Death of a 3-year-old girl in August 2012, from internal bruising to the abdomen as a result of blunt force trauma. Post mortem revealed evidence of older injuries. Father pleaded guilty to manslaughter and mother was convicted on a charge of child cruelty. Paternal history of: childhood trauma; time spent looked after by the local authority; frequent use of cannabis; controlling behaviour, especially towards females; and having his first child placed for adoption following an assessment that he was incapable of caring for a child. Father was known to criminal justice agencies and had spent time in prison for burglary and an offence of having sex with a girl under the age of legal consent. Mother had experienced a chaotic childhood, was identified as compliant and passive by professionals and was working long hours in two jobs prior to Child K's death. Sets out key findings using a systems model based typology developed by Social Care Institute for Excellence (SCIE) and raises issues for consideration in regards to the identified themes for learning. Key themes include: importance of enquiring into parents' history and how this might impact on parenting capacity; addressing professional optimism and lack of professional curiosity; addressing the needs of children who have a parent in prison; and increased and more consistent use of risk assessment tools and frameworks.
      
Title: A serious case review: ‘Child K’: the overview report LSCB: Lancashire Safeguarding Children Board Author: Peter Maddocks Date of publication: November 2013 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.   Page 1 of 69        Lancashire  Safeguarding Children Board        A Serious Case Review  ‘Child K’  The Overview Report      July 2013     Page 2 of 69 Index  1 Introduction and context of the review ..................................................... 4 1.1 Rationale for conducting a serious case review .................................... 5 1.2 The methodology of the serious case review ....................................... 5 1.3 Reasons for the review and terms of reference .................................... 7 1.4 The scope of the serious case review .................................................. 8 1.5 The terms of reference in national guidance ...................................... 10 1.6 Particular issues identified by the SCR panel for further investigation by the individual management reviews: ............................................................... 10 1.7 Membership of the case review panel and access to expert advice ........ 12 1.8 Independent author of the overview report and independent chair of the serious case review panel ......................................................................... 12 1.9 Parental and family contribution to the serious case review ................. 13 1.10 Timescale for completing the serious case review ............................... 14 1.11 Status and ownership of the overview report ..................................... 14 1.12 Previous serious case reviews ......................................................... 15 1.13 Inspections of services for children in Lancashire ................................ 15 1.14 Summary conclusion of the review panel .......................................... 16 1.15 The family and other significant people ............................................ 19 1.16 Cultural, ethnic, linguistic and religious identity of the family ................ 21 2 Synopsis of agency involvement ............................................................. 23 3 The critical reflection and analysis from the individual management reviews. . 31 3.1 Summary .................................................................................... 31 3.2 Significant themes for learning that emerge from examining the IMRs ... 31 TOR1 Historical information...................................................................... 33 TOR2 Child and her experiences at the centre of assessments ......................... 35 TOR 3 Consideration of diversity, social background and integration ................ 39 TOR 4 Information sharing and communication ............................................ 41 TOR 5 Examination of how relevant historical information was examined in assessment and taken into account for providing services .............................. 45 TOR 6 Extent to which services understood the significance of father’s personal and family history ................................................................................... 49 TOR 7 How child protection and safeguarding issues were identified and managed ........................................................................................................... 51 TOR 8 Resources and capacity ................................................................... 52 4 Analysis of key themes for learning from the case and recommendations ...... 55 4.1 Learning from previous serious case reviews ..................................... 56 4.2 Innate human biases (cognitive and emotional) .................................. 56 4.3 Responses to incidents or information .............................................. 60 4.4 Longer term work ......................................................................... 62 4.5 Tools .......................................................................................... 64 4.6 Issues for national policy ................................................................ 65 5 APPENDICES ...........................................................................................  Appendix 1 - Procedures and guidance relevant to this serious case review ....... 67 Legislation ............................................................................................. 67   Page 3 of 69 The Children Act 1989 .......................................................................... 67 The Children Act 2004 .......................................................................... 67 Safeguarding Procedures ......................................................................... 68 The local safeguarding children procedures .............................................. 68 Other local procedures relevant to this serious case review ........................ 68 National guidance ................................................................................... 68 Working Together to Safeguard Children (2013) ........................................ 68 Common Assessment Framework (CAF)................................................... 69    Page 4 of 69 1 Introduction and context of the review  1. In late August 2012 the regional ambulance service received an emergency telephone request to attend at the family home of a three year old child; the call had been made by the father aged 22 and the mother aged 20. Upon their arrival the paramedics found Child K to be in cardiac arrest. Child K was taken immediately by ambulance to the local hospital where the child was formally certified dead within 20 minutes of arrival; it was noted that there was already evidence of rigor mortis which can set in between one and eight hours after death.   2. The parents had told the paramedics that Child K had been unwell with sickness and diarrhoea on waking up; Child K had not been eating or drinking. The parents said that their child had collapsed after being taken to the toilet.   3. A post mortem examination identified internal bruising to Child K’s abdomen; this was judged to be consistent with blunt force trauma of the type that can be the result of a punch or being kicked. Damage to several internal organs was identified including the spleen and bowel. Older injuries were also diagnosed.  4. It was noted that the house had some animal waste inside (rodent) and outside the home (dog). Father had been using cannabis. Arrangements were made for Child K’s sibling to initially stay with her maternal grandmother.  5. Mother and father were both arrested.  No admission was made by either to causing injury to Child K.  They stated to the police (as well as to the media) that their child’s injuries were the result of falling off a swing.  Therefore a second post mortem was undertaken which provided the same result as the first; Child K had died as a result of a blunt edge trauma and internal bruising to the abdomen likely to be caused by a kick or punch.     6. Father was charged with murder and remanded into custody. Mother was subsequently charged with causing or allowing the death of a child and was also remanded into custody. The surviving sibling is subject of separate legal care proceedings.    7. During their trial, father changed his plea to being guilty of manslaughter; as a result of that change of plea, the judge directed the jury to discharge mother for the original charge of causing or allowing the death of a child and instead to consider whether she was guilty of a charge of child cruelty. She was convicted on that charge.   8. Both of the parents were criticised for their attempts to misdirect the investigation. The police had to balance whether their initial statements were true and believe that they were grieving parents or, as in fact proved to be the case the parents had relevant knowledge about the circumstances of the   Page 5 of 69 death of Child K.  There were only a small number of adults who had been in contact with Child K in the days leading to her death; some of these were not family members.  A public appeal in the local media had been made for information to assist the police with their inquiries.    9. Child K was the eldest of two siblings and was living with both of her parents when she sustained her injury. Father had been looked after by the local authority for several years when he was an adolescent. He was known to criminal justice services and this had included terms of imprisonment in regard to burglary and for an offence of having sex with a girl under the age of legal consent.   10. Child K’s mother was not known to any services other than the usual universal services associated with being educated and receiving health care for herself and her children.   11. Although there had been referrals to children’s social care services (CSC) in relation to the family with the last occurring about two weeks before Child K died children’s social care services were not involved when Child K died. The children had never been the subject of a multi agency child protection conference. Further information and analysis is provided in later sections of this report.  1.1 Rationale for conducting a serious case review  12. Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires a Local Safeguarding Children Board (LSCB) to undertake a review of a serious case in accordance with procedures set out in chapter 8 of Working Together to Safeguard Children (2010).   13. The LSCB should always undertake a serious case review when a child dies and abuse or neglect is either known or is suspected to be a factor in their death.   1.2 The methodology of the serious case review  14. A serious case review panel was convened of senior and specialist agency representatives to oversee the conduct and outcomes of the review. The panel was chaired by an independent and suitably experienced person.   15. Work began on compiling a chronology in October 2012, which coincided with the appointment of the independent chair of the serious case review panel and of the independent author of this overview report. Neither the chair nor the overview author has worked for any of the services contributing to this serious case review. Further information about their relevant experience and knowledge is provided in section 1.8.   Page 6 of 69  16. This serious case review was completed using the methodology and requirements set out in the government national guidance that applied at the time of the review being commissioned and completed. That guidance has been extensively revised in the latest edition of Working Together 2013 following the publication of the Munro Review’s final report and recommendations in 2011.   17. The government revised national guidance for assessment, multi-agency child protection and the conduct of serious case reviews in April 2013 as the review was nearing completion1.   18. The LSCB in Lancashire was already working on how future serious case reviews in the county could be developed in order to provide a more productive window into the local systems for safeguarding and protecting children2 and have participated in regional and national pilot work on using system learning within serious case reviews developed by SCIE (Social Care Institute for Excellence).  19. The SCR panel decided to build on the learning that had been developed from two previous SCRs in the county; one of those had been wholly conducted using the SCIE framework and another SCR had used the framework to present the findings from the review.  20. For this SCR the panel wanted to have greater level of practitioner involvement in compilation of information and in the development of analysis. A seminar style session was held in October 2012 that involved the panel members meeting with practitioners who were directly involved with the family. This session was used to help identify the key episodes of practice and outline some of the contributory factors influencing key events and decision making.   21. This material was incorporated into the individual discussions and the drafting of the agency individual management reviews (IMRs). A further session was held involving the panel and practitioners at the point that draft overview reports were being developed to contribute to the key findings and analysis.                                           1 Working Together to Safeguard Children. A guide to interagency working to safeguard and promote the welfare of children March 2013. which also incorporates the revised arrangements for assessment of children that will be based on locally determined single assessment.  2 Analysis of clinical incidents; providing a window on the system not a search for root causes. CA Vincent; Quality and Safety in Health Care, 2004;  The article argues that incident reports by themselves tell comparatively little about causes and prevention, a fact which has long been understood in aviation for example and is the basis of developing a systems learning approach to serious case reviews in England.    Page 7 of 69  22. The analysis in the final chapter of this report uses some of the framework developed by SCIE to present the key learning within the context of the local systems. This also takes account of recent work that suggests that an approach of developing over prescriptive and SMART recommendations have limited impact and value in complex work such as safeguarding children3. The final chapter of the review for example explores the influence of family and professional interactions, the responses to incidents and the tools that are used by professionals to help inform their judgments and decisions.   23. It is important to state that although the SCR panel has sought to place the learning from the review into a framework of systems learning this is not a SCIE review that has entirely used systems methodology to collect and analyse information from the people directly involved with the family. The evidence explores how the local systems both promote and in some circumstances inhibit professional practice and decision making.   24. The panel agreed case specific terms of reference that provided the key lines of enquiry for the review and were additional to the terms of reference described in national guidance. The panel established the identity of services in contact with the family during the time frame agreed for the review. For services that had significant involvement they were required to provide an independent management review (and are listed in section 1.4). These reports were completed by senior people who had no direct involvement or responsibility for the services provided to the children and their parents.   25. An overview of the health agencies was provided in a health overview report (HOR). This was provided by the Associate Director for Safeguarding, Assurance and Governance (incorporating designated nurse for safeguarding children) for the NHS in a specific part of Lancashire. The HOR was written in compliance with the expectations of Working Together to Safeguard Children (DCSF 2010) and combines information from health services commissioned by the NHS in Lancashire. This included three separate GP practices, health visiting services, maternity services, emergency care services and the historical information held by the child and adolescent mental health services (CAMHS) in relation to father.   1.3 Reasons for the review and terms of reference  26. The reason for undertaking this review is that Child K may have died as a result of non-accidental injuries. The death was reported to the Lancashire                                          3 A study of recommendations arising from serious case reviews 2009-2010, Brandon, M et al, Department of Education, September 2011 The study calls for a curbing of ‘self perpetuating and proliferation’ of recommendations. Current debate about how the learning from serious case reviews can be most effectively achieved is encouraging a lighter touch on making recommendations for implementation through over complex action plans   Page 8 of 69 Safeguarding Children Board (LSCB) on 3rd September 2012 and was considered by the serious case review (SCR) group who recommended to the independent chair of the LSCB that the circumstances of Child K’s death met the criteria for a mandatory serious case review.   27. The review was commissioned by Nigel Burke, the independent chair of the Lancashire Local Safeguarding Children Board (LSCB) on the 14th September 2012. A serious case review panel was convened and was independent of all the services involved.   28. The serious case review panel at their first meeting on the 2nd October 2012 confirmed the scope and terms of reference for the SCR. The scope and terms of reference of the review was routinely discussed and updated at subsequent panel meetings to take account of any new or emerging information and reflection.   29. The purpose of the review is to establish what lessons are learned from the case through a detailed examination of events, decision-making and action. In identifying what those lessons are, to improve inter-agency working and better safeguard and promote the welfare of children in Lancashire.  1.4 The scope of the serious case review  30. The time period covers the lifetime of Child K, including the time her mother was pregnant with her. The period under review is from the beginning of 2009 until the end of August 2012.  31. There is significant earlier involvement by universal or specialist agencies in the lives of the parents. Therefore organisations were asked to include any earlier information about both parents, especially where it had a bearing on understanding their capacity as parents, including any evidence of violent or sexual behaviour, mental ill health or substance misuse.  32. All information known to a service providing an IMR was reviewed. Any information regarding involvement prior to the period of the detailed chronology and analysis was summarised in the IMR and the health overview report.  33. All agency chronologies included detailed information about when the child was seen or observations were made about them.   34. Agencies that identified significant background histories on family members pre-dating the scope of the review provided a brief summary account of that significant history.   35. Reviews of all records and materials were considered including;    Page 9 of 69  Electronic records   Paper records and files  Patient or family held records.  36. Individual management reviews were completed using the template provided by the Lancashire Local Safeguarding Children Board (LSCB), and were quality assured and approved by the most senior officer of the reviewing agency.  37. The following agencies have provided an individual management review that was to be completed in accordance with Working Together to Safeguard Children (2010), Chapter 8 and the associated LSCB guidance and relevant procedures.   Health services in Lancashire that include:  o A Hospital Trust (provided maternity and paediatric services) o Lancashire Care Foundation NHS Trust (provided health visiting services) o NHS for a specific part of Lancashire (general practitioner services)   Lancashire County Council Children’s Social Care (historical involvement with father when he was looked after and provided after care services  in addition to completing assessments more recently)  Lancashire Sure Start Early Years (mother attended groups)   Lancashire Constabulary (in relation to father’s criminal behaviour and investigation of Child K’s death)  Lancashire Probation Trust (in relation to father’s criminal prosecutions)  Lancashire County Council Young People’s Services4 (mother was a very regular attendee at a local youth centre and participated in activities although there was less contact after father joined the household)  Cafcass (the children and family court advisory support service who provided reports in regard to the adoption proceeding for father’s first child)   Independent nursery (mother worked as an apprentice until Child K’s death; the children had attended another nursery until a few weeks before Child K died; the parents had withdrawn the children because they were falling behind in paying fees)                                           4 Both parents in this case would have been included in vulnerable group categories for different reasons.  