Non-accidental injury to a 4-month-old child in 2018, attributed to shaking. Mother received a custodial sentence. Learning includes: provide child impact chronologies to understand the daily lived experience of children; the views, wishes and feelings of children are critical to effective interventions; a trauma informed approach to assessment, incorporating a strengths based methodology, can be invaluable when adverse experiences in childhood have been identified; cannabis use, particularly if prolonged, is a significant feature contributing to poor mental health and compromised parenting; family engagement is critical to keeping children safe; consider the possibility of abusive head trauma in cases where there are young babies and children and domestic abuse is present. Recommendations include: planning and interventions should be informed by a conceptual model of change, particularly when working with families struggling with interrelated mental health issues, alcohol or substance misuse; ensure that a trauma informed approach to planning and interventions is embedded into practice, particularly where adverse childhood experiences have been identified.
      
 Title:  Chid W serious case review. LSCB: Manchester Safeguarding Partnership Author: Rafik Iddin Date of publication: 2020  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                            1    Manchester Safeguarding Partnership Child W Serious Case Review  This report was commissioned and prepared on behalf of the Manchester Safeguarding Partnership Independent Reviewer: Rafik Iddin Ratified by MSP Children’s Executive on 11th May 2020  Published by the MSP on the 22nd September 2020   2           Contents           1. Introduction           2. Planning and Methodology        3. Overview of what was known to Agencies      4. Analysis of Practice          5. Learning from the Review     6. Recommendations               Anonymisation Key    Designation   Referred to as: Subject Child Child  W Mother of subject child  WM Father of subject child WF Sibling 1  S1, 1st  child of WM Sibling 2 S2, 2nd child of WM Father of S1 Father of S2 S1F S2F Paternal Grandmother FM    1.  Introduction   1.1 Child W is the third child born child to the mother (WM), and the first child of WM and father WF.   Child W sustained a non-accidental injury when aged 4 months, at  3  which time Child W lived with  WM and two half siblings, S1 aged 10 years and S2 aged 7 years.    1.2 In November 2018 paramedics were called to WM’s home address, due to reports from WM that Child W was convulsing and had stopped breathing. Child W was revived by paramedics at the scene and admitted to hospital. Shortly after admission and following further examination, it was suspected that Child W had suffered a non-accidental injury, consistent with being shaken. Following completion of the MRI Scan the next day it was concluded that Child W had suffered subdural bleeding, consistent with being shaken without an impact.  1.3 At the time of the incident Child W was subject to a Child Protection Plan, as were S1 and S2, an Initial Child Protection Conference having been held on the 24/9/18.  1.4 Greater Manchester Police were alerted to the incident through the ambulance service and hospital and commenced an immediate investigation into the circumstances of Child W’s injuries.  WM was subsequently charged with a Section 18 assault, contrary to the Offences Against the Person Act 1861 (Inflicting Grievous Bodily Harm with Intent) and remanded in custody to Court. WM subsequently pleaded guilty to a Section 20 assault, contrary to the Offences Against the Person Act 1861 (Inflicting Grievous Bodily Harm without Intent) and was sentenced in June 2019 to 20 months imprisonment.  1.5 The circumstances of the incident were considered by the Manchester Safeguarding Children Board Serious Case Review Panel (now known as Manchester Safeguarding Partnership) and subsequently the Chair of the Board. A decision was made to convene a Serious Case Review in line with regulation 5 of the LSCB Regulations 2006. For this Serious Case Review Regulation 5(2) (a) and 5(2) (b) (ii) applied, that being that the abuse or neglect of a child is known or suspected and serious harm is caused: and there is cause for concern as to the way in which the Authority, their Board partners or other relevant persons have worked together to safeguard the child.    4     2. Planning and Methodology  2.1 An independent reviewer was appointed to facilitate the review and complete the overview report.  A first meeting of the Serious Case Review (SCR) panel took place in September 2019. The panel carefully planned the review process and set all milestone dates with the intention to complete the SCR by February 2020.   2.2 An initial multi-agency chronology of key interventions with Child W, the siblings and parents was compiled and through this the panel established that the optimum opportunities for learning about practice arose between September 2017, the date when WM became pregnant with Child W, and mid-November, the time of the non-accidental injury.  It was also agreed that any periods of multi-agency work with the family prior to this timeframe would be considered, but only in so far as it impacted on any assessment within the identified reference points. In that respect it is acknowledged that there is additional information in relation to both S1 and S2 prior to this timeframe in respect of the circumstances leading up to the injuries to Child W.  However, these events are significant in so far as determining how that history had informed any subsequent assessment of risk in relation to Child W.   2.3 The review panel agreed the following key lines of enquiry to be addressed within the review:  ● To review the approach to domestic abuse and how needs were assessed and met from the perspective of a victim, perpetrator and child. ● To what extent did assessment follow a strengths based model and consider the approach to building resilience within the family unit. ● To what extent was the presence of drugs and alcohol and mental health factored into any assessment and planning?  5  ● What approaches were taken to engage the family and was non-compliance addressed within the multi-agency approach. ● To consider the purposefulness and effectiveness of the Child Protection Plan and its delivery across the multi-agency partnership. ● To what extent was the risk of abusive head trauma in the mind set of professionals  It was also agreed that the terms of reference would be reviewed at each meeting pending any further information being submitted.  2.4 Each participating agency completed a detailed chronology and a reflective account from this of the issues they considered to be key for their own agency.   2.5 The methodology adopted by the review panel was committed to engaging with key practitioners and family members where possible and in particular, achieving a review that complied with statutory guidance contained in Working Together 2018. This requires the Serious Case Review to understand practice from the perspective of the individuals and organisations involved at the time, rather than relying on hindsight, and to recognise the complex circumstances within which professionals work together to safeguard children.   2.6 The Review provided a briefing session for key professionals involved in the case in November 2018. The purpose of this was to introduce practitioners to the methodology of the review, offer some re-assurance about a process that can invoke considerable anxiety and to facilitate a deeper analysis of the pertinent practice issues that were relevant to the case.  Practitioners then committed to participate in structured individual conversations about the case with members of the review panel.   2.7 The Lead Reviewer along with the Safeguarding Partnership Coordinator, met with both WF and FM, Child W’s father and Paternal Grandmother, to explain that a Serious Case Review had commenced and how this would be conducted. The review also sought to  6  elicit the views of both WF and FM as to the quality of services that Child W and the family had been in receipt of.  2.8 The Lead Reviewer, along with a Prison based Family Intervention Worker, met with WM, again to explain that a Serious Case Review had commenced, how this would be conducted and how WM, as Child W’s mother, had experienced the intervention of professional agencies.    3. Outline of how Child W and family was known to Agencies   3.1 The agency history dates back to 2008 when Child W’s father WF, was convicted of the possession of a bladed knife and controlled substances (Cannabis). Following a number of further offences in 2009 and 2010, WF received a 10 week custodial sentence for failing to comply with Community Orders. In 2012 WF received a further custodial sentence for threatening behaviour.  3.2 In December 2009 WM reported that she had been the victim of Domestic Abuse from S1’s father, S1F and also from S1F’s father, S1’s Paternal Grandfather. However, it is not clear what risk was posed to WM and S1. At this time WM was referred to Mental Health Services but was discharged due to not attending appointments.  3.3 The following year S1 was referred to the Children’s Community Nursing Team regarding constipation, although the agency could not contact either parent to arrange an appointment and S1 was consequently discharged.  3.4 In January 2014, WF was referred for an Autistic Spectrum Condition (ASC) assessment. A letter was also written to WF’s GP, requesting a referral for Anger Management. WF did not meet the diagnosis for ASC although was later assessed by the Psychological Formulation Clinic in 2016 and 2017. This clinic offers an assessment in respect of complex relationship difficulties, including a relevant management plan, and signposting to  7  appropriate therapy or other services. This assessment concluded that WF did not meet the criteria for a diagnosis of any specific personality disorder although in 2017 WF was accepted into an extended service under the ADHD clinic, and was seen on a 1:1 basis. The treatment plan was to assess and treat ADHD under NICE guidance medication although WF’s attendance was inconsistent. Whilst this is not unusual for someone with an ADHD diagnosis, WF responded well to assertive follow up, if appointments were missed.  3.5 In July 2013, S1 did not attend an appointment with Audiology Services and was subsequently discharged.  3.6 In December 2013, WM made a number of complaints regarding noise and drug use near the family home, which WM alleged was impacting on S1’s attendance at school. WM also reported being threatened by neighbours. WM’s behaviour was noted to be erratic when making the reports and was of sufficient concern for Housing Officers to consequently record their concerns about her mental health.  3.7 Due to corroborated evidence from a neighbour that WM’s life had been threatened, a decision was made to award priority for the family to move due to safety concerns. However, WM did not move until November 2014 and when questioned about this reported that she was waiting for a suitable property in an area where she was close enough to get family support. Surveillance was also actioned but no evidence of drug related activity was identified. Throughout 2014 WM continued to report concerns regarding noise, gang and drug related activity and nuisance behaviour which was impacting on the children’s sleeping. In November 2014, WM, S1 and S2 were rehoused to the address where the non-accidental injury to Child W took place.  3.8 During this period School raised concerns regarding the vulnerability of S1 and in June 2014 made a referral to Children’s Services regarding the safeguarding issues related to the property and S1’s poor attendance. Concerns were also raised regarding S1 not being  8  taken consistently to health appointments. This resulted in a professionals meeting at school although no further information was available to the review regarding this.  3.9 In March 2015 concerns were raised that WM had threatened a number of students who were living in the neighbourhood, and about whom WM had reported noise and nuisance behaviour. WM had also threatened to “break the students’ fingers” if they continued to behave in this manner. WM’s behaviour was reported to have been disproportionate to the disturbances which had been alleged and there were concerns that WM would act in the way that the witnesses had described and follow through on her threats.  