Neglect of a 14-year-old girl resulting in hospitalisation in June 2020. Learning includes: early help assessments should incorporate the views of children; when a support plan is closed, any outstanding issues should be relayed to relevant professionals to ensure continuity of service provision; practitioners should make direct contact with a child to ensure their wellbeing, rather than relying solely on parents; when there are concerns around neglect, professionals should be supported to use the neglect assessment tool; ambiguous information provided by a parent/carer should be triangulated from other sources to ensure accuracy; practitioners should be professionally curious and practice respectful uncertainty to ensure that information from parents is accurate and clearly understood; agencies should seek to understand the role of adults who are connected to a child's family, including whether they have parental responsibility or not. Recommendations to the local safeguarding partnership include: seek assurance on the quality of early help assessments, ensuring that issues outlined in referrals are addressed in the assessment and support plan; accelerate the implementation of the neglect assessment tool; ensure the child's experience is sought, recorded and reflected in service provision.
      
 Title:  Child safeguarding practice review: overview report: Child AC. LSCB: Children’s Safeguarding Assurance Partnership Blackburn with Darwen Blackpool Lancashire Author: Jenny Butlin-Moran Date of publication: 2022  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.                             Child Safeguarding Practice Review       Overview Report: Child AC  Author: Jenny Butlin-Moran Date:  4th March 2022  Page 2 of 17 Contents  1. Introduction ........................................................................................................ 3 2. Terms of Reference and Methodology ....................................................... 3 3. Brief Summary of the case ..............................................................................4 4. Analysis ................................................................................................................ 5 5.  Detailed Analysis ............................................................................................... 6 5.2  Multi-agency response to concerns of neglect ........................................ 9 5.3  Effectiveness of inter-agency and intra-agency communication ........ 11 5.4  How professionals work with the challenge of limited engagement from parents .............................................................................................................. 13 5.5  Multi-agency response to connected persons ....................................... 14 5.6  Consideration of the voice of the child ..................................................... 15 6.0 Conclusion......................................................................................................... 16 7.0  Learning and Recommendations ................................................................ 16    Page 3 of 17  1. Introduction 1.1 Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership decided to undertake a Learning Review in respect of a young person to be known as A.C, in July 2020 as it was felt that learning could be derived from the practice in this case. 1.2 A.C. was 14 years old when she was hospitalised due to a life-threatening condition. 1.3 It was agreed that the Learning Review would consider in detail the professional involvement with A.C. and her family from September 2018 to June 2020 which encompassed the provision of a range of services from the point at which A.C. moved to secondary school to the time of the incident. 1.4 While the statutory safeguarding partners initially agreed that the circumstances of the case did not meet the threshold for a Child Safeguarding Practice Review, they subsequently agreed that it should be published as such, on the grounds of transparency.  2. Terms of Reference and Methodology 2.1 An Independent lead reviewer was appointed to lead the review.1 The Review Team2 had access to the key single and multi-agency documents in the case and met with practitioners involved with the family in reflective sessions where the case was discussed. 2.2 The predisposing risks and vulnerabilities3 that were known at the time were considered, in order to understand the case. This was followed by the consideration of the preventative and protective actions taken, in order to understand the interventions. 2.3 The agencies that had involvement reflected on the agency specific learning and shared learning within their agencies. 2.4  The Lead Reviewer sought A.C’s views and those of her Mother and they are included in this report. They were informed of the conclusions of the review and the Partnership’s response prior to dissemination. 2.5  Drafts of this report were shared with those involved as well as with the statutory safeguarding partners to ensure collaboration and ownership and provide scrutiny and challenge. The recommendations were written by the Lead Reviewer and the Review Team. 2.6   This report has been written in the anticipation that it will be published and disseminated for learning to the members of Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership  and contains only the information that is relevant to the learning established during this review. 2.7  At the time of the report being written A.C. was looked after by the council and was living with foster carers.  1 Jenny Butlin-Moran is an experienced independent social work consultant who is independent of the partnership. 2 The review team was formed from senior managers from agencies who were involved with A.C and her mother. 3Complexity and Challenge: a triennial analysis of SCRs 2014-17. Marian Brandon, Peter Sidebotham et al. DfE 2020. Page 4 of 17  3. Brief Summary of the case 3.1 For the purpose of this report, the following family members are relevant:  Family Member  Known as Subject  A.C. Mother of A.C.  