Father as a former looked after child (LAC), having had a criminal background and links to the YOT; mother solely due to status as teenage pregnancy and a young parent.  As such, both would have received more regular contact in the post 16 years period and father during his involvement with the YOT.  This would have been delivered through the service obligations/responsibilities in delivering Connexions Services and through the voluntary attendance by both parents at youth centre activities including the young mums group.    Page 10 of 69 38. Information was sought from other services although these agencies were not required to provide an IMR.    North West Ambulance Service (responded to the initial emergency call)   Youth Offending Team (worked previously with father)  The Prison Service (father had served terms of imprisonment at two establishments for one offence; he was recalled under licence)  39. Information was also sought from members of the families and is described in section 1.9.  1.5 The terms of reference in national guidance a) Keep under consideration if further information becomes available as work is undertaken that indicates other agencies should carry out individual management reviews.  b) To establish a factual chronology of the action taken by each agency;  c) Assess whether decisions and action taken in the case comply with the policy and procedures of the Lancashire Safeguarding Children Board;  d) To determine whether appropriate services were provided in relation to the decisions and actions in the case;  e) To recommend appropriate inter-agency action in light of the findings;  f) To assess whether other action is needed in any agency;  g) To examine inter-agency working and service provision for the children;  h) To establish whether interagency and single agency policies adequately supported the management of this case;  i) Consider how and what contribution is sought from the family members;   j) To develop a clear multi agency action plan from the overview report.  1.6 Particular issues identified by the SCR panel for further investigation by the individual management reviews5: 40. In addition to analysing individual and organisational practice, the individual management reviews should focus on:                                           5 These are the detailed issues that are analysed by the IMRs and in the detailed analysis.   Page 11 of 69 a) The SCR should be focused on Child K and the safeguarding of her and her welfare. However, where historical factors have relevance, they should be included, with explanations as to their relevance to Child K. The Review will consider key episodes in the history of agency involvement with the child and her family in order to understand what factors may have influenced practice at the time.  b) Examine whether all agencies kept the child and her experiences at the centre of their assessments of and interventions with the family. The Review will consider interactions between professionals and the family in order to understand the aspects of the family which influenced practitioners’ thinking. c) Examine whether all agencies and professionals gave due and proper consideration to all diversity issues, including ethnicity, religion, language, disability, culture, social background and integration. d) Examine whether information sharing and communication systems within and between agencies were effective in safeguarding Child K. The Review will consider communication and collaboration in multi agency working in order to understand the influence of any significant factors on practice. e) Examine whether historical information was given appropriate emphasis within assessments and interventions. This relates to mother and father's histories, extending to others where this is relevant to the period under review and thus the care of Child K. Any relevant historical information prior to the timescale for the Review should therefore be summarised and included in IMRs. f) Examine whether agencies fully understood any issues about the father’s care history, offending history and mental ill health and the impact this may have had on Child K and took appropriate actions. g) Examine whether any safeguarding and child protection issues were identified and dealt with appropriately by agencies. Consider whether agency responses were correct and timely and whether safeguarding procedures were followed appropriately. The Review will consider the tools available to practitioners and the effect of management systems on practice in order to understand how these supported practice h) Consider whether agencies had the necessary resources and capacity. Consider also whether professionals working with the family were suitably skilled and adequately supervised and whether there is evidence of management accountability and support. The Review will consider the effects of human judgement and reasoning and any strategies used to combat biases in this case in order to understand how these impacted on work with the family.   Page 12 of 69  1.7 Membership of the case review panel and access to expert advice  41. The case review panel that oversaw this review comprised the following people and organisations;   Position Organisation Annie Dodd Independent Chair Directorate Safeguarding Manager Safeguarding, Inspection and Audit Services (LCC) Early Years Lead Quality and Continuous Improvement Service (LCC) Temporary Deputy Head of Children's Social Care Children’s Social Care Services (LCC) Strategic Safeguarding Lead Nurse  Lancashire Care Foundation Trust Detective Chief Inspector Lancashire Constabulary Senior Probation Officer Lancashire Probation Trust Designated Doctor Primary Care Trust for a specific part of Lancashire (PCT) Assistant Head Lancashire Young People’s Service (LCC) Designated Nurse Primary Care Trust for a specific part of Lancashire (PCT) Safeguarding Lead  Hospital Trust Panel Observers/Support Peter Maddocks Independent Author Business Manager Lancashire Safeguarding Children Board (LSCB)   42. The independent author of the overview report attended every meeting of the panel.  43. The panel had access to legal advice from a solicitor in the council’s legal service.  44. Written minutes of the panel meeting discussions and decisions were recorded by a member of the LSCB staff team in Lancashire.  1.8 Independent author of the overview report and independent chair of the serious case review panel  45. The independent chair of the serious case review panel was Annie Dodd. Ms Dodd was previously employed as an assistant director with a local authority children’s social care service and has over 30 years experience as a qualified social worker. Ms Dodd is now self employed as a consultant. She has previously chaired a serious case review for Lancashire SCB but has no other connection with Lancashire Safeguarding Children Board and has not been involved in any aspect of the management of the case.   Page 13 of 69  46. Peter Maddocks was commissioned in September 2012 as the independent author for this overview report. He has over thirty-five years experience of social care services the majority of which has been concerned with services for children and families. He has experience of working as a practitioner and senior manager in local and national government services and the voluntary sector. He has a professional social work qualification and MA and is registered with the Health and Care Professions Council (HCPC). He undertakes work throughout the United Kingdom as an independent consultant and trainer and has led or contributed to several service reviews and inspections in relation to safeguarding children. He has undertaken agency reviews and provided overview reports to several LSCBs in England and Wales as well as work on domestic homicide reviews. He has undertaken work as an overview author on two previous serious case reviews in Lancashire. Apart from this, he has not worked for any of the services contributing to this serious case review.  1.9 Parental and family contribution to the serious case review  47. The parents and other members of the extended family were made aware of this serious case review when it was commissioned. A letter was initially sent by the independent chair of the panel, who in consultation with the police ensured that the relevant national guidance was complied with6.   48. Father wrote a letter to the chair of the panel prior to the trial. Mother met with the chair of the panel. Information from both was considered by the panel and is incorporated where appropriate and relevant in the report.   49. The information that mother provided to the panel included her ambitions to get qualifications and to earn enough money through work to provide for her children. This impression of a motivated parent was consistent with the evidence from the IMRs. It contrasted with the difficulties that father had in finding work and holding down a job. Inevitably it meant that he gradually took on more daily responsibility for looking after the children while mother was working very long hours.   50. Mother had been aware of some of father’s history; this included knowledge of his first child and about his offences. She commented that although she was prevented from taking the children to visit father when he was in prison there was little contact in respect of risk assessment and management when he was released and became part of the household.                                            6 A Guide for the Police and the Crown Prosecution Service and Local Safeguarding Children Boards to assist with liaison and the exchange of information when there are simultaneous chapter 8 serious case reviews and criminal proceedings; April 2011   Page 14 of 69 51. Father wrote a letter to the chair of the panel. He commented on the amount of information that was provided when he consulted the NHS Direct website and had used the symptom checklist before calling the ambulance on the day Child K died. He reported that the website had provided many possible causes for the symptoms that he reported as having inputted into the website. He felt that there the information was not specific enough and asserted that it did not suggest that Child K’s life was at risk. The symptom checklist did not include a blunt trauma injury which both parents had denied any knowledge of until father changed his plea to guilty.  52. The letter was sent prior to the trial and before he admitted his responsibility for the fatal injury that killed Child K. In the letter he made clear statements that he intended to prove that both parents were innocent of any allegation that they were responsible for Child K’s death. He asserted in the letter that they did not know that Child K was so poorly. He stated that a two year old relative had similar symptoms and had to undergo a surgical procedure.  1.10 Timescale for completing the serious case review  53. The case review panel met on seven occasions between October 2012 and June 2013. The initial chronology of services involvement was completed by October 2012.  The first draft agency reviews were completed in late November 2012. The first draft of the health overview report was completed in December 2012. The independent chair of the LSCB agreed to an extension for completing the review to allow the panel an opportunity to consider any additional information to emerge from the criminal trial of the parents. This overview report was presented to an extraordinary meeting of the LSCB in July 2013.  1.11 Status and ownership of the overview report 54. The overview report is the property of the Lancashire Safeguarding Children Board (LSCB) as the commissioning board.  55. Since June 2010, all overview reports provided to LSCBs in England have to be published in full7. This overview report provides the detailed account of the key events and the analysis of professional involvement and decision making in relation to Child K and her family.                                            7 The coalition government’s notice issued on the 10th June 2010 under section 16(2) of the Children Act 2004 which amended the previous national guidance in Working Together to Safeguard Children requires that both the executive summary and the overview report with suitable redaction to provide confidentiality are published. This arrangement has been confirmed in the revised national guidance issued in April 2013 and referred to in earlier paragraphs. The coalition government had ended the formal evaluation of SCRs from the 5th July 2012.   Page 15 of 69 56. The report has to balance maintaining the confidentiality of the family and other parties who are involved whilst providing sufficient information to support the best possible level of learning.   57. In reading this report, it is important to remain clear about the purpose of the overall review and of this overview report in particular. The review examines with the benefit of hindsight, if it is possible to identify whether alternative judgments and decisions could or should have been taken, and whether different outcomes might have been achieved for Child K. The review does not investigate the circumstances of Child K’s death. That is a matter for the coroner and for the police.  58. The review aims to be very challenging of all services for the purpose of building on the considerable knowledge and expertise that has developed in relation to the safeguarding of children in the UK. In doing this work, the panel are mindful about how complex or unclear some of the information and events may have looked to practitioners at the time of events.  59. An executive summary was provided at the conclusion of the review. This provides a brief summary of events and the most significant points of learning identified as a result of the review. The LSCB will determine how and what further information is provided to the family at the conclusion of the review and following the submission of the overview report and executive summary to the Department of Education.    1.12 Previous serious case reviews  60. The LSCB in Lancashire had undertaken eight previous serious case reviews between 2008 and 2013.   61. Reference is made by several IMR authors to some of these and other previous serious case reviews completed in other parts of the country and is also referenced where relevant in this overview report. The purpose of this is to highlight where similar issues or themes have been identified in previous reviews. This ensures that action already recommended is not unnecessarily repeated.   62. Subsequent chapters of this review describe in greater detail the specific lessons to emerge from a detailed analysis of this serious case review and include comments on how learning from previous reviews has been used.  1.13 Inspections of services for children in Lancashire    Page 16 of 69 63. All children’s services in England are subject to inspections8. In December 2011 the comprehensive area assessment (CAA) annual rating given to children’s services in Lancashire was performing well9. This meant that services were above minimum national standards.   64. The CAA letter highlighted that although many aspects of contact, referral and assessment arrangements for children in need and children who may be in need of protection were satisfactory, a number of areas required attention. These included the uneven distribution of experienced and newly qualified staff within social work teams and the under-developed use of the common assessment framework (CAF) across the partnership. However, focused action was being taken by the local authority and plans were in place to address immediate deficiencies. These factors are identified as being contributory factors in how aspects of this case were managed.  65. In early 2012 there was a statutory inspection of safeguarding and looked after arrangements in Lancashire10. This evaluated safeguarding arrangements as being good in Lancashire with a well managed child protection service; Child K was never subject of any child protection plan. The inspectors commented that the local authority contact, referral and assessment arrangements had been comprehensively redesigned and had already had a positive impact. The quality of referrals made by partner agencies seen was good. Child protection enquiries were prioritised and responded to effectively to ensure children are safe. The CART (contact, referral and assessment team) had already led to improvements in the management of contacts and referrals but there were a small number of examples where referrers had not been satisfied with the CART and not all aspects of the service were subject to rigorous audit.  1.14 Summary conclusion of the review panel  66. The purpose of conducting a serious case review is to undertake a detailed examination of the events within the context of understanding how the judgements, decisions and actions were taken by the various professionals involved with Child K and her family for the purpose of drawing out learning to inform future policy, service development and individual practice.                                           8 The coalition government may change aspects of the inspection arrangements. 9 This profile includes findings from across Ofsted’s inspection and regulation of services and settings for which the council has strategic or operational responsibilities, either alone or in partnership with others, together with data from the relevant Every Child Matters indicators in the new National Indicator Set (NIS). 10 The inspection was carried out under section 138 of the Education and Inspections Act 2006. It contributes to Ofsted’s annual review of the performance of the authority’s children’s services, for which Ofsted will award a rating later in the year, subject to any changes that the coalition government may introduce. The inspections are part of a national programme of enhanced inspection of children’s services introduced in 2009 following the death of Peter Connolly (Baby P) and the two subsequent serious case reviews in Haringey.   Page 17 of 69  67. The Munro Review commissioned by the coalition government in 2010 has emphasised the importance for learning and improving services and practice by looking at information within the context of people’s professional and organisational arrangements and the information they knew at the time of events. Hindsight can distort and mislead and cause the focus to fall on how individuals behave and act rather than understanding how they are influenced by a range of contributory factors.   68. The influences on practitioners doing their work effectively include the stability of the organisation they work in, their personal workload and more generally of their services, the quality of their training and knowledge, the clarity of working arrangements in matters such as recording and sharing essential information as well as their cognitive functioning (how they are processing and analysing information). These were all important in understanding this case.  69. The review panel are agreed that no opportunities were missed to prevent Child K’s tragic death. Until Child K had been injured and died she had been seen by several different professionals who consistently recorded that the children’s physical care was appropriate. The house was generally clean as were the children, who were also kept warm and were fed appropriately. Before Child K’s death, it is possible there had been a deterioration given the description of the house on the day that Child K died during a period when no professionals had been to the home and was when mother was working much longer hours including evenings and father was increasingly responsible for the care of the children. This changing pattern of care was not known by any professional.  70. The children were taken to health clinics and had their immunisations and other routine treatments. Professionals were never prevented from going into the house. The parents displayed a high level of co-operation and apparent compliance in their dealings with services that included health, social care as well as the police.   71. The review panel concluded that greater attention to other sources of historical and other information would have given improved context to what was seen during routine or other visits to the home or when the children were in clinics or at nursery. The information and analysis provided in later sections of the report explores the circumstances and factors that influenced the processing of information. The children’s father was in prison during the first pregnancy and his history should have been explored much more thoroughly. This complex history was largely stored in archived and historical records that were not accessible through the electronic system and was not available in an easily accessible chronology. This was a significant factor for practitioners; the CSC IMR author spent two days collating information for this review.   Page 18 of 69  72. CSC had the most information about father because of his longstanding problems as an adolescent and young care leaver. Maternity services were not aware of this information as they were reliant on what was told them by mother. Yet there were indicators, by virtue of mother’s age and family circumstances that should have indicated a higher level of vulnerability.   73. It is apparent that the parents were keen to present themselves in a positive way. They acknowledged that they had both had difficult childhoods although the detail was not made explicit through the enquiries and assessments by health and social care in particular. Professionals generally relied on the parents following through their good intentions and did not receive any significant information to contradict this for much of the time.  74. There were reports about cannabis being in the house and objects that included screwdrivers and domestic knives being hidden as potential weapons that were reported by the police. Thus information was noted although was not regarded as a significant risk to the children.   