father’s further offending and association with other offenders.  Father’s continued fluctuating drug and alcohol use. 106. There appears to have been a tacit tolerance of Father’s presence in the family home and yet there continued to be consensus that he should not be there. It was noted core group meetings that there should be no contact between them. (Enforcement of the written agreement that he should have no contact is not possible in UK law and even if it had been possible it may well have increased risk to Mother and the children). 107. By the May 2016 core group Father had been involved in further offending, Mother had disengaged from The Children’s Centre and Sibling 1’s behaviour had begun to deteriorate at nursery. 108. Although the twin pregnancy had been confirmed on 26th May 2016 this did not appear to have been discussed at Core Group until late August 2016.  21  109. On 31st August 2016 a request was made for a pre- birth initial child protection conference and a Child and Family Assessment. It was noted that ‘Mother is pregnant with twins and is due 22nd November 2016, but could be induced 36 weeks onwards’. 110. Quite clearly this pregnancy confirmed that Mother and Father were still in contact and in breach therefore, of the Child Protection plan but this does not seem to have been addressed. 111. The first Core Group in respect of the unborn twins was held on 17th October 2016 and it was noted that ‘Mother had missed more ante-natal appointments than she had attended’.  112. In addition it was noted that Father was now attending appointments with CRC which he had previously missed. Concerns were noted about parental honesty.  It was also recorded that the Core Group were awaiting results of Father’s drug tests and that a referral to FIN had been accepted and the family were waiting for an allocated worker. A written agreement was signed stating that Father was not to live in the family home until ‘further assessments have been completed’. 113. This Core Group meeting repeated concerns and agreed and repeated actions which were very similar to those recorded at the first Core Group meeting in December 2015. The use of another written agreement despite two previous such agreements having not been adhered to throughout the previous 10 months was also agreed. 114. On 28th July 2016 a Review Child Protection Conference took place. This was an opportunity to assess progress and re-assess risk and need. The outcome of the review was that the Child Protection Plan should continue but there was no radical change in approach meaning that despite there having been no sustained improvement, fluctuating engagement and the significant new risk of a twin pregnancy and Father’s increased drug and alcohol use the plan was that Father should have no contact until a further risk assessment had been carried out. 115. This demonstrated what may have been over-optimism concerning the parents’ capacity to change but also a lack of understanding of the reality of life for Mother and the incredible  22  pressures she faced from Father, from practitioners, from the Child Protection arrangements, from her own family and from the pregnancy and impending birth of twins.  116. This may also have reflected that professionals were ‘stuck’ and were not able to devise a plan which would provide alternatives to the actions which had previously been agreed but which had not been effective in reducing risk to the children. 117. A pre-birth Child and Family Assessment commenced from 31 August 2016 and a Strategy discussion took place on 19 September 2016. Concerns were noted about Mother’s capacity to protect the children from Father's violent behaviours and other inappropriate adults. A large number of domestic abuse incidents which had been witnessed by the children was also noted.  The outcome of the Strategy discussion was a decision to progress to Section 47 investigation and an Initial Child Protection Conference in respect of the twins.  118. However, it was noted that a Core Group meeting had also been held on 15 September 2016 which had recorded good positive progress being made by the parents and that there were no significant concerns.  119. The Initial Child Protection Conference in respect of Child BY and Sibling 3 was held on 6 October 2016. The Conference noted that the Father had been substance misusing and that Mother had failed to engage with ante natal care and had also disengaged from the Children’s Centre. It was also noted that neither parent attended the Conference. 120. One of the outcomes of the Conference was that information was shared with agencies to state that Father should not be living at the family home. 121. As previously observed this repeated assertion that Father presented a risk to the children and should not be living in the family home was also repeatedly breached and was clearly not effective. 122. The Discharge Planning meeting at which arrangements were made for Child BY and his/ her twin to go home from the hospital was held on 27 October 2016. A further Written Agreement was put in place for Father to have supervised contact only, for a FIN worker to  23  visit daily, and for Homestart and the Children's Centre to also provide support. Mother was advised that if Father turned up at home address she must contact the Police otherwise she would be in breach of the written agreement and legal advice would be sought by the Local Authority.  123.  This Discharge Plan whilst putting daily support in place for Mother placed the responsibility upon her for keeping Father from the family home. This demonstrates the lack of understating of Mother’s position not least of which would be the very real possibility of her life (and the children’s lives) being in danger if she did attempt to prevent Father from accessing her or his children. 124. Research consistently shows that pregnancy and the post-partum period are particularly dangerous for women living with domestic abuse. For example, domestic homicide was found to be the biggest cause of traumatic death and injury in pregnant and post-partum women in the USA (Van Wormer and Roberts 2009).  