Mother Mother’s former partner Mother’s former partner  3.2  The family were known to a number of agencies in Lancashire during the period of the review. A.C. attended a secondary school where she received counselling, pastoral support and support from the Education Attendance Team. A.C. also received health services from the School Nursing Service and later from the Ambulance Service and the Hospital. A.C’s Mother also received support from the local Housing Department 3.3 In September 2018, A.C. started secondary school. The safeguarding records held by the previous primary school were transferred to the secondary school so that they were aware of the previous child protection plan in 2011, the recent early help support that had been provided to support A.C.’s emotional well-being following the death of her Father, poor school attendance and head lice. The school nurse for the primary school was providing support for A.C.  who was underweight and providing emotional support for A.C. following the death of her Father. It was agreed with A.C’s Mother that this support would continue when A.C. moved to secondary school. 3.4 In October 2018, the school made a referral to the Children and Families Well-Being service4 (CFW)  for support with housing for the family as they were at risk of homelessness and to provide A.C. with emotional support as she was grieving for her Father who had died some months earlier. An early help assessment was undertaken and support provided until a housing tenancy was secured three months later. The school counsellor worked with A.C. and this continued after the conclusion of the early help support 3.5 In January 2019, A.C. was sent home from school as she had head lice and episodes of infestation which continued and led to a number of absences from school which were addressed with A.C.'s Mother by pastoral support staff and the Designated Safeguarding Lead. A.C. was also absent from school which was reported by A.C’s Mother to be due to other health issues. 3.6 When schools were closed in accordance with the government restrictions due to the Covid-19 pandemic, the school maintained twice weekly contact by telephone and provided support for the family with food. 3.7 In June 2020, A.C. was admitted to hospital due to breathing difficulties, having collapsed at home. She presented as malnourished, had a significant infestation of head lice, and had multiple organ failure.  4 The council’s early help team. Page 5 of 17  3.8 A strategy meeting was convened and subsequently care proceedings were initiated and A.C. became cared for by a foster carer.  4. Analysis 4.1 To analyse the professional involvements and interventions with the family, consideration has firstly been given to the predisposing vulnerabilities and risks in the case, that were known or knowable to professionals involved at the time. This is followed by the preventative and protective actions taken by the agencies involved at the time.  Predisposing Vulnerabilities As a young person, A.C. was dependent on her Mother to meet the majority of her basic needs. A.C’s Mother did not have a housing tenancy and was reliant upon her former partner for housing. The family had previously experienced homelessness. A.C.’s Mother had a limited support network and had experienced bereavements previously. A.C’s Mother was not in employment and was reliant upon state benefits. A.C’s Mother previously used substances and had received support for her mental health.  4.2  It is recognised that the adults’ predisposing vulnerabilities may pose a predisposing risk to the child. The following additional risks have been identified:   Risks A.C. was at risk of social isolation and falling behind in her educational outcomes due to poor school attendance. A.C. was at risk of being alienated by her peers due to her persistent head lice. A.C.’s emotional well-being was at risk due to the loss of her Father. A.C. was at risk of unstable housing.  Page 6 of 17 4.3 There was evidence of protective actions from the family when considering the case:  Protective Actions taken by the family. A.C’s Mother consented to referrals to the Children and Families Well-Being (CFW) service andto the school nursing service. A.C’s Mother worked with the CFW in the formulation of the early help assessment and plan.  4.4 During the involvement of professionals with the family, there were both preventative and protective actions taken by the agencies involved.  Preventative and protective actions taken by the agencies.   There was an effective transition between the primary and secondary schools which enabled the  secondary school to have a good understanding of A.C.’s needs. The school staff were available to A.C.  and they were able to seek support when needed. Counselling was provided for A.C. by the school.  5. Detailed Analysis The review has established that the following areas require further analysis and provide us with the learning in this matter. 5.1  The effectiveness of early help 5.1.1  In September 2018, a member of the school pastoral team contacted A.C.’s Mother as they were concerned about A.C.’s emotional well-being due to her Father’s death in 2017. A.C’s Mother shared that A.C. never knew her Father. It was effective practice by the school to follow up their concerns with Mother as this demonstrated genuine interest in A.C.’s well-being and began forming a trusting relationship with A.C. and her Mother.  5.1.2 The following day, A.C.’s Mother contacted the Education Attendance Service and advised that A.C. would not be in school as she was very upset about her Father’s death and she would be seeing the G.P. to seek counselling for A.C. A.C’s Mother also clarified that this was to address the bullying that A.C was experiencing. A few days later the school provided counselling and peer listening services for A.C.  A.C. received two counselling sessions and it was stated that A.C. was happy to self-refer if she required more.  