Overdose of medication by an adolescent girl in 2019. Charlie's mother was found unconscious by ambulance services after taking a drug overdose, and had reportedly given Charlie tablets. Family were known to health services and children's services. Mother had problematic drug issues, using prescription opioids and illicitly obtained drugs. Charlie had a history of poor school attendance and repeated hospital attendances and was suspected to have been the subject of fabricated or induced illness (FII). Ethnicity or nationality are not stated. Learning is embedded within the review. Recommendations include: review data to benchmark the number of families with children who could be affected by parental opioid prescribing; parental substance misuse guidance should include further guidance regarding safeguarding concerns arising from parental dependence on prescribed drugs; a designated doctor review Charlie's medical records to establish lessons on identifying and responding to indicators of FII, particularly in older children and adolescents; agencies identify how to improve practitioner engagement with fathers in safeguarding and child protection work; regular dip-sample audits of cases where child protection enquiries have concluded with substantiated concerns but where the decision was made not to proceed to a child protection conference.
      
 Title:  Child safeguarding practice review: Charlie. LSCB: St Helens Safeguarding Children Partnership Author: Isobel Colquhoun Date of publication: 2021  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                             1    Child Safeguarding Practice Review  Charlie    This Child Safeguarding Practice Review has taken steps to preserve the anonymity of the children in this family by representing the children by names chosen at random.   The names chosen do not necessarily reflect the children’s true gender.   In addition, the review has avoided the use of exact dates and has removed details about local services which could contribute to the recognition of the children and family.    This document is classified as “Protected” and therefore may be circulated freely to selected partners and partnerships where Information Sharing Agreements are in place and registered with the St Helens Safeguarding Children Partnership Business Manager. This is not a public document.  Neither the report nor any of its contents may be disseminated further without the prior agreement of the originator  .      2  1. Background to review  1.1 In 2019, the ambulance service attended Charlie’s family home, following a 999 call by her sibling, Frankie.  Charlie’s mother (MC) was unconscious: it was reported that she had taken an overdose of drugs.  Charlie was present, and the ambulance crew was informed that MC had ‘given her tablets’.  Charlie was fully conscious but feeling unwell: her speech was slurred, and she was lethargic.     1.2 MC was taken to a local hospital where she was intubated on the Intensive Care Unit.  On her way to hospital; Charlie lost consciousness.  FC was told about what had happened but said that he would not attend as he was at work ‘over 100 miles away’.     1.3 The local authority notified Ofsted of an incident of serious harm to a child and the Safeguarding Children Partnership (SCP) undertook a rapid review of the facts readily available to local agencies and organisations providing services to children and families.   1.4 The Rapid Review Panel of the SCP concluded the circumstances of the case met the criteria for a local safeguarding children practice review (previously known as a serious case review), facilitated by an independent reviewer.  This recommendation was endorsed by the SCP Chair, the Strategic Director for People’s Services, St Helen’s Council.  This decision was communicated to the national panel of independent experts on serious case reviews where it was endorsed.    1.5 The SCP agreed that the review should be conducted using a hybrid systems method.  The review would take account of complexity of the circumstances in which professionals work.  It would seek to understand both what happened and why.  A learning event for practitioners and first line managers would provide the opportunity for learning for those working with the family.  Single agency analyses would promote learning at organisational level from the case.  The final review report would seek to reflect that learning in the context of lessons for multi-agency practice and recommendations for change.     1.6 A Safeguarding Children Practice Review Panel (SCPRP) of senior managers from relevant agencies and organisations was established to oversee the conduct of the review.   1.7 A learning event from practitioners and managers was held in December 2019.  With the exception of GP services, this event was well-attended by representatives of agencies and organisations which had been involved with the family.  Attendance by practitioners and first line managers who had had direct contact with family was reduced, however, by a combination of staff turnover and the nature of family’s contact with health services.  All participants engaged constructively in building case detail.  As individuals, participants were open about their own agency’s practice and were respectfully enquiring of others.  As a group, they impressed by their capacity to identify both case specific and wider learning.     3  1.8 In January 2020, a structured conversation between Named GP for safeguarding children, the Designated Safeguarding Nurse (CCG) and relevant members of the GP practice.  The resulting report has informed this review.   