3.10 Consequently a referral was made to Children’s Services concerning WM’s erratic behaviour and the impact that this might be having on the children. Concerns were raised that WM was violent and aggressive but then quickly calmed down. The Multi Agency Safeguarding Hub (MASH) recommended further assessment, however the case was closed without an assessment being completed.  3.11 At the same time WM reported to her GP that she had been having suicidal thoughts and that she would end her life if there was someone to look after the children. WM was consequently prescribed anti-depressants and referred to the CRISIS Team. A referral was also made to the Mental Health Home Treatment Team, although when contact was made with WM she reported no longer having any suicidal ideation although GP records noted a high risk of self-harm.   3.12 In November 2015, S1’s father made a referral to Children’s Services. Whilst asking to remain anonymous, he raised concerns that WM was using drugs and misusing alcohol. The referral also referenced concerns regarding WM’s mental health and allegations of erratic behaviours. Whilst further assessment was recommended the case was closed, following a duty management decision that the threshold for Level 5 was not reached and that support could be provided by school under the auspices of an Early Help Plan.    9  3.13 In April 2016 a further referral was made to Children’s Services by S1’s father, reporting that an incident had taken place between himself, WM and WM’s sister which resulted in the Police being called. This resulted in WM and her sister being arrested and sustaining bruising, which WM and her sister alleged was from the Police Officers. The circumstances of this incident, whilst outside the time frame of the review are concerning. It is reported that S1’s father S1F, had returned S1 to WM’s home address but there had been no suitable adult at the address. S1F had then returned a short time later and WM and her sister had then attempted to assault S1F, causing damage to his car whilst he was sat inside. S1F had then reversed at speed and collided with several cars in the process. As members of the public had then contacted the Police, officers attended S1’s home address and both WM and her sister are arrested for a Section 47 assault. Both WM and her sister then attempt to assault the officers which result in CS gas having to be deployed. Both WM and her sister are then further arrested for assault with intent to resist arrest and criminal damage. WM is additionally arrested for the possession of cannabis. A Child and Family Assessment was completed although both parents gave differing accounts of what had taken place. WM had also alleged that S1’s father had been violent towards her and that if he was now seeking contact with S1 this would now need to be agreed in Court. The children were seen who did not report any concerns and the home conditions were noted to be appropriate. The school also reported a good relationship with WM and the case was closed on the 20/7/16.  3.14 On the 22/8/16, WM contacted her GP and spoke to reception stating that “she gets angry with her husband”. WM insisted on seeing the GP and was given an appointment which then took place on the 9/9/16 WM. Information provided by WM also suggested that she had been violent towards previous partners. A safeguarding referral was made but no further information was recorded. No further information is available regarding this.  3.15 In December 2016, S1 was referred to the Children’s Continence Team, although there were a number of missed appointments, which were a feature of the period between December 2016 and September 2018. Records note that the reason given for a missed appointment on the 21/5/18 was that WM was “heavily pregnant and was unable to  10  attend until after the baby was born”. Concerns have also been expressed in the Learning Review as to why S1, who had presented with a history of chest pains, fatigue and blue lips, was not brought to a cardiology appointment. Whilst this referred to the period between November 2016 and November 2017, this does suggest non-compliance.  3.16 In January and February 2017, S1 sustained three bruises which were located on the wrist, arm and head. S1 did not know how the arm and wrist bruises were caused and these were observed in school. These were not reported to Children’s Services and no further action was taken.  3.17 On the 6/9/17, WM arrived late to collect the children from School and presented as under the influence of alcohol. School staff were of the view that she was not too drunk to care for the children and reported that WM was distressed due to meeting up with her father. WM had also reported that her relationship with her previous partner had just ended. Consequently, WM was asked to “get some fresh air” and return within the hour. S1 was distressed due to WM’s presentation and it was suggested to S1 that, “if frightened when back at home to call 999”.  As WM did not return to school as agreed it was proposed that school staff would meet WM on the cycle path later that evening. School staff also contacted S2’s father S2F, who attended and it was agreed, after S2F had contacted WM, that S2F would take the children for the night. S2F also expressed a concern as to how “out of it” WM appeared to be.  3.18 When WM was visited as part of the review, she reported that she had been drinking on this occasion as it had been the anniversary of a miscarriage.  3.19 A referral was then made to Children’s Services the following day, the 7/9/17, resulting in a Child and Family Assessment which highlighted concerns regarding WM’s mental health, challenging and violent behaviour and ”potential” alcohol and drug use. WF’s cannabis use was also referenced in terms of how this might be impacting on the children. WM also reported that the episode at school with alcohol was a “one off” incident. The case was closed to Children’s Services on the 25/10/17.  11   3.20 However, within this period, during a meeting on the 3/10/17 between WM, S2F and the Social Worker (SW1), the Social Worker recorded that WM was acting erratically, in a way that was consistent with amphetamine use. The school had also recorded at this time that there were concerns regarding WM’s presentation, that she sometimes appeared “manic or high”, but that, “she is different to other parents and assumptions can be made that has taken something”. The school records also noted that there were two previous incidents related to WM’s alcohol use, in June 2016 and July 2017, but not enough to raise concerns.  3.21 On the 29/11/17 a request for Social Work Support and a pre-birth assessment was made by midwifery to Children’s Services. This related to conflicting and inconsistent information regarding WM’s alcohol use and that there had been a history of maternal cannabis use during previous pregnancies. WM had also reported ongoing anxiety related to a previous termination, a miscarriage and the impact on her of her father’s poor mental health.  This was a precise and well written referral, clearly identifying risk which resulted in a further Child and Family Assessment recommending Child in Need planning.  Whilst WM was initially extremely resistant to further assessment visits were completed although on the 20/12/17 concerns were expressed, during a conversation with the Social Worker and the School Safeguarding Lead, that WM had been “telling professionals different stories”. This appeared to be in relation to substance misuse and it was later confirmed, in July 2018 that WM had been using cannabis until 25 weeks gestation. The case was closed on the 22/1/18, although the school expressed concerns that Social Work involvement had not continued. Within this period, on the 15/12/17, at a booking appointment for midwifery at St Mary’s hospital records also noted that “safeguarding concerns” had been identified, and that this had been referred to Children’s Services. Records noted that WM was upset about the referral and extremely agitated on the phone.  3.22 In late January 2018, concerns were expressed by school during a “Bridging the Gap” meeting regarding WM’s mental health, S1’s attendance, which had dipped to 92%, and  12  S2’s attendance and frequent lateness. “Bridging the Gap” aims to resolve issues and concerns at an earlier stage via the facilitation of discussions between Schools, Social Care and Early Help. This is provided via a regular “Clinic” based approach, which aims to develop partnership working and respond quickly to concerns where the key focus is “the right service at the right time”. Following this meeting the School were advised to share concerns with Children’s Services and the Social Worker (SW1) was e-mailed.  3.23 A self-referral had been made by WM to CGL (Change, Grow, Live) and an appointment was made for the 10/1/18, however WM did not attend. A follow up letter was sent on the 25/1/18 encouraging WM to make contact. As there was no response the case was closed on the 26/3/18.  3.24 On the 25/5/18, WM attended the GP Surgery but left without being seen, as she was called 15 minutes past her appointment time, due to complications with the previous patient. It was also reported that WM was “verbally challenging” towards the receptionist and consequently a chaperone was recommended for midwifery visits.  Records also note that there were a number of failed appointments with health professionals at this time.  3.25 On the 20/6/18 following a conversation with WM regarding S2’s behaviour in school, the school noted that WM’s approach towards S2 was inconsistent, “loving one minute and threatening to send them to their father’s the next”. It was noted that WM was having a new baby and that she was stressed. It was also noted that school decided to document the concerns rather than refer to Social Care, to avoid adding to WM’s stress.  3.26 On the 2/7/18, Child W was born at St Mary’s Hospital. Child W was born by Caesarean Section, due to foetal distress and WM reported to school on the 6/7/18 that she had been traumatised by the delivery and she had nearly lost the baby, but that she had been offered counselling to help cope. During a telephone consultation with the GP Surgery a few days later, WM reported that she had asked WF to move out, that she was stressed and that the only things that made her happy were her children.   13  3.27 On the 10/7/18 WF was reported as missing from home by his mother FM who reported that, “he was suicidal following a split from his girlfriend”. He was located by Police at a nearby water park and disclosed that he had not been taking his medication and that he also had a “cannabis addiction”. FM reported that following an argument with WM he thought he would not see his 10 day old baby again and Greater Manchester Police (GMP) consequently made a safeguarding referral. However, during a new birth visit on the 12/7/18, the Health Visitor (HV) noted that “a close bond was observed between mother and baby”, that Child W was gaining weight and was assessed as “well cared for”.  3.28 On the 16/7/18, a further referral was received by Children’s Services from FM, as WF had told his mother that he wanted to kill himself and that the relationship between himself and WM was under immense strain and was also volatile. On the 19/7/18, WM contacted the Police to have WF removed from her address following a verbal argument. No offences were disclosed by either party. On the 21/7/18 a domestic abuse incident was recorded, due to WM having ended her relationship with WF, whilst he was at her address to see Child W.  