Page 7 of 17 5.1.3 In October 2018, the school made a referral to the CFW, with the consent of A.C.’s Mother, requesting support with identifying a new tenancy for A.C’s family, following concerns raised by A.C. of risk of homelessness and police involvement with her step-father. It was noted that A.C. said that her Mother did not like them talking about the family. This was an appropriate and helpful response by the school. The referral was made using the appropriate electronic form and provided appropriate historical and current information and they received prompt feedback from the council. However, the school did not advise the CFW service that A.C. was receiving free school meals and this was a missed opportunity for the CFW to include this in their assessment.  5.1.4 An early help assessment was undertaken which identified that the family was living with Mother’s former partner and their relationship was fractious. However, the assessment did not explore the relationship between them. The review learned that direct work was undertaken with A.C. to ascertain her wishes and feelings to inform the assessment which was expected practice. However, the outcome of this was not included in the narrative resulting in her views being absent. Two of the six appointments made were cancelled and re-arranged by A.C’s Mother, however this was not regarded as unusual by CFW. Consequently, the focus of the work was on supporting the identification of a new tenancy and supporting A.C.’s Mother into employment.  5.1.5 The ensuing support plan included that counselling for A.C.’s bereavement would be provided by the school and A.C.’s Mother’s benefits were reviewed to ensure that she was receiving all of her entitlements. The early help plan was reviewed twice and was closed within 3 months because a new tenancy was secured for Mother. Counselling was to be continued by the school, however, work to support Mother with gaining employment was not achieved. Prior to closing the case, A.C’s Mother was contacted by a member of the school regarding A.C’s uniform and she declined the offer of support for uniform and would not discuss further. This information was not shared with CFW and as the early help support was still in place, it was a missed opportunity to engage Mother in further discussions about her finances and provide support for A.C.  5.1.6 Whilst the early help support was helpful in securing a new tenancy, and identifying counselling for A.C, it did not address all of the concerns, including the concerns that A.C. raised about her Mother’s former partner. The assessment does not include an understanding of Mother’s partner and all of the information was self-reported, thus being totally reliant on information from A.C’.s Mother. The review found that at the time, the early help assessments focused on presenting needs rather than on exploring needs holistically. In 2020, the council’s children’s services underwent a transformation programme in which early help and children’s social work services became more aligned and resulted in holistic early help assessments being undertaken. 5.1.7 Just prior to A.C.’s move to secondary school, A.C.’s weight was reviewed by staff nurse 1 with school health who agreed with A.C’s Mother that A.C. would continue to receive support as Mother reported that she was being bullied because she was underweight. The notes recorded that A.C. was now plotting in the lower centile of the healthy range bracket for her age. A.C was subsequently seen by the staff nurse in September and then her support was transferred to the school nurse in the secondary school. 5.1.8 In September 2019, the school made a referral to the school nursing service to support the management of A.C.’s head lice. The school nursing service did not understand the level of concern held by the school about A.C’s head lice because the referral was not designated as a safeguarding referral and therefore A.C. was offered a universal service. The review learned that the service receives a high volume of requests to manage head lice and in this case they were not aware of any additional concerns to review the type of service to be delivered. Page 8 of 17 5.1.9 Staff Nurse 2 with school health promptly contacted A.C’s Mother but was unable to obtain a response . A further attempt to contact A.C.’s Mother was not made until two months later by Staff Nurse 3 and Mother agreed to support with a follow up in a week’s time. The review found that the delay in making contact with Mother was due to a change of staffing in the team. However, this led to a significant delay in improving A.C’s experience of head lice.  5.1.10 The review learned that when A.C’s Mother spoke to staff nurse 2 it would have been good practice for the staff nurse to refer to the NICE guidance5 and check that A.C.’s Mother was treating the head lice in accordance with the manufacturer’s instructions and check that all family members were routinely checking their hair. This was a missed opportunity for the staff nurse to understand why there was no sustained improvement in the treatment of the head lice and to share this with the school for further consideration. As a result, A.C. continued to have head lice. 5.1.11 In March 2020, the school made a second referral to the school nursing service by email and a school nurse responded to say that they could ring A.C’s Mother the following week , as was expected practice. A further telephone message was left for the school nurse but there was no evidence that this was listened to or responded to. 5.1.12 Later in March, the school held a meeting which was attended by the Designated Safeguarding Lead6 (DSL) and a School Nurse, the former partner of A.C’s Mother, provided their apologies. The concerns included the management of the head lice and that A.C. had inappropriately been given her sibling’s medication.  The outcome of the meeting was shared with Mother by telephone who denied that she had given A.C. her sibling’s medication and was hostile and threatened to remove A.C. from the school. It was good practice to hold a meeting to discuss the concerns however, a review meeting was not scheduled which meant that the practitioners did not have a shared understanding of A.C.’s progress. The review learnt that a review meeting would have been held but shortly after the meeting, the national lockdown was instigated and the school closed. 