75. Father in particular has had a difficult and at times traumatic history and was allowed to minimise aspects of his behaviour including his sexual offence. There are many factors in that history that resonate with research evidence in relation to a heightened concern about whether children are more likely to be maltreated. This does not mean that it predicts that child abuse or a child death will occur but it does provide important context for deciding on the type and style of assessment that is appropriate.   76. If practitioners, especially in CSC had been in a position to understand the history and significance more clearly, it would have created better opportunities for a more rigorous and searching assessment and ongoing contact. It would have challenged people to look beyond the behaviour being displayed in the contacts between the parents and various professionals.   77. The reasons that intervention was not better focussed included a reliance on unqualified or inexperienced practitioners, complex information systems that did not contain chronologies that could have shown up history and patterns as well as overstretched supervisors. These were the conditions in which misplaced optimism prevailed.   78. It is significant that father’s first child born to a previous partner had been placed for adoption following an assessment that had very clearly identified that he was incapable of caring for a child. Hindsight reinforces that this should have been explored far more carefully as part of the work with Child K and her sibling to establish what had changed. The adoption proceedings were still in progress when Child K’s mother had become pregnant.    Page 19 of 69 79. There are themes for learning in regard to how the children of prisoners are supported and information is exchanged. There was some evidence that confidence in how sensitive information is shared and managed between statutory and independent providers might require further development. The invisibility of men is a recurring theme in reviews and is an issue in this case where there was probably an overreliance on what mother was able to offer the children that mitigated the deficits in regard to father.   80. Information and support was never properly coordinated through either a CAF or other framework. If the risks had been properly identified, it is likely that either a CIN (child in need) or child protection plan would have been developed; this would have meant that a more experienced lead professional would have been allocated responsibility for the case. There was no CSC involvement at the time that Child K died and the health visiting service had also stepped down their level of contact in the absence of any concerns.  1.15 The family and other significant people  81. Mother was aged 21 years old when Child K died and Father was 22 years old. Although CSC was not involved with Child K at the time of the death, there had been historical and more limited recent involvement.   82. Father had been looked after by the local authority in several different placements from the age of 12 years old until he was 16 and then continued to receive support as a care leaver until he was 21 during which time he had lived in seventeen different addresses that were mainly bed and breakfast. His mother had died when he was seven years old following an overdose of paracetemol. These traumatic events in his childhood in relation to attachment difficulties, abuse and transience were not mentioned or analysed within any assessments on Child K and his ability to meet her needs or consider any potential risk that he might pose. He had an unhappy education that was apparently compounded by the unrealistic expectations he felt his father had for him. He was assessed as having special education needs in regard to social, emotional and behavioural problems and was eventually permanently excluded from school and had attended a pupil referral unit (PRU).   83. He has 16 convictions from ten court appearances the first of which occurred when he 13; the majority have been for financial gain (he has had a chaotic lifestyle throughout much of his adolescence and been a long term user of cannabis; he had a series of disrupted placements and being homeless); his first custodial sentence was for criminal damage, burglary and arson (setting fire to a van at a car sales premises) when he was 16 and he served a sentence of five months at a youth offender institution (YOI).  By this stage he was habitually using drugs and alcohol and was presenting with problematic sexualised and violent behaviour to carers and to other young people.     Page 20 of 69 84. He was violent in his relationship with a previous girlfriend who became pregnant during that relationship in 2007. Care proceedings were taken in regard to that child and he had no further contact with that child after April 2008. By November 2008 mother had become pregnant with Child K. In August 2008 he was convicted of three sexual offences as a 17 year old involving a 13 year old girl and a separate offence of criminal damage for which he received a suspended sentence and a requirement to complete 100 hours of unpaid community work; he returned to court for further offences of burglary for which he received a suspended sentence of 12 months. Father maintained that he believed the girl had been 16 and on the day of his court appearance he overslept and was convicted in his absence.   85. Father participated well in the community work and complied with supervision requirements. Father was living with his brother at this time but ended in January 2009 due to domestic violence between the brother and his partner.  In April 2009 he was arrested for burglary and was sentenced to 29 months at a YOI. He did not receive visits from mother until he moved from the first YOI in August 2009. Child K was born in July 2009.  86. During his time in prison father showed effort and motivation to participate in vocational and educational programmes and acquired several certificates including parenting, ICT, health and safety, food and catering, social and life skills as well as numeracy and literacy. Although he has been a long term user of cannabis and experimented with other drugs he was not apparently considered eligible for any specialist drug intervention programmes.  87. Other information from his time in prison indicates that father had a degree of vulnerability that reflected the very difficult childhood and later life experiences. There are reports of immature behaviour and he was involved in bullying incidents as a victim as well as perpetrator. He did try to circumvent restrictions placed upon him especially during his prison term in 2009 through to 2010 when he had restricted contact with mother and no contact with his daughters. His relationship with mother and the birth of his two daughters appear to be important sources of resilience for him and a motivating factor in addressing issues such as his impulsive behaviour and offending.   88. Mother had been reprimanded for criminal damage in 2005 but was otherwise unknown to the police. The police had executed search warrants of the family home in July 2012 when a small amount of cannabis was discovered along with a significant amount of money which was confiscated.  89. In 2009 mother and Child K were referred to the children’s centre to offer support and help encourage use of local services. There were 15 contacts between September 2009 and April 2010 when involvement by the early year’s services finished. Child K attended a nursery one day a week in the   Page 21 of 69 autumn term of 2009 whilst mother completed a young parent’s course provided by the county young person’s service.   90. In February 2011 Child K had begun attending the same nursery again for two and a half days a week while mother was at college. In September 2011 the sibling also had begun attending for one day a week. Mother began working as an apprentice at another nursery operated by the same owner. Mother was working full time and both children also attended nursery fulltime. By December 2011 Child K was attending only four days a week although the sibling continued to be at nursery full time. Mother continued to work at the nursery until the death of Child K. The children had been withdrawn from their nursery placements in early August 2012 at which point their parents’ owed £1200 in nursery fees.   91. The synopsis in chapter two of involvement by services from 2009 onwards provides further information.   1.16 Cultural, ethnic, linguistic and religious identity of the family  92. Child K’s maternal and paternal families are white British. Their first and only language is English and there is no record of a physical or learning disability. Child K was living with her parents in rented accommodation at the time of her death. Her father was unemployed.   93. Lancashire has a population of 1.16 million, which is projected to grow by almost eight per cent to 1.23 million by 2028. The county comprises a mixture of urban, rural and coastal communities and covers twelve district councils four of which (Burnley, Hyndburn, Pendle and Preston) rank in the top 30 most deprived districts in the country (Index of Multiple Deprivation 2007).   94. Five per cent of the population are from minority ethnic backgrounds, predominantly Pakistani and Indian, clustered mainly in parts of the east of the county and in Preston. The particular area that Child K and the family lived is one of the most densely populated in the county and reflected the general ethnic profile of the county. More recently, small but growing numbers of people from Eastern Europe have begun to settle across the county, with concentrations in Lancaster and Preston.   95. A total of 20 per cent of children across the county are income deprived according to the Index of Multiple Deprivation 2007. Six areas (three in Burnley, two in Preston and one in West Lancashire) are ranked in the two per cent of the most deprived in England for child poverty and 9.5 per cent of children in Lancashire live in super output areas ranked among the 10 per cent worst nationally for income deprivation.     Page 22 of 69 96. The particular area where the family were living in Lancashire in the region has almost 23 per cent of children living in poverty. This is just above the national average of 21.3 per cent and higher than the county average of 18.6 per cent.   Of the adult population living in the area, just over 75 per cent are classified as being economically active.     Page 23 of 69 2 Synopsis of agency involvement   97. This narrative summary of professional contact with Child K provides an account of the most significant events and decisions from the different services involved with Child K during the timeframe established for the review.   98. This summary, and indeed the whole overview report, has to strike a balance between protecting the confidentiality of the children, their family and the various people who were in contact with them whilst providing a sufficiently detailed account of events in order to draw out the points for learning and development in the later chapters. The summary does not therefore contain every contact with the children and their family; for example, the children attended a nursery at different times on a regular basis until they were withdrawn in early August 2012.  99. Mother’s pregnancy with Child K came soon after the termination of contact between father and his first child as a result of the care proceedings that resulted in that first child being placed for adoption (although this had not been completed). The parents were not living with each other during the pregnancy and by the time that Child K was born her father had been sentenced to 29 months at a YOI that began in the summer of 2009 following his conviction for burglary. Mother was living with the maternal grandparent before and after the birth of Child K.  100. Before and after the birth of Child K there was routine contact and follow up by primary health care services in relation to GP, midwifery and health visiting services. In September the health visitor in consultation with mother made a referral to the local children’s centre. Mother accepted a place on a young parent’s course run by the county young people’s service during the autumn term of 2009 and Child K attended a nursery one day week while mother was on the course between September and December 2009.   101. The maternal grandmother had been pregnant at the same time and there was a referral to the vulnerable family’s panel in late September 2009 in regard to the maternal grandmother’s pregnancy that noted that maternal grandmother had declined to engage with any offers of support made earlier in the year.  This contrasted with the more positive engagement that Child K’s mother had with services.   102. A joint visit was made by two heath visitors following that panel discussion and a decision was made to continue follow up at level 2; this is an enhanced level of contact over and above the core universal provision for all new parents. The significance is that the additional need for support was recognised by health professionals but the family were reluctant to take up offers of help and contact. In the absence of more specific concerns,   Page 24 of 69 professionals were reliant on continuing to work on a voluntary basis with the family.   103. In October 2009 mother responded to a suggestion by the teenage pregnancy support worker to join a parent and child group. In October it became apparent that father was writing letters to mother despite restrictions in contact that had been imposed by the prison’s governor. The leaving care worker wrote to the prison supporting contact between father and mother.   104. A home visit in October 2009 by the children’s centre worker provided an opportunity for the maternal grandmother to speak about the difficulties she was having with one of her other teenage daughters who was refusing to go to school.   105. In late October 2009 mother was offered the tenancy of a house and she had moved to the property by November 2009. Child K had a recurring upper respiratory tract infection for which mother sought advice and treatment from the GP and discussed with the health visitor. In late November mother took Child K to the local hospital A&E service with a particularly chesty cough.   106. Mother continued to receive support from the children’s centre and also attended groups such as a weaning group.   107. In January 2010 the offender manager contacted CSC to request an initial assessment to be completed to assess father’s request for contact with mother and Child K and it was clear that his sentence plan was being updated to reflect planning for discharge from prison under licence. The initial assessment was completed by a student social worker as an office based ‘paper exercise’ according to the CSC IMR author. Further analysis and comment is offered in later sections that include the IMR’s commentary about the acute staffing problems at the time and the consequences it had on aspects of case management and assessment.   108. There was a telephone discussion between mother and the student social worker during which mother stated that father had been convicted of the sexual offence because he had not attended court and that the offence occurred because the girl had not told him that she was only 13 years old. Mother also indicated that it was her intention to marry father on his release from prison and thereby signifying this was to be a long term relationship.   109. The referral was the subject of a discussion between the assistant team manager (ATM) and the after care worker in late February when the ATM indicated that father’s sexual offence was a source of risk that would require a specialist risk assessment of a type not undertaken by CSC and that a strategy meeting would be required as and when father was due to be   Page 25 of 69 released and intended to live with mother. This never happened and is analysed in later sections of the report.  110. A couple of days later during a visit by the children’s centre worker she was told that the social worker had visited and had told mother that it would be inappropriate for her to visit father with Child K; there is no record of that visit by CSC.  111. A letter from the offender manager to father in mid March 2010 informed him that the issue of father’s risk to children was a matter for CSC to assess and make decisions but advised father to undertake a parenting course whilst he was still at the YOI; he completed this course.   112. In April 2010 mother had some concerns about weaning Child K that she discussed with the health visitor. Maternal mood was described as good. No concerns were identified in regard to mother’s parenting and care of Child K.  113. A telephone discussion between the offender manager and the leaving care worker in May 2010 confirmed that mother and father had no direct contact with each other due to the prison governor’s prohibition and acknowledging that if father was planning to live with mother upon release an assessment of risk would be required.   114. In late June 2010 a core assessment was opened because a strategy meeting was to be convened to discuss father’s release from prison. The assessment was completed by early July 2010 and states that father did not pose a risk on the basis that his conviction occurred because he did not attend court when convicted to explain that he had not known the girl was 13 with whom he had sexual relation on at least two occasions (he had been convicted of other offences at the same hearing that included burglary). The assessment commented on how father had engaged positively with his offender manager. The IMR provides further detail and analysis that is reflected in later sections of this report.   115. A meeting took place on the 8th July 2010 which was referred to as a strategy meeting (which has a specific purpose and function in national and local safeguarding guidance); it was referred to as a multi agency meeting by services such as probation confirming some lack of clarity about the status of the meeting; the record of decisions was written up by the after care worker who was about to transfer to a another job who also appeared to chair the meeting. As the CSC IMR comments this was inappropriate given she was not a qualified social worker and it was not compliant with local and national   Page 26 of 69 standards and therefore could not be regarded as a strategy meeting11. The meeting agreed that father could move in with mother and Child K and that CSC would close their involvement. Further analysis is provided in later sections.   116. For the purpose of clarity, the IMR and this author do not place responsibility for the decision making on the leaving care worker; this was a multi agency meeting and therefore there was a shared responsibility for all services to have been satisfied about the rigour and robustness of arrangements.   117. Father was released from YOI under licence at the beginning of August 2010 having served just less than 14 months of his custodial sentence; the conditions of his licence included continuing supervision by an offender manager employed by the local probation service. Coincidentally, two days after this Child K was taken to the local hospital A&E with a rash; there were no other concerns were identified.  118. Father complied with the terms of his supervision and this included attendance at a job club. He was receiving medication for depression.   119. In September 2010 father talked with his offender manager about his problems with attending CAMHS; he felt that he did not have the same problems of anger management that his paternal grandfather and his brother have had and questioned why he needed involvement by that service; he said that he was not finding it helpful.   120. In November 2010 father’s benefits were stopped and later the same month the police interviewed him about a number of local burglaries. He denied involvement. Father secured a temporary employment working as a painter and decorator.  121. In January 2011 the police executed a search warrant of the family home and of other family member’s homes and located a small amount of drugs and a significant cache of money. Members of the extended family were charged with money laundering offences.                                           11 Readers of this report who are not professionally involved in safeguarding work will suspect that the author is indulging in irrelevant semantics about what a meeting is called; the significance of being clear about the status and purpose of the meeting is that a strategy meeting is supported by clear multi agency protocols that should ensure all relevant services give priority to the meeting, will bring all relevant information to the discussion and will understand that the meeting is focussed on assessing whether a child might be at risk and considering what actions need to be taken. It will also ensure that only a suitably qualified and experienced person is responsible for chairing the meeting and making sure there is a clear record of key information and actions agreed. Little of this was achieved in this case.    