WM had reported that WF was sat with Child W in his arms, verbally abusing WM, who then took Child W from him and left her address. WF then contacted the Police, expressing concerns that WM had post-natal depression and that she was “rough” with Child W.  3.29 The following day WM again contacted GMP, as WF had again attended her address, despite being asked to leave the previous day. However, WF reported to the Police that after he had been advised to leave the property the previous day, WM had phoned him, “begging him to come back”, which he did. WF reported that they then spent the evening together before WM demanded that he leave the property in the morning. WF reported that he told WM that he could not cope with her mood swings, to which WM told him to “go and kill himself”. WF was located, found to be in possession of a bag of cannabis and detained at hospital under S136 of the Mental Health Act. It was also noted that there was difficulty in ascertaining who the victim was, due to both parties “potential mental health issues”. WF was assessed by the Mental Health Service and discharged home.   14  3.30 It is also recorded that WF had attended Accident and Emergency on the 23/7/18, presenting with a superficial abrasion to his face and head and an open wound to his right hand and right knee. WF reported that a glass light fitting had fallen on his head and there were no indicators of domestic abuse.  3.31 Police information however noted that WM had reported that WF was, “smashing the house up and would not leave”, consequently Police attended and removed WF. WM also disclosed that she had been assaulted by WF “three days ago” which she had not reported and was in respect of cannabis. WM alleged that WF had “punched her in the back causing a small bruise”.  3.32 Whilst WM refused support from Children’s Services and would not attend Court. WF was arrested for the assault but was intoxicated at the time. WF’s father was also in attendance as an Appropriate Adult, due to concerns raised by FM that WF had been “diagnosed with Autism and ADHD, that he was suicidal and that he was suffering with PTSD”.  When interviewed, WF denied the assault, citing self-defence and that he had been the victim of numerous unreported assaults by WM, including a broken nose in January 2018. WM reported that on the 25/7/18, WM had threatened not to name him on W’s birth certificate “unless he returned home”. WF reported that during the night an argument then occurred over him making too much noise and WM had attacked him and that consequently during this, he “caught WM on the side of the ribs in self-defence”. WF also reported that on the 22/7/18, WM had “thrown a mirror at him”. Due to the absence of any independent witnesses no further action was deemed appropriate by the CPS.  3.33 On the 28/7/18, Children’s Services received Police information confirming that there had been 5 domestic incident reports over three weeks. Whilst a further Child and Family Assessment was initiated, no Strategy discussion or Section 47 Enquires had taken place. In addition, no immediate action was taken to safeguard the children and there is no evidence that a Child Protection Conference was considered. Records note that WF was bailed until the 25/8/18 not to attend WM’s address. Following WF’s release from custody with bail conditions, the matter continued to be investigated and a prosecution file was  15  submitted to the Crown Prosecution Service (CPS). However the CPS made a decision not to charge WF as there was insufficient evidence. WF was then advised of the decision and bail cancelled. In addition, whilst the case was being managed on a CIN basis, there was only one CIN Meeting, which was held on the 23/7/18, which suggests that CIN processes were not sufficiently robust.  3.34 On the 7/8/18, an e-mail from a Community Midwife to the HV reported that WM had denied domestic abuse in the relationship, but reported that WF was argumentative. During a HV appointment on the 13/8/18, an assessment of WM’s mood for Post Natal Depression “did not show any issues”. It was reported by WM that “the parents had now separated”.  3.35 On the 31/8/18, a 3rd party reported to the Police (GMP) that “he could hear screaming” from WM’s address and “a female shouting for the Police”. Police attended and WM reported that WF had forced entry to her bedroom and “slapped her twice on the face causing swelling on her lip”. WM reported that WF then threw step ladders at her as she ran down the stairs. WM also reported that she ran out of the house, called for help and shouted for someone to call the Police although WF then threw her against the stairs. However, WM declined to make a statement and said that she was going to move back to Blackpool to be nearer her mother. It was noted that Child W, only two months old at the time, was present during the incident, although both S1 and S2 were away on holiday.  3.36 On the 1/9/18 GMP completed a Multi-Agency Risk Assessment Conference (MARAC) referral due to the severity of the incident, as WM had sustained injuries resulting in a swollen lip, bruising to the wrist and pain to the back.  3.37 A referral was made to Children’s Services, a Strategy Meeting was arranged for the 7/9/18 and joint Section 47 Enquiries were initiated. WF was arrested although a “no comment” interview was provided. The Section 47 Enquiry recommended that an Initial Child Protection Conference (ICPC) be convened for all three children and a referral was received for an ICPC on the 11/9/18 by the Manchester Safeguarding and Improvement Unit (SIU). The concerns noted were the volatile relationship between WM and WF, the  16  number of Police call outs where Child W was present and WF’s alcohol and criminal history.  3.38 On the 6/9/18 the Independent Domestic Violence Advocate (IDVA) received the referral for MARAC. This service works with cases that are deemed to be at high risk of serious harm or homicide that have been referred to the MARAC. Support and advice are offered to victims of abuse and children, aiming to reduce risk and increase safety. However, there was a 5 day gap between the incident and the receipt of the MARAC referral by the IDVA.  3.39 On the 19/9/18 the case was heard at the MARAC and it was agreed that the SW would discuss with WM if support was required from the IDVA, including assistance regarding an application for a non-molestation Order. However, there was an 11 day gap between the incident and the IDVA’s first attempt to call WM. On the 21/9/18 the case was closed to the IDVA, as WM indicated that she did not want any further support.  3.40 On the 7/9/18 the HV requested an update from the SW regarding the ICPC, as it was apparent that WF was staying over at WM’s address. The HV noted that there have been 4-5 incidents in 9 weeks which were, “the length of W’s short life so far”. The elder children had also indicated that they would prefer WF not to be at the house, due him being argumentative.  3.41 On the 10/9/18 Child W was seen at the Baby Clinic with WM. It was noted that Child W was appropriately dressed and that there was evidence of a good attachment. WM reported that despite the concerns regarding domestic abuse, she did not want to apply for a non-molestation Order in case WF breached it, which meant that he would go to prison. On the same date, WM reported to the GP Surgery that whilst the Local Authority were involved, there was no threat to herself, either physically or verbally.  3.42 The Child in Need (CIN) Meeting scheduled for the 14/9/18 was then cancelled as safeguarding procedures had been invoked.   17  3.43 On the 24/9/18 an ICPC was held. All three children were made subject to CP Plans under the category of neglect. The outline plan specified that WF was not to visit WM’s address and that if he did, WM was not to let him in and to call the Police. The GP report for the Initial CP Conference did not reference domestic abuse.  3.44 On the 1/10/18, WM contacted GMP to report that WF was at her address stealing her belongings. WM was not at her address at the time of the call, however when officers attended the address there was no sign of WF or of any forced entry. Whilst GMP completed a MARAC referral for a repeat incident, it was noted that there was no evidence that WF had been at WM’s address.  3.45 During a home visit by the HV on the 9/10/18, it was observed that Child W was calm, interacting well and sleeping independently. WM confirmed that her relationship with WF had ended and that she was now feeling much better, although GP records noted that there were no records of primary immunisations for Child W.  3.46 On the 22/10/18 the case was allocated to the IDVA. There was a 13 day gap between receiving the referral and allocation. On the 26/10/18, four days following allocation, the IDVA attempted to contact WM. This was unsuccessful as the call just “rang out”.  3.47 On the 27/10/18, a 3rd party reported to GMP that WM had run to their address stating that she had been assaulted by WF. This incident followed WF and WM having spent the day together, although WM had become angry with WF as he was going to work the following day and was not spending time with W. WM reported that WF had picked up a vase and had attempted to hit her with it, and then kicked WM twice, whilst she attempted to leave the room and as she was carrying Child W. WM reported that she went upstairs, picked up S2, managed to get past WF and then ran to her neighbour’s house who called the Police.  3.48 WF had also sustained a wound to his chest, which he reported had been caused by WM as she attacked him with a bottle. WF reported that WM had fabricated the allegation that he had assaulted her, although WM reported that WF had stabbed himself with a  18  shard of glass. As WM had left the address and had recently reported 2 domestic abuse incidents, she was treated as the victim. Due to counter allegations and no independent witnesses to the assault the CPS made a decision not to charge.  3.49 WF had also made an emergency 999 call reporting that he had “been bottled”. The call taker noted that WF appeared to be intoxicated and consequently a safeguarding concern was raised for the children. However, whilst at hospital, WF provided his home address, which was not Child W’s address and Child W’s date of birth was recorded incorrectly. WF was also unwilling to provide further details and whilst indicating that he had a partner at home with children, including Child W, WF reported that he was “afraid of breaking up the family”.  This was followed up by the MFT Safeguarding Nurse on the first working day following the incident, who attempted to locate the children via a comprehensive system check. This was unsuccessful as inaccurate and limited information had been provided by WF. Again, on the 5/11/18 the same nurse made a further attempt to identify the partner of WF and Child W and contacted WF’s GP. This was a different GP based in Trafford and on the basis of the information reported by WF, the children could not be identified. Consequently, it was agreed that no further action would be taken. A risk assessment was completed and submitted to MARAC noting the concerns regarding domestic abuse and details were provided to WF regarding a men’s “advice line”. This was good practice and the Safeguarding Nurse made more than one attempt to locate the children based on the address, date of birth and GP details provided.  3.50 However, whilst Child W was subject to a Child Protection Plan, no Strategy or legal planning meeting took place, which would have considered the immediate safety of the children.  3.51 Whilst the IDVA made eventually made contact with WM on the 29/10/18, there was some confusion as to the identity of the primary victim in the relationship. On the 29/10/18 the IDVA agreed to call WM back on the following day. However this was unsuccessful.   19  3.52 On the 29/10/18, WM reported to school that WF was the perpetrator of the assault and that the police had confirmed that WF’s wound was self-inflicted, although GMP had no evidence that this was the case. The CPS reported that both the accounts of WF and WM were plausible, but as there was no CCTV or witnesses and because the scene was consistent with both versions, it would be difficult to prove beyond reasonable doubt. However, WM reported that S2 had also witnessed the incident, including a threat from WF to “kick her face in”. WM also reported to school that the SW had agreed that WF could be allowed back in the house. On the 29/10/18, WF also reported to the GP that she “had not let WF near the children”.  