5.1.13 During the period of lockdown, the school continued to support A.C. in accordance with government guidelines. A.C.’s needs were classed as requiring a minimum of weekly telephone contact by the school and the review found evidence of successful telephone contact with A.C’s Mother taking place up to twice per week by a learning mentor who had a good relationship with A.C’s Mother.  This was good practice.  A food parcel was delivered to the home and food vouchers were supplied. However, there was no consideration given to contact with A.C., such as virtual meetings using technology or a telephone call to A.C.  which would have enabled professionals to hear directly from A.C. This was effective in maintaining contact with A.C’s Mother and supporting with food but was not effective in hearing directly from A.C. how she was.  5.1.14 The review recognised that at the start of the national lockdown, schools had to deal with a range of unprecedented issues in order to continue to provide education for pupils.  The scale of this and the impact upon every aspect of the functioning of a school cannot be underestimated. In this case, the school had not yet developed virtual methods for communicating and teaching. Since this time, the school has improved access to technology and is able to maintain contact with children even when the schools have been required to close.  5 NICE Guidance. Head Lice management December 2016. 6 The designated safeguarding lead should take lead responsibility for safeguarding and child protection (including online safety), Keeping Children Safe in Education 2020. Page 9 of 17 5.1.15 Despite the provision of early help, there was no sustained improvement in A.C.’s outcomes over a 21-month period. 5.1.16 Learning ● Assessments should incorporate the views of children and young people to ensure that there is a lasting record for current and future reference. ● When a referral is made for an early help assessment, the assessment should address all of the issues and should be incorporated into the plan. Any new or emerging issues should be shared at meetings for inclusion in the plan. ● When a support plan is closed, any outstanding issues should be relayed to relevant professionals to ensure continuity of service provision. ● Continuity of professionals is key to ensuring a consistent understanding of the child’s needs. ● Practitioners should make contact with the child in order to ensure their safety and well-being, rather than solely through the parent.  5.2 Multi-agency response to concerns of neglect 5.2.1  The review learned that in this case practitioners did not recognise that A.C. was experiencing neglect, partly because there were periods of improvement in her circumstances. The challenge of recognising neglect has been highlighted in research; “neglect can in some cases be challenging to identify because of the need to look beyond individual parenting episodes and consider the persistence, frequency, enormity and pervasiveness of parenting behaviour which may make them harmful and abusive.” 7 5.2.2 The early help support introduced from September 2018, included a review of the benefits that A.C.’s Mother was receiving to ensure that she was receiving the appropriate entitlements. The school also provided A.C’s Mother with advice regarding support for school uniform and head lice treatment. However, there was no clear understanding of A.C.’s Mother’s financial situation and how this impacted upon her parenting. Research8 has found that “When faced with families in situations of poverty, practitioners should seek to understand the pathways through which socio-economic issues interact with other factors to influence parenting and outcomes for children. It is important neither to ignore the impacts of poverty, nor to simplistically attribute the family’s problems solely to economic hardship.” 5.2.3 By March 2020, there was evidence of emerging neglect. A.C. had persistent head lice which despite consistent attempts by school staff and some advice from the school nurse, was not clearing up. A.C. 's attendance at school had significantly deteriorated to 68.2% due to head lice and a number of minor illnesses reported by A.C’s Mother and her former partner. These minor illnesses followed a pattern of Mondays and Fridays, which was indicative of school avoidance.  There was an unresolved concern that A.C.’s Mother had given A.C. her sibling’s medication. In addition, A.C’s  7 “Missed opportunities:indicators of neglect –what is ignored, why, and what can be done?” Marion Brandon, Danya Glaser et al. Research report. Department for Education. November 2014 8 “Complexity and challenge: a triennial analysis of SCRs 2014-2017.” Marion Brandon, Peter Sidebotham et al. Department for Education March 2020. Page 10 of 17 Mother was, on occasions, hostile or avoidant of support. Despite the best intentions of practitioners, there was no sustained improvement in A.C.’s well-being. 5.2.4 The school was rightly concerned about A.C.’s poor attendance but did not consider that the absences may be a means to keep A.C. from surveillance by school staff. In discussion with A.C’s Mother she confirmed that sometimes she said A.C. was ill when A.C. had head lice as she felt unable to share this with the school for fear of being judged. The triennial analysis9 identified that “attending school has the potential to decrease the child’s social isolation, and to increase opportunities for development, as well as providing respite from everyday difficulties at home.” 5.2.5 When the school was closed due to the pandemic, a learning mentor maintained regular contact with A.C.’s Mother. However, as A.C. was not spoken to directly, the school could not be reassured that A.C’s welfare was safeguarded. 