Possible neglect of a boy since birth until an incident in January 2019 when he was 11-years-old. Harry was seen with facial injuries by staff at a local leisure centre where he attended alone. Police were initially unable to contact his mother and she was later arrested for neglect. Learning themes include: the voice of the child; recognising the signs and symptoms of neglect in children, the assessment of risk and enhanced professional curiosity; supervision, sharing information, communication and record keeping; professionals working together, compliance to policies and procedures and escalation processes; disguised and varied compliance; and child protection medical examinations. Recommendations to the Safeguarding Practice Review Group include: be assured that all partners keep focussed on the child or young person, and that a professional meeting can be called by any partner to ensure communication and challenge of safeguarding concerns; review and update the local 'Multi-Agency Threshold Guidance '; make sure all staff utilise the available 'Neglect Strategy and Tool' to assist in identifying the signs and symptoms of neglect and abuse and to take immediate and necessary action if required; ensure agencies' record keeping systems are robust, accurate and efficient for purpose and staff are complying with policy; ensure staff are supported and trained in dealing with difficult and confrontational parents or guardians; include within child protection training the range of options practitioners can take, including legal advice when a parent or guardian refuses consent to a child protection medical.
      
 Title:  Child safeguarding practice review: Harry (TT): overview report. LSCB: Slough Safeguarding Partnership Author: David Byford Date of publication: 2023  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                            1        Child Safeguarding Practice Review  Harry (TT)  Overview Report           A Slough Safeguarding Partnership Commission. Independent Author – David Byford  2 Table of Contents  Chapter 1 ......................................................................................................................... 3 Executive Summary- Introduction and Background ................................................................... 3 Periods of Concern- key areas for consideration and Initial Findings .......................................... 5 Chapter 2 ......................................................................................................................... 7 Terms of Reference (TOR) summarised ..................................................................................... 7 Chapter 3 ....................................................................................................................... 10 Circumstances of Harry’s life, case and background history of the family ................................. 10 Police Investigation and Harry’s current situation ................................................................... 21 Chapter 4 ....................................................................................................................... 22 Analysis of Profesional Practice using the KLOE’s, SPR Findings and Recommendations……..……22 Chapter 5 ....................................................................................................................... 32 Conclusions- Predictability and Preventability ......................................................................... 31 Appendix 1- Bibliography ................................................................................................ 35 Appendix 2-Glossary  ...................................................................................................... 36               3 Chapter 1 Executive Summary  1. Introduction   1.1 This Child Safeguarding Practice Review (SPR) was commissioned by the Slough Safeguarding Partnership (SP) in respect of Harry (not his real name) an 11-year-old, Black British Boy of African origin and of Muslim faith. This Overview Report (OR) has been anonymised to protect the identity of Harry and his family.  1.2 In January 2019, Harry was seen with facial injuries by staff at a local leisure centre where he attended on his own. The injuries were significant enough for the staff to call both Police and South Central Ambulance Service (SCAS).  Police called to the scene, saw Harry had fresh and bleeding injuries and took him to the local Hospital Accident & Emergency Department (ED) prior to the arrival of an ambulance. At the hospital, Harry gave differing accounts to police and hospital staff as to the causation of the injuries sustained. He stated he had injured himself skateboarding two days previously. However, this was inconsistent with the medical diagnosis and the account given to clinicians.  1.3 Police were initially unable to make contact with his mother. In order to safeguard Harry, he was placed into Police Protection (PP) and remained overnight in hospital for treatment. Slough Children’s Services Trust (SCST), acted promptly to safeguard Harry’s health and wellbeing, pending scrutiny of the facts at the time. Harry was subsequently placed into a foster placement after his discharge from hospital.  1.4  The Safeguarding Practice Review Group (SPRG) were informed of Harry’s injuries from a referral received from the acute Hospital Foundation Trust following his presentation. A Rapid Review (RR) was carried out by agencies due to the injuries sustained and previous child protection concerns (he and his family were known to Children’s Social Care (CSC) and health care and teaching professionals since his birth). 1.5 A Section 47 Investigation was instigated at the time of the disclosure following the incident. The circumstances of Harry’s case of Neglect and Physical Abuse is currently being investigated by Thames Valley Police (TVP) and has resulted in the arrest of Harry’s mother who is currently released under investigation. 1.6 Harry’s case was considered by the SPB and SPRG, and after safeguarding partners and agencies involved with Harry contributed to the Rapid Review, the Independent Scrutineer and Chair of this group made the decision that the criteria was met to commission this SPR. The criteria is in accordance with s5(2)(a) and (b)(i) LSCB Regulations 20061 and Working Together to Safeguard Children 2015 and 20182: -  ‘Abuse or neglect of a child or young person is known or suspected and                                                             1 2006 Section 5 (2) (a) and (b) (i) Local Safeguarding Children Board Regulations 2 Working Together to Safeguard Children, 2015 and 2018, Guidance - HM Government    4  the child or young person has died or been seriously harmed 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 or young person.’ 1.7 Statutory Guidance 1.8 The DfE,3 provides statutory guidance and requirements on how to conduct a SCR which:   Recognises the complex circumstances in which professionals work together to safeguard children;  Seeks to understand precisely who did what and the underlying reasons that led to individuals and organisations to act as they did;  Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;  Is transparent about the way data was collected and analysed; and  Makes use of relevant research and case evidence to inform findings. 1.9 Purpose of the review 1.10 The purpose of this SPR is to: -  Establish whether there are lessons to be learned from the case about the way in  which local professionals and organisations work together to safeguard and  promote the welfare of children and young people.  Identify clearly what those lessons are, how they will be acted upon and what is  expected to change as a result, and as a consequence, improve inter-agency working and better safeguard and promote the welfare of children and young people. 1.11 Background 1.12 The Rapid Review showed significant involvement of SCST social care services with Harry. He had been in care for a year from birth when he was a baby due to concerns about his birthfather, who had schizophrenia. Harry was returned to his mother’s care in 2008, as she was no longer in a relationship with Harry’s father. There were further concerns in 2011, when his father wanted contact. CSC did not agree with this contact and it never materialised.  1.13 His school had long standing concerns for Harry and his mother (this is discussed further within Chapter 3 and 4 of this report). He had behavioural issues, frequent injuries and health issues with his diagnosed skin condition. The school concern was further compounded with the behaviour and confrontational attitude of Harry’s mother’s parenting, and her relationship with the school when challenged about her parenting and concerns for her son. Harry was often reluctant to speak or give a plausible explanation regarding causation of presenting reported health and wellbeing concerns when questioned by school staff.                                                            3 Working together to safeguard children 2015 and 2018, Chapter 4 Guidance - HM Government.   