Page 27 of 69 122. In February 2011 mother had begun attending a local college for two and half days a week. To enable her to study Child K began attending nursery again, this time for two and half days per week. After Child K’s sibling was born the sibling began attending the same nursery from September for one day per week.   123. In March 2011 father told his offender manager that mother was pregnant. At the beginning of April 2011 father was questioned and bailed in relation to charges of burglary. He was subsequently charged with the offences that triggered the revocation of father’s licence and he was remanded to appear before magistrates in Lancashire. He was in prison for almost six weeks during which time he had visits from mother and child. He was convicted of the offences and sentenced to a 12 month community order and 80 hours unpaid work. He failed to attend an initial supervision session but then attended subsequent appointments and work sessions. He completed the sentence in October 2011.   124. The second child had been born in July 2011. There developed a pattern of no access visits for primary health care workers such as the health visiting service. This prevented any routine assessment of mother’s emotional and mental well being. Child K was taken to the GP and the A&E with a chesty cough on different occasions in late 2011.  125. In early September 2011 the family moved to their second property.  126. On the 7th October 2011, the Health Visitor took a telephone call from a social worker. The purpose of the phone call as documented in the health visiting records was to share information regarding father’s criminal activity including being convicted of a sexual assault on a minor when he was 17 years of age. It was also documented that children’s social care had completed a core assessment in July 2010; the health visitor was informed that the assessment had concluded that father was not a risk to children  127. Following this phone call the health visitor increased the dependency tool12 to level 2 indicating the need for additional contact above that of the core programme. Two attempts were made to see the family and although these were appointed visits the outcome was ‘no access’.  Around this time Child K was due for a two year development review but the planned visit again resulted in a ‘no access’ visit. However during the course of these ‘no access’ visits the sibling attended the GP surgery for a routine immunisation appointment and both Child K and sibling were seen in the well baby clinic.                                           12 This is the tool used to help determine workload allocation across a caseload based on the level of need; it is not a risk assessment tool and is an area for analysis by the HOR that is commented upon in later sections of the report.    Page 28 of 69 128.  In November 2011 mother began work as an apprentice at a nursery operated by the same proprietor as the nursery that Child K and sibling attended. In late 2011 and in 2012 Child K was looked after by her father for some of the days that she had been attending nursery; it is unclear if this was to help reduce the cost of nursery care.   129. In April 2012 Child K was seen for a routine health development review and a two year review of Child K in June 2012 found her to be developing appropriately and to be suitably dressed. Health visiting contact was stepped down to the level of a universal pattern of contact. There had been few contacts within the home which both the LCFT and HOR comment was unusual for a case where the children are subject of targeted support although acknowledge that there had been a good level of contact at the clinics.   130. In July 2012 there was a further search of the family home by the police looking for drugs. Father was found to be smoking cannabis and was looking after both of the children on his own. A small cannabis plant was seized along with two knives and a screwdriver that had been hidden and apparently intended for protection if required. The police officers confirmed that the children were dressed appropriately and were clean and that the house was warm and there was food in the kitchen. They had no concerns about the immediate safety of the children but made a report to the police public protection unit (PPU) given the circumstances of the search and their knowledge of father’s history. Information was shared with the health visitor and a referral was made to CSC.  131.  The CART who received the police referral made telephone checks with the health visitor and the nursery; mother was an employee and therefore arrangements were made to speak with the owner. The case was allocated for an initial assessment by the IAS (integrated assessment and support team). Telephone checks took place with the nursery about whether they had any concerns regarding either child; they confirmed they did not. The proprietor did not deal with the enquiry but was told by the nursery manager and asked the manager to contact CSC to check whether there were any concerns that the nursery needed to know about to ensure the children were kept safe as well as anything that might compromise mother’s suitability working in another nursery. This check was done and CSC confirmed that mother had not been at the house when the police search had taken place and did not appear to be involved in the issues raised by the police.   132. In the absence of any specific information suggesting concern about mother, the nursery management did not feel that that a referral to LADO   Page 29 of 69 was necessary13. As part of the review process, the panel have been made aware of revised regulations that have extended the scope of disqualification to apply to the partners of early year’s staff working in a registered day care setting. Father was disqualified by virtue of his conviction in regard to sex with an under age girl and therefore according to the panel’s understanding of the interpretation of the regulations by Ofsted14, this would probably have disqualified mother from working in a registered child care setting. Further comment and analysis is provided in later sections of the report about this and how communication was managed with the nursery about issues such as the children’s attendance at the nursery.  133. Neither mother or either child attended at nursery on the day of the telephone check was done and father came to the nursery to say that mother had been having an affair with the father of another child which she denied although had exchanged messages on a social networking site. When mother did not come into work and both children were not at their nursery on a second day a member of nursery staff made a home visit and saw mother at home. Mother returned to work but was warned about breaching the nursery code of conduct. During a discussion about the referrals to CSC the issue of over £1000 in unpaid nursery fees was raised; both children were removed from the nursery by their parents.  134. A developmental assessment of Child K in early August was routine. On the 10th August 2012 father texted the social worker to express his dismay that CSC were involved because of ‘a plant’ and referred to how he was a different person from when he was younger. The case was closed to CSC four days later on the 14th August 2012. The IMR for CSC highlights a number of issues for analysis in later sections; these include for example a lack of contact with services such as probation or the leaving care service and the                                          13 This is a reference to the Local authority designated officer (LADO) works within the local authority and should be alerted to all cases in which it is alleged that a person who works with children has behaved in a way that has harmed, or may have harmed, a child possibly committed a criminal offence against children, or related to a child or behaved towards a child or children in a way that indicates s/he might be unsuitable to work with children. The LADO has the role, knowledge and responsibility to be consulted in regard to any allegations or concerns in relation to people who have responsibility for the care and supervision of children.  The LADO gives advice to employers and others regarding action they should take and provided an important co-ordinating role of information within a local area.  14 Disqualification from working in children’s social care No 080157 published October 2011 and Early Years Foundation Stage (EYFS) “3.14 In the event of the disqualification of a registered provider, a person living in the same household as the registered provider, or a person employed in that household, the provider must not continue as an early years provider – nor be directly concerned in the management of such provision. Where an employer becomes aware of relevant information which may lead to disqualification of an employee, the provider must take appropriate action to ensure the safety of children. In the event of disqualification of a person employed in early year’s provision, the provider must not continue to employ that person.”    Page 30 of 69 information about mother working as a dancer in a local resort was not explored.   135. In late August 2012 the ambulance service were summoned by an emergency phone call made by the parents in regard to Child K. Those details have been summarised at the start of this report.  136. The ambulance control alerted the police to the incident and police responded. They alerted the PPU who in turn contacted CSC. A strategy meeting involving the relevant services took place at 19.00 on the 30th August 2012. The meeting was told of police concerns about some of the conditions within the home; descriptions of rabbit droppings in the house, no bedding for the children and dog mess in the rear yard.  There was evidence of cannabis having been smoked in the house. There had been delay in seeking medical attention for Child K and the medical opinion was concerned about the injuries although the bruising that was visible was a possible consequence of falling from the swing as father had described; the post mortem and skeletal survey subsequently identified further injuries.  137. A visit was made to the family and consent was secured for mother and Child K’s sibling to stay overnight with a relative. Further analysis and comment is made in later sections of the report along with comments about the manner in which the safeguarding and the unexpected death in childhood (SUDC) protocols were used.   138. Mother did not return to work at the nursery although the outstanding balance of nursery fees was paid off.     Page 31 of 69 3 The critical reflection and analysis from the individual management reviews.  3.1 Summary  139. All of the individual management reviews were completed using Working Together to Safeguard Children (2010) which was also supported with additional local guidance provided on behalf of the LSCB. The IMRs include action plans for implementing recommendations. All the IMRs are countersigned by the senior manager for the individual commissioning agency.   140. Many of the services have already taken action or initiated action in response to improvements or areas of development identified through their individual review.   141. For some of the authors, they were simultaneously working on other IMRs for other serious case reviews and were also undertaking their usual range of professional roles and responsibilities. All of the IMRs provided to the review were of a standard necessary for a serious case review and more than one were of particularly good quality and detail.   3.2 Significant themes for learning that emerge from examining the IMRs  142. The agency reviews identify themes that have implications for policy development and staff training that applies to all services working with children. In the summary of the review’s finding provided in chapter one there is acknowledgement that some of the issues to come out of this review are reflected in the findings from national evaluation and research. The HOR identifies the following learning themes;  a) The importance of identifying early whether parents and mother’s in particular are vulnerable and likely to require additional support; in this case, the factors of vulnerability were most acute in regard to father (but were hidden) although mother was a teenager when she became pregnant and at the time was living in a chaotic and crowded home;   b) The invisibility of men in SCRs generally and in this case when father was in prison he was out of sight in respect of assessment and planning; he did not feature sufficiently in the collation of ante natal information;  c) The poor recognition of risk factors and associated information that should have been indicators of vulnerability;    Page 32 of 69 143. The HOR also discusses the confusion that occurred following the death of Child K in regard to how the SUDC (sudden unexplained death in childhood) process was invoked and managed. This led to misunderstanding about what information had been taken and which professionals had completed respective tasks. The events of that day have been the subject of a learning event involving police and health. Processes have since been put in place which aim to ensure consistency in action, robust information sharing and have reinforced the importance of all professionals having sufficient confidence to seek clarification and to challenge each other if there is cause for concern about the robustness of the process or actions of others.   144. Other important messages for learning from this review include:  a) The unintended consequences that can arise when the leadership of planning is taken by staff who are not sufficiently experienced or qualified or do not have the appropriate emotional and psychological aptitude (are more focussed on supporting a vulnerable adult rather than seeing more clearly the consequent needs and risk to a child);  b) Not using opportunities such as CAF/TAC systems (team around the child) to help co-ordinate earlier help; c) Information systems that are cumbersome and difficult to navigate will discourage proper checking of historical information and inhibit meaningful and contemporaneous recording; d) Understanding the importance of getting a good enough history about parents and families and being aware of the factors that can indicate increased risk of harm (although not predict it) and to understanding current events and circumstances. e) The dangers of relying only on observing behaviour or conversations with parents and not triangulating with other sources such as history and third party information; f) The influence of mindset and language and how it can lead to misdirected conclusions or inference; parents stating good intentions and evoking emotional responses in workers who want to give parents ‘a chance’; g) Impact of organisational stress on workload; this has implications for supervision and quality assurance as well as face to face contact; h) Ensuring there are no cultural barriers in regard to information sharing for example in treating independent or third sector services as less robust in managing sensitive or confidential inquiries and information; i) The invisibility of prisoners and the vulnerability their children in regard to their overall wellbeing; in this case Child K’s father was managed as an invisible part of the family although clearly had an ongoing contact and influence through the mother; upon his release and in spite of efforts to have a risk assessment done, his return was accepted without enough attention to the implications or his history or the risk assessment that had been completed while father was in prison;   Page 33 of 69 j) Co-ordination between prison and other services working with the families of prisoners.  145. It is important that constructive feedback and reflection continues to be provided to all the practitioners involved in this case and who have helped provide the learning from the review and to give them the appropriate positive encouragement for their continued professional development and retention in the workforce.   146. The remainder of this chapter summarises key evidence relating to the terms of reference established for the IMRs.  TOR1 Historical information  The SCR should be focused on Child K and the safeguarding of her and her welfare. However, where historical factors have relevance, they should be included, with explanations as to their relevance to Child K. The Review will consider key episodes in the history of agency involvement with the child and her family in order to understand what factors may have influenced practice at the time.   147. The history of agency involvement with the families of both parents was not known to the midwifery service when Child K’s pregnancy was initially booked and managed. Father’s childhood includes the traumatic loss of his mother, a difficult relationship with his father and being looked after in several different placements during his adolescence.  He had displayed significant emotional and behavioral needs that represented considerable challenge in various care and educational settings and many of which had ended in disruption. These problems had been exacerbated by his use of cannabis and possibly other substances and he has continued to use cannabis on a very regular basis although this had never been quantified in assessments.  148. His sexually coercive behaviour to peers and female staff and his persistent criminal behaviour had required the intervention of criminal justice and specialist services over several years and he was in prison for much of the pregnancy with Child K who was born before his release from prison.  149. Father’s first child with a previous partner had been placed for adoption due to concerns about the child’s safety and the ability of the child’s needs being met. He had been found guilty of sexual offences with a thirteen year old girl although denied his responsibility and culpability.  150. Mother lived with the maternal grandmother until after the birth of Child K. There had been involvement with maternal grandmother in regard to the care of the younger siblings and mother had been used to provide care for her siblings.    Page 34 of 69 151. The childhood experiences of both parents were significant in terms of their capacity to meet the needs of their two children. Although the majority of people who were in contact with the family during the timeline for this serious case review were aware of some of this history none had a complete understanding of the narrative or apparently the implications of it.  152. This lack of historical context meant that everybody relied on the information they got from direct observation and conversation with the parents in particular. This had consequences for how the family were viewed by the different people in contact with Child K and her family. Both of the parents were positive and outgoing in their attitude and behaviour with the various professionals and services that came into contact with them and their children; they were polite and did not obstruct for example when the police searched the house. The house was seen to be clean and the children were appropriately dressed and fed.   153. Although the house was described as being ‘a little basic’ reflecting a family living with a limited income from mother’s work and casual work by father there was no concern about the children’s physical care and safety. Both parents had been regarded as managing well in spite of the difficult childhoods they had both experienced; one of the IMR author’s comments on how neither of the parents had been provided with a positive role model upon which to base their own parenting.    154. Father declared on more than one occasion his intent to give his children a different experience to the one he had as a child. He received good encouragement in this from professionals but there were not enough enquiries into his personal and family history or analytical discussion about the barriers and deficits he would have as a result of his own experience of childhood trauma his chaotic lifestyle and vulnerability.   155. Both parents had a strong bond with each other but there is little knowledge or understanding about the circumstances of their meeting, the dynamics of their relationship or the different vulnerabilities each of them brought to the relationship. Given father had only recently been assessed as unsuitable to parent a child, the assessment needed to address explicitly what the relationship with mother had achieved in counteracting that risk. Such enquiries require more purposeful empathy and sensitivity than just listening to statements of good intent.   156. Although professionals working with adults who have experienced trauma and difficulty in their lives will want to be positive and encouraging to a young parent for example, the consistent lesson from this and other reviews is that care needs to be taken in not relying on optimism alone; human behaviour and interaction is shaped by personal history and circumstances and denying history is unhelpful for example when assessing parenting capacity or the quality of emotional care and stimulation. Later sections of   Page 35 of 69 this report highlight particular aspects of history that had a direct relevance to this case.   TOR2 Child and her experiences at the centre of assessments  Examine whether all agencies kept the child and her experiences at the centre of their assessments of and interventions with the family. The Review will consider interactions between professionals and the family in order to understand the aspects of the family which influenced practitioners’ thinking.  