5.2.6 The review learned that it would have been beneficial to undertake an early help assessment to understand A.C’s needs and formulate a plan to address them. The absence of a full assessment of A.C.’s unmet needs meant that practitioners did not have a true picture of A.C.’s lived experiences and had not considered that A.C. was experiencing neglectful parenting. This meant that the school did not consider that the concerns should be escalated to the council for early help support and/or for consultation with the MASH, nor would they have been able to clearly articulate them in the context of the multi-agency agreed threshold. The review learned that the council now offers consultation to agencies within the early help network to support early help assessments and plans. 5.2.7 The school nursing service offered support to the family but was not pro-active in following up A.C.’s progress. The service did not recognise that the lack of action taken by A.C.’s Mother was neglectful. The review learned that the school nursing service provides a responsive service and when parents do not take up the offer of support, this is usually seen in the context of parental choice rather than a neglectful act. The volume of work for the service means that it is difficult for practitioners to identify emerging neglect.  5.2.8 The review learnt that there is an agreed neglect tool kit available to all practitioners but the application of this was not considered in this case because the practitioners did not recognise that A.C’s circumstances were indicative of neglect. 5.2.9 The review found that whilst the safeguarding partnership introduced a multi-agency tool to assist practitioners in identifying and responding to neglect in July 2019, the roll-out has been slow and therefore it is not widely used by professionals. In this case, this led to a lack of a shared understanding of A.C’s lived experiences and that these constituted neglect. 5.2.10 Learning ● The safeguarding system should enable practitioners to consider that children’s needs may be neglected.  ● When there are concerns that are indicative of neglect, all professionals should be supported to use the neglect assessment tool.   9 Pathways to harm, pathways to protection; a triennial analysis of serious case reviews 2011-14”. Peter Sidebotham at al. Department for Education 2017.  Page 11 of 17 5.3 Effectiveness of inter-agency and intra-agency communication 5.3.1 The transitional arrangements between the primary school and the secondary school were effective. The transfer of records enabled the secondary school to have written information about the previous child protection plan in 2011, the recent early help support that had been provided to support A.C.’s emotional well-being following the death of her Father, poor school attendance and head lice.  There was also a face-to-face meeting between members of the primary and secondary schools which provided the opportunity for the secondary school to explore things further. This was effective practice and meant that the school was alert to A.C’s needs. 5.3.2 The referral made by the school to the CFW service was detailed and communicated the concerns expressed by A.C. about being evicted, her Mother’s former partner and included information provided by A.C.’s Mother. However, the request for support by the school to the CFW only focused on helping A.C’s Mother to secure a new tenancy, helping her into employment and providing emotional support to A.C. Despite the concerns A.C. raised about her Mother’s former partner, these were not included in the areas to be explored in the assessment. The review found that this was because the school staff believed that the change of tenancy would reduce A.C’s concerns. The CFW service helpfully liaised with the school in order to inform the early help assessment which was expected practice.  5.3.3 The early help assessment was reviewed on two occasions at formal meetings which were attended by a member of school staff, CFW and A.C’s Mother. This enabled the progress of the issues to be considered. However, there was no clear understanding of the role of A.C.’s Mother’s former partner. 5.3.4 Prior to the closure of the early help assessment, A.C.’s Mother was contacted regarding A.C.’s school uniform but declined the offer of support and would not discuss this further. There is no record of this being discussed with the professional from the CFW and this was a missed opportunity to engage A.C.’s Mother in a discussion regarding any further support she may have required. 5.3.5 When the early help support led to the provision of a new tenancy, it was decided that the plan would be closed as the counselling for A.C. was to be provided by the school. The information obtained during the work with A.C. included her concerns about her teeth and her weight. However, as this information was not included in the assessment form, it was not known to the school and was not relayed to the school counselling service or the school nurse and therefore were not addressed with A.C. This was an oversight on the part of the CFW. The review learned that following improvements made to the service, early help work is now undertaken more holistically and therefore it is likely that this information would now be shared. 5.3.6 The school appropriately made a referral to the school nursing service to support A.C.’s Mother with managing the infestation of A.C.’s head lice. However, as the referral did not include their concerns about the family’s history, the service was not aware of the extent of the school’s concerns and offered a universal service.  The school nurse promptly contacted Mother by telephone, but she did not reply, and a response was not pursued. This was not fed back to the school as was expected practice and there was no evidence that the school pursued this with the school nursing service until several months later. This led to significant delays in helping A.C. The Page 12 of 17 review learned that there had been a number of changes of staff in the school nursing service due to staff turnover which meant that the continuity of service was disrupted. 