5 1.14 The school made a referral to CSC in 2016, regarding a concern of possible neglect of a significant foot injury which became infected due to the delay in his mother seeking treatment. A Section 47 investigation was conducted, and he was subsequently made subject to a Child Protection (CP) Plan. This was later stepped down to a Child In Need (CIN) plan which is subject to comment within the analysis in this report. A Children and Family (C&F) assessment was then carried out. The outcome was that no further action (NFA) would be taken as it was determined there was no evidence of neglect. Harry’s case was closed to CSC in December 2017. Key events for Harry which arose subsequently, are addressed within Chapter 3 of this report. 1.15 Family  1.16 The family unit subject to this SPR consists of: -  Harry - The subject in relation to neglect and physical abuse of Harry.   Mother - The suspect of neglect and physical abuse of Harry.  Father - Estranged from both Harry and his Mother and referred to only in the background of Harry’s life history.  1.17 Harry is a child of black African heritage. His mother and his father come from different African countries which are not recorded in order to protect their identity. His parents’ religion is Islam and Harry is known to celebrate ‘Eid.’ 1.18 Periods of concern and key areas of consideration. There are several periods of concern for Harry. These concerns are discussed within Chapter 3, details of Harry’s life and the analysis of the terms of reference (TOR). Key Lines of Enquiry (KLOE) and Professional Practice are discussed within Chapter 4. The periods of concern are: -  Period 1 - History and background of family and previous child protection concerns.  Period 2 - Child Protection concerns within the terms of reference (TOR) scoping period and  action taken.  Period 3 - Disclosure of incident which led to Harry’s Physical Abuse and Police Criminal  Investigation.   1.19 Findings. The SPR identified the following findings which are detailed and analysed further within Chapter 4 together with SPR and Agency Recommendations are: -  Finding 1 - The need for practitioners to remain child focused in order to capture the  voice of the Child and a review of the Slough Multi-Agency Threshold Guidance form  children.  Finding 2 - Recognising the signs and symptoms of neglect in children, the assessment of risk  and enhanced professional curiosity.  Finding 3 - Supervision, sharing information, communication and record keeping.   Finding 4 - Review of the TVP function within the Multi-Agency Safeguarding Hub  (MASH).  Finding 5 - Professionals working together, compliance to policies and procedures and  escalation processes.   Finding 6 – Further Multi-Agency training in disguised and varied compliance.   Finding 7 - Child Protection Medical Examinations.   6 1.20 This SPR has identified seven SPR Overview Report Recommendations outlined in Chapter 4 of this report. There are nineteen Individual Agency Recommendations which form part of a SPR Action Plan which follows the completion of this review.                        7 Chapter 2 2 Terms of reference (summarised) 2.1 The terms of reference (TOR) for this SPR have been summarised below. Slough Safeguarding Partnership retains a full version of the TOR for reference.  2.2 Introduction 2.3 The TOR relate to the SPR for Harry and sets out the statutory requirements, followed by a brief case summary. The Key Lines of Enquiry (KLOE) are questions to be addressed by the SPR review process and methodology as agreed by the Slough Strategic Safeguarding, Leaders Group. 2.4 The purpose of reviews of serious child safeguarding cases is to identify improvements to be made to safeguard and promote the welfare of children. Learning will be relevant locally, but it may also have a wider importance for all practitioners working with children and families and for government and policymakers. Understanding whether there are systemic issues, and whether policy and practice need to change and if so how, is critical to the system being dynamic and self-improving. 2.5 Reviews should seek to prevent or reduce the risk of recurrence of similar incidents. They are not conducted to hold individuals, organisations or agencies to account, as there are other processes for that purpose, including through employment law and disciplinary procedures, professional regulation and in exceptional cases, criminal proceedings. These processes may be carried out alongside reviews or at a later stage.  2.6 In Slough, the statutory safeguarding partners are the Slough Borough Council, who commissions the Slough Children’s Services Trust to deliver the statutory services; East Berkshire Clinical Commissioning Group and Thames Valley Police.  2.7 Working together to Safeguard Children (WTSC) 2018 guidance indicates that safeguarding partners must make arrangements to:  identify serious child safeguarding cases which raise issues of importance in relation to the area, and  Commission and oversee the review of those cases, where they consider it appropriate for a review to be undertaken.  2.8 The three safeguarding partners have equal duties in this regard. Safeguarding partners met on 4 July 2019 as the safeguarding practice review panel (SPRP). Having carried out the Rapid Review and unanimously agreeing the case met the criteria for commissioning a SPR.  A summary of the Harry’s case is outlined in Chapter 1 – Introduction. 2.9 Key lines of enquiry (KLOE) 2.10  Information available from the RR the SPR Group hypothesised that Harry had been living with neglect and abuse all his life. This overview report analyses the five identified KLOE’s from  8 agency Individual Management Reports (IMR) submitted for the SPR process and from the Practitioners Event held, as outlined within Chapter 4 of this report.  2.11 Scope of the review:  2.12 The rationale for the proposed timeframe is that practice and arrangements have changed considerably during Harry’s lifetime. Learning is most likely to be of benefit when considering the last 3 years and especially the last year. 2.13  The review considered information available from partners from July 2016 when a referral was made in relation to a report of an injury until January 2019 which includes the incident reported which led to the commissioning of this SPR. Further emphasis and analysis for the year leading up to the trigger incident, to help examine recent practice, was assessed. 2.14 All partner agencies were asked to complete a short summary of their knowledge of Harry’s history from birth in order to provide a background history to inform their IMR’s and this review.  2.15 Methodology 2.16  David Byford was commissioned as the SPR Independent Reviewer and Author for this SPR. He has no involvement with the case or agencies involved in the review. 2.17 There are six stages to this review: Stage 1 – Background and agency reports;  Stage 2 – Practitioners and management engagement. This involved a Practitioners Event which was held and subject to analysis in Chapter 4;  Stage 3 – The completion of the overview report and consideration of engaging with the family. (In the circumstances neither Mother (Police investigation) nor his estranged Father were asked to participate in this review. His Father is believed to be accommodated in a mental health hospital and was not part of Harry’s life during the scoping period for this review. Stage 4 – The overview report will be shared with Slough Strategic Safeguarding Leaders group who will sign off the report and agree to ensure an appropriate action plan is delivered and monitored; Stage 5 – The publication of the finalised report; Stage 6 – The Safeguarding Practice Review Group will monitor the delivery of both the multi-agency and single agency action plans, delegating tasks to other groups, such as the quality assurance  and/or the learning and development  groups where appropriate.  2.18 A Practitioners Event was held that was well received and attended by agency practitioners involved in the SPR. The issues submitted for discussion were elicited from the analysis of agency submissions including the KLOE’s and practitioner’s own views and opinions at the event. The information received was taken into consideration and analysed within Professional Practice and KLOE’s and subject to the Findings and SPR OV Report Recommendations in Chapter 4.  2.19 Agency involvement 2.20 The following agencies were involved in the SPR process and completed Individual Management Reports (IMR) or a summary of their agency involvement: -  9  Primary Care - Report completed on behalf of Primary Care by East Berkshire Clinical Commissioning Group (CCG).  Education/School - Report completed.  Frimley Health NHS Foundation Trust- Report completed.   Slough Children’s Services Trust - Report completed.  Solutions 4 Health - Report completed.  Thames Valley Police - Report completed.  South Central Ambulance Service (SCAS) - No information obtained. 2.21  Publication - There is an intention by Slough Safeguarding Partnership Board to publish the Overview Report in an anonymised version to preserve the identity of Harry and his family. 2.22 Acknowledgements  2.23 The Independent Author would like to take the opportunity to thank Slough Safeguarding Partnership and participating agencies and key professionals who contributed to the SPR.  