157. Knowing what life is like for a child growing up in their family is a recurring theme in reviews, inspection and research. All too often the focus of any recorded information is on the physical standards such clothing and cleanliness of the house with much less information that describes the emotional and psychological well being of children. A preoccupation with physical standards and the positive inferences that were drawn from that information is a factor in this case.   158. Frequently in reviews, the needs and problems of adults dominate the interaction and narrative. It is especially problematic in cases where children have not yet developed very much language. It is for this reason that work with the parents of very young children has to explore with the parents what their child means to them and whether their behaviour reflects what they say. In this case for example, both parents expressed a wish to provide a better childhood than they had experienced for Child K and her sibling although their behaviour often provided some contradictory or perplexing evidence.   159. The prevailing mindset that influenced the interaction with the family was focussed on helping and supporting two parents who appeared to be motivated and wanted to overcome their difficulties. A common theme for all the services providing IMRs for the review is that professionals generally felt very positive and optimistic about the parents’ ability and motivation to look after their children.   160. The children were seen by several different services and conditions in the home were described as clean if basic and the children were appropriately dressed, fed and clothed. It was noted that conditions in the home on the day that Child K died were not as clean as had been observed on previous visits and may be attributable to the fact that mother was going out to work and leaving father in sole charge of the children and that he had been found on more than one occasion smoking cannabis.   161. Ensuring that children are at the centre of assessments especially when the children are very young and language is not yet developed requires more than relying only on observation of physical standards and the interaction between professionals and the family. The fact that the parents were friendly influenced how practitioners generally viewed the needs of this family. This   Page 36 of 69 had an impact on how inquisitive and curious people were about information about father in particular. There was a great deal of empathy with the parents but not enough sceptical curiosity and challenge.   162. There is research evidence that validates the value and importance of health and social care practitioners talking with new parents about their experience of becoming parents, the significance of the child to each of them and the implications for their relationship. Mother and father began their relationship while father was still opposing the adoption plan in regard to his first child. Mother became pregnant very quickly in the relationship with father. Both parents were in flight from difficult circumstances.   163. Having a well informed knowledge about families requires time to develop appropriate relationships; the CSC author refers to the work of Harry Ferguson15 who describes the complexity of cognitive influences, systems and processes and understanding the significance of the factors that are linked to increased harm; recognising the families who through their history as well as immediate circumstances, are likely to have less resilient to face events that can derail them; how this relies on professionals having the capacity and aptitude to develop appropriate relationships with the family that goes beyond relying on empathetic support.   164. In this case there is evidence that a series of events were occurring over the summer; this included the strains in the relationship between the parents that was doubtless exacerbated by mother working very long hours in two jobs; the evidence of potential crimes combined with father’s continued use of drugs. It was unclear how secure their tenancy was at the house and there were financial problems. In looking at this information there is little sense of understanding what the implications were for the children and how they were feeling.   165. Purposeful enquiries do not predict that a child might be harmed but it will provide the improved opportunity to identify sources of particular stress or difficulty and explore the parent’s capacity and motivation to use help and advice meaningfully. Issues such as child neglect are a reflection of parents for example having little empathy for each other or for their baby or being overwhelmed by their own needs and problems.   166. The CSC IMR is critical of the quality of assessments and provides a good deal of information about the various factors that contributed to the inadequacies in practice. This included an organisational preoccupation with meeting timescales reflected in national frameworks at the time that was not sufficiently focussed on quality and the problems of complex systems for managing information.                                           15 Child Protection Practice; Palgrave Macmillan; 2011.   Page 37 of 69  167. Another factor explored in that IMR was the degree to which the needs of the parents came to dominate; this is an area of practice recognised frequently in other serious case reviews. In this case there was some understanding about the difficult childhood that father in particular had and professionals had a great deal of empathy for him and the rest of the family; they wanted the family to overcome the history.   168. Although this motivation by professionals to encourage the apparent determination of the parents is understandable, it did require a far more informed and rigorous approach that kept the needs of the child at the focus of the help provided and to counteract misplaced optimism. This is a difficult balance to achieve and requires access to professional supervision that can provide appropriate levels of challenge that provokes more analytical reflection rather than just checking on compliance or reciting narrative detail.   169. Unqualified or inexperienced practitioners could not be expected to have the degree of knowledge for complex work. The recruitment and retention of experienced practitioners is a regional and national issue. Matters were compounded by the categorisation of the case as being a child in need case that may have inferred that it had a lower level of complexity in comparison to a more explicit child protection case. The CSC IMR concluded that this was influential in the mindset and overall approach to the case.   170. Problems in securing a clear enough focus on the children and the history of the parents was a factor that was common across the health and social care support.  171. For some like the midwifery service it reflected an absence of information certainly at the time of the first pregnancy about father and with the benefit of hindsight a degree of misplaced confidence in the extent and quality of support that could be available from the extended maternal family. Other services had different levels of detail that in general was confined to the separate agency silos that generally contributed to people believing that they were doing well enough in spite of the difficulties each of them had experienced.   172. Although the history of both parents was not completely known or understood, for services such as leaving care, health visiting and early years there was a clear motivation to help the family overcome the difficulties that were known about. The extent to which their childhood experiences had the potential to be a negative influence in spite of any positive intentions and impact on their parenting capacity was less well attuned to.   173. This reflects a common difficulty in assessment practice where there is a pre-occupation with recording observation of current behaviour and interaction without dealing with the underlying influences and factors.   Page 38 of 69 Although there was a recognition that both parents appeared to be motivated to do the right thing for their children and that they had the disadvantage of not having had positive roles models, the emotional damage was not recognised or enquired into.  174. The notification of Child K’s birth to the 0-19 health visiting team provided no advance advice and information about a young mother having her first baby whilst the father was in prison and she was living with her mother who was reluctant to accept help from services. The midwives did not regard Child K as a pregnancy that merited significant additional support. Some of this was attributable to a mistaken understanding about the quality of support that would be forthcoming from the maternal grandmother.  175. The 0-19 service made their first home three weeks after the initial notification and completed an assessment; the assessment acknowledged that although mother was young and living in very crowded and chaotic conditions she was providing appropriate care to Child K. She was assessed at level 2 which reflected an additional level of contact and visits by health visitors but not intensive support. A referral was made to the local children’s centre with the purpose of reducing mother’s social isolation and encouraging her to use the services.   176. The LCFT IMR author comments that although mother’s needs are acknowledged there is no reference or analysis in the records of the potential impact of her early experiences or her young age is sufficiently acknowledged in relation to Child K. In order to meet the needs of the child the parental needs cannot be ignored, and must be skilfully addressed, balancing risk and resilience factors; in this case the IMR found documentary evidence as well as the reflections of the practitioners that focused on resilience but without the balancing knowledge in regard to history. This contributed to the degree of optimism exhibited and is referenced to national studies and research.  177. There was further evidence of professional optimism when father returned to the family home and the health practitioner reminded mother to prioritise the needs of herself and Child K. It was presumed that mother would be able to do this as father joined the household for the first time when he was released from prison. This did not apparently take account of mother’s high degree of compliancy that had characterised her relationship with her own mother and was present in the relationship with father who had a history of abusive behaviour with other women.  178. The potential impact on Child K of his father’s return to the home was not sufficiently analysed or documented by any of the services in spite of the team manager’s practice direction in 2006 (which predated the timeline for the review and was before the birth of Child K). It was apparently overlooked and therefore was not carried forward into the subsequent work. No information was known about father at the time by the health visiting service   Page 39 of 69 and the contact by CSC apparently took little account of his history and its significance.   179. Local SCRs for Child S (2010) and Child M (2010) and national reviews have included analysis of the inclusion of fathers in assessments. It has been found that practitioners sometimes ‘forget’ about fathers when they carry out assessments and interventions with families. Recurrent problems have been identified amongst many different professional groups in taking sufficient account and notice of men in households where young children are living.   TOR 3 Consideration of diversity, social background and integration  Examine whether all agencies and professionals gave due and proper consideration to all diversity issues, including ethnicity, religion, language, disability, culture, social background and integration.  180. National research and inspection evidence highlights the considerable variability in how information about the overall environment of a child is collated and analysed. For example, the degree to which parents may have undiagnosed learning or cognitive difficulties is a common theme in serious case reviews and there is some evidence of this occurring in this case. Father had been assessed as having special education needs as a child but the detail was not sought in any assessment associated with Child K.  181. Very little is known about either of Child K’s parent’s educational history or whether mother had ever been identified with any additional need. Certainly the impact of father’s much disrupted care and education history was not explored meaningfully in this case. Mother’s difficulties in processing information and advice were noticed during the pregnancy and she presented as being very passive and compliant.  182. In contrast to the worrying history that largely remained hidden and unknown to many people in contact with the family, there were more positive indicators suggesting that the family were reasonably integrated with their local community. The fact that mother was taking up opportunities to go to college was a sign of an adult keen to improve her parenting and work related skills, She was successful in securing an apprenticeship and was working well in that role.   183. The extent to which individual families as well as communities can be deeply suspicious about statutory services having contact with them and their families can have an impact on how they interact with significant services such as health, police and social workers.   184. The family are white British and speak English as their only language. There is no information regarding any religious affiliation; this is commonly not explored and yet research studies highlight that religious or cultural affiliation is an important source of resilience. The area in which the family rented their   Page 40 of 69 home was not particularly deprived and was popular with a broad range of people including students. There is no indication as to how far the family felt they were part of their local community and were integrated.  Simply by living in a better neighbourhood does not mean a family feel part of it or participate in the daily life and activity of the area.    185. Specific reference is made to mother’s social background and integration. Some health practitioners recognised her vulnerabilities including her age, her own poor experience of parenting and as she moved into her own home her isolation. Appropriate steps were taken by the health visiting team to address this, through referrals to services and additional visiting over and above the core programme.   186. Poor social integration and chaotic family background are significant risk factors for children that are commented upon by the LCFT IMR and also can influence the way in which parents work with agencies (Brandon et al 2009, NSPCC 2010). The 0-19 Team were sympathetic to mother’s background and aimed to understand and support her need for parenting support as a result. It appears that the extended family were reported by mother to be supportive but the extent of the support they actually offered was not known.   187. There was no evidence to suggest that mother was not being honest and open in her communication with health professionals. She disclosed some information regarding her background and regarding Father of Child K, but this was not explored further by professionals and therefore did not feature in assessments. There was for example a remarkable lack of curiosity on the part of some people in why father was in prison.   188. The historical information now known concerning father’s mental health, self-harm, experience of physical abuse, history of disrupted care and offending behaviour are important predictor’s of his ability to parent Child K appropriately. Research suggests that parents who have been in the care system and have experienced abuse and chaotic parenting are less likely to display positive parenting approaches and are more at risk becoming abusers of their own children (Brandon et al 2009, NSPCC 2010). None of this information was taken into account.   189. This is not intended to suggest that parents who grew up in public care cannot be good and effective parents for their children; it is an acknowledgement about the importance of understanding the childhood experience of parents and the implications for their capacity to parent and the help that they might require.    190. The CSC IMR describes how the overall presentation of this family had an influence on how the family were viewed. The family lived in an area where CSC does not often receive referrals. The property was well maintained and   Page 41 of 69 the street they lived on was quiet. The house was also quiet whilst the social worker visited in the summer of 2012 and there were no visitors to the property on her first visit. The mother worked in a nursery which was unusual in families referred for CSC support and there did not appear to be any financial issues.   191. The children were attending nursery four times a week, albeit at a discounted rate which would still have been quite expensive in a household with limited income. The social worker did not know and neither was she informed by any of the agencies that were contacted, that the children had stopped going to nursery due to the debts the family had incurred. The observations about the family's property and apparent circumstances influenced the conduct of the assessment and view of risk which would realistically only have been recognised with closer regard to the significant historical information.  192. A considerable range of research describes how professionals can be trapped into ignoring or dismissing the contribution, positive or negative, of fathers or loading responsibility onto the children’s mother for keeping the children safe16.   193. It was mother who appeared to provide the best level of reassurance. Mother (but not father) participated well in groups at the children’s centre and the health visiting service found her to be a good clinic attendee who enjoyed being a mother. She sought advice from the GP appropriately. These are all important and relevant indicators about the quality of care that Child K and her sibling received but took little account of father’s role and contribution or the relationship between the parents.  TOR 4 Information sharing and communication  Examine whether information sharing and communication systems within and between agencies were effective in safeguarding Child K. The Review will consider communication and collaboration in multi agency working in order to understand the influence of any significant factors on practice.  194. The quality of information sharing and communication are frequently an area of particular difficulty identified in serious case reviews. Successive child death inquiries or serious case reviews have shown that failure in communication and information sharing between professionals played a pivotal role in the way parent behaviours or life style was understood.   195. The features that are identified frequently in reviews include an absence of chronologies that could have helped reveal the underlying themes or issues not obvious by the current observation of parent and child behaviour. Other                                          16 Scourfield, Gender and Child Protection, Palgrave MacMillan 2003.   Page 42 of 69 similarities include no single professional having a sufficient overview of the case (which does not mean that it always has to be the task of a social worker if for example CAF/TAC had been used at an early stage); and different pieces of information held by individuals and services that appear insignificant (the jigsaw pieces that make no sense until assembled).   196. The importance of information sharing has been a cornerstone of national and local guidance. The response to this area of practice has led to an increasing array of protocols and form’s exemplified by the recently abolished national assessment framework. The framework which was amended by the publication of the latest Working Together guidance in April 2013 had created burdensome bureaucracy that had inhibited professionals in working with families.   197. In considering the quality of information sharing the focus needs to be on the extent to which information sharing and communication reflected a proportionate understanding and intelligence about the circumstances of Child K and her sibling.  198. Effective information sharing is a balancing act of collecting sufficient data in order to reveal any underlying patterns that are not obvious in isolated episodes. Simply collecting information can overwhelm individual professionals and result in not seeing ‘the wood for the trees’.  199. There was not enough discussion between professionals at the point at which referrals were made or formal enquiries were completed. Although mother was a teenage parent she was not regarded as requiring any specialist or enhanced support by the midwife service and therefore a verbal handover to health visiting services was not deemed necessary.   200. When the health visiting service became involved they considered that mother required social and practical support and a referral was accordingly made to the local children’s centre. This did not involve any direct discussion between the health visitor and the early year’s worker who worked directly with mother.   201. The involvement of the children’s centre provided access to individual support as well as participation in group sessions with other parents. There was no direct communication between these activity leaders.  202. Although the referrals to CSC did result in routine telephone contact with the health visiting service the discussions were limited to checks regarding any current concerns. The reasons for the phone checks were not fully explained or discussed.   203. The ‘strategy meeting’ (which was not properly constituted) called to discuss the planned release of father from prison did not result in a   Page 43 of 69 sufficiently planned discussion and participants did not bring historical information; the CSC IMR author includes comments from a worker who attended the meeting recalling that the meeting did not resemble a strategy meeting in the way they understood them to be as it was not clearly structured and organised.   