5.3.7 The school made a further request of the school nursing service in March 2020 by email and a school nurse responded to say that they could ring A.C’s Mother the following week. Again, the school nurse did not feed back to the school about the outcome of this and it was the school who pursued a response. Similarly, it is likely that the changes in staff led to a lack of continuity and understanding of A.C’s needs by the school nursing service. 5.3.8 The information about the family was provided by A.C.’s Mother and although professionals were concerned that Mother was “closed” and did not share relevant information, no attempt was made to triangulate this with any other professional for example by seeking A.C.’s Mother’s consent for the school nurse to liaise with the G.P. Research highlights the importance of this issue. “In addition to gathering and sharing information, information must be triangulated and verified. This involves seeking independent confirmation of parents’ accounts and triangulating information between professionals.” 10 5.3.9 There was good evidence of information sharing between the Education Attendance Team and the Pastoral Team. By March 2020, the school had a number of concerns regarding the head lice infestation and A.C.’s poor school attendance, and A.C. possibly having been given her sibling’s medication. A meeting was held which was appropriate but as a review meeting was not scheduled due to the school closure as part of the national lockdown it meant that the opportunity to liaise as a group and create a shared approach was missed.  5.3.10. Learning ● The school nursing service experienced a number of staff changes which meant that the practitioners did not have a clear understanding of A.C’s needs.  ● The school nursing service is responsive to parents who engage but insufficient consideration is given to why parents may not engage in the offer of support from the service. ● The volume of work in the school nursing service makes it difficult for practitioners to identify emerging neglect. Therefore, when professionals seek support from the service, a detailed background of concerns should be provided. ● When information that is available to agencies is reported by parents, consideration should be given to triangulating this to inform a robust assessment and appropriate support plan. ● When there are concerns about a child’s welfare, the progress of the plan should be regularly reviewed by the relevant staff to ensure that there is a shared understanding of a child’s progress and a shared approach to managing this.    10 “Pathways to harm and protection- a triennial analysis of SCRs 2011-2014” - Department for Education 2016.   Page 13 of 17 5.4 How professionals work with the challenge of limited engagement from parents  5.4.1 The review learned that on occasions, A.C.’s Mother’s behaviour towards professionals was hostile or avoidant and on occasions, contradictory. The review examined how this impacted upon the outcomes for A.C. 5.4.2 Throughout the review, professionals expressed concern that A.C’s Mother was quite closed and it was difficult to understand the family’s history and the current situation. On occasions, she provided contradictory information. For example, A.C.’s Mother advised that A.C. did not know her Father, however, A.C. was visibly upset about his loss on a number of occasions. On one occasion, A.C. brought in a note from her Mother which said she was being bullied but she didn’t feel that she was. When this was queried with A.C’s Mother, she did not respond. 5.4.3 From January 2019, A.C. developed persistent head lice and the school staff had a number of discussions with A.C.’s Mother to try to address this in the longer-term. Initially, A.C’s Mother presented as embarrassed but there were several  episodes of her using abusive language towards staff which resulted in a letter from the head teacher. Despite this, staff continued to contact Mother and raise concerns with her although they were not resolved.  5.4.4 As a result of A.C’s Mother’s inability to make sustained improvements for A.C. and her hostility towards staff on occasions, school staff spoke to A.C ’s Mother’s former partner by telephone instead of Mother as they felt that he was more amenable. However, this was not appropriate as he was no longer in a relationship with A.C.’s Mother and did not have parental responsibility for A.C. and therefore could not make decisions about her. This also meant that the focus of improving A.C’s well-being moved from A.C.’s Mother to Mother’s former partner and was likely to have deflected from identifying that A.C.’s needs were being neglected by her Mother. 5.4.5 In January 2019, A.C. began to have a number of absences from school which were reported by her Mother to be for minor illnesses and combined with absences due to head lice, her school attendance began to suffer. These absences were promptly followed up by a member of the  Education Attendance Team however, by the end of March 2020, A.C.’s school attendance had deteriorated to 68.2 %.  No consideration was given to the absences being a warning indicator of wider concerns nor to triangulating the information with health agencies. 5.4.6 In March 2020, a meeting was held between the DSL and the school nurse to which Mother and her former partner provided apologies. The outcomes from the meeting were discussed with A.C.’s Mother in a follow-up telephone call and she threatened to remove A.C. from the school as she felt she was being accused of being neglectful. The review learnt from discussions with A.C’s Mother that she felt “judged” by school staff. Shortly after this, the school closed due to the national lock down and its communication with A.C’s Mother was limited to telephone calls by the learning mentor. As A.C. was not in school, all of the communication was with A.C’s Mother who shared some information which reassured the learning mentor. It is likely that the impact of the pandemic upon children, families and the community and the school closure prevented professionals from challenging A.C’s Mother. Page 14 of 17 5.4.7 The review learned that the school nursing service and the school have systems in place to provide clinical supervision and this helps to provide professional challenge and support for practitioners.  