125. Furthermore research and data also shows that the youngest children are at the greatest risk of injury and death. In the 2011 to 2014 analysis of Serious Case Reviews the largest proportion of cases related to the youngest children, who were aged under one year. 120 of the 293 children (41%) were aged under one year at the time of their death, or incident of serious harm; and nearly half of these babies (43%) were under 3 months old. The Triennial Review also noted “We know from our past biennial reviews that the very young are particularly vulnerable, and that premature babies, babies with a low birth weight and/or requiring initial (or in some cases lengthy) special care baby unit nursing, and babies born with neonatal abstinence syndrome potentially pose challenges to their parent(s) over and above the considerable demands of any new-born infant.” 126. On 10th November 2016 a legal planning meeting was held as pre-proceedings legal advice had been sought from Blackpool Council’s Legal Department by the family’s Social Worker.  24  127. The planning meeting must determine if the threshold criteria for an application to court under s.31 of The Children Act is met (The court can create a care order under Section 31(1) (a) of the Children Act, placing a child in the care of a designated local authority, with parental responsibility being shared between the parents and the local authority). 128. In this case the planning meeting concluded that the threshold for commencing proceedings was not met. 129. Whilst the planning meeting may have considered the likelihood of success in a court based on the risks discussed it did not fully consider all risks to the children nor the cumulative impact of those risks. This may have been because the risk assessment was poor. 130. There does not appear to have been any challenge to the advice or a decision made to proceed despite the advice. Nor did this advice prompt an urgent review of why an appropriate assessment of the risk posed by Father and of Mother’s capacity to protect had not yet taken place. 131. The first post-birth Review Child Protection Conference took place on 5 December 2016. It was noted that Mother’s day to day care of all 4 children was adequate and that she had engaged well with services. It was also noted that Father would be released from prison on 9 December 2016 (he had received a custodial sentence on 11 November 2016 for Breach of Suspended Sentence Order, for Handling Stolen Goods and for Failing to Surrender). It was also noted that he would move back into the family home upon his release. 132. The review meeting noted that when Father was back in the family home Mother withdrew her engagement with services. In other words the positive progress was made when he was not able to have any contact with the family.  133.  In summary, the majority of the various multi-agency processes including statutory Child Protection visits, Core Group meetings and Review Meetings took place on time and at the correct frequency. However these various processes were not always effective at identifying, assessing, responding to and reducing risks and the cumulative impact of them.  25  134. The outcomes of agreed actions in particular in respect of written agreements and assessment of the risks posed by Father were not robustly reviewed and it was difficult to establish from agency records why this was the case. For example it was acknowledged that the written agreements had not been complied with and yet they were used repeatedly and there was no alternative put forward to try and reduce risk to the children. 135. In particular there was no evidence to suggest consideration of or exploration of the impact of Mother’s own adverse childhood experiences and years of extreme coercion, control and abuse upon her parenting capacity.  136. The various processes did not focus sufficiently upon the needs and lived experience of the children and what we know about children who are living with multiple risk factors.  137. Nor did the various assessments and processes consider the extent of the neglect suffered by the children and the focus largely remained on the contact between the adults and the domestic abuse. 138. The fact was that throughout the period of time the children were subjects of child protection arrangements they continued to live with and be harmed by ongoing domestic abuse, parental substance misuse and offending. They also suffered from neglect that may well have been a consequence of these factors.   139. In addition to the child protection and family focused arrangements Father was in regular contact with the criminal justice system for various offences including those related to domestic abuse. He received custodial and community based sentences during and before the timescale of this SCR. This meant that he was subject to various processes including pre-sentence reports and prison release plans. 140. These arrangements too would have included an assessment of any risks that Father posed to Mother and the children.  141. Father’s impending release from prison was discussed by his SO and SW2 in late November 2016. The discussion was recorded thus “E-mail from SW1 stating that she had been speaking  26  to the new social worker (SW2) and they both want to promote Father to reside in the family home over Christmas. In her view if Father was residing at his parents property with a "tag" it would be “setting him up to fail” as it would be difficult to have contact with his children. Confirmed Children's Services are supporting curfew to Mother’s address and asked if release address could be changed by the Responsible Officer if Father agrees”.  142. The communication agreed that the actions following Father’s release from prison were to include; “FIN are in daily, recommending children stay on the CP plan and that the new social worker is going to complete a thorough risk assessment with both father and mother, and that they have had no DV incidents for 11 months.” 