204. Child K's social worker's core assessment or risk assessment was not referred to at this meeting. The social worker who had been involved with Child K’s father's previous child was not invited or present. Neither the leaving care worker for father's previous partner nor the social worker for the mother to the child being placed for adoption was invited or present. Agencies working with Child K were not present or invited, for example the health visitor and early years workers.   205. Health services sought insufficient information about father in particular; the true vulnerability of both parents’ histories was insufficiently understood. Staff shortages and the changes to corporate working in the health visiting service created barriers in regard to different health visitors having contact with the family. CSC undertook superficial consultation with other services when assessments were required.   206. The CAF was never considered by any service. The CAF could have been used to co-ordinate information. The LCFT IMR comments that CAF and TAC meetings would have supported a more consistent approach to information sharing with other agencies. Lack of integrated working is often criticised when a review takes place (Laming 2003, Laming 2009, Brandon et al 2009, Brandon et al 2012) and this has also been acknowledged in local reviews (Child Z 2009, Child C 2009, Child S 2010, Child M 2010). Certainly with hindsight more cooperative working and regular multi-agency reviewing of all relevant information would have enabled consideration of the risk and protective factors by all agencies for Child K.    207. There were opportunities for multiagency information sharing but these were not utilised well enough to inform the assessment and to re-evaluate evidence from different sources. On two occasions health practitioners received a call from CSC to determine if they had any concerns and advised there were none evident. The health visiting service did not adopt a sufficiently inquisitive approach and did not question why the phone inquiry was being made. Some of this might have reflected a lack of professional self confidence as well as knowledge about what information can be asked for.  208. Simple accumulation of information does not lead to more analytical assessments and safer practice and these episodes should have resulted in further assessment of risk. It is important that when agencies are requesting information a reason for the request should routinely be given or asked for. This would promote shared discussions that are more meaningful and purposeful and support better informed decision making.    Page 44 of 69  209. The LCFT IMR points to examples of where information sharing and communication was managed more proactively. There is evidence of an appropriate response to information sharing, when thorough information is shared. When the HV received a call from CSC informing of information regarding father, records are detailed and this contributed to an assessment of dependency level and increased contact to the family.   210. This appeared to be a turning point as there seemed to be evidence that some health professionals became more curious and started to adopt more of an ‘assessment mind-set’ and take opportunities to ask questions and re-evaluate their work in light of new information and changes in family circumstances; an example of this is the opportunity taken by the community nursery nurse to question mother about the police visit to the family home. Such responses need to happen consistently to manage risk. The gaps in information that was exchanged with the nursery in August 2012 have been highlighted in previous sections.   211. Hindsight often makes people feel they would have done something differently if they had been given all of the relevant information at the time. For example, the nursery had tried to find out more about why CSC had made telephone inquiries in August 2012 to establish if the nursery had any concerns about Child K or the sibling. The nursery asked if there were any concerns and were advised there were none. The issue of unpaid fees might have been seen differently if all the information about the family’s history had been known to the nursery.    212. The nursery had very little information about the background of the children and when for example in early August 2012 the nursery attempted to get further information they faced limits in what CSC felt they could legitimately say.   213. The lack of confidence about how far to share information had some implications for other conversations for example in mid August about removal of the children from the nursery.  The social worker assumed that the children were attending the nursery when following up the referral from the police.   214. The nursery IMR authors acknowledge the importance of routine contacts between different services and people being used to create more complete information through a reciprocal and sufficiently curious exchange in such discussions.  In this case for example, CSC did not know the children had been withdrawn from the nursery. Nothing in this commentary implies that any of this would have changed decisions or outcomes in this particular and tragic case.     Page 45 of 69 215. The CSC IMR describes the complexity of different sources of information storage and archiving and the restrictions of electronic recording systems and how this influences important professional activity by being confusing, time consuming and hard to navigate. Additional issues are highlighted regarding weaknesses in systems being able to support practitioners in elementary task such as identifying associations and relationships for example. The CSC IMR explains that a new and hopefully improved system is being procured.   TOR 5 Examination of how relevant historical information was examined in assessment and taken into account for providing services  Examine whether historical information was given appropriate emphasis within assessments and interventions. This relates to mother and father's histories, extending to others where this is relevant to the period under review and thus the care of Child K. Any relevant historical information prior to the timescale for the Review should therefore be summarised and included in IMRs.  216. Although there are clear and validated reasons about why early years, health and social care professionals need to know about relevant historical information about families where pregnancy and young children are concerned, this continues to be an area of practice that is highlighted frequently in child deaths and serious case reviews as requiring further development.   217.  Although the serious injury and killing of children is rarely a predictable event, there are factors that have their origins in personal and family history that can indicate a child might be more vulnerable to neglect or significant harm. This does not mean that where such factors are recognised should lead to parents being suspected or accused of harming their children but rather should alert and provoke a higher level of informed and skeptical curiosity that is proportionate, respectful and persistent. The HOR author along with several of the IMR authors comment on the general lack of professional curiosity displayed.   218. The factors that are identified in research as being likely to be found in the maltreatment of children include the following;  a) Isolated parents who have little or no extended family capable of providing good emotional and practical support or have other forms of support available for example from a community or faith based group for example; in this case father had very limited family support available and some professionals may have been over optimistic about the quality of family support that mother had;  b) A history of being abused or rejected as children or had multiple changes of carers; father’s history is especially   Page 46 of 69 relevant and there are gaps and mistaken assumptions in regard to mother;  c) Mental illness, personality disorder and/or a learning disability/difficulties; these are often not recognised or diagnosed and in this case father declined to participate in assessments when younger and both parents may have unrecognised needs; the education history in respect of both despite being young parents was not sought to establish if there was any evidence of special educational needs as school students and it is known that father was subject of an SEN statement;  d) Particular vulnerability if there is no other parent or extended family member is available to share parenting (that becomes exacerbated if a child is hard to parent which does not appear to been the case for Child K); father was in prison and mother was clearly being expected to look after her younger siblings whilst she lived with the MGM; latterly father was caring for both children whilst mother was working; there is evidence that professionals noted that the parents appeared to be providing appropriate care although is was often couched as admiring the extent to which both parents were overcoming the legacy of their own upbringing; for example there was a tolerance of father using cannabis whilst in sole charge of the children;  e) The parents have different children by different partners often involving abusive relationships; father had his first child placed for adoption and had a history of being abusive, had minimised the offence with the 13 year old girl for which he had been imprisoned; there is no information about mother’s previous relationships or the circumstances under which she met Child K’s father and the pregnancies;  f) There is reliance on alcohol or drugs and do not accept they need to control it; father had a historical and problematic use of alcohol and drugs and continued to use cannabis even when he was the sole carer for two young children; there is no evidence of enquiry about his use of substances and similarly no enquiry regarding mother; this is an area of practice that is frequently not managed well by any professional group outside of specialist services and was a theme in a recent serious case review;  g) There is a history of aggressive outbursts and a record of violence including intimate partner violence; father’s record of   Page 47 of 69 violence was known to CSC, CAMHS and to YOT although not so well understood by early years the other health professionals in contact with the family; no inquiries were made during any of the assessments about the circumstances of the adoption and the relationship between father and the child’s mother;  h) There is a history of obsession/very controlling personalities often associated with low self esteem; father’s history included episodes of very controlling behaviour especially to females and his history of being bullied and his childhood trauma of maternal death were all factors that were not looked at and the implications for his sense of identity and self worth;  i) A history of being in care and having multiple placements; father’s care history was very problematic and had involved him living in a succession of placements and at times being in unsupported arrangements such as bed and breakfast outside his home environment;  j) There is fear of stigma or suspicion about statutory services; this is a frequent and unrecognised factor in interaction between professionals and families and in this case there was clear evidence for example at the children’s centre about concerns of involving services such as CSC; it has implications for how parents will seek to present themselves and manage information that minimises the motivation and reasons for key professionals to become curious and further involved when it is not welcomed.   219. It is apparent that many of these factors were present in this case but either went unrecognised or that individual practitioners were misdirected by a false sense of reassurance largely from what father and mother said. In addition to these factors that are indicators for enhanced historical curiosity there are specific areas that a sufficiently competent parenting assessment would give attention to and requires historical inquiry; this includes the style of attachment experience that parents had as a child and bring to their own parenting for example.   220. At the time of mother booking the pregnancy with Child K the midwifery service were unaware of father’s history although because of the MGM’s pregnancies felt they had good enough understanding about mother’s background. Arguably, this apparent knowledge about mother was insufficiently informed and was unduly optimistic about the extent of support and therefore resilience that Child K’s mother had to draw on as a pregnant teenager. This assessment of mother’s background persisted even when the   Page 48 of 69 information about involvement of the vulnerable families team with maternal grandmother became known during the second pregnancy.  221. Mother did volunteer information that father was in prison but this did not provoke any further inquiry by the midwives or by subsequent health professionals and was largely minimised in CSC assessment; it became part of the environmental background to the case that did not attract curiosity or interest.   222. It is not clear if the lack of interest in this and other information reflected a lack of knowledge about the potential significance of information to help inform observation of current circumstances or was the behaviour of professionals who were clearly experiencing considerable change to their organisation and working arrangements that are described elsewhere in this review. Similar issue in terms of not identifying historical information are identified by the early years IMR and from CSC.   223. The consequence is not that any professional could have predicted that Child K would be killed by one of the parents but rather all of the observations, judgments and decisions about the needs of Child K and the sibling were not sufficiently informed by historical understanding that could inform and balance the optimistic information that both parents wanted to present to services.   224. The only agency that realistically could have known about most of the information was CSC although this should not have prevented other people from becoming more curious about aspects of information and family circumstances.   225. The police made appropriate referrals to CSC following their search of the family home; they did not have any immediate concerns about the safety of either children but they were correct to see that evidence of involvement in using drugs and threats of potential violence were factors of potential interest to other services.   226. There were opportunities for CSC to have undertaken an assessment on more than one occasion that could have revealed both the history and its relevance; the CSC IMR provides a detailed critique of how those opportunities were not taken and the significance for the management of the case and for multi-agency working. A significant contributing factor discussed in the IMR was a pre-occupation with meeting performance targets on issues such as timescales during periods of high demand and staffing shortfalls and insufficient attention on the purpose and quality of key activities such as collating chronologies and history for the purpose of assessing a vulnerable child and their family. The same IMR acknowledges the considerable work by managers and practitioners to address the shortcomings identified.     Page 49 of 69 227. Although there is reference to some aspects of father’s history principally in regard to having been looked after it is used as a narrative background that describes a difficult and harsh childhood; little information or understanding about the implications for him as a parent is explored.  228. In 2008 as part of the adoption process involving father’s first child the assessing social worker had found that father was barely able to meet his own needs and was very immature. The assessing worker had concluded that father was likeable but was not thought to have the requisite parenting ability required. The assessments that were completed in regard to Child K were all regarded as being unsatisfactory by the CSC IMR. The superficial approach to the assessment extended to not seeking information in regard to the adoption or the assessments that were undertaken at that time.   TOR 6 Extent to which services understood the significance of father’s personal and family history Examine whether agencies fully understood any issues about the father’s care history, offending history and mental ill health and the impact this may have had on Child K and took appropriate actions.  229. The extent, significance and relevance of father’s history and the potential impact it would have upon his role as a parent has been referenced in other and earlier sections of this report. The role and significance of father’s and the extent to which they are often invisible to the various professionals supporting very young children in particular has also been described.   230. CSC had longstanding and historical involvement with father and other members of his family from 1997. Latterly and before the birth of Child K the contact had been through the leaving care service. The account from the CSC IMR is comprehensive in describing the extent to which the history was not sufficiently accessed when referrals were made and assessments undertaken after the birth of Child K. An account of the reasons and the contributing factors are dealt with in detail in the agency report and are referred to in other parts of this report. Of particular note is the fact that it took the IMR author two days to collate the history for the IMR.  231. This first assessment of father in relation to his risk to his children was completed by a student social worker that concluded that a prison visit was not in the interest of Child K and further made clear to the leaving care worker that as and when father was released from prison and intended to move into the household, an expert and forensic assessment of risk was required; this was never undertaken. The student social worker had concerns that mother was minimising father’s offence and history and was concerned about her vulnerability; the nature of that vulnerability does not appear to have been developed in that or the subsequent assessments.     Page 50 of 69 232. In June 2010 the leaving care worker was made aware that father was due to be released from prison and a further referral to undertake a risk assessment was made; this was allocated to a temporary although qualified agency social worker.   233. A subsequent core assessment relied on information that had originally been collated by the student social worker and still lacked any evidence or analysis about Child K’s developmental or other needs or analysis.   234. According to the CSC IMR some individual workers saw their role as primarily being an advocate on behalf of father and determined to see that because of his poor life opportunity he was to be ‘given every chance’.   235. The work of the leaving care service was primarily focussed on trying to help father and was the overriding focus of their involvement. The focus of the relevant regulations for providing leaving care support is upon the support given to a young person gaining independence.   236. Although there was information stored in various health records it was not available or accessed to be considered in regard to the impact on Child K and her sibling. The LCFT had historical records relating to CAMHS involvement that the 0-19 team were not aware of and did not have any reason to access at the time. This information was therefore not known to the midwifery service. No detailed information was apparently sought in regard to father as part of the ante natal care and planning to trigger any further curiosity. The importance of seeking information about fathers is now given much clearer focus.  237. When father arrived at HMP/YOI in August 2009 with a history of arson, self harm, violence and a risk to children a detailed risk assessment was carried out in September 2009 and level 1 child restrictions were applied.  This meant that he was not allowed contact with any person under the age of 18. However it must be noted that mother at times tried to visit father possibly utilising false ID. In addition this restriction authorised the monitoring of all calls and correspondence that father may have made.   238. A copy of that report was sent to the GP who acknowledged that it was a very thorough letter with lots of information within it and if there had been any mention of father leaving prison soon it would have been vital to try and identify the mother and Child K and thus share information. However as father was still in prison the letter was simply filed and was not accessed until this serious case review. If the CSC assessments had been more rigorous and had asked for information from the GP along with other relevant services, it would have possibly caused the information to be retrieved from the patient record.    Page 51 of 69 239. There were a number of reports of father trying to circumvent the level 1 restrictions placed upon him, by attempting to contact mother.  These attempts took the form of written communication, telephone conversations and attempting to arrange a visiting order for her.    240. There were also reports of father being the victim of bullying and at times he was involved in fights with other prisoners.  One report of concern came from a cellmate who feared for his own safety as father had on more than one occasion attempted to set fire to his mattress; he had been convicted of arson as a teenager.  