The review could not have been completed without theirs and the valued assistance of the Independent Chair of the Slough Safeguarding Partnerships Board, the Safeguarding Partnership Manager and Business Support staff and SPRG members.               10   Chapter 3 3 Period 1 - Circumstances and details of the events in Harry’s life and background history of the family 3.1 This SPR covers the period from July 2016 until January 2019, however, the family background history and Harry and his parents are also recorded for context of the events in order to capture the life of Harry.   3.2 Harry’s parental family background 3.3 Harry’s mother and father were both born in the same African country (redacted) in 1983.  The maternal grandmother (MGM) died during child birth and Harry’s maternal grandfather (MGF) remarried. Harry’s mother moved to the UK in 1995 with her step mother and the MGF joined them later. The MGF followed the Muslim way of life and as a teenager Harry’s mother rebelled against this and at the age of 15 years was placed into the care of a London Borough. 3.4 A preliminary report from her previous London Borough Children’s Services (LBCS), at a Looked After Child (LAC) review in 2001, disclosed Harry’s mother’s behaviour was very challenging including several episodes of dishonesty, additional concerns about lying, anger, hygiene and self-care issues, with a history of criminal behaviour and involvement with the Youth Offending Team (YOT). Harry’s mother sought support as she felt she would like some further help with aggression and anger management. Whether this occurred prior to her moving to the Slough area is not known to this review. 3.5 Harry’s parents were reported to have been in a relationship since they were in their teens. Their relationship ended prior to Harry being returned to his mother’s care in November 2008 which is detailed further below. 3.6  Harry’s life prior to the TOR scoping period.  3.7 In December 2007, Harry’s parents moved into the Slough area. Harry’s mother was pregnant with him at the time. A referral was received from the London Borough they had moved away from, informing Slough Children’s Services of child protection concerns about the safety of mother’s unborn child (Harry). This was due to the father’s criminal history. He had mental health difficulties and posed a risk to children and both parents were reluctant to engage with professionals. 3.8 The LBCS had completed a core assessment and was initiating care proceedings in respect of the unborn baby when the parents moved out of their area. Both parents were known to have a history of violent behaviour towards each other and other persons and were known by several Police Services. This was good safeguarding practice to communicate the concerns by the previous LBCS with Slough whose CSC acted positively to protect the unborn Harry. He was born later that month and put into foster placement under an Interim Care Order (ICO) by the LBCS.  11 3.9 In January 2008, an Initial Assessment (IA) was completed by SCST4. Harry’s case was transferred to Slough and an ICO granted to them.  3.10  In July 2008, police record allegations between Harry’s parents, made against each other of domestic abuse (DA). This was concluded after police took advice from the Crown Prosecution Service (CPS) who decided NFA should be taken. Harry was not mentioned in the report and from the dates, it is suggested, this would have been likely due to Harry being in his foster placement. Harry was returned to his mother’s care in November 2008, aged 10 months old under ICO, Placement Parents Regulations. 3.11  The ICO was discharged on the 9 March 2009 and a Supervision Order (SO) was granted for one year. During the period of CSC involvement, it was consistently noted that Harry was meeting developmental milestones. Harry had eczema whilst in foster care and this was treated with ‘Vaseline’. The case was closed on 30 June 2010 when Harry was 2 years old. After the CP plan ended, he became subject to a Child in Need (CIN) plan. 3.12 Between 2011 and 2015, there were episodes of involvement with CSC, Police and the School. 3.13 2011 - Harry’s birth father wanted contact with him, but this was not recommended by CSC and never occurred. In August, mother reported a domestic incident with her new partner (not Harry’s birth father) which amounted to a verbal exchange in the street. No offences were identified. Harry was not listed as present or involved. 3.14 2012 - There was a Domestic Abuse (DA) incident between mother and her partner. Harry was present during the DA. Appropriate CP enquires and a joint Section 47 investigation were conducted with police. All necessary action to safeguard and protect Harry was taken by his mother by her ending the abusive relationship with her partner. SPR Comment: Mother refused to engage with police officers investigating the DA. Harry was 5 years old at the time and was listed as “child other” within the police report. The report gives no indication as to whether Harry was seen or spoken to at the time. If he was present, he should have been spoken to and if he was not present police should have enquired where he was. TVP have addressed this as learning within their report to the SPR. 3.15 2013 - In March there was police contact with Harry’s mother’s ex-partner who was sending texts and telephone calls to Harry’s mother in breach of a non-molestation order. NFA was taken as she was deemed to have taken appropriate action and the partner was issued with a harassment warning by police.  3.16 Later in June, Harry’s school reported that he had a mark on his cheek. When asked what had happened, he thought for a while before saying “It wasn’t my mummy.” When asked again, he said he did not know. The Head teacher (HT) spoke with his mother and warned her regarding hitting a child which she denied. NFA was taken. It is reported in the school chronology submitted to this review that Harry had a similar mark on his face before this and he had said to his teacher his mum had done it. (The education submission to the review does not give a date for the previous mark observed by staff on Harry’s face).                                                            4 SCST only came into being in 2016, prior to this services were provided through the SBC.   12 SPR Comments:  The school should have reported both incidents to CSC as there was, in the first occurrence, an element of assault accusing his mother and, on the second occasion, where he had a mark on his cheek, he clearly contemplated his response insisting his mother did not do it. (There is a reasonable assumption by his response; his mother had spoken to him after the first incident about alleging she had caused the marks and possible element of grooming his answers to professionals). It has been pointed out to the review that this action was taken by a former head teacher. The school believe there were very different procedures and expectations in place within social care at the time. It is suggested many schools were trying to do the best, but Slough CSC were struggling and rated inadequate. The view of this review is that the incidents should still have been shared at the time. It has also been acknowledged these incidents would now be shared by the school. Following an inspection, the leadership of the school changed in April 2014 with a substantive head teacher taking up a full-time role in 2015. The school then brought about rapid change to safeguarding procedures and the concerns alluded to were identified and shared at Harry’s ICPC subsequently.  3.17 2014 - In February, the school noticed Harry had a cut of approximately 2cm on his forehead which was slightly scabbed over. He said he did it skateboarding. When asked when it had happened, he said it was in the garden. When asked what he hit his head on he said, “I’ve changed my mind, I actually hit it on the door.” This was reported to the school Family Support Worker (FSW) who spoke to Harry. He said his mother had put ice on it and made him comfortable. He was reminded that he could speak to staff if he had any worries or concerns. SPR Comment: This was a third opportunity to share the information regarding facial injuries Harry had sustained to CSC. This information was provided by the school in the Rapid Review completed for the SPR.  3.18 Home alone occurrence (1) aged 6 years. In July 2014, an anonymous referral reported Harry’s mother was leaving him home alone while she went to the shops or visited friends. CSC followed up the information and carried out an unannounced Home Visit (HV) and Harry was spoken to alone (he was not home alone on this occasion). He presented as being healthy and well dressed. His mother denied leaving him home alone. NFA was taken and his mother was given suitable advice and the NSPCC leaflet on ‘Leaving children home alone’ and referred to Early Help. The school were unaware of this incident and it would be good practice to have shared the information with them.  3.19 2015 - In June, on the way back from a school walk, Harry was noted to be limping. He told school staff his foot hurt as he had fallen off his bike the previous day. He had marks on his head and cheek. Harry refused to take off his shoe at school saying the school first aider had looked at it the day before which was not the case. School staff were concerned as he had told the first aider that his brother had bitten him and that’s why he had marks on his face and head (he does not have a brother). As a result, the Head Teacher (HT) arranged an appointment with Harry’s mother who came into school. His mother was very defensive and said his foot was fine and Harry was making it up as he was tired from the walk. She said he should take part in all activities as per normal.  