3.53 On the 30/10/18, a Core Group was held, where a number of concerns were discussed, particularly that a core element of the Child Protection (CP) Plan had been breached. It was confirmed that WF would not be having any contact with Child W until a risk assessment had been completed.  3.54 On the 5/11/18 (Monday) S2’s father, S2F, contacted Children’s Services to report that S2 had told him that WM had stayed at WF’s address on the Friday evening (2/11/18) and looked after S2 on Saturday (3/11/18). The SW visited S2 in school and whilst S2 denied that WF had been at the family home (and that S1 looked after him and Child W), S2 then subsequently told school staff that they had seen WF, but only for a few minutes. It was also noted that S2 was unsettled in class and was complaining of various illnesses.  3.55 On the 7/11/18 the SW2 reported to the IDVA that the case was being taken to a Legal Gateway Panel. The SW reported that WM had become very upset at hearing this, and stated that that “if her children were removed she would kill herself”.  3.56 On the 9/11/18, a report from the Psychological Wellbeing Service (PWS) noted that the SW had been called who then informed the PWS that “WM is quick to lose her temper, often with partners and around the children”. The SW confirmed that “two weeks ago WM had a very physical altercation with her partner in front of the children”.   20  3.57 The SW reported that legal advice was being sought regarding the children, but that there was a concern that WM would self-harm if the children were “taken off her”. Consequently, WM was assessed by PWS and it was concluded that there were “no self-harm thoughts or thoughts of harming others”. However, whilst WM was assessed as not having any risks, she told the PWS that, “this will change if the children are taken off her”.  3.58 On the 14/11/18 paramedics were called to WM’s home address due to reports from WM that Child W was convulsing and had stopped breathing. Child W was revived by paramedics at the scene and admitted to hospital. Shortly after admission and following further examination, it was suspected that Child W had suffered a non-accidental injury, consistent with being shaken. Following completion of the MRI Scan on the 15/11/8 it was concluded that Child W had suffered subdural bleeding, consistent with being shaken without an impact.     4. Analysis of Practice   4.1 The analysis of the practice is informed by the written agency records, the reflections of practitioners who had direct involvement with Child W and the key adults around the child, the experience and local knowledge of the members of the SCR review panel and the lead reviewer’s independent contribution.   4.2 Prior to September 2017 there was a significant although not extensive history of agency involvement with WM which dated back to 2009 including WM being a victim of domestic violence and having been a Looked After Young Person.  4.3 Concerns were also recorded from this time regarding WM’s mental health and this is referenced following the complaints that WM had made regarding nuisance behaviour in December 2013. In 2015 a referral was made to the Local Authority in respect of  21  WM’s mental health, which included suicidal ideation, and her challenging and potentially violent behaviour.   4.4 In December 2014 concerns had already been raised regarding the vulnerability of S1, a number of missed health appointments for S1 and the housing situation, which resulted in a professionals meeting at the school, although there is no further information regarding this. Missed health appointments for S1 are also a consistent feature between 2016 and 2018.   4.5 These elements suggest that WM was struggling to parent and that there had been a number of adverse experiences during her earlier years. It has been difficult for the review to precisely identify the nature of any early help that was offered during this time, although there were three referrals to Children’s Services in 2015 and 2016 which resulted in no further action, or assessment followed by case closure.  4.6 The incident at school which took place in September 2017, whilst resulting in a referral to Children’s Services the following day, suggested concerns relating to both WM’s mental health and alcohol use. The case was closed 6 weeks later in October 2017, although a further referral was made by midwifery in November 2017 due to WM reporting regarding alcohol use during pregnancy which contradicted previous disclosures. Whilst this referral was both comprehensive and timely, the case was again closed in January 2018 despite concerns regarding S2’s attendance at school and frequent lateness, that WM had been “telling different people different stories”, further safeguarding concerns being raised by midwifery in December 2017 and WM’s resistance to interventions. By this time WM was now pregnant with Child W, which was an indicator that interventions should have continued.  4.7 Of particular concern is the observation made in October 2017, by the Social Worker (SW1), where WM’s presentation is noted to be consistent with amphetamine use, although this matter is not pursued.   22  4.8 Following the birth of Child W in July 2018 there were a number of incidents which warrant further analysis. The volatility of the relationship between WM and Child W’s father WF is particularly evident during this time and there were at least two occasions where WF was distressed and had indicated suicidal ideation. This does not appear to have triggered an assessment of the family’s circumstances, and in particular the impact of WF’s presentation and mental health on the children, which, given the history would have been appropriate. Previous concerns regarding WF’s anger management, cannabis use, poor impulse control and his possession of weapons are also referenced at this time. Consequently, it was noted that there was an ongoing concern for the safety of WM and the children and whilst there is reference to a Strategy Meeting in the Police records, it is unclear as to whether any assessment then took place by Children’s Services.  4.9 By late July 2018 there had also been two further domestic abuse incidents which had taken place at WM’s address and which had involved both WM and WF, whilst Child W was present. Whilst this initiated a fresh assessment, no Strategy discussion leading to any Section 47 Enquiries took place, which would have been entirely appropriate, particularly given that Child W was less than a month old at this time and was extremely vulnerable.  Given the previous referral history, the concerns regarding alcohol and cannabis use, WM’s resistant, volatile and challenging behaviours and lack of engagement, the concerns regarding WF’s mental health and the level of domestic abuse already taking place within the family home, this would have been an opportune moment to undertake robust safeguarding enquiries and to holistically assess the family’s circumstances.   4.10 Whilst WF had been bailed until the 25/8/18 with conditions not to attend WM’s address and files were submitted to the CPS, the CPS were of the view that there was insufficient evidence to agree a charge. Whilst consideration was given to an investigation under the Serious Crime Act 2015 regarding controlling or coercive behaviour in a family relationship, information from FM and a friend of WF suggested, even at this point, that this was not the case.    23  4.11 Four of the incidents reported in July 2018 were not reviewed by GMP until the 28/7/18 and referred to Children’s Services on the same day. The triage unit had a considerable number of medium risk domestic abuse incidents requiring review during this period which accounted for the number of days taken to process the incidents. In that respect there was clearly a capacity issue although officers had recognised the need for these incidents to be referred to Children’s Services, which under a revised protocol would now ensure that incidents are referred immediately to the MASH. In July 2019 GMP introduced a new IT system (IOPS). This requires the attending officer to submit a care plan to the MASH at the time the incident is updated.  Incidents in all three Manchester Divisional Safeguarding Teams (DSTs) are now discussed as Domestic Abuse Child Concern (DACC) Meetings.  4.12 It has also been very difficult for the review to specify the nature and robustness of any Child in Need (CIN) planning during the period up to July 2018, both in terms of the frequency of meetings and the quality of any CIN plan. In that sense it has also been difficult to see how any previous interventions or concerns, which have been referred to earlier and which resulted in either no further action or case closure, had impacted on the assessment and planning within the review period. It was evident that there had been several child and family assessments which had been completed to address referrals from professionals, family members and the wider public and that there had been ten referrals made to Children’s Services from June 2014 up to the incident on the 31/8/18 which triggered Section 47 Enquiries and the convening of the ICPC. Whilst four of these referrals took place prior to September 2017, the start point for the terms of reference of the review, this information provided a historical and contextual base in which to understand and respond to the more recent concerns and would therefore have enabled a more holistic overview and analysis. As referenced earlier there was just one CIN meeting held, on the 23/7/18, which suggests that processes were not sufficiently robust. However, information was provided to the review which indicated that a more rigorous approach is now taken with CIN planning and review and that CIN meetings must now take place within 20 days of initial contact where an a decision to assess has been made.   24  4.13 The high gravity domestic abuse incident which took place at the end of August 2018 resulted in a referral to children’s services, a Strategy Meeting and joint Section 47 Enquiries being initiated. An ICPC was arranged for the 24/9/18, however the review has not been able to confirm that a safety plan or risk management plan was implemented prior to the Conference, which took place nearly 4 weeks after the incident. This is concerning as the HV had reported in early September 2018 that WF was continuing to stay at WM’s address. The only reference to any pre-conference activity was the cancellation of a Child in Need Meeting on the 14/9/18, due to the implementation of Child Protection procedures.   4.14 Whilst a MARAC referral had been completed on the 1/9/18, there were delays in both the time between the date of the incident and receipt of the referral (5 days) and the date of the incident and the IDVA’s first attempt to contact WM (11 days). This is outside the 48 hours recommended by Safe Lives although information provided at the Practitioners Event suggested that capacity issues within the service had impacted on the timeliness of responses. Had the IDVA contacted WM within this timeframe, it may have resulted in further action to minimise any risks. However, this is speculative, particularly given the information which suggested that WM was resistant to interventions and was complicit in a manipulative dynamic regarding WF.  4.15 Whilst the case was heard on the 19/9/18 and again on the 14/11/18, the date of the incident, both of these noted WM as the victim and WF as the perpetrator. After the date of the non-accidental injury to Child W, there were three MARAC hearings and all but one referenced WF as the perpetrator and WM as the victim. This had been a feature of the case during the review period even though there was information to suggest that WM was complicit in initiating at least some of the violent exchanges. This is reflected in the fact that it was WF who had attended Accident and Emergency following the domestic abuse incidents. As WF was not present at Conference this limited the ability of Conference to explore this matter further and the assumption remained that WF was the perpetrator of any domestic abuse.    