143. It is difficult to establish how the discussions between SW1, SW2 and the SO recognised the risk Father posed to the children especially to the unborn twins. The discussions and in particular the statement ‘setting him up to fail’ acknowledged  that he would breach conditions placed on him to stay away from the family home. The decision made to release him from prison to the family home unwittingly colluded with him and potentially placed the children at greater risk. 144. This significant decision was made outside of the multi-agency child protection arena however a core group meeting took place the following day on 25th November 2016 and it does not appear that Father’s release to the family address was discussed and challenged.  145. There are examples of projects which provide a service to families with children where there are domestic abuse and child safeguarding concerns and where the victim states that she wishes the relationship to continue. The Maze Project based at WomenCentre in Calderdale was a specialist project that works with women who are affected by domestic violence and their partners and children. There is currently no equivalent service in Blackpool. 146. The evaluation of this approach demonstrated improved outcomes for children and young people (and the adults) across a range of safety and wellbeing measures which included women and children leaving the relationship in a planned manner. Dr Sue Peckover 2010.  27  How did we know that what we are doing was reducing risk? 147. As previously described there was no information to suggest that risk was meaningfully and permanently reduced by any actions carried out by agencies involved with the family. 148. The measures for reviewing whether or not risk was reducing were not clearly articulated. The main identified risks were Father’s domestic abuse and drug and alcohol use. All attempts to reduce the risks focused on keeping Father away from the family home by use of a written agreement. It was apparent that this was not effective and that he was in constant contact with the family and that the relationship between him and Mother had obviously continued with her becoming pregnant with Child BY and Sibling 3. 149. However it is important to note that because not all risks were identified and the cumulative impact of all risks was not recognised the task of reviewing whether or not risk had reduced would only have been partially possible.  150. Some of the practitioners who contributed to the Learning Event described their anxiety about the risks to the family and there was consensus that any or all of the children and Mother herself could have been harmed.  151. Despite this anxiety there was no professional challenge of the multi-agency plans or decisions which largely repeated previous actions. 152. There was also no information to suggest that management oversight challenged ‘drift’ (specifically the contact of Father with the children) or that supervision enabled practitioners to explore their anxieties. 153. This case highlights a widespread problem with how the multi-agency system responds to families who share similar risks to Child BY. There is a combination of an incident by incident response and a partial understanding of risk and cumulative risk and how to assess it which can lead to lack of clarity about how to reduce and manage risk. This can, in turn, lead to an unintended increase in risk (e.g. the focus on Mother keeping Father out of the family home potentially increased the risk to her and the children).  28  154. This case also reflects a national issue which is that there are also currently few effective measures which can be put into place to protect children and their mothers in cases of sustained and determined domestic abuse, coercion and control. 155. In considering this key line of enquiry the author of this report considered that a question which could routinely be asked in cases where risks to children have been identified is ‘How do we know that what we are doing is not increasing risk’?  156. In cases where families are facing multiple risks professionals and multi-agency groups should consider the potential unintended consequence of their decisions and actions.  157. In this case pressure was put on Mother to end the relationship with a determined and violent man who had threatened to kill her and harassed and coerced her on the two occasions she had attempted to separate from him previously.  158. The support which was put in place to improve Mother’s parenting (including the NSPCC intervention which she do not engage with) may have helped her manage Sibling 1’s behaviour but may also have increased pressure on her whilst doing nothing to address the domestic abuse, coercion, drug and alcohol use and offending of her partner.  Communication between agencies including information transfer/handover issues, recording events 159. There were examples of good and effective communication between agencies in this case for example on some occasions between the SO and CSC. 160. The SO’s Recording of events and communications was sometimes poor however and it was difficult to establish who had made contacts with the SO including which agency the contact had been made by. 161. On other occasions communication between agencies either did not happen or was confused and / or late/ sent to the wrong place. For example Sibling 1’s primary school did not always receive minutes of meetings including the Review Conference and the October  29  2016 Core Group meeting nor were they provided with a photograph of the other family member (see para. 46) who had been identified as a risk to Mother and children (and potentially to school staff) despite them having asked SW2 for this several times.  162. On one occasion a Core Group meeting was cancelled and re-arranged and school and other agencies were not advised of this and there was confusion about the time that the re-arranged meeting started meaning that school and other agencies did not attend. 