SPR Comment: This was the fourth occasion when Harry was found with marks on his face at his school.  Professional curiosity should have been applied regarding sharing the information with CSC. If the events in 2013 and in February 2014 had been shared there may have been a different outcome, and this was another missed opportunity as it was another element of concern. (The  13 information was subsequently shared later at the ICPC in July 2016, see below). The SPR Independent Author is satisfied the school would have no hesitation in referring to CSC if similar circumstances occurred now. If reported at the time, the information could have been investigated further and added to the historical child protection concerns Harry faced and these were missed opportunities.  3.20 Home alone occurrence (2) aged 7 years. In August 2015, similar concerns were reported when CSC received an email from a member of the public, expressing concern about Harry’s mother leaving him home alone. It alleged his mother was shouting, drinking, smoking and being in an unsuitable relationship (a man known for drug offences allegedly staying at the family home). The school were unaware of this incident. 3.21 CSC received a further email sent by the same person a few days later; retracting the concerns, saying it was all a misunderstanding. CSC in any event conducted an unannounced home visit which was good practice and later confirmed NFA. Information showed ‘Early Help’ were already involved and it was agreed these issues should be addressed as part of a Team around the Child Meeting. 3.22 On the 1 September 2015, as part of the referral, Harry’s voice was heard. He was spoken to alone and expressed his upset about visits by the police and social services. He is noted as having said he did not want to go back into care and (if this was to happen) he would prefer to live with his maternal grandfather (MGF).  3.23 At the same time the school recorded an incident between an older girl and Harry at school. His mother had allegedly shouted at the girl the next morning resulting in the girl being very upset (this was evidence of her aggression towards others and a worry). 3.24 Period 2 - Harry’s Key Events within the TOR timeframe of the SPR  3.25 2016 - Home alone occurrence (3) aged 8 years. In May 2016, the school reported a staff member walked past Harry’s house at 7am on the way to work. She saw him leaving the house and asked him where his mother was. Harry told the staff member his mother left for work at 6:30am which left him on his own for 30 minutes. Harry walked to the school with the staff member. The school phoned his mother. Harry’s mother phoned the school back as they could not initially get hold of her. She said that she never leaves him for more that 2 to 5 minutes. Harry’s mother was warned previously by CSC about leaving a child home alone, however, she did not heed the warnings and was continuing to flout this appropriate and good advice.  3.26  Foot Injury - On the 15 June 2016, at a Breakfast Club in school, it was noted Harry was not walking properly. He said he fell at home but would not show his leg to staff, who were concerned.  He fell asleep at the table in the club and said he had not gone to bed until midnight as he was doing his homework. The school’s cumulative concerns at the time were his bad leg, the inconsistent account of the reason for this and his tiredness and refusal to show his injury. The HT made a decision not to allow Harry to go on a school trip that day as he was unable to walk. When his mother was telephoned at her employment, Harry became very distressed at this and said, “mum would be angry.” When his Mother was later seen at school, she said he had hurt himself jumping off the stairs. She had considered asking his grandparents to look after him as he complained to her about his leg that morning, but he wanted to go on the school trip. The school are of the opinion the information presented was by both Harry and his mother were both credible.  14 3.27  There was a follow up meeting at the school with mother who was invited to attend a couple of days later and talk to the FSW. Harry’s mother disclosed about him being removed from her at birth and her personal background details. She disclosed the fact she has told Harry about his birth father including rape and his mental illness. This was the first time the school had learned of his past. She agreed with the school’s request for Harry to be referred to the Educational Psychologist (EP). Harry felt his mother’s work was more important than him, but she stated she is working so that they can be independent.  3.28  Foot Injury referral - In July SCST received a referral from Harry’s school in respect of an injury to his left foot as he was struggling to walk. He had told the school he had stepped on a drawing pin but was reluctant for school staff to examine his injury. The HT managed to persuade him to remove his shoes and noticed he had a cut like wound to his foot which looked infected and swollen. Harry and his mother were seen at the school. The school remained concerned there was no clarity as to whether mother had sought medical support for Harry’s foot. Mother was reported as being defensive and angry and was advised to take him to his GP.  The school referred the injury and possible neglect by mother to obtain medical treatment to CSC. The school state they had to insist someone from CSC attended the school. They sent photographs of the injury to his foot which stimulated a SW to attend after the school had finished whilst the school were managing Harry and his mother. 3.29 A strategy discussion took place the following day between CSC and the Protecting Vulnerable People (PVP) Referral Centre (pre Multi Agency Safeguarding Hub - MASH). A Sec 47 single agency Investigation was agreed for CSC to be carried out. There followed a strategy meeting attended by the MASH Supervisor. CSC indicated they would keep the MASH5 updated and disclosed that Mother had refused a full medical assessment however, Harry agreed to go to hospital for treatment to his foot. This resulted in him being admitted as an in-patient for three days for treatment due to the infection, but no formal child protection examination was conducted as Harry was aware his mother did not want this. The examining doctor however, treated him and confirmed the injury was consistent with Harry’s explanation and that the injury had become infected.  SPR Comment: It is confirmed that the school were not invited to participate in the strategy discussion. Considering they were the referrer of suspected neglect and his mother’s delay in seeking treatment, they should have been made aware by SCST and invited to participate in the discussion. 3.30  A Local Authority Designated Officer (LADO) meeting was held later in the month and information was shared by CSC and the school.  Mother had been suspended from her job (care role) where she had been completing a level 2 apprenticeship and the reasons were not known whether it was as a result of the safeguarding concerns raised or for a separate matter. The LADO reserved any final decision pending the planned ICPC on the 26 July 2016. Police from the Child Abuse Investigation Unit (CAIU) assessed the threshold for a criminal neglect case was not met.  SPR Comment: Subsequently a later C&F assessment was completed in November 2017, which recorded Harry’s mother worked ‘in adult services as a carer.’ There is no additional information to say where she worked, her hours and her child care arrangements for Harry in the context of him being reported as home alone.                                                            5 This case arose at a time when the PVP Referral Centre was being replaced by the MASH.  15 3.31 An Initial Child Protection Conference (ICPC) was held on 26th July 2016 and Harry was made the subject of a Child Protection Plan (CPP) under the category of Neglect. This was primarily due to the delay in his mother seeking medical attention for his foot injury. It was known at the time that Harry had severe eczema and a fungal infection on his scalp which smelt and was weeping and required treatment and medication. Harry would not allow his hair to be cut which may have aided treatment. The GP along with other agency practitioners were made aware of safeguarding concerns relating to Harry when they were asked to complete a report of their agency involvement for the ICPC. The school reported to the ICPC that Harry had a number of injuries which had been observed by school staff and when asked how they occurred, they said he would not say, or he made it unclear how they were caused.   