25  4.16 Information provided to the review by WF’s mother FM, and which is also contained in Police records, suggest that WF was “thrown out” by WM on several occasions but then was accused of being a “bad father for leaving” and that WM then insisted that he return. FM reported to the review that her son was struggling with this dynamic in the relationship before Child W was born and that WM’s behaviour in this respect was both manipulative and coercive. Health Professionals from the Extended Service also reported that on one occasion WF received at least 50 text messages from WM during an appointment, which WF struggled to manage and respond to.  4.17 Whilst WM had reported that WF’s parents were supportive of her, this view was challenged by FM, who reported that WM was controlling and manipulative. Whilst FM had arrived at Conference, WM had refused to allow FM to attend. FM reported to the Review that she had not participated in any meetings other than having had a conversation with the Chair of the ICPC, prior to Conference. FM reported that WF was “manipulated” into not going to meetings by WM.   4.18 FM reported that WF had been diagnosed with Attention Deficit Hyperactivity Disorder and had “autistic traits” and that he found WM’s behaviours particularly distressing, but was perceived by professionals as being aggressive and challenging. This will have further reinforced the prevailing view that it was WF who was the sole perpetrator of any domestic abuse.   4.19 The Child and Family Assessment undertaken for Conference does not consider these issues, particularly as WF’s mental health was impacting on his presentation which was also described by both WM and S1 as very aggressive. Nor does it consider WM’s volatility, erratic behaviour, alcohol use or possible drug use, the daily lived experience of the children and consequently these elements are not addressed in any depth. The assessment also relies heavily on self-reporting, particularly from WM and does not take into consideration the family history referenced earlier or any Child Impact Chronology, particularly given the episodes referred to above.    26  4.20 Information provided to the Practitioners Event suggested that both S1F and S2F, the fathers of S2 and S1, were frightened of WM and that this had impacted on dynamics within the family and arrangements regarding contact with the other children. This was not considered as part of the assessment provided to the ICPC and whilst S2F was present at Conference, in a capacity to support WM, this was an issue that could have benefitted from further exploration.  4.21 The GP was not consulted with regarding the assessment and did not attend the Initial Conference, which is a significant omission, particularly given that the GP had information regarding the number of “was not brought appointments” which included important appointments to see a cardiologist and an ophthalmologist.  There was also a GP history of mental health difficulties, anxiety, panic episodes, low mood, aggressive and challenging behaviours and self-harm.  Importantly, there had been disclosures by WM that she had been violent towards previous partners and that this had included WF. Of particular concern was information provided to the GP which suggested that in 2016 WM had assaulted a previous partner and that the matter had been placed before the Court. Given the critical importance of GPs as “lynchpins” in families, which is acknowledged in NSPCC thematic review findings (Learning from Case Review Findings, 2018), the lack of involvement of the GP in the assessment, planning and Conference process is a significant omission.  4.22 The GP learning review also acknowledged that the “Think Family” perspective, which considers family context and in particular the lived experience of the children, could have been considered more broadly and may have led to earlier progression and referral. The GP had considerable information regarding WM’s difficulties regarding relationships, anxiety, mood swings around the children, anger management and missed appointments. However, it is not clear whether referrals were made to Early Help or to the MASH. The GP was also of the view that fundamentally, WM was a protective mother, who presented well and would respond vociferously to any criticism regarding her care of the children. In that sense therefore the involvement of the GP in the assessment, planning and Conference process would have provided additional and critical information regarding WM’s behaviours and presentation.   27   4.23 Similarly, the Extended Service, which was providing interventions for WF regarding ADHD, was not invited to Conference or consulted with as part of the assessment. This would have provided valuable insight regarding WF’s functioning, particularly when under stress and would have facilitated a more robust analysis of parental and family dynamics. In that sense there was a failure to properly assess and consider how WF’s needs and vulnerabilities were impacting on his parenting abilities, which was further compounded by a poor analysis of the domestic abuse dynamic.  4.24 One Manchester Housing, which had considerable involvement with WM regarding tenancies and a number of complaints, was not invited to attend conference or involved in any previous assessment, which would have provided relevant information regarding WM’s non-engagement, non-compliance and erratic and threatening behaviours. Information regarding WM’s patterns of behaviour particularly regarding her allegations of anti-social behaviour in the neighbourhood, often made after concerns had been raised regarding WM’s parenting or behaviour, would have been valuable. One Manchester Housing had been unaware of the non-accidental injury to Child W until attending the first SCR Meeting in September 2019.  4.25 The category of planning, whilst noted as a primary concern in respect of neglect, was not appropriate, as given the issue regarding high gravity domestic abuse and the age of Child W, it would have been more appropriate to reference the risk of physical and emotional harm.  4.26 Whilst the CP Plan specified that WF was not to visit WM’s address a further high gravity domestic abuse incident took place on the 27/10/18. This occurred at the weekend during the early hours of the morning. However, whilst four referrals were received by the Contact Centre from various agencies regarding this incident, the information was not passed to the Emergency Duty Service (EDS), which was a significant omission. The rationale for this appears to be based on the fact that as WM remained at home and WF was taken to hospital there was therefore no risk to Child  28  W. The assumption was therefore made that there was no need to refer into the EDS. In all cases the information was passed directly to Central Court and Locality Team 3, to provide a response during core business hours.  4.27 This information should have been communicated to the EDS by the Contact Centre, as a matter of urgency, particularly given that all the children were at this time subject to Child Protection Plans and a key requirement of the plan had been breached. None of the contacts were appropriately reviewed or provided with sufficient oversight and consequently no consideration took place to ascertain whether further or immediate enquiries were necessary to ensure that Child W or the other children were adequately protected, or what further action was required. This is a critical juncture in Child W’s history and suggests that a more robust approach was required at this point.  4.28 Consequently the only involvement that the EDS had in respect of Child W was in November, on the date of the non-accidental injury. However, it must also be noted that WF had previously refused to provide Child W’s name, address and correct birth date to the hospital which inhibited the ability of the hospital to correctly identify any of the children, who were all at this point subject to Child Protection Plans.   4.29 Whilst this breaching of the plan was discussed at a Core Group on the 30/10/18 and a further stipulation made that WF would not be having any further contact with Child W until a risk assessment had been completed, further information from S2, via a referral by S2’s father, also suggested that WF had been at the family home during the first few days of November 2018. At the time of the injury to Child W, Child W was still residing at the family home with WM. Whilst it had been agreed that a Legal Gateway Meeting was to be convened, and this had been communicated to the IDVA by the SW (SW2) on the 7/11/18, there had already been a period of eleven days since the date of the domestic abuse incident on the 27/10/18. Information provided to the review indicated that a referral had been made to the Legal Gateway Panel, but that following oversight by a manager, this required further work which resulted in a delay. Again, this is a critical juncture in Child W’s history and whilst WM had indicated that she  29  would end her life if the children were removed, which would have understandably created some reticence regarding professional responses, a more timely and robust arrangement was necessary.    5. Learning from the Review   The terms of reference for the review are specifically addressed below from which the key findings are drawn.      5.1 Key Line of Enquiry 1  Review the approach to domestic abuse and how needs were assessed and met from the perspective of victim, perpetrator and child.  5.1.1 In recent years there has been an increasing recognition of the costs of domestic abuse in society. The cost to children was recognised by the amendment to the definition of significant harm in Section 31(9) Children Act 1989 in 2002 to include the “impairment suffered from seeing or hearing the ill treatment of another”.  A holistic approach to domestic abuse requires services to address three core elements, a programme to work with perpetrators, a programme of support for victims and access to expert risk assessment for those affected by domestic abuse.   5.1.2 This review has evidenced that these services are in place in Manchester and able to respond in collaborative manner to the needs of a whole family. This is particularly evident in the “Safe and Together” approach which was implemented in October 2017 and which emphasises keeping children safe, partnering with the non-abusing parent and undertaking focussed interventions with the perpetrator. It has also been proposed that a “Safe and Together” Clinic takes place which provides an opportunity for discussing complex cases.   30  5.1.3 However, there were key factors that obstructed a clearer analysis of the abusive dynamic in the relationship between Child W’s mother and father.  This was primarily, but not exclusively, a reliance that WF was the perpetrator and that WM was the non-abusive parent, exacerbated by WF’s presentation which was often challenging, due to the complexity of his needs. This perspective was also reinforced by agency perceptions of WM, particularly the school and the GP, which suggested that WM presented well and had her children’s best interests at heart.  5.1.4 The domestic abuse incidents, notably during July, August and October 2018 were characterised by allegations, made against WF by WM, and then counter allegations, made by WF against WM, which impeded the possibility of any prosecution. There does not appear to have been any referral of WF to a perpetrator programme or further support systems. WF reported to the review that he had not received any help or support during this time.  5.1.5 As described earlier in this report, strenuous attempts were made by the MFT Safeguarding Nurse to identify Child W, S1 and S2. However this was unsuccessful as limited and inaccurate information had been provided by WF.  5.1.6  Whilst WM was referred to the IDVA, this service was not taken up, although a lack of clarity regarding the identity of the perpetrator and victim resulted in a delay in the initial contact with WM.  There was also a lack of oversight and a proper consideration of WF as a victim. Whilst this was exacerbated by capacity issues within the service, management oversight and audit arrangements have now been strengthened to ensure a more accurate identification of the origin of any risk and to ensure a more timely response. It has also been proposed that Women’s Aid will attend the DACC meetings from March 2020.  