1.9 The final key lines of enquiry for the review were:  a) In as much as can be ascertained from information available, how effective were assessments and services in the pre-review period?  b) During the review period; how effectively did agencies evaluate mother’s strengths and vulnerabilities and the impact that these had on her ability to care for her children?  Specifically consider MC’s prescribed and illicit drugs use.  c) How well did agencies understand father’s circumstances and the role that he had in caring for the children and keeping them safe? d) How well did agencies understand grandparents’ circumstances and the role that they played in caring for the children and keeping them safe? e) What did agencies understand about allegations of sexual harm relating to individuals in this family and how did that affect professional practice? f) How well did agencies understand the children’s needs and the risks of harm to which they were exposed?  In particular, what assessments took place in respect of Charlie’s attendances at hospitals with acute symptoms which were medically unexplained? g) How well did agencies understand the everyday lives of the individual children in the family, including the nature of sibling relationships?  h) What did agencies understand about allegations of sexual harm relating to individuals in this family and how did that affect professional practice? i) How effective was single- and multi-agency communication during the review period?  In particular, how effective was communication between adult-focused services and child-focused services? j) How effective were single- and multi-agency services in promoting the children’s welfare and in keeping them safe?  1.10 Throughout the review, the SCPRP met regularly to consider the emerging picture of local safeguarding practice.  In February 2020, additional specific questions were sent to public health, St Helens Clinical Commissioning Group (CCG), the local substance misuse service and to Children’s Social Care (CSC).  Their responses have also informed learning and recommendations.  The SCPRP contributed to the final analysis and the construction of the recommendations of this review.    1.11 The detail which underpinned the learning from the key lines of enquiry has been shared with the Safeguarding Children Partnership.  The Partnership has confirmed that the findings of the key lines of enquiry are consistent with the analysis and recommendations which follow.    1.12 The review process was actively supported by the Safeguarding Partnership dedicated staff within the local authority.     4  1.13 As criminal investigations and care proceedings were active during most of the period of the review, the decision was taken not seek the involvement of the child and/or family members in the review until those processes had come to an end.      5  2. Analysis  2.1 A challenge to this SCPR has been the degree to which the recorded family history is characterised by gaps and uncertainty about both what happened and why it happened as it did.  The key lines of enquiry revealed a significant absence of multi-agency work.  This had a number of consequences for developing a picture of Charlie and her family as well as for examining safeguarding practice.    2.2 Incidents and events that were likely to be multi-dimensional in their origins were not recognised as such.  Instead, they were managed as if they were simple, single-issue problems rather than being representative of an underlying complexity of family circumstances and relationships.  There was a focus on medical issues both in respect of MC and in relation to Charlie.  While this should have increased joint-agency analysis and planning; it did not.    2.3 In addition, there was a weak application of locally and nationally agreed thresholds for assessment and interventions by the local authority.  This meant that the children and family did not receive the service that they might have expected, and, at the same time, parents were not adequately challenged about the care they were giving their children.  There is very little evidence, however, that partner agencies expressed dissatisfaction with decisions made by CSC or that they escalated any concerns they might have.   2.4 From the point at which this SCPR began, St Helens SCP has been keen to ensure that the lessons from this case can be translated into specific actions which will make a difference to outcomes for children and families locally.  As a consequence, the SCPR has identified specific lessons in respect of parental problematic drugs use and relating to a child’s attendance at hospital with clinically unexplained symptoms.    2.5 At the same time, it has been evident that there were many shortcomings in general safeguarding practice in this case.  It is acknowledged, however, that the nature of many of those shortcomings is already known to the Partnership and that, in many instances, improvements are being made.  This has been taken into account in the analysis and recommendations which follow.  Finally, as poor school attendance was an issue for Charlie, this is considered as a potential safeguarding matter. Parental problematic drugs use  2.6 A key feature of this case was MC’s problematic drug use.  MC had initially been prescribed drug treatment for pain management but, over time, she both sought access to additional opioids through medical channels and supplemented her use with illicitly obtained substances.  Although there were allegations that MC’s drugs use was having a negative impact on family life; no professional had a clear picture of its effects on her functioning as an individual and as a parent.  