SPR Comment: The school shared the information of previous injuries from 2013, 2014 and 2015 at the ICPC. This information should have been referred to CSC at the time of the occurrences and discussed at the review conference when Harry’s case was stepped down after 9 months from the ICPC CP Plan to a CIN Plan. Areas of concern required further examination as there was no retrospective analysis of the long-term cumulative history. Furthermore, details regarding his father were not known; what his mother’s childcare arrangements were for him; being left home alone and what support the extended family were able to offer to reduce the concerns for Harry’s welfare. The CP Plan should have remained open for a sufficient period to demonstrate sustained change. These same outstanding actions are concerns which still persisted at the time of the current event in 2019 and have been addressed in this review within a CSC IMR and SPR Recommendation in Chapter 4.  3.32 The GP provided two case conference reports for Harry, with no reported GP safeguarding concerns for Harry or his mother. The Primary Care IMR states that it must be appreciated; however, the GP’s interaction with Harry was for a short duration only when attending surgery appointments. Other agencies it was suggested were better placed who saw him for longer periods on a daily or more frequent basis to assess him. This SPR believes that GP’s should still be mindful of neglect and be professionally curious and to question, challenge and verify possible safeguarding concerns, especially when there is knowledge of a child’s previous CP history, who comes into the practice. 3.33  Breakdown in the relationship between School staff and Harry’s SW. The School Deputy Designated Safeguarding Lead (DDSL) consulted with the School Nurse (SN) for clinical advice on the management of Harry’s skin condition, while not identifying Harry. The SN advised the school to be proactive and suggested he saw a special paediatrician. The DDSL then spoke to Harry’s mother and she asked the DDSL to write her a letter so she could inform her GP. The DDSL informed the SW that Mother then denied the advice. The DDSL felt her relationship with the SW had broken down as the school felt their views on Harry and his mother were not being appropriately considered by the SW as the SW informed the DDSL “she does not have to follow advice” which the school believed was an unhelpful response. The school’s opinion was the SW may be undermining their challenge of his mother.  The school sent a formal complaint on 23 December 2016 to CSC. A response from the SW’s line manager was not promptly received. SPR Comment: The school, should have used the Pan-Berkshire multi-agency child protection escalation policy that was in place at the time which is now called the Resolving Professional Disagreement and Escalation policy updated in 2019 as laid out in the CP manual, thereby keeping  16 Harry at the centre of concern. The tension between agencies obscured the focus on Harry and his needs even though it may have been for a short time.  3.34 2017 - In January 2017, the Head Teacher escalated the situation with the SW with an email to the CEO of the SCST who forwarded it onto the Director of Operations who, later visited the school. The school felt however that nothing changed, and the promise of an investigation did not materialise. Eventually there was a subsequent meeting between the DDSL and the same SW which focused on their relationship rather than Harry. The school further reported that his mother removed Harry for a month during January 2017, blaming the HT and DDSL for bullying her. At no time did the school lose sight of Harry during this time but when the meeting occurred the focus needed to be on Harry and not on the disagreement between two agencies. 3.35 At a core group meeting held in January 2017, there was a discussion with his mother about the fact she had taken Harry out of school as she had alleged that he was being bullied and she was not happy with the school’s handling of this. Harry’s mother was advised about seeking an alternative school place. As confirmed by the SCST IMR, there was no one from Harry’s school in attendance at this meeting and it is not known or recorded if they were invited. Considering their level of involvement with Harry and his Mother, this was a serious omission.  At a core group meeting held in March however, it was noted Harry had returned to the same school where he had been absent for a period of 4 weeks from the 20 January 2017.  SPR Comment: At a meeting with the HT and DDSL at the school, the Independent Author asked whether Harry was subject to bullying due to comments made together with the insinuation that the school were bullying his mother as outlined above. The school reported no record of Harry being bullied and deny ever bullying his mother who resented the school’s involvement with Harry. It is not known if Harry was seen when he was allegedly off school. Professional curiosity should have been used to check on his welfare to see if there were any other underlying reasons for his school absence.  3.36 The SCST IMR states at a Review Child Protection Conference (RCPC), in April 2017 the CP plan ended. There is reference to therapy having not been available for Harry and it was noted that it was hoped that this might happen as a referral was made for his mother to receive counselling through ‘New Horizons’ and it was hoped that Harry could join in with this. There is also no record of Harry ever having been offered one to one support or counselling despite being identified as a need in assessments and core group meetings. The lack of direct work with Harry is an agency finding and subject to a CSC IMR Recommendation.  SPR Comment: In assessing this period, the SCST IMR concludes there were timely CP visits conducted with seven core groups held, and Harry’s case was stepped down. A CIN Plan was initiated and this concluded on the 9 August 2017 with no final meeting taking place or Lead Professional (LP) being allocated, both of which should have occurred. He was then made subject to a C&F assessment which concluded in December 2017. These aspects have been addressed within the CSC IMR and SPR Recommendations in Chapter 4. 3.37 Following the RCPC in April 2017, the GP and the school were informed by CSC there had not been any significant incidents since the last conference in October 2016 and the CP plan had ended. CSC informed the GP that a CIN meeting would be held on the 2 May 2017. The GP did not receive any further information from CSC until December 2017 when a SW requested a report with up to date health information as part of Harry’s C&F assessment. The GP sent a report and also informed CSC his mother acted in a timely manner and had no concerns about her managing Harry’s chronic  17 skin problem. It transpired, the origins of Harry’s fungal infection were deemed consistent with accounts from Harry and his mother who claimed treatment of his eczema was hindering him from washing his hair or allowing his mother to cut his hair. The HT reported to the chair that the plan had progressed slowly, and the SW advised that a referral should be made to the wellbeing and coaching service, but this hub was not available and had been discontinued. At the last core group meeting on the 12 December 2017, when Harry’s mother had started counselling through the Coaching and Wellbeing Service, it was suggested that perhaps Harry might also become involved in this but there is no evidence that this happened, it was agreed there will be a referral to family therapy. The SW sent a letter to the school informing them that Harry had been removed from the CP process and the SN had seen him and had no concerns beside his appearance which is taken to mean he appeared unkempt.  SPR Comment: Whilst subject of the CP Plan for nine months, the CSC IMR reports he was being seen regularly and there were notable improvements in his appearance and overall demeanour. He was reported to be smiling more, was doing better in school and generally engaged more positively with professionals. At the point when the case was closed in August 2017, Harry was 9 years, 8 months old. The CSC IMR stated the CSC records did not provide a detailed picture of Harry as a child and do not describe his personality, including information on his likes and dislikes and what he did for fun which should have been obtained and considered by professionals. This has been addressed by a CSC IMR recommendation and within SPR Recommendations in Chapter 4. 3.38 Referral. On the 7 November 2017, a Family Support Worker (FSW) from school expressed concern when Harry attended school with a swollen eye following a period off school for a reported skin infection. School had asked him about his injury, and he told the FSW that he had not been to the GP as his mother was treating it. A Multi Agency Referral Form (MARF) was submitted to CSC who advised the school to seek mother’s permission for the School Nurse (SN) to look at Harry’s eye and to contact his GP. The outcome was that the school informed CSC that mother had given permission, although had been hostile and defensive accusing the school of “persecuting her.” In light of previous concerns, CSC progressed the referral through the ongoing C&F Assessment which, concluded on 20 December 2017 with NFA taken, as according to the assessment, no evidence of parental neglect. The focus was on Harry’s sore eye; however, the assessment should have considered the wider historical information and the cumulative effect on Harry.  