5.1.7 The lack of family history in the Child and Family Assessment to the ICPC in September 2018, including the number of previous referrals and assessments, was also a critical  31  omission as this suggested that there were concerns regarding WM’s violent and challenging behaviours as early as 2015 and 2016. The contributions of the fathers of S1 and S2, who were frightened of WM, are also missing and would have provided a more holistic perspective regarding WM’s behaviours.  5.1.8 The lack of attendance, not only at the ICPC, but also at any previous multi agency meetings by the GP, One Manchester Housing and the Extended Service precluded a clearer analysis of the complexity of the dynamic between the parents and the way in which this was impacting on not just Child W, but also on S1 and S2. This inhibited a clearer evaluation of the risks to Child W which was reinforced by a lack of child impact chronology and an over reliance on self-reporting from WM. This rather “skewed” analysis of the family circumstances contributed towards a category of plan that was therefore inaccurate. The GP had provided a comprehensive report to the ICPC although the issue of attendance needs to be considered in the context of busy GP schedules. It has been confirmed to this review that GPs have practice diary space, which can now be utilised to discuss concerns with Child Protection Conference chairs and Social Workers. In this respect the Practice Manager is key in securing discussion/meeting time and ongoing work has been undertaken to develop greater collaborative working with GPs, whether in face to face meetings or via telephone liaison.  5.1.9 The attendance at hospital by WF on the 27/7/18 with glass injuries to his head, knee and hand resulting from a domestic abuse incident, did not result in a domestic abuse response, which may well have been triggered if the victim had been female. As a result of this review, a review of training and development packages regarding male victims of domestic abuse is now taking place within the Manchester University Hospitals Foundation Trust (MFT).  5.1.10 Importantly, the domestic abuse incidents which took place in July 2018, did not result in any consideration regarding a multi-agency Strategy Meeting, or discussion and a possible Section 47 Enquiry. This was a significant omission, particularly given Child  32  W’s vulnerability and whilst the reasons for this are unclear, given the prevailing assumptions regarding WM as the non-abusive parent in the relationship, it is likely that there was a rule of optimism in play (Dingwall, Eckellar and Murray, 1983). This is a tendency towards rationalisation and under responsiveness in certain situations, where practitioners focus on strengths, rationalise evidence to the contrary and interpret data in the light of this optimistic view. Participation is thus often viewed as co-operation. However it is critical to understand that practitioners work within contexts in which difficult decisions have to be made on the basis of imperfect, limited and fragmented information (Dingwall, 2013, The Rule of Optimism 30 years on).  5.1.11 This is particularly evident in the records made by the school regarding WM which noted that WM “can act inappropriately at school and makes her own set of rules, we do treat her differently but this due to her being her”.  5.1.12 The domestic abuse incident which took place during October 2018 and which did not result in a referral to the EDS from the Contact Centre is a significant concern. This suggests that arrangements will need to be made for a more robust overview of decision making, regarding appropriate “routing”, particularly those contacts where domestic abuse is a feature.  5.1.13 The lack of information regarding the daily lived experience of the half sibling children S1 and S2, with particular reference to their views, wishes and feelings, also precluded the ability of the professional partnership to understand the impact of WF and WM’s violent relationship on their day to day lives. Ascertaining and understanding the narrative of children and young people, particularly as it relates to domestic abuse, is critical in shaping any planning and interventions and providing effective risk management.   Learning Opportunity  33  ● That any previous family and agency history, including any previous assessments, are always taken into consideration when undertaking planning and interventions. ● That domestic abuse referrals, especially involving new born children, are always subject to multi agency Strategy Meetings or discussions, and that Section 47 Enquiries are always considered. ● That parental self-reporting is subject to evidence based triangulation to enable accurate analysis of parental and family dynamics. ● That all relevant agencies, including GPs, Housing and Adult Mental Health Services are consulted with as a matter of course in the assessment and planning process. ● That all relevant agencies, including GPs, Housing and Adult Mental Health services are invited to any multi-agency planning meetings including Child Protection Conferences ● That child impact chronologies are provided to understand the daily lived experience of children and that the views, wishes and feelings of children are critical to effective interventions. ● That arrangements in the Contact Centre are reviewed to enable appropriate oversight and decision making. ● That Child in Need processes regarding case closure are subject to multi-agency consensus   5.2 Key Line of Enquiry 2  To what extent did assessments follow a strengths based model and consider the approach to building resilience within the family unit.  5.2.1 A strengths based approach focuses on identifying the strengths or assets, as well as the needs and difficulties of children and families. It is this asset based approach which enables families to appreciate that their strengths are being recognised but also that risks are being addressed in a fair and “non-judgmental” manner. It includes an acknowledgment of “signs of safety” and essentially views parents and carers as resourceful and resilient in the face of adversity (A Strengths Based Approach to Child Protection, BASW 2015).  34   5.2.2 It has not been possible to interview the Social Workers involved with Child W’s case as both have now left the Authority. However, the Child and Family Assessment provided to the ICPC relied extensively on self-reporting from WM and there was a deficit of external evidence and information from partner agencies. This was reinforced by the absence of key agencies at the ICPC such as the GP, the Extended Service and One Housing. There was no thoughtful consideration of family history or chronology in the assessment which would have allowed a more incisive analysis of family functioning and a more evidence based analysis of the family’s strengths. Key concerns noted in the chronology regarding WM’s volatility, erratic behaviour and alcohol use are not addressed in any depth, so it was not even possible to provide a holistic and accurate picture of the family’s functioning and wider context.  5.2.3 The ICPC was described at the Practitioners event as positive, although this will have been reinforced by WF’s non-attendance, WM’s refusal to allow FM into the Conference and the non-attendance of agencies who had critical information. The weak assessment and analysis will also have contributed towards an incomplete view of the family’s circumstances, which in turn led to an inaccurate category regarding the Child Protection Plan.  5.2.4 There was insufficient consideration given to the views of S1 and S2’s fathers in assessment, particularly as information was provided by external agencies that both fathers were fearful of WM and that their contact with the children would be affected if WM’s wishes were not complied with. This lack of consideration regarding wider family systems contributed to a lack of clarity in respect of external support systems for WM.  5.2.5 The review could not identify any assessment, including the assessment to the ICPC, which explored in any depth the adverse childhood experiences (ACEs) that WM had experienced as young person. This included at least one period as a Looked after Young Person, previous domestic abuse and significant grief and loss. Whilst these  35  incidents were outside the timeframe for the review they are helpful in understanding a “trauma informed” approach to assessment, practice and intervention. Research has indicated that there is a close relationship between ACEs and poor mental and behavioural health, including a propensity towards violence. Sustained or prolonged exposure to stressful or traumatic circumstances without the buffering care of a supportive adult can also impact on neurological functioning, impulse control, contributing towards a defensive and “offensive” positioning and posture. It is therefore important to use protective factors to build resilience, develop secure attachments, maximise and create opportunities for positive activities and build supportive networks ( Vincent Felitti, “The Relation between Adverse Childhood Experiences and Adult Health: Turning Gold into Lead”, 2002).  A trauma informed approach to assessment and intervention has been successfully piloted in a district of Manchester and ACE awareness and training is now being developed and provided across the wider Manchester area. However, success will often depend on consistent relationships between Service Users and professionals and will be impeded by constant changes in workers, due to thresholds or staff turnover.  5.2.6 There is no in depth analysis of WF’s mental health, the way that complex needs were impacting on presentation and the way in which episodes of mental health deterioration, particularly in July 2018, just after Child W was born, were impacting on the wider tasks of safe parenting and relationship management.  This was critical in understanding and acknowledging WF’s strengths as a father as there was information presented to the review from health professionals, that WF wanted to care for both WM and Child W and that WF was genuinely delighted that he was a new father.   Learning Opportunity ● That when Adverse experiences in Childhood have been identified, a trauma informed approach to assessment, incorporating a strengths based methodology, can be invaluable  36  ● That training and development across the multi-agency partnership, regarding trauma informed approaches, are invaluable in embedding a strengths based approach ● That all relevant agencies are involved in assessment and planning, particularly adult mental health and support services. ● That wider family members are routinely consulted in assessment and planning, to assist the development of more robust support systems and networks.    5.3 Key Line of Enquiry 3  To what extent was the presence of drugs and alcohol and mental health factored into the assessment and planning?  5.3.1 The relationship between substance misuse, mental health and child safety is well documented and research has provided a strong correlation between parental substance misuse, poor mental health and domestic abuse. The potential for parenting capacity to be undermined and children’s health and development to be harmed is considerable (Cleaver et al, 2011 “Children’s Needs, Parenting Capacity. The Impact of Parental Mental Illness, Problem Alcohol and Drug Use and Domestic Violence on Children’s Safety”, DfE), (Horgan 2011, “Parental Substance Misuse. Addressing its Impact on Children, National Advisory Committee on Drugs”). If children are exposed to parental substance misuse and other risk factors such as poor mental health and domestic abuse, there is also an increased likelihood that they will also display similar symptoms in later life (Velleman 1993, “Alcohol and Drug Related Problems and the Family”, Institute of Alcohol Studies).  