163. The breakdowns in communication described above happened at a crucial time for the family (Father was in prison and Mother was in advanced pregnancy with the twins) and also happened as there was a change of social worker from SW1 to SW2 which may partially explain why they occurred.  164. Some of the practitioners who contributed to the Learning Event described the confusion concerning whether or not Father was ‘allowed’ to be in the family home and confusion about who was and was not assessed as safe to bring and collect Sibling 1 and later Sibling 2 from nursery and school. There were as many as 7 agencies working with the family at any one time and ensuring that the regular changes to who was and was not allowed to have contact with the children was managed through the core groups and on the whole (other than the exceptions described above) this worked well. 165. However the fundamental issue of Father being seen with Mother in and out of the family home despite written agreements being in place remained confusing and, as previously stated in this report, this was never resolved. The views of family members’ and incidents reported by the public and whether professionals effectively considered these.  166. Throughout the timescale of the SCR the agency chronologies contained references to MGM.   30  167. It was recorded that Mother and MGM’s relationship was troubled and that MGM had been abusive towards her daughter. 168. On other occasions the pair were reconciled and she was involved in her daughter and grandchildren’s lives. 169. When the relationship between MGM and Mother broke down and became abusive it appears that on some of those occasions it was MGM’s negative view of Father and his relationship with her daughter that was the source of the antagonism. For example on 15th November 2015 Mother contacted Lancashire Police reporting that MGM had visited her home and was banging and kicking at the door threatening to have the children removed from her as she was unhappy that Mother was in a relationship with Father. When the Police later spoke with MGM she reported that was concerned about her daughter. This incident suggests that MGM recognised that there was risk to the children hence her threat to ‘have them removed’. 170. On another occasion in March 2016 Mother again reported MGM to the police as she had sent abusive messages to her about Father who was, at that time in prison. 171. Also in March 2016 MGM called the police to an incident she alleged had taken place between Mother and Father. The police records indicate that MGM stated that she and Mother and Sibling 1 and Sibling 2 had been followed by Father back to Mother’s address. He took Sibling 1 and put him/ her into his car stating that no one will stop him from seeing his children.  MGM claimed that Father was aggressive and shouted abuse from his car.  The police attended and Mother denied that the incident had occurred and stated that MGM was lying and that she did not like Father and told lies about him.  MGM stated that Father was not allowed to see Mother. Mother however stated that she and Father were friends and may become a couple in the future. 172. When the relationship between Mother and MGM broke down Mother repeatedly stated that MGM had mental health problems and this was recorded by the police. It is not clear  31  from agency records whether or not this information was ever verified however statutory health agencies have no record to indicate that MGM was assessed for or diagnosed with a mental health condition.  173. The practitioners who attended the Learning Review reflected that how MGM presented and how her concern manifested as aggressive and abusive behaviour. It was felt that this would have become a distraction from what her actual concerns were. It was also reflected that Mother may have used MGM’s ‘aggressive’ presentation to deflect professionals’ focus from herself and Father. 174. MGM had legitimate concerns about her daughter’s continuing relationship with Father. She reported incidents of domestic abuse and shared her concerns that the couple were still in contact with each other with professionals.  175. How family members’ concerns are viewed and responded to is a feature of other serious case reviews (and domestic homicide reviews). Family members often feel that their concerns are not listened to or taken seriously or taken into account in assessments of risk and need. It would be particularly difficult to express your concerns and have them taken seriously if you experience mental health issues or communication difficulties or are unable to ‘regulate’ your distress and present as aggressive. It does not mean however that your concerns are less valid. 176. It is not recorded whether or not MGM’s concerns or reporting of incidents were ever used as part of a risk assessment process nor did she appear to have been asked, formally,  for her views and / or to contribute towards plans for the children.  177. There were two incidents reported by members of the public. The first in September 2015 is described earlier in this report and was the occasion that Sibling 1 was found alone and partially dressed in the street leading to the discovery of Sibling 2 also alone in his cot. 178. The second incident occurred in November 2015 when Lancashire Police received a telephone call from a member of the public that he had seen a male kicking at the front door  32  of Mother’s house and that and a female (Mother)  and children were present.  The children were crying.  Mother initially denied that Father was present but then told the attending police officer that Father was in the kitchen.  Father had left the property via the back door, but returned a short time later and denied there had been any altercation.  Whilst police officers were at the address CSC also arrived.  Father was asked to leave whilst a risk assessment was carried out on him. Father had just been released from prison. 