3.39 Home alone occurrence (4) aged 9 years 11 months. On the 29 November 2017, information obtained from the TVP IMR state that South Central Ambulance Service (SCAS) reported a request for assistance to force entry to his home address as he had been left home alone in the premises. SCAS had referred to the Fire Service to assist in gaining entry as there were no police resources available. The police downgraded and closed the incident to a telephone resolution.  3.40 The TVP IMR records that SCAS raised concerns regarding Harry being left alone at the address. Harry eventually opened the door to SCAS, and the assistance of the Fire Service was no longer required. They again contacted police regarding child protection issues for Harry being left home alone. They also managed to make contact with his mother. When she returned home, SCAS paramedics apparently described her as being irate. 3.41 The incident was originally downgraded by TVP but was appropriately reopened by TVP as Harry was found home alone by SCAS. Police officers were sent to the address and spoke with Harry who they described as scared. SCAS managed to contact his mother who came home and who they  18 described as irate. He was seen by police at the scene and spoken to. Police stated when Harry’s mother returned home, she was ‘upset and defensive.’ An ABCDE vulnerability assessment6 was completed and police assessed that Harry was not mature enough to be left alone. His mother insisted a neighbour was nearby and would have kept an eye on Harry. Police made enquiries and established this was not a firm arrangement with the neighbour. Police sent a tasking request to MASH who made a referral to CSC. The case was already open to CSC and the incident was considered as part of the ongoing C&F assessment.  SPR Comment: It would appear as Harry opened his door to SCAS, the fire service was no longer required. As he was found home alone, the police correctly upgraded their response and attended the scene. The police attendance has been addressed within their IMR and Agency Recommendation to this review. SCAS could not initially find details of this call for the purposes of the review. The logged call was subsequently identified but there was no details of any record made by paramedics who had attended the scene being located. This is a clear recordkeeping issue for SCAS to address, as defined in Recommendation 5 within Chapter 4. Mother was again inconsistent with her explanations to professionals. Appropriate questions were asked to establish Harry’s competence to be alone, such as whether he knew what to do in the event of a fire etc but despite the answer being unsatisfactory, and his mother being very difficult and argumentative, NFA was taken beyond the creation of a CP occurrence. Police in their IMR believe this was potentially because of the failure to identify the significance of previous Police and CSC involvement and as a minimum CSC should have been consulted whilst Police were still in attendance at the address. This would have led to a more holistic exploration with partner agencies information and potentially a trigger for the removal of Harry under S46 Children’s Act Police Powers at the time if necessary. It was felt by the TVP IMR Author that a strategy meeting (SM or discussion) should have taken place and this review agrees with this as it was the fourth occasion when Harry was left home alone. The C&F assessment should have put more significance on the possibility of neglect and the family background history and, at the least should have been extended the period in order to assess the cumulative occasions and impact on him being left home alone. The neglect concerns were continuing despite the advice from practitioners to Harry’s mother who, was agreeing but then ignoring safety advice and is an element of disguised compliance.  3.42 On the 20 December 2017, as alluded to above, the C&FA was completed. It noted Harry’s “chronic skin condition” was described by his GP as “atopic dermatitis - eczema” (a long lasting and chronic condition which flares up periodically). The assessment which commenced at the conclusion of Harry being taken off his CIN plan as outlined above, concluded there was no evidence of parental neglect and CSC closed the case.  3.43 2018 - In July 2018, Harry attended two GP appointments with his mother due to a hand injury he had sustained. He informed the GP that this had been as a result of an incident with another child at school, which was being investigated by the school.                                                             6  The ABCDE model was devised in 2013. Initially it was an assessment tool purely for mental health issues.  Several Police forces, including TVP, are now using it to assess a wider spectrum of vulnerability. The tool consists of 5 areas: Appearance, Behaviour, Communication, Danger and Environment.   19 SPR Comment: The GP should have applied more professional curiosity and made a referral to CSC for it to be duly investigated. 3.44 Period 3 - The disclosure of Harry’s injuries on 7 January 2019 and the police investigation. 3.45  2019 - On the 7 January 2019, at 7.39pm, Police were called to a local leisure centre to Harry (aged 11 years) who had attended the location.  Leisure centre staff noticed he had several recent facial injuries. He was unaccompanied and stated he had injured himself skateboarding two days previously. This was, however, inconsistent with the current state of his injuries as subsequently reported to both Police and later to the hospital. Police who attended the leisure centre also noticed Harry had fresh injuries to his face and hands which were actively bleeding.  He had given the police officers differing accounts as to the cause of his injuries which were not believable. He also told police he had 'room surgery' for his injuries and was not in pain but could not explain what this term meant or where it had taken place and by whom. Police were unable to make contact with his mother and as a result Police Protection (PP) powers were used to safeguard his health and wellbeing and to have his injuries tended to at the hospital. The Frimley Health NHS Foundation Trust (FHNHSFT) Trust IMR states SCAS were also called to the scene but there is no record they attended. It is reported both by the FHNHSFT and TVP IMR’s that police took Harry to the Hospital ED and SCAS confirm they did not. 3.46  At the hospital, Harry was reviewed by a nurse and then a senior doctor in the ED. Harry still insisted he sustained the injuries falling off his skateboard but changed his story saying it occurred before Christmas’ (2018), two weeks previously but was unable to recall the date. Medical practitioners confirmed the injuries were new and not consistent with his explanation.  3.47  It is reported he remained steadfast that the injuries were old and stated that no person had inflicted them. He reported that he lived with his mother and disclosed his father lived elsewhere which he said was complicated and he was not willing to expand further regarding his father. He denied substance misuse and gang activity, sharing that he mostly enjoyed school, had good friends but had been beaten up by the same pupil in his class, many times. Bullying at school is not recorded as having occurred or confirmed from the education submission to the review. 3.48 The triage nurse in ED reported that Harry was wearing a cap and was very reluctant to remove it. He eventually agreed to remove his cap so the nurse could clean his wound. The nurse observed his face had ‘make up foundation applied’ to a healing 1-inch cut. It was also observed that there was a dry blood-soaked plaster/bandage at the back of his head covering a healing injury. The numerous injuries, as outlined below, were treated with ED nursing and medical staff liaising with the CSC Emergency Duty Team (EDT). Police and EDT stated that Harry was not to be discharged to the care of his mother and that she could not visit him on his hospital ward as he was to be detained for treatment. A SM was arranged later the same day (8 January 2019).  3.49 Harry was reviewed by the paediatric registrar following his transfer to the ward. Harry was placed in a side room to afford privacy, where police presence remained. The police shared their concern with the paediatric registrar as presented to them and that his injuries are inconsistent with the explanations given. Police were initially unable to make contact with his mother and following subsequent contact she stated Harry’s injuries were a few days old. She was unclear as to their mechanism. The FHNHSFT IMR reported that neighbours said Harry did not have the injuries at school that day as he had not attended school. It is presumed this information came from the police during their investigation and communicated later and will form part of any evidence in subsequent  20 criminal proceedings. The school were not informed immediately of Harry’s presentation with head injuries to hospital until they were contacted by SCST the following day when they were told he was in hospital with several injuries under police protection.  The school was invited and attended a strategy meeting on the 9 January 2018 for Harry. 