As a consequence, the potential impact of their mother’s accumulating difficulties on the children’s lives was not recognised.  This is a common   6  characteristic of safeguarding work where parental substance misuse is a feature of family life.   2.7 In 2014, the NSPCC published a summary of the key issues identified in learning from serious case reviews .  On one level, had safeguarding practice in this case taken account of the lessons contained in that summary, it is likely that the risks for the children could have been recognised more quickly and addressed more thoroughly.  Circumstances were perhaps complicated, however, by the fact that the drugs in question were believed to be primarily prescribed rather than illegal drugs obtained by street purchase.       2.8 From contact with professionals at all levels in different agencies during the course of this review, it has become clear that there is:  a) Limited general knowledge about the nature, purpose and efficacy of opioid treatment;   b) Limited awareness of how to form a comprehensive picture of the impact of prescribed drugs on an individual’s behaviour and consequent safety concerns; c) Uncertainty about how to identify and respond to indicators that patients are seeking to ‘top up’ their prescribed drugs either through medical routes or by illicit means; d) Lack of knowledge about the link between prescribed drugs use and illegal drugs misuse; and,  e) Little recognition of the implications for children living with parents with problematic prescribed drugs use.     2.9 It is notable that there have been very few high-quality research studies on medicine dependence and withdrawal, and their prevention and treatment, in the last 10 years.  The following, however, describes some of what is known nationally about opioid prescribing.  It also provides a summary of information that has been made available to the review about local arrangements about developments at a local level to support individual patients; to reduce harm in the population; and, to safeguard the children of substance misusing parents.  These are the details which have informed subsequent recommendations.  a) Opioid prescribing: the national picture  2.10 In September 2019, Public Health England (PHE) published an evidence review of dependence and withdrawal associated with some prescribed medicines which included a literature review of the effectiveness of certain drug treatments used in the management of mental health and chronic pain.    2.11 This report1 revealed that 5.6 million adults in England (13% of the adult population) received one prescription or more for opioids between 2017 and 2018.  Although long-term prescribing of opioids for chronic, non-cancer pain is not beneficial for most patients;  1 The information which follows is taken from a summary provided on www.nhs.gov.uk   7  researchers estimated that around 500,000 were taking opioids continuously for at least 3 years (from 2015 to 2018).  The report also identified inequalities in prescription rates based on gender, age and local levels of poverty.   2.12 The report is clear about effectiveness of particular drug therapies when used as recommended and cautions that that ‘inappropriate limiting of medicines may increase harm, including the risk of suicide, and lead some people to seek medicines from illicit or less-regulated sources’.  Nevertheless, it suggests that local areas should review both prescribing practice and the availability of alternative treatments, as well as considering what more can be done to educate and support patients.     2.13 The lessons from this report have particular significance in St Helens as the local Clinical Commissioning Group (CCG) is ranked 7th out of all CCGs in England for opiate prescription and is the highest prescribing CCG in Cheshire and Merseyside. b) Opioid prescribing: the situation locally i. Individual patients: prescribing practice  2.14 In response to questions from SCPRP, St Helen’s CCG acknowledges that reducing opioid prescribing is a local priority.  Within the CCG, it is the role of Medicines Management Team both to support the commissioning of effective services and treatments and to assist individual clinicians to prescribe the most cost-effective, evidence based and safe medicines.      2.15 To support clinicians in reducing their overall levels of opioid prescribing, the Medicines Management Team has introduced a number of initiatives including education sessions; a prescribing incentive scheme; and, the sharing of prescribing data.  The CCG recognises, however, that ‘reducing patients off opioids is slow and time consuming for clinicians’, particularly within the context of high levels of deprivation locally.     2.16 The CCG reports that some GP practices are considering developing ‘opioid contracts’ with patients.  To date, safeguarding children issues have not consistently been taken into account in relation to opioid use.  To begin to address this gap, therefore; the Named GP, the Designated Nurse and Assistant Director of Medicines Management plan to incorporate safeguarding children and awareness of young carers into any parental opioid contracts.   