TOR 7 How child protection and safeguarding issues were identified and managed Examine whether any safeguarding and child protection issues were identified and dealt with appropriately by agencies. Consider whether agency responses were correct and timely and whether safeguarding procedures were followed appropriately. The Review will consider the tools available to practitioners and the effect of management systems on practice in order to understand how these supported practice  241. The assessment in regard to father’s first child was recent and unequivocal; he was not suitable to parent a child. This was the opinion of the social workers completing assessments and providing reports to court and also reflected the view of the child’s mother. These assessments were not accessed when enquiries and assessments were completed in regard to Child K and her sibling.   242. The prison service was otherwise the only service to make a clear assessment that father was a risk to children and had controlled prison contact and visits accordingly. This assessment was completed after father had been convicted and placed in custody for having a sexual relationship with a 13 year old girl. The prison service do not appear to have had information about other aspects of father’s adolescence that were also risk factors although there had been assessments of father’s mental and emotional health.  243. It is notable that father minimised the significance of the offence and maintained that he would not have been convicted if he had appeared in court to defend himself against the charge before he was convicted and sentenced. He also relied on claiming that the girl had misled him about her age. The offence had occurred following a significant history of sexually abusive behaviour displayed to other females. It seems clear that father’s minimisation was accepted by several professionals working with him; when the prison governor made the decision that he was to have no contact with Child K the leaving care worker advocated on his behalf and the core assessment of risk by CSC also relied on father’s account about the offence to judge that he represented a low risk to his children.     Page 52 of 69 244. Although there were referrals made to CSC on three occasions, the concerns did not arouse explicit safeguarding concerns and this was significantly influenced by how the parents behaved with different professionals who took reassurance from their demeanour and apparent openness.   245. The way in which the opportunity to refer information to the LADO in August 2012 reflected an approach focussed on offering help and support rather than taking a more rigorous and questioning approach. If the LADO had been consulted, it would have prompted more searching queries in regard to aspects of lifestyle and how it related to the care and supervision of very young children.   TOR 8 Resources and capacity Consider whether agencies had the necessary resources and capacity. Consider also whether professionals working with the family were suitably skilled and adequately supervised and whether there is evidence of management accountability and support. The Review will consider the effects of human judgement and reasoning and any strategies used to combat biases in this case in order to understand how these impacted on work with the family.  246. The importance of organisational context was highlighted by Professor Munro’s review commissioned by the coalition government in 2010 and completed in May 2011. The review explored how the effective safeguarding of vulnerable children depends upon the ability of organisations to create the working conditions and arrangements that place a value on the development and retention of professional expertise.   247. The evidence and information provided in this and other serious case reviews illustrate the complexity of information that professionals deal with and the extent to which they have to have the capacity, motivation and support to develop appropriate skills and knowledge that help them make balanced and effective judgements in relation to vulnerable children and their parents.   248. The limitations of trying to redress shortcoming in knowledge and expertise through over prescriptive procedures and protocols were a central aspect of the Munro review and a reasons for embarking upon wide ranging change at national and local levels.   249. There is a degree of irony that according to the IMR, the best of the assessments undertaken by CSC was completed by a student social worker in response to the first referral in February 2010 requesting a risk assessment of father, although the IMR comments that this assessment was not satisfactory. This is not personal criticism of the student social worker but of the supervision and oversight provided at the time. It invites further reflection in regard to the quality of learning and development being offered   Page 53 of 69 to a trainee social worker who will be using their experience to inform their future practice.   250. The empathy and ability to build relationships with vulnerable adults whilst at the same time achieving and maintaining an appropriate level of professional detachment and sceptical rigour is not to be underestimated and it requires all professionals to have access to appropriate advice, supervision and mentoring.   251. What is clear in regard to this specific aspect of the case is that the organisational capacity of CSC was impaired in regard to the quality of referral management, assessment and multi-agency communication. No manager was involved in the decision making that took place in regard to the strategy meeting.   252. The CSC IMR also discusses the importance of a service such as CSC having the capacity to support social workers to be a source of ‘good authority17’ and the extent to which this was not achieved in this case. The IMR describes the extent of difficulties in the district social work service at the time and the impact it had on the standards of practice and oversight.  253. The referral in July 2012 from the police to CSC did not identify concerns about the safety of the children. In the absence of any immediate a concern regarding the safety of the children, the response was to make routine checks with other services which focussed on whether any body else had current worries or concerns; none were identified as a result of the enquiries which in turn did not attract any request for further information from the other services.   254. The referral from the police had included information that father had been using cannabis whilst supervising the children on his own; there was reference to the cannabis plant, the hidden ‘weapons’ and the fact that mother was working as a dancer in a club. It was also not disclosed during the assessment that the children were no longer attending nursery due the parents withdrawing them because they were in significant arrears with the fees. The parents provided a reassuring response when the social worker followed up the information.   255. The IMR process has identified that during the timeframe of the SCR there were also difficulties with staff shortages within the health visiting team. This was reported to senior management appropriately at the time and action plans were established. However this resulted in a number of different health visitors visiting the family and workload was becoming ‘task orientated’.                                            17 The IMR author attributes Harry Ferguson and his book Child Protection Practice which was also referenced in the professional capabilities framework developed by the Social Work Reform Board 2011.   Page 54 of 69  256. The individual practitioners fulfilled core aspects of their roles and responsibilities, but there was at times a narrow focus dealing too much with current observation and not always considering more historical and longer term perspectives; this was an issue identified in CSC as well. Sickness levels have now improved within the health visitor team and according to the IMR the difficulties in capacity will also be resolved with initiatives such as the health visitor implementation plan.   257. Under corporate working arrangements the named health visitor maintains overall responsibility for assessment and planning of the health related interventions with children and families. However certain targeted and routine interventions are delegated to staff nurses and nursery nurses in the team with expectation that they will report back to the relevant health visitor. There is evidence of this practice within the records and community nursery nurses confirmed this was the case with this family. They felt supported by the named health visitor and felt there was sufficient opportunity for discussions and ad hoc supervision.  258. The CSC author describes and analyses the impediments that confronted practitioners from using cumbersome systems for the retrieval and collation of information which are being addressed through a plan to procure new systems. This implies there will be some further risk to be managed during any transfer to new systems as and when this occurs.      Page 55 of 69 4 Analysis of key themes for learning from the case and recommendations  259. This report begins with an acknowledgment of the imminent changes that will take place over the forthcoming months in the conduct of serious case reviews throughout England. These changes are driven by the recognition that for any meaningful analysis of the complex human interactions and decision making processes that are involved in multiagency work with vulnerable families has to understand why things happen and the extent to which the local systems (people, processes, organisations) help or hinder effective work within ‘the tunnel’18.   260. In this chapter the panel set out key findings that are designed to offer challenge and reflection for the LSCB and partners. The emphasis is not on the more traditional articulation of SMART recommendations. The key findings are framed using a systems based typology developed by SCIE. Although this serious case review has not used systems learning to collate evidence there is value in using the following framework to identify some of the underlying patterns that appear to be significant for local practice in Lancashire whilst accepting there are some limitations and mismatch between how the evidence has been collated and this form of presenting the key findings.   a) Innate human biases (cognitive and emotional) b) Family-professional interaction c) Responses to incidents d) Longer term work e) Tools f) Management (and agency to agency) systems 261. The remainder of this report aims to use this particular case, and to reflect on what this reveals about gaps or areas for further development in the local child protection system and use it as a limited window into the local systems.   262. In providing the reflections and challenges to the LSCB there is an expectation that the Board will provide a response to each of the key findings as well as to the recommendations and action plans that are described in the IMRs. As far as the key finding described in the remainder of this chapter it is anticipated that the Board will take the following action.  LSCB response  a) Does the Board accept the finding?                                          18 View in the Tunnel is explained by Dekker (2002) as reconstructing how different professionals saw the case as it unfolded; understanding other people’s assessments and actions, the review team try to attain the perspective of the people who were there at the time, their decisions were based on what they saw on the inside of the tunnel; not on what happens to be known today through the benefit of hindsight.   Page 56 of 69  b) How is the Board to take this forward? If not, please explain why.  c) Who is best placed to do this?  d) What are the timescales for response?  e) How and when will it be reported?  263. The LSCB will determine how this information is managed and communicated to relevant stakeholders. This report recommends that the LSCB discuss the key findings and make a formal response that is also published.   4.1 Learning from previous serious case reviews  264. The LSCB in Lancashire had undertaken eight previous serious case reviews between 2008 and 2010.   265. Reference to the evidence from serious case reviews has been made throughout the IMRs, the health overview report (HOR) and this overview report.  4.2 Innate human biases (cognitive and emotional) Thinking, fast and slow; busy professionals rely on intuitive and impressionistic data and information and clear visible signs of abuse including what parents disclose.  Sceptical and inquiring curiosity about family history and parental motivation and lifestyle requires more deliberate, purposeful effort to identify the underlying patterns of history and vulnerability.   266. The influence of human bias in how information is processed and analysed in complex processes such as children’s safeguarding enquiries and assessment is an area that a learning based review attempts to explore in order to understand how people make their judgments and decisions. The title of Daniel Kahneman’s book, Thinking, fast and slow19, refers to two systems of the human mind used to process information.   267. System 1, or fast thinking, operates automatically and quickly with little or no effort and no sense of voluntary control; it is the ‘secret author of many of the choices and judgments you make’. Most System 1 skills such as detecting the relative distances of objects, orienting to a sudden sound, or detecting hostility in a voice are innate. Some fast and automatic System 1 skills can be                                          19 Penguin Books Ltd, November 2011   Page 57 of 69 acquired through prolonged practice, such as reading and understanding the nuances of social situations. Experts in a particular field or discipline can use System 1 to quickly retrieve stored experience to make complex judgments that would be more challenging for others. These are the sorts of skills that workers in emergency services will use along with other practitioners who work with volatile and unpredictable situations such as alcohol, drug, mental health and social care settings.   268. System 2, or slow thinking, allocates attention to the mental activities that demand effort, such as complex computations and conscious, reasoned choices about what to think and what to do. System 2 requires most of us to pay attention when doing things such as drive on an unfamiliar road in poor weather, complete a crossword, or understand a complex ethical argument.   269. Kahneman focuses much of his book on the interactions of System 1 and System 2 and the problems inherent in those interactions. Both systems are “on” when we are awake. System 1 runs automatically and effortlessly but System 2 idles, because using it requires conscious effort and is tiring.   270. It is System 1 that generates impressions and feelings, which then become the source of System 2’s explicit beliefs and more deliberate choices. System 1, when it encounters something it cannot quickly understand and did not expect (in other words, a surprise!), enlists System 2 to make sense of the anomaly. The alerted System 2 takes charge, overriding System 1’s automatic reactions. System 2 always has the last word when it chooses to assert it although is fallible. It can for example, allow the rule of optimism to operate20.  271. The systems operate to minimise effort and maximise performance and are the result of hundreds of thousands of years of human evolution in our environment. They usually work extremely well. System 1 performs well at making accurate models and predictions in familiar environments. System 1 has two significant weaknesses: it is prone to make systemic errors in specified situations; these are “biases” and it cannot be turned off. System 2 can, with effort, overrule these biases if it recognises them. Unfortunately,                                          20 In 1983, Dingwall, Eekelaar Dingwall and Murray, (The Protection of Children: State Intervention and Family Life, Blackwell, Oxford) investigated professional decision making in an English child protection system. They developed the 'rule of optimism' to explain how health and social workers were screening or filtering out many of the cases with which they were involved. These researchers asserted that under the 'rule of optimism' workers applied a heuristic or routine method of practice which was used to reduce, minimise, or remove the concerns for the child's welfare or safety. This was done via the workers applying overly positive interpretations to the cases that they were assessing. The same research suggested that the 'rule of optimism' was only discounted when parents refused to cooperate with workers and rejected help (a 'failure to cooperate'), or when there was a 'failure of containment' where a number of workers became involved with the case and the pressure for protective action became too great. Child death inquiries and serious case reviews have continued to comment on the phenomenon and Lord Laming has also referred to the same rule of optimism.   Page 58 of 69 System 2 is demonstrably very poor at recognising one’s own biased thinking. Trying to engage System 2 at all times to prevent System 1 errors is impractical and exhausting.  272. Within this model for example there are a number of phenomena that have relevance to complex work such as safeguarding. It is System 1 that will initially make an active effort to assign meaning to events and phenomenon, and to make judgments about people and events. Because System 1 is tasked with doing this very quickly, and as in this case, often in very busy and stressful circumstances, it must rely on short-cuts and educated guesses.  273. In addition to making sense out of the events unfolding before it, System 1 is also involved in judging and evaluating the people and behaviours it experiences. Here again, System 1 must resort to shortcuts and educated guesses to render its impressions as quickly as possible. Essentially, what System 1 does is that it jumps to conclusions based on what limited information it has access to; information, which given that it lives very much ‘in the moment’, is confined to what is directly in front of it, and/or most readily comes to mind.  274. System 1’s tendency to consider only the information that is directly at hand is so pervasive and Kahneman refers to it so often, that he uses a cumbersome abbreviation to represent it: WYSIATI: what you see is all there is. In this case, what people saw was two young people who had not had the greatest of starts in their lives saying they wanted to do the best by their children and presented themselves as being motivated, friendly and kind.    275. In addition to WYSIATI, System 1 also jumps to judgments and evaluations in several other ways. For example, when we are presented with a question that we do not know the answer to, System 1 will simply get to work and answer a related but much easier question, and then offer up this answer to System 2 as the solution to the more difficult question. In a case such as this, a question might be whether a parent has changed or is able to care effectively for their child and will be much more difficult than the question is the parent likeable?   276. System 1 is also very susceptible to first impressions. System 1 also takes a third short-cut in evaluating people, and this short-cut is known as the ‘halo effect’. As Kahneman explains, the halo effect is “the tendency to like (or dislike) everything about a person including things you have not observed”. Essentially, System 1 tends to evaluate someone on one or a handful of traits, and then simply extends this evaluation to other traits. For example, “you meet a woman named Joan at a party and find her personable and easy to talk to. Now her name comes up as someone who could be asked to contribute to a charity. What do you know about Joan’s generosity? The correct answer is that you know virtually nothing… But you like Joan and you will retrieve the feeling of liking her when you think of her. You also like   Page 59 of 69 generosity and generous people. By association, you are now predisposed to believe that Joan is generous. And now that you believe she is generous, you probably like Joan even better than you did earlier, because you have added generosity to her pleasant attributes”  277. Thinking, Fast and Slow provides an accessible vocabulary to discuss the processes of human cognition which are the interactions between System 1 and System 2 thinking. It does not, however, provide solutions or reliable approaches to bias mitigation. According to Kahneman, the best we can hope to do is learn to recognise the situations in which mistakes are likely, and try harder to avoid specific errors when the stakes are high; for example when making enquiries and completing assessments where there is evidence of vulnerability.  278. A significant theme in this and a previous serious case review is the influence that was exerted on professional mindsets arising from how the adults presented themselves combined with an absence of historical perspective and knowledge and it implications and an optimistic tendency to treat information for example about cannabis use without much concern.   279. All of the IMRs confirmed the views that were expressed during the initial practitioners learning event at the outset of the review that both parents were polite and not obstructive in their interaction with professionals. This included the contact they had with health professionals, social care as well the police.   