3.50 There was further good communication between the paediatric registrar and CSC Emergency Duty Team (EDT), where a brief history of Harry’s social care involvement was shared and confirmed with the registrar, there was no current social care involvement with him. 3.51 Harry’s account to medical practitioners as to the causation of his injuries. Harry told the paediatric registrar that he did in fact attend school on the 7th contradicting his statement to Police earlier that he had not. He went to the Park Arcade after school having first gone home (it is not known if his mother was home, but police tried to contact her) and then to a Sainsbury’s supermarket. He stated his injuries happened “before Christmas” when he was trying to do a trick on his skate board but again was unable to recount the exact date. He denied that an assault had caused his injuries. He stated that he was happy in hospital and compared the hospital room to a hotel.  3.52 Child Protection Medical. The same day, a CP Medical was completed by a Consultant Paediatrician. There was a small-time delay in completing the medical as Harry’s mother refused to consent. This was the same scenario previously when she did not want him to have a CP medical for his foot injury in 2016. On this occasion his mother’s objection was overridden by Slough CST, as Harry was under police protection, who consented to the CP medical being carried out.  SPR Comment: There must be parental consent for Harry to have had a child protection medical which his mother had declined. SCST could have decided at that stage to apply for an ICO or an Emergency Protection Order (EPO) in order for the Local Authority to attain parental responsibility allowing them to give consent which in this case they did not. SCST took the decision, as he was under police protection, to authorise the medical. Where a medical assessment or treatment is required as an emergency, parental consent is not required. The question is whether Harry’s case was considered as an emergency. This SPR believes there was a sufficient case to say it was as the welfare of the child is paramount, as Harry was required to become an inpatient for the treatment of his injuries. In the event, the CP medical confirmed significant and unexplained acute injuries which resulted in this SPR being commissioned. The issue of parental consent has been addressed as learning in this review in Recommendation 7 in Chapter 4. 3.53 The history taken from Harry at his CP Medical by the Consultant Paediatrician records that he persisted in saying he fell off his skate board ‘before Christmas.’ He reported the linear marks which extended from the top of his back to the bottom and on his chest were “caused by sunburn” and he was observed as being unkempt.  3.54 Injuries observed at the CP Medical were: -  Cut on right lower lip. Labial frenulum intact.  Fresh blood inside his nose.  Smaller cut below right eye.  Open cut above left eye.  Blood and swelling on the right ear lobe.  Matted blood on right side of the back of his head.  21  Left lower cheek 2cm linear cut – fresh blood.  Numerous linear marks all over his body ranging from 2.5cm to 7.5 cams.  Linear cut on left side of neck.  Steri-strips on eyebrows and periorbital swelling.  Numerous keloid scars all over his body.  Superficial scratch upper right arm.  Blood round index finger nail.  Scattered scratches on neck.  Swelling to lower jaw.  Dried blood on back of his head.  Multiple linear marks on his back. Some healed, some with scabs.  X-rays reported no obvious facial bony injury and his left index finger: recent injury, not acute.   3.55 Conclusion of the CP Medical:  The acute injuries are not consistent with a history of falling from a skateboard more than two weeks previously.  There were several marks and scars with no clear explanation of how they might have occurred.  Acute injuries include a swollen left eye, dried blood on scalp not consistent with the history of skate boarding accident before Christmas. Other marks noted have no clear explanation of how they occurred.  3.56 Police Investigation and Harry’s current situation     3.57 Harry remained overnight in hospital under Police Protection with police having made a formal referral to CSC. At the SM held on 8 January 2019, it was decided there would be a Joint Section 47 investigation with a follow up SM held the following day. CSC confirmed Harry was placed in foster care direct from hospital with Care Proceedings initiated.  3.58 Harry’s mother was arrested for neglect at her home address the same day. The premises were searched, and a small quantity of cannabis was seized along with two grinders. Blood stained clothing together with mother’s blood-stained pillow was also seized for potential evidence. Harry’s mother denied the drugs and grinders were hers and stated the blood stains came from her which forensic examination confirms this was not the case. This may form part of the evidence in any potential criminal proceedings. Harry’s mother has denied any involvement in her son’s injuries. 3.59 A police investigation by the CAIU into criminal neglect is ongoing and has resulted in the arrest of his mother who is currently released under investigation pending further enquires. There has been a delay in concluding the police investigation, compounded by a delay in receiving third party material from the Family Court care proceedings which Slough Children’s Service Trust, had commenced in order to safeguard Harry. 3.60  This SPR awaits the outcome of the police investigation and the decision of the Crown Prosecution Service (CPS) whether there will be any subsequent criminal proceedings instigated against any person.  22        Chapter 4 4 Analysis of Professional Practice using the KLOE’s, SPR Findings and Recommendations 4.1 This Chapter analyses professional practice. It assesses responses from Agency IMR’s submitted to the SPR and from professionals’ views from the Practitioners Event (PE) held to consider and evaluate Harry’s case. The analysis has identified for each of the five KLOE’s, seven Findings and SPR Overview Report Recommendations. They should be read in conjunction with the preceding Chapter which discusses Harry’s key events and interaction with practitioners. It must be noted, several KLOE have similar elements in the question asked. These are highlighted with reference to the KLOE, Findings and SPR Recommendations below.  4.2 KLOE 1 - Was Harry’s voice listened to, heard and acted upon?  4.3 What were the issues in this case? There was good communication by some practitioners who attempted to communicate with Harry which, the narrative in Chapter 3 describes. There were, however, concerns identified by agencies to the review. This includes the actions of practitioners including within the CP, CIN meetings and core groups who must be child focused and consider all presenting options which was not consistent in Harry’s case. The school attempted to capture the voice of Harry, but this was a very difficult situation for the school as he was heavily influenced by his mother. There were however, as highlighted in agency IMR’s, missed opportunities to hear his voice and work with him. His mother presented differently towards professionals with a particular animosity shown towards the school. No professional managed to really understand Harry without him reflecting on what his mother would say or think. It appears he did not have his own voice by his reluctance to speak about current concerns within and outside the home and how he felt being left home alone. 4.4 The practitioner’s event suggested there no focus on Harry who was lost amongst adults, particularly his domineering mother. It is the view of this report that practitioners did put Harry at the centre of concern, but the focus was temporarily lost when there was tension between partners (the school and social worker). However, the school are of the opinion although they were not always able to fully capture Harry’s voice, they constantly tried to engage with him which this SPR agrees with, as evidenced within the narrative in Chapter 3. There were, however, many instances when Harry was listened to by professionals, such as when TVP were called to the leisure centre. They listened and supported him and took him to the ED. Harry’s voice, however, was not always consistently captured to consider his inner thoughts. From Harry’s perspective, practitioners  23 engaged with him and made every effort to help him articulate what was happening to him, but practitioners felt that his voice, wishes and feelings were not fully expressed because he was afraid of and was deeply loyal to his mother. Also, his mother’s volatile and difficult behaviours required a focus on her, so overall his voice did not have sufficient weight. Therefore, opportunities to work with him, to obtain an overview of his lived experience, was not always taken, as outlined in Agency IMR’s to the review. The following finding and themes have been identified: -  4.5 Finding 1.  The need for practitioners to remain child focused in order to capture the voice of the child and a review of the Slough Multi-Agency Threshold Guidance for children. 