2.17 It is notable that no clinician contacted the Medicines Management Team in respect of MC during the review period. ii. Individual patients: identifying those seeking additional prescription drugs  2.18 MC sought additional drugs from the GP for a variety of reasons which led to daily prescriptions; she attended the Urgent Treatment Centre (pre-review period) asking for 18 prescriptions; she phoned the police and reported that her cousin had stolen a safe with   8  her medication; and, she appears to have manufactured opportunities to obtain additional drugs through ambulance services or ED.   2.19 It has been said in learning summaries that there should have been an MDT to coordinate and oversee MC’s medications, but no clear process has been identified in respect of expectations of agencies and organisations in that regard.  This was discussed in the SCPRP and it was agreed that there would be merit in the CCG developing a Drug-seeking Patient Policy.  Examples of such policies are available elsewhere.  The CCG representative on the SCPRP has agreed to pursue this locally.   iii. Individual patients: prescribed opioid use supplemented by drugs acquired elsewhere  2.20 The local substance misuse service (commissioned by Public Health) reports that of the 995 people in structured treatment at present, 79 have declared requiring support with medication, even if that was not their primary reason for entering the service.     2.21 The service currently has the same pathway for assessment and risk management for those struggling either with prescribed or illicitly purchased medication.  If, however, individuals are addicted to a medicine which is currently prescribed by their GP or through a pain management clinic, they remain under the governance of the GP, but additional support would include:  i. Clinician to clinician advice in relation to prescribing and community-based reduction; ii. Assessment, referral, preparation and aftercare for inpatient detoxification; and  iii. Access to ‘recovery’ interventions.  2.22 The same service would be available for individuals who are receiving a GP prescription for pain killers and were then ‘topping up’ their supplies through the internet or from over the counter pharmacies.        2.23 Parents who are prescribed opioids are also provided with safe storage, a home environment assessment and information regarding the potential harm of medication.  The substance misuse services states that all staff are trained to service standard levels on safeguarding and the risks associated with substance use.  The service also has a specialist family team which includes three senior social workers.   2.24 As with the medicine’s management team; there was no referral to, or professional consultation with, the substance misuse team in respect of MC during the review period.   c) Reducing harm from prescribed opioids in the population  2.25 There is currently no specific local drugs strategy in St Helens.  Strategically, reducing harm from alcohol has been identified as a priority by the People’s Board and the Public Health response to SCPRP indicates that local partnership action has focused on this during the last 12 months.  It is noted, however, that the Partnership is currently reviewing its terms   9  of reference along with the Community Safety Partnership.  This would offer an opportunity to consider a joint strategic approach to reducing harm from both alcohol and drugs in 2020.  The SCPRP would strongly support this action.   2.26 In the meantime, PH is supporting a dedicated task group, led by the CCG, to review the levels of opioid prescribing in St Helens and to reduce any associated risk.    2.27 The SCPRP is not aware of any specific actions being taken locally to raise awareness of the issue of opioid addiction.  In their responses, both the CCG and GP referred to the Faculty of Pain Medicine’s webpages Opioid Aware.  The SCPRP was of the view that this information, while useful, would be unlikely to be accessed by a high proportion of people affected.   2.28 At a service commissioning level, the CCG intends to review the effectiveness of its commissioning of pain management services and to ensure that patients have access to psychology and physiotherapists.    d) Safeguarding children  2.29 As already noted, the focus on an adult’s health and substance misuse can prevent the needs of, and risks to, children in the family being recognised and addressed.    2.30 In December 2018, HM Government (PHE) published guidance for local authorities in respect of safeguarding and promoting the welfare of children affected by parental alcohol and drug use.  This guidance recommends having a local protocol whose purpose is to safeguard and promote the welfare of children and young people, including young carers, whose lives are affected by substance misusing parents or carers.  It should also promote effective communication between adult drug and alcohol services and adult, children and family social care services, and set out good working practice for the services involved.   2.31 The substance misuse service reports that, in St Helens, there is no formal protocol.  It states, however, that the guidance was the foundation for the Building Bridges Project which is delivered by the substance misuse team and is funded by Public Health England.  The Building Bridges Project is a partnership between PHE, the service misuse service and CSC.  The substance misuse service gives examples of the ways in which it is working in line with the government’s good practice guidance.  There is little evidence, however, that practitioners and managers in CSC are aware of the expectations of joint working contained in that agreement.    2.32 CSC has provided details to the review of practitioner training ‘Assessing the impact of substance misuse on parenting and childcare’ which is available as part of the training matrix.  It is noted that practitioners are also able to access Research in Practice and to seek additional advice, guidance or training through the Principal Social Worker and Workforce Development Team.  