5.3.2 Concerns regarding WM’s alcohol use and mental health were raised by S1’s father as early as November 2015, via a referral to Children’s Services. Whilst further  37  assessment was recommended, the case was closed following a management decision that the threshold for Social Work intervention had not been reached and services could be provided by the school under the auspices of an Early Help Plan.  5.3.3 The incident at school in September 2017 suggested that alcohol misuse was a concern and a referral was made to Children’s Services the following day which resulted in an assessment. S2’s father had also expressed a concern as to how “out of it” WM appeared to be at the time although WM reported that this was a “one off incident” and the case was closed at the end of October 2017. This was despite observations by the Social Worker, made earlier in October that WM was acting erratically, in a way that was consistent with amphetamine use. The school also reported that WM had “appeared to have taken something which made her high” but also stated that WM’s presentation is “different to other parents and assumptions may be made that she is on/taken something”. School also reported that there had been two previous incidents when WM had appeared under the influence of alcohol. Information from the practitioner’s event suggested that drug and alcohol use were “mentioned regularly” at this time.  5.3.4 The timely referral by the midwife in November 2017, a month after the case had been closed, also suggested that ongoing alcohol and cannabis use was a concern and that WM’s poor mental health, due to significant loss and her relationship with her father, was also evident in episodes of panic and anxiety. Whilst a further assessment was undertaken, the case was again closed in January 2018. School were also raising further concerns regarding WM’s mental health In January 2018 and by June 2018 these concerns remained, although it is noted that the school did not refer to Children’s Services to avoid increasing any stress to WM.  5.3.5 The relationship between cannabis use and poor mental health and psychosis is well documented (Royal College of Psychiatrists, 2017). The incidents in July 2018 indicated that WF “had a cannabis addiction”, which is supported by information held by the Mental Health Team as early as February 2017 and which suggested that WF was using significant amounts of alcohol and cannabis, on a daily basis and that his mental health  38  had deteriorated significantly, resulting in suicidal ideation. Even at this point it had been reported by a previous partner that WF could become verbally aggressive and “enraged very quickly”. WM reported in July 2018, following a domestic abuse incident that WF had previously assaulted her “over a bag of cannabis” and reported to the review that WF was spending in excess of £500 per month to sustain his habit. WF was also intoxicated both at the time of his arrest on this occasion and following the domestic abuse incident on the 27/10/18.  5.3.6 Whilst WM’s alcohol use, volatility and erratic behaviour were referenced in the chronology, these issues were not addressed in any depth in the Social Work assessment presented to the ICPC and there was no reference to WM’s cannabis use or possible amphetamine use. Additionally, there was no in-depth analysis of WF’s mental health.  5.3.7 This suggests that alcohol, substance misuse and poor mental health were not sufficiently factored into the assessment and planning processes. The number of repeat referrals, followed by assessment followed by case closure, as a pattern suggest an ongoing superficial level of intervention, compounded by parental non-compliance, a rule of optimism and a shallow level of analysis within the assessment process. Given the difficulties in ceasing or moderating any kind of substance misuse, the impact of alcohol use, drug use and poor mental health on parenting capacity, particularly during July 2018 when Child W was only a few weeks old, a far more robust intervention would have been necessary which adequately addressed these issues.  5.3.8 During the period from September 2017 to August 2018, which is characterised by some multi agency involvement, albeit on a Child in Need basis, there was also insufficient attention given to the process of change. Research suggests that change is a complex but necessary process in safeguarding children that can supported and promoted through multi-agency working, however it cannot be imposed (DfE 2014) and therefore inevitably takes time. Research findings also indicate that professionals need a conceptual model of change, as a framework to enable thorough analysis of a family’s circumstances and greater understanding of the  39  factors that influence parental capacity for change. A widely used model for change (1992 Prochaska, Di Clemente and Norcross, “In Search of How People Change”) outlines six psychological stages through which individuals advance during intentional change behaviour – pre-contemplation, contemplation, preparation, action, maintenance and relapse. The model also warns that relapse should be seen as the rule, rather than the exception regarding chronic behavioural disorders and which include addiction. This serves as a reminder to be realistic about the length of time to embed change and that interventions should be of sufficient longevity to facilitate this process.  Learning Opportunity ● That alcohol use, substance misuse and poor mental health must be given significant consideration within assessment and planning, providing in depth analysis which reflects current research, good practice and which enable time for sustained change. ● That cannabis use, particularly if prolonged, is a significant feature contributing to poor mental health and compromised parenting ● That the use of a conceptual model for change is valuable in providing a framework for assessment, analysis, planning and interventions.   5.4     Key Line of Enquiry 4    What approaches were taken to engage the family and was non-compliance addressed within a multi-agency approach  5.4.1 Meaningful engagement with the family provides practitioners with a broader, deeper range of data which support more informed decisions regarding child safety and well-being. Family engagement, including the wider family is a major key to success and will depend on the development and maintenance of dynamic  40  and focused relationship building, even within the context of challenging and difficult conversations (DOH, “The Challenge of Partnership in Child Protection”, 1995,HMSO)  5.4.2 There is considerable evidence that WM was reluctant to engage with a number of agencies as early as 2015 and 2016 and this is reflected in information from the NHS Foundation Trust. This included not following advice, non-attendance at appointments and asserting that the involvement of midwifery had caused a previous miscarriage. School reported that WM would lose her temper with staff when issues were addressed with her and this would often result in WM shouting at the Head Teacher over the phone. WM had also threatened one of the midwives after she had made a referral to Children’s Services in December 2017. Consequently, two midwives would visit WM, which is unusual. Whilst WM subsequently made a self-referral to Change, Grow, Live, following concerns in respect of her alcohol use, the appointment was not attended and as there had been no contact the case was closed in March 2018. The Health visitor reported to the review that her first contact with WM was a telephone call where WM was “yelling at her”, although when visited WM presented differently. A feature of WM’s presentation was that she would initially appear very agitated and hostile but would then calm down.  5.4.3 Despite concerns discussed between the school and the Social Worker, in December 2017, that WM had been “telling professionals different stories”, the case, which had been open on a Child in Need basis since the midwifery referral, was closed in January 2018.  5.4.4 There is also considerable information which suggested that whilst WM would report that WF had been violent towards her, particularly in contacts with the Police, she would then report to other agencies, such as midwifery, that this was not the case. This was apparent following the incidents during July 2018, with WM then reporting to the GP, in September 2018, that there was no threat to her,  41  either physically or verbally. WM was also resistant to make any application for a non-molestation order in case WF “breached it and was sent to prison”.   5.4.5 Following the domestic abuse incident in October 2018, which involved WF attending WM’s address and which was a breach of the Child Protection Plan, WM reported to the school that the Social Worker had agreed that WF could be allowed back in the house, which was untrue. A further referral from S2’s father on the 5/11/18 also suggested that WF had been continuing to stay at WM’s address during the weekend of the 2/11/18.  5.4.6 The number of periods of intervention, followed by case closure, particularly during the timeframes for the review, suggest that efforts to engage the family were at best superficial and did not provide the time needed to address deeply entrenched patterns of resistant behaviour. This was compounded by less than robust multi-agency planning, particularly on a Child in Need basis. This did not take into consideration WM’s resistance to agency intervention and the inconsistent way in which WM was presenting to different agencies although information sharing between Health Visiting and Midwifery was good. Whilst some agencies reported that WM was coercive and controlling, the Continence Nurse by contrast, was “staggered” at what had subsequently taken place with Child W. When WM was seen with Child W by agencies such as Health Visiting, interactions appeared to be good, Child W appeared well cared for and bonding and attachment appeared to be strong. Information from the GP and the Independent Chair of the ICPC also suggested that WM presented well and appeared to have her children’s best interests at heart.  Whilst these observations were undoubtedly positive, they will have contributed towards an over optimistic view regarding WM’s capacity to engage and the family’s circumstances and dynamics.   5.4.7 Importantly, non-compliance with the Child Protection Plan regarding WF visiting the family home, whilst discussed at a Core Group on the 30/11/18, did not result  42  in immediate action to safeguard Child W and there was a considerable delay in convening a legal planning meeting, Whilst the impact of WM reporting that she would “kill herself if the children were taken off her” cannot be underestimated, this was a critical juncture in the planning process.   5.4.8 Engagement with the wider family which included the fathers of S1 and S2 and Child W’s Paternal Grandmother FM, were also superficial and would have provided a helpful perspective regarding family dynamics and functioning.  5.4.9 Parental resistance is a persistent feature of child and family Social Work and research has identified five principle causes why parents may be resistant. These include social structure and disadvantage, the context of child protection work, parental resistance, denial or minimisation and the behaviour of the Social Worker. It is argued that Motivational Interviewing (MI) provides particularly useful skills and concepts for firstly reducing the Social Worker contribution to resistance and secondly, maintaining a focus on the child’s welfare and safety. MI balances being directive with being supportive and non-judgmental and offers an opportunity to improve practice by increasing parental engagement, combining  an attention to broader social structures with the micro skills required in social work interviews. There are four key parts to MI which consist of open ended questions, affirmation, reflection and summary (OARS) (Forrester and Westlake, 2012, Parental Resistance and Social Worker Skills: Towards a Theory of Motivational Social Work: Child and Family Social Work, Guthrie 2018).   Learning Opportunity ● That family engagement is critical keeping children safe ● Professionals will enhance safeguarding practice by adopting a “whole family” approach and mind-set throughout assessments, and by adherence to multi-agency guidance which addresses information sharing and addresses parental resistance.  43  ● That where parental resistance and non-compliance are evident, then Motivational Interviewing (MI) can be a helpful tool. ● Supporting professionals into better standards of critical thinking will enhance the quality of interventions in order to better assess the impact of harm or risk to children. ● That multi-agency planning is effective when a holistic analysis is provided regarding parental resistance and time is allowed for sustained change.  