280. Initially, when the first pregnancy was booked, father was in custody and the main point of contact was with mother. From the outset, both parents were keen to minimise the sexual offence for which father had been convicted in regard to a 13 year old girl. There was a lack of challenge from the outset about how father in particular wanted to have it regarded as an injustice done to him in his absence from the court as a result of him oversleeping.   281. The couple expressed on more than one occasion a desire to provide better childhoods for their children compared to their own and the observations recorded by the different services visiting the house confirmed that the children were clean, fed and kept warm and were dressed in appropriate clothing.   282. All of the services were influenced to some extent and was a product of a lack of knowledge about the history of either parent. The police and probation service knew of father’s criminal history and the police were continuing to keep an active interest in father’s activities. The police made a referral following a search of the family home which found father smoking cannabis and in possession of a plant along with a substantial cache of money and a collection of hidden weapons.   Page 60 of 69  283. In making the referral the police acknowledged that the children were apparently well cared for. The disclosure that father made about mother working as a dancer was subsequently dismissed by father as an effort to wind up the police.  284. There was additional susceptibility that arose from the relative inexperience and lack of training for some of the professionals who were allocated responsibility to take a lead at various times; a student social worker completed the initial assessment following the referral regarding the risk of father and the role of the leaving care worker when father was released from prison and joined the family.   285. A significant learning point to come from this and other serious case reviews is the requirement for professionals to have had the opportunity to cultivate the appropriate emotional and mental skills through which to process information and observation. This was unlikely to have been achieved for workers who were unqualified or had not completed their training or were still at a relatively early stage in their career let alone whether they had an understanding of constructs such as Kahneman’s ‘Thinking, Fast and Slow’.  286. Another dimension examined in the IMR from CSC explores the requirement for key professionals in social care (and by implication primary health and early year’s settings) to have the motivation and capacity to develop relationships with parents who have additional needs or vulnerability.   287. These relationships have to create the conditions within which there can be a level of knowledge and confidence to challenge and understand the underlying patterns. In this case, there was significant history in both parents that if it had been known and explored would have created an improved context within which the parents behaviour and interaction was better understood.   Issue for consideration by the LSCB  1. How can practitioners develop and improve their cognitive framework upon which to evaluate their experiences and improve the manner in which they process and analyse information about children?  4.3 Responses to incidents or information Enquiries have to be a reciprocal exchange of relevant information and intelligence that requires both parties to have confidence in the local information sharing protocols and develops common trust and confidence in how sensitive information is managed   Page 61 of 69 288. A central theme of the serious case review is the extent to which the opportunities for making sufficient enquiries and sharing of information were not sufficiently exploited. The considerable history of father in particular remained undiscovered for many of the services.  289. The enquiries and assessments that were completed were hampered by the complications of several different people handling individual incidents or reports such as in the exchanges between the police and CSC as well as health. The focus tended to be on what adults were saying or doing with insufficient attention to the implications for children. The manner in which father joined the household in spite of the offence and concerns expressed from within the prison service, the information sent from the police in regard to the presence of drugs and weapons and evidence of offending.   290. A significant episode in respect of responding to information was the way in which the police referral was followed up in August 2012. The referral highlighted lifestyle issues in relation to the use and presence of cannabis in the house, evidence of involvement in crime and mother working as a dancer.   291. A telephone conversation between CSC and the nursery did not achieve a full exchange and disclosure of relevant information. It appears that there was a reluctance to share much information about the referral with the nursery for reason of maintaining confidentiality and managing third party information.   292. A degree of misplaced reassurance was taken from the social worker having an understanding that both children were attending the nursery and the nursery had no concerns to report. The narrow focus of the enquiry did not encourage a wider discussion and the social worker did not for example have an understanding that the pattern of attendance had reduced and the parents had already incurred debts in regard to fees that were also not disclosed.   293. The panel spent time discussing the biases that might be operating in regard to the confidence and trust that services such as CSC have in for example sharing sensitive information with independent operators of services.   294. There was no reason for a referral to have been made to the LADO because there was no information that suggested that parents were committing an offence against a child. What was not known at the time or to the panel at the outset of the review was that under the statutory framework for the early year’s foundation that is referenced in footnote 14 earlier in this report, Ofsted have applied the scope of disqualification to apply to partners or other people living in the same household under section 75 of the Children Act 2006. If this had been known, a referral to the LADO would have been   Page 62 of 69 made. The panel were otherwise not persuaded that the information in regard to drugs which had not suggested involvement by mother would have merited consideration as to whether it had implications for her employment as a trusted adult. The CSC IMR makes the point that the relative inexperience of the social work team might have been counterbalanced with the input from a more experienced professional designated as the LADO.   295. Information about the use of cannabis was generally not regarded as a significant threat to the well being of the children. Father’s long term use including during his adolescence had implications for his emotional and mental well being and should have been explored within any parenting assessment.    296. There was also information held by the GP from risk assessments conducted in the prison that was not shared or accessed at any stage. When the GP received the information, father was not living with the family and therefore the GP judged there was not a duty to disclose. The GP was not then made aware when father was released and had moved in with the family. The GP along with other services was not asked to provide information for any of the enquiries or assessments which would have been the opportunity to share the information.   Issue for consideration by the LSCB  1) Is the LSCB sufficiently confident that information sharing protocols are operating effectively enough in respect of enquiries with all providers of early years services? 2) Is the LSCB satisfied that the management of enquiries made during statutory enquiries and assessment are able to identify relevant information held by services such as early year’s services and GPs? 3) What are the factors that discourage practitioners from regarding information about cannabis use as meriting more rigorous enquiries within children’s assessment?  4.4 Longer term work Longstanding contact or knowledge with a family can be a source of misdirection and assumption leading to misplaced belief in parental resilience and capacity   297. The fact that both families had some significant contact with services over several years has been an important area for analysis and reflection. It is a paradox that knowledge about father’s particular history was insufficiently understood particularly by the social workers who had responsibility for assessing whether there was evidence of need or risk.   298. The first assessment that was completed was a desk based activity although does not appear to have secured any substantial information in regard to the   Page 63 of 69 childhood history of father. It failed to enquire into the circumstances under which father’s first child had been removed and placed for adoption and it also failed to uncover the compelling evidence from a previous partner in regard to father’s potential for coercion.   299. It is not apparent that archived information was examined and might reflect an over reliance on what the electronic record system is able to deliver. It is also probable that for a practitioner still undergoing training, they would have a less developed insight and understanding about the significance of childhood and family history although this is an area of practice that is often identified in assessment practice and serious case reviews. It is also a fact of life that in services that are under significant workload pressure, there is less capacity and motivation to be looking for evidence and information in regard to referrals that are not presenting evidence of immediate risk and concern.   300. Assumptions were also made by services such as midwifery that the geographical proximity and involvement of maternal grandmother in domestic arrangements was a source of greater support and resilience than was in fact the case.   301. The police and probation service along with the leaving care service had considerable knowledge of father and his offending although did not appear to have concerns about him being a risk to his children. There may have been some assumption made that the sexually coercive behaviour he displayed to previous partners as well as carers was historical.   Parents who are in prison continue to exert influence and have significance for the partners and children and have implications for assessment and the planning of appropriate intervention  302. It is apparent that father and mother were determined to keep their relationship intact when father was imprisoned. The request by the prison service for a risk assessment to be completed as part of the sentence planning process was postponed until the imminent release of father.  303. In the spirit of identifying learning that applies more widely than a single case, Child K provides an opportunity to reflect upon the needs of children who are frequently hidden from view. An estimated 160,000-200,000 children in the UK have a parent in prison. This is about twice the number of children looked after (91,000) and over three times the number of children who are subject of a child protection plan (50,500).  304. Children who have a parent in prison are more likely than others to experience poverty, mental ill health, poor housing and other negative outcomes, but are much less likely to receive any help or assistance. Although government policies refer to them as one of the groups of disadvantaged   Page 64 of 69 children who should receive attention it is a minority of local areas that make any reference to this group in their children’s plan.  305. The history of father combined with his record of being a prisoner had implications for his children in the immediate and longer term.  306. It is not infrequent for a father to be absent from the family home as in this case; the particular issues that arise from managing relationships for example between men in prison and their children is a significant issue. Professional vigilance by all relevant services is essential to ensure as much information is collated about fathers especially as they can exert considerable influence even when they are not living in the household for example as a result of returning to prison. It is essential that consideration and assessment of such factors is built into assessments that are routinely completed by early years, health or social care services.   Issue for consideration by the LSCB  1. To what extent are the needs of children who have a parent in prison included in local strategic plans and professional development and training?   4.5 Tools The use of recognisable tools or frameworks can enhance the collation and analysis of information in regard to risk from offenders who may pose a source of harm to children  307. The review has highlighted gaps in how assessments were sufficiently focussed on risk. The removal of the first child should have been considered; understanding access to confidential and archived adoption records was a factor. If the records had been examined along with evidence from a previous partner the assessment in relation to Child K and sibling would have been much more focussed.  308. The fact that father appeared able to minimise his sexual offence and the manner in which the practice direction for a forensic assessment was not followed through might have been a product of not having enough confidence in handling this specific aspect of work.  309. The information that was provided in regard to father’s use of drugs does not appear to have been assessed meaningfully. It is possible that some of this might reflect a misplaced tolerance of what appeared low level substance use. It is an example of some of the areas of practice where there has to robust supervision to deal with ethical dilemmas that some individual practitioners are dealing with.    Page 65 of 69 310. In the absence of any tools, scales or other frameworks, the practitioners were even more reliant on observation and inferring and interpreting significance without recourse to more objective measures to help inform their judgments.   Issue for consideration by the LSCB  1. How will the LSCB promote the increased and more consistent use of relevant risk assessment tools and frameworks that include the use of cannabis?  4.6 Issues for national policy  311. The issues raised in the CSC report for this review in regard to social work training that underpins a concept of investigative social work and the use of good authority versus anti oppressive practice, partnership working and support in social work practice.  312. The Ofsted guidance (No. 080157) issued in November 2011 on disqualification from working in children’s social care states that a person is disqualified from working in specified settings including registered child care setting ‘if they live in the same household as person who is disqualified’. Child K’s father was disqualified by virtue of the sexual offence he was imprisoned for. According to the panel’s understanding of the Ofsted guidance, Child K’s mother should have been disqualified from working in a nursery despite the fact that she had not at that stage committed any offences and was not undertaking and registered child care in premises shared with Child K’s father.  313. The Ofsted guidance on this specific detail is not widely known in Lancashire and has implications for the recruitment policy and practice of registered services. Early year’s providers in other parts of England may be similarly unaware of the interpretation.  314. In the opinion of the panel, there are significant policy implications of the interpretation for the initial checks at recruitment and selection stages and for ongoing disclosure in early year’s settings.   Peter Maddocks, CQSW, MA. Independent author July 2013    Page 67 of 69 Appendix 1 - Procedures and guidance relevant to this serious case review Legislation  The Children Act 1989  Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act21 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others.  Section 17 imposes a duty upon local authorities to safeguard and promote the welfare of children in need.  Section 47 requires a local authority to make enquiries they consider necessary to decide whether they need to take action to safeguard a child or promote their welfare when they have reasonable cause to suspect that a child is suffering, or is likely to suffer significant harm.  These enquiries should start within 48 hours. The local authority is required to consider whether legal action is required and this includes exercising any powers including those in section 11 of the Crime and Disorder Act 1998 (Child Safety Orders) or when a person has contravened a ban imposed by a Curfew Notice within the meaning of chapter I of Part I of the Crime and Disorder Act 1998.  Section 46 provides the Police with Powers of Protection to take children into police protection where a constable has reasonable cause to believe that a child would otherwise be likely to suffer significant harm.  The Children Act 2004  Section 10 requires each local authority to make arrangements to promote co-operation between it, each of its relevant partners and such other persons or bodies, working with children in the authority’s area, as the authority consider appropriate.  The arrangements are to be made with a view to improving the wellbeing of children in the authority’s area – which includes protection from harm or neglect alongside other outcomes.  This section is the legislative basis for children’s trusts arrangements.                                           21 Local Authorities, including District Councils, the Police,  National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training     Page 68 of 69 Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act22 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others.  Safeguarding Procedures  The local safeguarding children procedures  The procedures provide advice and guidance on the recognition and referral arrangements for children suffering abuse. This includes emotional abuse that involves causing children to feel frightened or in danger. The procedures also cover physical abuse of children. The procedures also describe abuse involving the neglect of children that includes failing to protect children from physical harm or danger or the failure to ensure access to appropriate medical care or treatment. This includes describing distinct action to be taken when professionals have concerns about a child, arrangements for making a referral, and the action to be taken. The procedures cover arrangements for the ACPC (now superseded by LSCB) to ensure there are effective arrangements that promote good interagency working and sharing of information and training. The procedures describe specific responsibilities for all agencies contributing to this serious case review.   Other local procedures relevant to this serious case review  National guidance23  Working Together to Safeguard Children (2013)  The national guidance to interagency working to protect children is set out in Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. The guidance includes safeguarding and promoting the welfare of children who may be particularly vulnerable.  The guidance in respect of the Framework for the Assessment of Children in Need and their Families was replaced by the Working Together 2013.                                            22 Local Authorities, including District Councils, the Police, National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training Centres. 23 The election of a coalition government in May 2010 may result in changes to guidance and policy developed by the previous government.     Page 69 of 69 Assessments should be centred on the child, be rooted in child development that requires children being assessed within the context of their environment and surroundings. It should be a continuing process and not a single or administrative event or task. They should involve other relevant professionals. The outcome of the assessment should be a clear analysis of the needs of the child and their parents or carers capacity to meet their needs and keep them safe. The assessment should identify whether intervention is required to secure the well – being of the child. Such intervention should be described in clear plans that include the services being provided, the people responsible for specific action and describe a process for review.   Common Assessment Framework (CAF) The CAF is a key part of delivering direct services to children that are integrated and focused around the needs of children and young people. The CAF is a standardised approach to conducting assessments of children’s additional needs and deciding how these should be met. It can be used by practitioners across children's services in England. The CAF promotes more effective, earlier identification of additional needs, particularly in universal services. It aims to provide a simple process for a holistic assessment of children's needs and strengths; taking account of the roles of parents, carers and environmental factors on their development. Practitioners are then better placed to agree with children and families about appropriate modes of support. The CAF also aims to improve integrated working by promoting coordinated service provisions. All areas were expected to implement the CAF, along with the lead professional role and information sharing, between April 2006 and March 2008.     