As already described, however; the evidence from this   10  case review is that CSC practitioners and managers did not ensure that assessments of the impact of MC’s substance misuse met the expected standard for practice in this area.   2.33 As the focus of any CSPR is on learning, with a view to reducing the likelihood of similar incidents in the future; in this case, the Safeguarding Children Partnership needs to be satisfied that professionals working with children and families should be aware of the problems which can result from parental dependence on prescribed opioids.  They should know what steps they need to take to ensure that a comprehensive picture is developed of the impact of opioid dependence on the individual’s behaviours and of any consequent safety concerns.  They should also understand how to ensure that the impact on children’s lives is understood and, where necessary, addressed.    2.34 Although current local child protection procedures refer to parental substance misuse as including prescribed drugs, where there is dependent use; this review suggests that additional specific information would be helpful both for primary and secondary health care and social care practitioners.   2.35 Recommendation 1:  Although it is accepted that the level of opioid prescription is high in St Helens, the demographic details of the affected cohort of patients are not known.  It is recommended, therefore, that the SCP asks PH to provide the data that it needs to benchmark the number of families with children who could be affected by parental opioid prescribing, with a view to determining what action might be required.    2.36 Recommendation 2:  Alongside disseminating learning from this review; the SCP should:  a) quickly revise its current procedures in respect of Parental Substance Misuse, to include more detailed guidance in respect of identifying and responding to safeguarding concerns arising from parental dependence on prescribed drugs; and, b) require agencies and organisations to provide details of how they are implementing the Parental Substance Misuse guidance and what steps they are taking to assess its impact on practice.  2.37 Recommendation 3:  Before March 2021, the Safeguarding Children Partnership should undertake a multi-agency audit of cases where substance misuse is a feature of family life.  That cohort of cases should, if possible, contain examples of parental dependence on prescribed drugs. Responding to a child’s attendance at hospital with clinically unexplained symptoms  2.38 During her lifetime, Charlie has had repeated hospital attendances to exacerbation of asthma.  More recently, she began to attend with symptoms that were not medically explained.  The SCPRP discussed this situation at length but was unable to draw definite conclusions about the implications for safeguarding practice.  There were a number of factors which contributed to this.    11   2.39 Firstly, it is acknowledged that adolescents experiencing medically unexplained symptoms are not unusual, with an estimate between 10-25% of adolescents reporting recurrent chronic somatic complaints only a small proportion of which have an identifiable medical cause.     2.40 In Charlie’s case, however, she was suspected to have been the subject of fabricated or induced illness in the past and there are features of her recent presentations in hospital which could suggest that this might have been a continuing issue.  At the same time, there was a considerable gap between the original concerns which could suggest the contrary.    2.41 Similarly, the review suggests that MC’s own presentation with ill health and her particular relationship with Charlie may have influenced how Charlie revealed her own emotional state.  It is notable, however, that during the years following suspicions about fabricated or induced illness, there were no satisfactory assessments of Charlie’s needs or family relationships.      2.42 Finally, it is notable that the local Safeguarding Children Partnership has not been able to recruit to the role of designated doctor.  This leaves a gap in necessary safeguarding expertise particularly in respect of medical issues.    2.43 Despite being uncertain as to underlying factors which might have led to Charlie’s presentations at hospital, therefore, the SCPRP remains concerned that there may be unidentified practice issues in respect of fabricated or induced illness.  It is acknowledged that this has been identified as an area for improvement in the recent past.  At the end of 2014, St Helens LSCB undertook a SCR in which fabricated and induced illness was the principal concern.  Findings in that case were similar to concerns which were then identified in a multi-agency review undertaken in 2019.      2.44 Following the review of 2019, the Safeguarding Children Partnership agreed to undertake a multi-agency audit of cases where fabricated or induced illness had been identified as a risk; to measure compliance with procedures and to ensure that children’s general safeguarding and welfare needs had been adequately addressed and recorded.  It is important that the findings of that audit are translated into effective actions.  2.45 In order to be satisfied, however, that potential learning from this particular case is identified; the SCP has secured funding for ‘designated doctor hours’ to support the implementation of the following recommendation.  2.46 Recommendation 4:  The Safeguarding Children Partnership should commission a short life group to be overseen by an agreed ‘designated doctor’.  