179. The first incident led to an initial assessment being carried out by CSC however it was December 2015 before the children were made subjects of child protection arrangements. It is not clear what assessment of the specific risks posed by Father (and Mother) were carried out during that period of time. Summary Reframing our Response to Risk 180. In this case Mother had experienced significant historical traumas and loss and was subjected to ongoing coercion and control in her relationship with Father which had begun when she was very young. These factors are indicators that her parenting may have been compromised. 181. Factors that are known to be associated with risk to babies and very young children (Ward et al 2012) include parents who have experienced abusive childhoods themselves and have not come to terms with the abuse. Additional risk factors include domestic abuse and environmental stressors such as housing. Significant protective factors are the presence of a supportive non-partner, wider family and informal support and parent’s insight understanding and capacity to change. Severe risk of harm is most likely where there is an absence of protective factors as in this case.  (Ward, H., Brown, R., and Westlake, D. 2012) Safeguarding Babies and Very Young Children. London: Jessica Kingsley Publishers.    33  182. Women with Mother’s history of extreme trauma caused by ongoing physical abuse, coercion and control (including threats to kill) may suffer from Complex Post Traumatic Stress Disorder (C-PTSD) which results from chronic or long-term exposure to emotional trauma over which a victim has little or no control and from which there is little or no hope of escape, such as in cases of domestic, emotional, physical or sexual abuse. 183. The impact of C-PTSD on parenting (and in this case specifically on being a mother) is not fully understood.  184. However there is significant research about women with similar experiences of childhood trauma and abuse which continues into adult hood and the impact that this has on parenting.  185. It is only by considering Mother’s full history and understanding the impact of trauma, loss and ongoing abuse and coercion on her capacity to parent and her ability to keep herself and her children safe that we would see the need for a much more pro-active and evidence based approach to assessing risk and need. 186. What this may mean for practice is that a highly individualised or personalised approach should be taken with women who have multiple vulnerabilities. In this case a trauma informed, gendered approach which took into account Mother’s full history had the potential to safeguard Child BY and Child BY’s siblings.  187. Mother’s apparent unwillingness to end the relationship with Father may be understood in the context of  a 2013 research publication ‘Domestic Abuse Gender and Homicide’ (Monckton-Smith et al 2013) which states: “According to our research the most common safety strategy employed by domestic abuse victims is to demonstrate love, loyalty and devotion to appease the abuser. To achieve this they must give the impression, true or not, that they love him, respect him, and want him squarely in their lives and their homes. Abusers always seem to require that the object of  34  their abuse declare and demonstrate love and devotion”. If we understand this then we can refocus and reframe our attempts to protect women and children.  188. The risks to the children in this case were legitimately perceived to be presented by their Father who was a violent perpetrator of domestic abuse, using drugs and alcohol and who was a repeat offender.  189. In this case the family had a 2 year history of contact with agencies because of the domestic abuse (and Father’s other offences) but this did not lead to a holistic assessment of the multiple and ongoing risks. To be effective this would have included direct contact between professionals and Father on a regular basis with the specific aim of assessing the risk he posed to the children.  190. As previously described the focus of multi-agency child protection arrangements was to support Mother to end the relationship and ensure no contact with Father. This approach did not recognise the extreme difficulty of living in a situation of severe domestic abuse to effect any change. Nor did it acknowledge the increased risk of any attempt to end the relationship. 191. There is a need to provide long term, tailored support which show a deeper understanding of the ongoing nature of coercive control and its impact on women and children.  (Holt, 2015; Humphreys and Bradbury-Jones, 2015).   192. In addition this case reflects the gendered nature of child protection work and, as described in their 2013 publication ‘Multi-Agency Working in Domestic Abuse and Safeguarding Children’ Peckover and Golding et al describe how professional and agency understanding often does not conceptualise domestic abuse in gendered terms. This may impact on child safeguarding practice in a number of ways. “For example failing to differentiate between the perpetrator and the victim when assessing parenting capacity; all too often the emphasis is placed upon the mother to protect children with shortcomings in parenting becoming the focus of attention as men disappear from the professional gaze. Indeed the most manifest impact of failing to consider domestic abuse in gendered terms is that too often  35  professionals fail to consider male perpetrators in their assessments or recognise and address their behaviour and accountability for it. The invisibility of men and failure to consider or assess the risks they pose are critical issues”. 193. In the longer term there is a need to reframe risk and our response to it by radically changing how we work with perpetrators of domestic abuse. “If we perceive domestic abuse perpetrators as one dimensionally violent, the logical solution may seem to be to punish that violence until it stops. However, if the perpetrator is perceived as dependent, dangerously manipulative and obsessive, then our solution may be different”. (Monckton Smith et al 2014) 194. Father was being managed within the criminal justice system in relation to multiple offences including those arising from domestic abuse. He was also a voluntary participant in a programme which focused on his domestic abuse however it is not clear what impact this had on Mother and the children (e.g. did it reduce incidents and risk).  