5.5 Key Line of Enquiry 5    Consider the purposefulness and effectiveness of the Child Protection Plan  5.5.1 The overall aims of the Child Protection Plan are to ensure that the child is safe and to reduce any risk or likelihood of harm by supporting strengths, addressing vulnerabilities and risk factors, and enabling parents or carers to meet the child’s unmet needs. Developing a meaningful safety plan is a collaborative endeavour involving all relevant agencies, parents and where possible, children and young people (Iannos and Antcliff, 2013 “Planning for Safety with At Risk Families”).  5.5.2 Maslow’s Hierarchy of Needs suggests that people are unlikely to focus on family relationships if survival and safety needs are being threatened. Therefore families with complex problems may not have the capacity to engage in parenting interventions if they still being exposed to domestic violence.  5.5.3 Whilst the Child Protection Plan was strong in that it appropriately referenced strategies to support WF and WM to manage their mental health and WM’s anger management, there is no evidence of support services responsibilities within the plan for the children. This is pertinent as there was evidence to indicate that both parents were finding the parenting of a new baby highly stressful. This was exacerbated by the fact that WM was highly resistant to professional interventions and the involvement of wider family as a support mechanism. When WM was seen as part of the review, a particularly salient point was when, in acute distress, she  44  described how hard she had found parenting and that her actions in mod-November were “just a blip”, as Child W had been unwell, constantly crying and she was at the end of her tether and was just struggling to cope.  5.5.4 In that respect though, the Child Protection Plan addressed the key concern regarding domestic abuse in the relationship and stipulated that as a fundamental requirement, WF was not to attend WM’s address. This was clearly not adhered to and the domestic abuse incident at the end of October 2018 occurred in the context of WF having spent the majority of the weekend with WM and Child W, visits which were also continuing into November 2018. Whilst this matter was addressed at a Core Group on the 30/10/18, and arrangements made to refer the case to a Legal Gateway Meeting, there was a significant delay in progressing this. This was due to the referral requiring further work and the Social Worker’s Manager taking a period of extended sickness absence. Consequently, the matter had not been actioned by the time that WM injured Child W, although the injury took place when WF was not at the family home. WM and WF were both seen as part of this review and whilst both parents differed in their accounts regarding who was responsible for the domestic abuse incidents, each blaming the other, the one area where they were agreed on was the need for WF to have had contact with Child W away from the family home. The relationship between WF and WM was very much characterised by a dynamic of co-dependency which both parents found difficult to break away from. In that respect the plan did not consider the impact of the separation of WF and WM, which neither parent was able to adhere to.  5.5.5 The incident at the end of October 2018 was not referred to the EDS, which was a significant omission, given that all three children were subject to Child Protection Plans and the absence of appropriate oversight in the Contact Centre has already been referred to.    45  5.5.6 The length of time between the incident at the end of August 2018 and the date of the ICPC on the 24/9/18 is significant, as there was no safety plan for Child W during those 4 weeks.   Learning Opportunity  ● That the time between the conclusions of Section 47 Enquiries and the date of an ICPC is critical for formulating a safety plan. ● That the effectiveness of the Child Protection Plan will depend on the clear roles and responsibilities of support services. ● That significant breaches in a Child Protection Plan will require a timely and robust response which incur the minimum of delay. ● That having qualified social work oversight as part of the Contact Centre arrangements is a critical feature of safe and effective decision making. ● That alternative arrangements for contact between WF and Child W may have lessened the impact of a co-dependent dynamic in the relationship between WF and WM.  5.6         Key Line of Enquiry 6  To what extent was the risk of abusive head trauma in the mind set of professionals  5.6.1 Abusive Head Trauma (AHT), often referred to as Shaken Baby Syndrome results in serious injuries which often present in a constellation, including intracranial injuries, retinal haemorrhaging, long bone fractures and spinal fractures which can led to brain damage, blindness, learning disabilities and death. Research suggests that two years after injury, 25.5% of babies with AHT will have died and 40% will have significant disabilities. UK studies indicate that it affects approximately 24 of every 100,000 babies admitted to hospital each year and that 1 in 9 mothers have shaken their babies  46  and 2 in 9 have felt like doing so. Critically, an inability to cope with a crying baby is one of the key reason for carers losing control and shaking their baby. It has also been noted from previous Serious Case and Learning Reviews that AHT features more in 2nd, 3rd and 4th babies (Learning from Case Reviews, 2018)  5.6.2 The multi-agency partnership has implemented a national programme known as ICON, based on the study of AHT prevention programmes in the USA and Canada, learning and research. This is a multi-agency co-ordinated programme comprising a series of touch points which reinforce a simple evidence based 4 point message which makes up the ICON acronym.   ● Infant crying is normal and it will stop (I) ● Comfort methods can sometimes soothe the baby and the crying will stop (C) ● It’s ok to walk away if you have checked that the baby is safe and the crying will stop (O). ● Never, ever shake or hurt a baby (N).  5.6.3 Research suggests that some carers lose control when a baby’s crying becomes too much and may go on to shake the baby with serious consequences. Apart from preventing AHT most adults who have ever cared for a baby appreciate some advice about how to comfort a crying baby and how to cope when it goes on for a long time. The key to the ICON approach is that the message is simple, consistent and is reinforced by different professionals at key points.  5.6.4 The Manchester ICON Steering Group was set up in April 2018 and the South Manchester Pilot commenced in May 2018, concluding on the 31st August 2018.  A city wide implementation has been taking place in 2019 and all Midwives and Health Visitors are currently receiving brief training on the ICON model. Whilst the pilot has been focused on health touch points, it is clear that this is a universal health message and as such, all partnership organisations working with families need to adopt the approach.  47   5.6.5 Information provided to this review suggested that the possibility of AHT was not present in the mind set of professionals and practitioners across the multi-agency partnership. The review could not find any evidence from any agency that this possibility was given consideration. The GP reported that “this did not cross her mind once, WM was always immaculate and well turned out and this was mirrored in her children who were also well turned out”. The GP reported that WM always appeared to have her children’s interests at heart and had been seen by the GP two weeks prior to the incident, who noted that her anxiety had lessened and that medication was no longer required. There was no information that suggested Child W was causing WM undue stress and the Health Visitor reported that the relationship between WM and Child W was “thriving”.  Information from the Child Protection Conference Chair indicated that WM appeared engaged during the Conference and appeared to understand the reasons for the Conference and agreed with the recommendations, including that WF was not to visit the family home.  5.6.6 These factors will have mitigated against professionals considering the possibility of AHT, despite Child W’s age and vulnerability, the presence of domestic abuse, substance misuse, poor mental health, parental resistance, erratic behaviour and insufficient support systems for the family. The lack of any referral onto EDS by the Contact Centre is particularly concerning, given Child W’s age, the level of domestic violence, previous history and importantly that Child W was subject to a Child Protection Plan.    Learning Opportunity  ● That the possibility of AHT is always considered in cases where there are very young babies and children and domestic abuse is present  48  ● That AHT is currently not sufficiently profiled across the safeguarding partnership.  ● That the ICON Model as a helpful and informative approach for parents and carers can be profiled on a city wide basis. An invigorated approach to the education of professionals and the public will reduce the risk of fatal and non-fatal injuries      6. Recommendations   6.1 This review has evidenced that whilst there are structures to support an efficient and collaborative response to domestic abuse in Manchester, there were a number of deficits in the timeliness and rigour of interventions with the family.  6.2 There are five particular points in the critical pathway of intervention that deviated from the systems and procedures in place. Firstly, that the incidents in July 2018 did not trigger a co-ordinated Section 47 Enquiry where previous history, particularly the number of referrals, re-referrals and previous assessments were considered. Secondly, that the Child Protection Plan, whilst strong in some respects, was not appropriately categorised, did not reference support service responsibility and did not address the issues of parental resistance. Thirdly, that the high gravity domestic abuse incident which occurred in October 2018 was not referred onto the EDS by the Contact Centre, despite Child W being subject to a Child Protection Plan. Fourthly, that the breach in the Child Protection Plan which took place did not result in a timely and robust response to ensure that Child W remained safe. Fifthly. That there was a significant delay in actioning the Legal Gateway Meeting, following the incident  49  on the 31st October 2018, and which had still not taken place by the time that Child W was injured in mid-November 2018.   6.3 Key Recommendations  1. For all Child in Need and Child Protection planning to routinely consider;  ● The longitudinal family history with and levels of engagement with the agency   ● Chronologies that identify the impact on the child  ● Comprehensive agency involvement, particularly adult mental health and GPs ● An evidence based analysis of what is known to agencies that excludes an over reliance on self-reporting  ● Addresses domestic abuse from a gender neutral perspective  ● The strengths and significance of the importance of wider family  ● Contingency planning and responsiveness, particularly where there are breaches in a Child Protection Plan  2. Safety planning to be  routinely in place between the conclusion of any Section 47 investigations  and a subsequent  ICPC  3. That planning and interventions are informed by a conceptual model of change, particularly when working with families struggling with inter related mental health issues, alcohol or substance misuse.  4. That a trauma informed approach to planning and interventions is embedded into practice, particularly where Adverse Experiences in childhood (ACEs) have been identified.  5. That the use of Motivational Interviewing (MI), incorporating a “Signs of Safety” approach is embedded in thinking and practice.   50  6. That the ICON approach is embedded across the partnership and informs advice, guidance, thinking and practice.  7. That the role of the IDVA is promoted in all responses to domestic abuse     