The purpose of that review would be to conduct a medical review of Charlie’s records and to establish what, if any lessons there are for professionals, in respect of identifying or responding to indicators of fabricated or induced illness, particularly in older children/adolescents.   12  Basic Safeguarding Practice  2.47 In addition to issues arising from maternal drug use and questions about Charlie’s attendance at hospital with clinically unexplained symptoms; this review has revealed many shortcomings in basic safeguarding practice, particularly within the local authority.  The majority of these have been acknowledged by CSC.    2.48 As has already been noted, key features of practice included the tendency to treat each reported incident or referral as a single issue to be resolved as quickly as possible.  There was little reference to previous history or information which might have been held by partner agencies.  Family relationships and family functioning were not understood, so that key safety plans over-estimated Charlie’s father’s motivation to keep his children safe and the nature of the support which grandparents were able to offer.  In addition, little real knowledge was gained about the children’s experience; their family relationships and friendships; or, about their opinions, feelings or wishes.  No child in need plan was established and no child protection conference took place, although both were possible outcomes during the review period.  While this might not have prevented the precipitating incident with its serious medical and legal consequences; it could have provided an earlier insight into underlying causes of difficulties in the family and an assessment of the prospect of change.  2.49 As the analysis was developing; the SCPRP requested further information from the local authority in respect of improvements which have already been made or are planned, following focused visits by Ofsted in July 2018 and November 2018, and an inspection of children’s social care services in September 2019.  The purpose of that request was to ensure that recommendations from the review tie in with, wherever possible, existing action plans.  In addition to specific questions in respect of the response to referrals and to the quality and outcomes of assessments; the local authority was asked to give brief details of any cultural or organisational issues which might have contributed to practice shortcomings; and, to identify any systemic changes that have been made to support social work practitioners undertaking assessments of need and risk of harm.    2.50 A full response was received describing the changes to which the Council Cabinet and Chief Executive have committed in order to modernise Children’s Services.   Reference is also made to the overarching improvement plan, overseen by the Children’s Improvement Board, and to the key principles which underpin the management and leadership approach.  ‘Signs of Safety’ is being implemented as the practice model and it is anticipated that this ‘way of being’ will be embedded in all aspects of practice across the partnership.  Changes are also being made to improve accountability for decision-making; to overcome inconsistency in the quality of management supervision and oversight; and to embed audit and a quality assurance framework.  At the same time, additional permanent funding allows increased service options and more manageable individual caseloads for social workers.  Social workers have also been provided with IT equipment and mobile phones to enable more efficient and flexible working arrangements.  Arrangements have been established to provide feedback from frontline practitioners to senior managers.       13   2.51 These changes, if effective and sustained, should provide an environment which will make good practice more likely.  2.52 In January 2020, however, the Head of Service for Safeguarding and Quality Assurance presented an audit of assessments to the local Improvement Board.  This audit had been prompted by data which indicated that, during the year, a high percentage of referrals closed on completion of assessment, with no services being offered.  This was a feature of practice in this case.  The audit confirmed concerns about the application of thresholds and concluded that the quality of assessments; management oversight; and, the quality assurance of assessments were poor.    2.53 Accurate assessments of need and of risk of harm are crucial to multi-agency safeguarding and child protection.  The SCP should be satisfied that anticipated practice improvements within CSC are being delivered.    2.54 Recommendation 5:  An audit of assessment (CSC/ January 2020) made six recommendations for action to improve the quality of assessments.  They include proposals with implications for both single-agency and multi-agency practice.  It is recommended that the SCP requires the local authority to report, by December 2020, on the implementation of the six recommendations made.   2.55 “It is now well established that fathers matter to children’s wellbeing.  When fathers are positively involved in their children’s lives, their children are more likely to do better at school, have better relationships with their peers, have better mental health and are less likely to be in trouble with the police.  When social workers work with fathers to improve their involvement with children, they can help to improve outcomes for children”2.    2.56 Research has consistently found that child protection work tends to focus on mothers, with fathers having a peripheral presence in case files, child protection conferences and home visits.  