195. It is not clear that the management of Father reduced risk to his children as he was impervious to any sanction other than a custodial sentence. This should have led to a reappraisal of how risk was assessed and managed and a consideration of what legal measures (and specifically the new offence of controlling or coercive behaviour in intimate or familial relationships) could be used to disrupt and prevent his contact with the children and their mother. 196. However using the criminal justice system as the only, or main, response to domestic abuse, coercion and control is neither appropriate nor effective (Hester 2013b) and should be combined with the long term, multi-agency, multi-disciplinary supports to the victims of abuse and their children which are described above.  197. In this case it is apparent that (despite the commitment and efforts of the practitioners working with the family) Child BY and siblings were living with multiple risks and endured  36  ongoing harm from their exposure to domestic abuse. The serious injuries suffered by Child BY was the ‘turning point’ for the all of the children. 198. The Independent Reviewer/ Author wishes to express her thanks to the practitioners who attended the Learning Event. Their openness and willingness to contribute was invaluable and enriched the SCR process and the learning to be gained from it.  Learning arising from this Serious Case Review 199. This section focuses on how practitioners and the multi-agency system recognised, assessed and responded to need and risk in this case.  200. The LSCB should assure itself that the Domestic Abuse and Interpersonal Violence strategy and commissioned services respond effectively to cases which feature domestic abuse and consider the following:       That such cases are assessed as potential coercive offences.       Domestic abuse training and development content is focused on increasing the understanding of risk. For example ensure that the training is informed by the research (and other research) cited in this review particularly focusing on the risk indicators for homicide and serious harm to adults and children which arise from separation or attempts to separate.      Where practitioners are working in adult focused services such as offender management, substance misuse, mental health services, and primary care services that they have sufficient information and professional support to identify and respond to the risks posed by the adults they are working with to children and young people. For example through regular training and awareness raising, opportunities for professional development and inter-agency working.  37       Using the learning from this review the LSCB and other strategic partnerships such as the Community Safety Partnership should assure themselves that work with perpetrators of domestic abuse is developed and/ or commissioned to reflect what is known about perpetrators’ behaviour and the efficacy of existing perpetrator programmes and sanctions.       Using the learning from this review, the LSCB and partners should consider what their approach will be to domestic abuse child protection cases where the victim expresses a wish for the relationship to continue and specifically how this impacts on risk to the children.     The LSCB should seek assurance that future risk assessments in domestic abuse child protection cases include direct and frequent contact with the perpetrator specifically to inform risk assessments (ensuring the safety and supervision of any staff working with perpetrators).     The LSCB should assure itself that the impact on children of living with domestic abuse is understood taking into account how manifestations of distress may differ according to gender, age and personality and should ensure that the voices and experiences of children and young people have been observed, listened to, understood and responded to in planning and decision making.  201. It is essential that the learning from this Serious Case Review is used by the LSCB partners to assure themselves that their approach to families with similar histories to Child BY is effective. In particular how practice and supervision are influenced by the understanding of the long term impact of unresolved childhood trauma, loss and abuse, and serious and chronic domestic abuse and coercion on parenting capacity. For example, practitioners should be able to evidence that plans, risk and need assessments have taken account of these issues.   38   202. The learning from this Serious Case Review should also be used by the LSCB and partners to consider how agencies currently respond to families where neglect may co-exist with domestic abuse and ensure that neglect is responded to as a child safeguarding issue and not solely as a symptom of domestic abuse. 203. The learning from this SCR should be used by the LSCB and partners to consider current single and multi-agency approaches to ‘stuck’ case i.e. those cases where risk is not reducing, including long standing neglect cases, where sustained improvements have not been achieved or where there are long standing child protection arrangements in place. In particular the potential of focused reflective supervision, challenge, peer or independent review to re-assess such cases should be considered.  204. The LSCB and partners should assure themselves that the increased child safeguarding risks associated with twin pregnancies and births (and families with multiple young children) inform assessments and practice particularly where twins are born into families who may already have support needs.          39  References Brandon, M., Sidebotham, P., Bailey, S., Belderson, P., Hawley, C., Ellis, C. and Megson, M. (2012) New learning from serious case reviews: a two year report for 2009-11. 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