5.4.8 Learning ● Ambiguous information provided by a parent/carer should be triangulated from other sources to ensure that it is accurate and provides a shared understanding. ● Practitioners should be professionally curious and practice respectful uncertainty to ensure that information provided by parents/carers is accurate and clearly understood  5.5 Multi-agency response to connected persons 5.5.1 The review learned that during the scoping period, A.C.’s Mother was living with her ex-partner. A.C. told a member of staff that she was concerned about visits from strangers to the house who argued with him and that he had threatened people (including her granddad) with a machete and had destroyed her grandmother’s furniture with a knife. The school was aware that Mother had previously been in domestically abusive relationships.  5.5.2 The referral made by the school to the CFW service included information about Mother’s former partner. However, the referral did not include supporting A.C.’s Mother with managing the situation with her former partner. This meant that when they undertook the early help assessment, they did not seek to understand more about Mother’s current relationship and how this was impacting upon A.C. and instead focused on securing an alternative tenancy as a solution.   5.5.3 Following the tenancy being awarded to A.C’s Mother, her former partner continued to be a feature in the family’s life. In February 2019, A.C.’s Mother was contacted by the Pastoral Team and advised that A.C. was to be sent home because she had head lice. A.C.’s Mother was verbally abusive and put the phone down and consequently a call was made to Mother’s former partner as a means to address the concerns because A.C’s Mother had named him as an emergency contact.  This was inappropriate as he was not responsible for A.C. and was not responsible for making improvements to her well-being. 5.5.4 It is of note that Mother’s former partner was referred to as “step-father” in the school’s records seen by the review team and was consulted on a number of occasions about A.C. by the Pastoral Team. This was inappropriate as they had not been married, they were no longer in a relationship, he did not have parental responsibility for A.C. and was not in a position to make decisions. Given that professionals did not have a clear understanding of Mother’s relationship with her former partner, it was concerning that they treated him as if he had responsibility for A.C. 5.5.5 The early help support plan was closed in January 2020 when A.C.’s Mother was allocated a housing tenancy. However, Mother’s former partner continued to be present on a number of occasions during contacts with Mother. None of the school professionals sought to clarify this with Mother as they were aware that historically their relationship was “on-off.”  The review learned from discussions with A.C’s Mother that her former partner had found it difficult to dis-engage with her and told people they were still in a relationship when they weren't, which she had found difficult to manage.  5.5.6 Mother had previously provided his contact details as an emergency contact and did not remove them once she obtained her own tenancy and therefore, they believed that it was still Page 15 of 17 acceptable to contact him in Mother’s absence. A.C’s Mother advised the review that she had not always been aware that the school was contacting him. Given Mother’s history of domestically abusive relationships, it was concerning that their relationship was not explored further.  5.5.7 In this case, the involvement of Mother’s former partner deflected from Mother’s inability to address the concerns regarding A.C.’s care for which she was responsible. 5.5.8. Learning ● Agencies should seek to understand the role of adults who are connected to a child’s family including whether they have parental responsibility or not. ● Where a connected person does not have parental responsibility, they should not be involved in making decisions about a child except in emergency situations.  5.6 Consideration of the voice of the child 5.6.1 A.C. was an articulate young person who was able to verbalise her views. A.C approached members of the school staff when she needed support and shared personal information about herself and her family. A.C. also communicated her views non-verbally- practitioners spoke of how A.C. wore a hooded top which covered her hair and they felt this demonstrated her embarrassment about the head lice. A.C. informed the review that she had found it relatively easy to speak to school staff. 5.6.2 From the point A.C. moved to secondary school, staff were alert to her needs because this had been provided by the primary school and the school promptly made a referral to the CFW service when it became apparent that A.C.’s family needed support outside of the school’s system. 5.6.3 The school also ensured that A.C. received counselling and this was made available to her as required although A.C. informed the review that she had not found it particularly helpful. A.C. attended a meeting at school in March 2020. This was good practice and demonstrated a commitment to listening to A.C. and to meeting her additional needs. 5.6.4 The review learned that the school applied a “RAG rating” to identify the level of support to pupils during the school closure and A.C. was awarded an amber rating as they were concerned about her welfare. The school helpfully arranged for a learning mentor, with whom A.C’s Mother had a positive relationship, to undertake the telephone calls to her. However, given the lack of availability of virtual means to communicate with children at that time, the school staff were not able to hear A.C’s voice. The review learned that this is now in place and pupils were communicated with during subsequent school closures. 