In this case, assumptions were made about father’s capacity to keep his children safe and there was insufficient challenge to him when he demonstrated that they were not his priority.  This issue of ‘hidden males’ is generally well-known to safeguarding practitioners, but individual and joint practice may still be influenced by unconscious personal biases and by the weight of cultural norms.  It is also acknowledged that, in some cases, involving the father might require additional safeguards to avoid putting the mother and children at risk.  2.57 The SCPRP was reluctant to make a recommendation which would be in effect ‘more of the same’ and unlikely to make a difference, while recognising that, in a context of a shared emphasis on improving the quality of assessments overall; there are opportunities to focus on improving this area of practice.     2 https://www.communitycare.co.uk/2018/02/19/working-fathers-key-advice-research/    14   2.58 Recommendation 6:  The SCP should require agencies and organisations to identify how they intend to measure and improve practitioner engagement with fathers in safeguarding and child protection work.    2.59 Recommendation 7:  The SCP should ensure that all multi-agency audits commissioned by the Partnership take account specifically of the engagement of fathers in safeguarding processes.  This will allow the Partnership to measure improvements in practice over time and to identify where further action may be required.   2.60 Improving the involvement of children in assessments of their needs and in managing risks to them is a crucial factor in improving safeguarding and child protection practice.  It is a key finding of this SCPR.  Again, however, practitioners and managers are aware that children and young people should be continually involved in work with them and their families.  They generally understand that children should have the opportunity to describe things from their point of view and to have information fed back to them in a way that they can understand.  Practitioners and managers know that there should always be evidence that ‘the child’s voice’ has influenced decisions that professionals have made.  And yet, this appears to be difficult to achieve in reality.  This is also reported to be reflected in practitioner responses to multi-agency ‘Working Together’ training.  2.61 As before, the SCPRP is reluctant to repeat recommendations or duplicate work already in hand.  At the same time, it is keen to make use of the opportunities for change which are currently available.  A slightly different approach is, therefore, recommended.  2.62 Recommendation 8:  Arrangements should be made to feedback the findings of this review specifically to St Helens ‘Voice of the Child Champions Group’ so that they understand the key issues and challenges of the case.  Following that, colleagues from the multi-agency partnership should be recruited to contribute to planning and delivering a 'Speed Resources' event.  That event should target multi-agency practitioners to share tools/resources to improve participation of children in safeguarding/ child protection processes.  2.63 The question which was raised in the course of this review about assessments of need closing with no further action has already been considered by the audit report prepared by CSC for the Improvement Board and which forms the basis of Recommendation 5.     2.64 In addition, the key lines of enquiry highlighted that decisions were made not to progress to child protection conference, although the child protection concerns had been substantiated.  It is the legitimate function of CSC team managers to make this decision but, in this case, their rationale was not entirely evident.  At the same time, referrers (or members of strategy meeting) appear not to have challenged that decision, although it is not clear that they were aware of the outcome.  Ensuring that children who need the protection of a multi-agency plan is another of the most important planks in the child protection framework.  It is currently not known to the SCP in what proportion of child   15  protection enquiries, where initial conference did not follow, concluded that concerns were substantiated.  2.65 Recommendation 9:  The SCP should ask the local authority to undertake and report on regular dip-sample audits of cases where child protection enquiries have concluded with concerns being substantiated but there being a decision not to proceed to child protection conference.   Dip-sample should focus on the rationale for decision-making and the level of consultation with the referrer/other professionals involved with the family.   2.66 Recommendation 10:  The SCP training manager should disseminate the pan-Merseyside multi-agency training course in respect of professional challenge to relevant practitioners and managers in the local area.  Improving this area of practice would support efforts to ensure consistent application of thresholds of need and support across the borough.  2.67 Finally, concerns were noted in the key lines of enquiry about the impact that Charlie’s poor school attendance had on both her education and on professional understanding of the levels of her vulnerability.  Further information was, therefore, requested by the SCPRP about Charlie’s levels of attendance throughout her school life as that might be an indicator of how her care was being managed at home.  Charlie’s poor attendance was thought to be a factor in her reported difficulties in making friends.  Charlie attended 3 primary schools.  In Y4 her attendance fell below 85% and in Y5 there was a further fall to less than 65%.  In Y6, Charlie’s attendance was 75%.  2.68 The local authority Education Welfare Service has provided details of expectations of schools and governing bodies in respect of identifying pupil absence related to illness or medical conditions and of providing co-ordinated support to children and parents.  It would be anticipated that support plans would be reviewed on a regular basis with health professionals being invited to show progress or to identify changes that are needed to be meeting the individual child’s current presenting needs.  The need to consider referrals to any other support services, such as Early Help, CSC, or CAMHS is also highlighted.  2.69 No evidence has been made available to the review in respect of compliance with those expectations.    2.70 Recommendation 11:  The SCP should audit school compliance with local authority guidance in respect of children who are absent from school due to illness or medical conditions under S175 of the Education Act 2002, as a basis for determining what, if any, further action may be required.      16  3. Summary of Recommendations  Recommendation 1:  Although it is accepted that the level of opioid prescription is high in St Helens, the demographic details of the affected cohort of patients are not known.  It is recommended, therefore, that the SCP asks PH to provide the data that it needs to benchmark the number of families with children who could be affected by parental opioid prescribing, with a view to determining what action might be required.   Recommendation 2:   Alongside disseminating learning from this review; the SCP should: a) quickly revise its current procedures in respect of Parental Substance Misuse, to include more detailed guidance in respect of identifying and responding to safeguarding concerns arising from parental dependence on prescribed drugs; and, b) require agencies and organisations to provide details of how they are implementing the Parental Substance Misuse guidance and what steps they are taking to assess its impact on practice. Recommendation 3:   Before March 2021, the Safeguarding Children Partnership should undertake a multi-agency audit of cases where substance misuse is a feature of family life.  That cohort of cases should, if possible, contain examples of parental dependence on prescribed drugs. Recommendation 4:   The Safeguarding Children Partnership should commission a short life group to be overseen by an agreed ‘designated doctor’.  The purpose of that review would be to conduct a medical review of Charlie’s records and to establish what, if any lessons there are for professionals, in respect of identifying or responding to indicators of fabricated or induced illness, particularly in older children/adolescents. Recommendation 5:    An audit of assessment (CSC, January 2020) made six recommendations for action to improve the quality of assessments.  They include proposals with implications for both single agency and multi-agency practice.  It is recommended that the SCP require the local authority to report, by December 2020, on the implementation of the six recommendations made. Recommendation 6:  The SCP should require agencies and organisations to identify how they intend to measure and improve practitioner engagement with fathers in safeguarding and child protection work.       17  Recommendation 7:  The SCP should ensure that all multi-agency audits commissioned by the Partnership take account specifically of the engagement of fathers in safeguarding processes.  This will allow the Partnership to measure improvements in practice over time and to identify where further action may be required. Recommendation 8:   Arrangements should be made to feedback the findings of this review specifically to St Helens ‘Voice of the Child Champions Group’ so that they understand the key issues and challenges of the case.  Following that, colleagues from the multi-agency partnership should be recruited to contribute to planning and delivering a 'Speed Resources' event.  That event should target multi-agency practitioners to share tools/resources to improve participation of children in safeguarding/child protection processes. Recommendation 9:   The SCP should ask the local authority to undertake and report on regular dip-sample audits of cases where child protection enquiries have concluded with concerns being substantiated but there being a decision not to proceed to child protection conference.  Dip-samples should focus on the rationale for decision-making and the level of consultation with the referrer/other professionals involved with the family.  Recommendation 10:   The SCP training manager should include the pan-Merseyside multi-agency training course in respect of professional challenge to relevant practitioners and managers in the local area.  Improving this area of practice would support efforts to ensure consistent application of thresholds of need and support across the borough. Recommendation 11:   The SCP should audit school compliance with local authority guidance in respect of children who are absent from school due to illness or medical conditions under S175 of the Education Act 2002, as a basis for determining what, if any, further action may be required.   Isobel Colquhoun Independent Reviewer 9 March 2020      18  Appendix 1 List of Acronyms  SCP – Safeguarding Children Partnership SCPRP - Safeguarding Children Practice Review Panel CCG – Clinical Commissioning Group CSC – Children’s Social Care PHE – Public Health England ED – Emergency Department  MDT – Multi Disciplinary Team  PH – Public Health LSCB – Local Safeguarding Children’s Board  