5.6.5 However, it is recognised that virtual forms of communication provide only a limited means to safeguard a child’s welfare. This was explored by the Association of Directors of Children’s Services  (ADCS) in some research undertaken about the impact of the pandemic. 11 “Using electronic communications, such as Skype and WhatsApp, as a means of ‘visiting’ children in need  11 ADCS Discussion paper: Building a Country that Works for All Children Post Covid-19 July 2020.  Page 16 of 17 or in care may not be as effective if there isn’t a safe, quiet space to talk openly at home or if families do not have access to the right technology to engage.” 5.6.6 The CFW service undertook a RADAR assessment12 with A.C. to seek her views as part of the early help assessment and support. This enabled A.C. to explore her feelings and for CFW to identify a suitable resource to support her. However, A.C.’s views were not fully incorporated into the early help assessment nor the plan and this meant that they were not available to the wider professional network at the time or for future reference.   5.6.7 The school nurse provided support to A.C. via her Mother and did not hear directly from A.C. how her head lice was being treated. During March 2020, A.C’s Mother told the school nurse that A.C. had been treating the head lice herself. A.C’s Mother advised the reviewer that given A.C’s age she found it difficult to supervise her treating her hair. This meant that professionals had a clearer understanding of why the head lice treatment was ineffective. If the school nurse had spoken to A.C. directly following the first referral it is possible that this information would have been known to the nurse much earlier and corrective action could have been taken.  5.6.8 The school nurse did not have any contact with A.C. during the period of the school closure because the service did not recognise the extent of the concerns and A.C was being provided with a universal service. This was a missed opportunity to review the progress of the treatment of A.C.’s head lice and to listen to her. 5.6.9 Learning ● A child’s views should be incorporated into the written assessment and plan in order they are available for current and future reference. ● The lack of contact with A.C. by school nursing service meant that they did not have a clear understanding of the impact of the head lice and how it was being managed.  6.0 Conclusion 6.1 The service provision by agencies during the period of the review identified some good and conscientious practice that was child focused. All of the practitioners presented as dedicated individuals who worked hard to safeguard A.C’s well-being. 6.2 Despite the best efforts of the practitioners involved, A.C. experienced serious harm and this review has identified a number of areas of learning about the effectiveness of the safeguarding system in Lancashire.  7.0 Learning and Recommendations 7.1 The main issues that have been identified as learning from this case have been highlighted within the analysis (section 5.) The Lead Reviewer and the Review Team have considered the learning and have identified questions and recommendations for the Children’s Safeguarding Assurance Partnership in the areas thought to be of most importance.  12 A RADAR assessment is part of the assessment used to understand a child’s perspective. Page 17 of 17 7.2 The Triennial Review 13  states that ‘good quality SCRs should incorporate particular characteristics. These include lessons learned which are clearly linked to the findings of the review; findings and questions for the LSCB, to promote deeper reflection on the lessons of the review, and leading to a response and action plan developed by the Board to address that learning; specific recommendations where there is a clear case for change, again with a response and action plan developed by the Board; and a strategy for dissemination and learning of the lessons that will reach relevant practitioners and managers within the Board’s constituent agencies’. Whilst this review was not a mandatory review, it is arguable that the same principles apply. 7.3 The recommendations for the Children’s Safeguarding Assurance Partnership are directly linked to the learning areas of; Recommendation 1: Effectiveness of early help  The Children’s Safeguarding Assurance Partnership should seek assurance as to the quality of early help assessments, with a particular focus on ensuring that the issues outlined in the referral are addressed in the assessment and support plan. Recommendation 2: Multi-agency response to concerns of neglect The Children’s Safeguarding Assurance Partnership should accelerate the implementation of the neglect tool for use by professionals and seek assurance that it is being used effectively. Recommendation 3: Effectiveness of inter-agency and intra-agency communication The Children’s Safeguarding Assurance Partnership should promote the triangulation of information by agencies when information is provided by parents/carers and there are unresolved concerns. Recommendation 4: How professionals work with the challenge of limited engagement from parents The Children’s Safeguarding Assurance Partnership should reinforce with professionals the need to practice respectful uncertainty when working with parents/carers. Recommendation 5: Multi-agency repsonse to connected persons The Children’s Safeguarding Assurance Partnership should reinforce with professionals the need to ensure that there is a clear understanding of the role of connected persons in the child and parent’s life, particularly where they are assuming some responsibility for a child. Recommendation 6: Consideration of the voice of the child The Children’s Safeguarding Assurance Partnership should seek assurance from agencies that consideration is given to ensuring that the child’s experience (in accordance with their age and understanding) is sought and recorded and is reflected in the provision of services.     13 Complexity and challenge: a triennial analysis of SCRs 2014-17. Brandon, Sidebotham et al. Department for Education March 2020. 