4.6 What should be considered? Finding 1 - It is incumbent on practitioners to listen to the voice of the child and consider and look at the child’s life experience and how they present to others. Any child protection concerns must be recognised and acted upon. Practitioners should always ‘Think children first’ with an emphasis on the priority of a child’s welfare over a parent or guardian. There must be awareness for the need to apply professional curiosity and act on concerns of disguised compliance. Some practitioners had no concerns regarding his mother, contrary to the impression the school had. There were missed opportunities to ensure the whole picture of Harry’s life was captured and assessed. There must be proactive engagement with children to actively capture their voice. The school attempted to capture his voice but felt they were left to deal with Harry without effective support from other professionals. A professional meeting can be instigated by any partner to share concerns and should always be considered. It is acknowledged this can sometimes be difficult as social workers may not or be unable to attend a non-statutory meeting, but this should not stop a meeting being held. It is imperative that practitioners, must have the confidence to challenge and talk to people. Furthermore, the Safeguarding Practice Group should review the current Slough Multi-Agency Threshold Guidance (2018), which provides a framework for all professionals working with children and young people, to ensure it is up to date and relevant in order to support and guide practitioners. The following SPR Recommendations 1 and 2 are made: -   SPR Overview Report Recommendation (1) for all Safeguarding Agencies to the Review The need for practitioners to remain child focused in order to capture the voice of the child. It is recommended that Slough Safeguarding Practice Review Group are assured by all safeguarding agency partners to the Safeguarding Practice Review for Harry that the voice of the child  is always captured and the focus remains on the child or young person, and that a professional meeting can be called by any partner to ensure communication and challenge of safeguarding concerns.   SPR Overview Report Recommendation (2) for the Slough Safeguarding Practice Review Group A review of Slough Multi-Agency Threshold Guidance It is recommended that Slough Safeguarding Practice Review Group, review and update the Slough Multi-Agency Threshold Guidance (2018) for all professionals working with children and young people. 4.7 KLOE 2 - Were there missed opportunities to provide appropriate interventions to help  Harry?  24 4.8 What were the issues in this case? There were clear elements of neglect or the concern of neglect in practitioner’s involvement within Harry’s life since his birth. He was subject to CP and CIN Plans and most recently a C&F assessment. There were persistent concerns of his presentation and behaviour at school. He appeared intimidated and was defensive of his mother with both giving inconsistent accounts when challenged regarding Harry’s health concerns, injuries sustained and questions over the mother’s parental care. The concerns raised should have stimulated a more robust response and assessment of risk. There were missed opportunities to consider the risk with signs and symptoms of possible neglect and abuse being present and not considered or identified. Capturing and understanding the family dynamics and other family support available should always be established which, was not sufficiently carried out in Harry’s case. The four occasions when Harry was left home alone should have stimulated more action to be taken using professional curiosity. Other action could have been taken into consideration such as police protection and having a strategy discussion on the occasion Harry made a 999 call which, TVP have addressed within their Agency Recommendation to the review. There were also missed opportunities by the GP to question further or consider a referral to CSC, when Harry attended appointments with his mother, during the period he was subject to a CP Plan. This included the delayed presentation for treatment with his infected foot, injuries to his hand allegedly occurring at school and his recurring skin infection, all were never fully assessed. Furthermore, there were four missed opportunities by the school when injuries to Harry’s face were noticed. They were dealt with internally and his mother spoken too. These events should have been referred to CSC at the time, in order to assess and consider the wider picture of what had occurred.   4.9 The review has disclosed issues of failure to effectively communicate, share information and concerns with the quality of recordkeeping, a continual theme in SPR’s and in serious case reviews previously. This also includes practitioners increasing the use of professional curiosity. All these issues have been identified by CCG, Solutions 4, SCST and TVP in their IMR’s and subject to their own agency recommendations. When dealing with a child known to be or has been the subject of child protection, they should take account of the previous history when assessing current concerns.  All staff should be aware and comply with the Slough Neglect Tool 20197 which is currently being updated, to identify the signs and symptoms of neglect, including physical and emotional abuse; to act at the earliest opportunity; making sure the family dynamics are known, with a full assessment of risk conducted. There needs to be a more consistent approach to the neglect of leaving a child of Harry’s age home alone by developing and agreeing a ‘Home Alone” multi-agency strategy with particular emphasis on repeat occurrences. The CSC IMR also confirms there should have been more unannounced visits during the assessment period and more communication with his mother about what support was available, which this review concurs with.  4.10 Not all relevant safeguarding minutes of meetings were completed and shared with relevant agencies in a timely way. In this case it did not always occur and when they were shared, they were not received expeditiously. There is limited evidence of any management oversight of delivery of the scrutiny of chairs of meetings or supervisors, as some actions remained outstanding throughout the CP and CIN plans. No Lead Professional was allocated for Harry as the final CIN meeting was never held and this is an omission, and this was not picked up in reviewing and supervising the CIN process. Furthermore, the CSC team managers summary at the conclusion of the SW’s C&F                                                            7 Slough Neglect Tool, 2019  25 assessment completed in November 2017, records it was thorough, analytical and reflective, providing a summary of past concerns which, would appear optimistic in light of the findings in this review. Overall this SPR and the opinion from the practitioner’s event, questions whether the step-down arrangements were carried out too soon when actions to be taken in the CP and then the CIN Plans were still unresolved.  4.11 The TVP IMR reports that this particular MASH had an expectation that the conference chair persons would escalate matters when necessary, as the police do not have the capacity to review every set of CP conference or minutes of meeting. This SPR agrees with the TVP IMR Author, that this creates an area of risk, placing too much expectation on the conference chair, or other non-police personnel to recognise what is relevant to a criminal investigation. It also creates a danger of new evidence or intelligence from other agency sources not being brought to the attention of the police and raises a risk of intelligence or allegations of crime being missed. The following findings and themes have been identified: - 4.12 Finding 2. Recognising the signs and symptoms of neglect in children, the assessment of risk and enhanced professional curiosity.   4.13 Finding 3.  Supervision, sharing information, communication and record keeping   4.14 Finding 4.  Review of the TVP function within the Multi-Agency Safeguarding Hub (MASH).   4.15 What needs to be considered? Finding 2 - Greater professional curiosity should have been applied by professionals as identified by CCG, Solutions 4, SCST and TVP in their IMR’s and subject to their own agency recommendations. All relevant agency staff involved in this SPR should be aware of and comply with the Slough Neglect Tool 2019 which is currently being updated, to identify the signs and symptoms of neglect, including physical and emotional abuse; to act at the earliest opportunity; making sure the family dynamics are known, with a full assessment of risk conducted. There needs to be a more consistent approach to the neglect of leaving a child of Harry’s age home alone by developing and agreeing a ‘Home Alone” multi-agency strategy with particular emphasis on repeat occurrences. He had been left home alone on four reported occasions, with advice previously given to his mother about not leaving him home alone, was clearly not being followed. Professionals should have considered the cumulative effect it was having on Harry which, if there was an agreed strategy, would outline the action that should be considered and expected to be taken. The CSC IMR identified, and which this review agrees with, there should have been more direct work with Harry to assess his needs, his ability to ask for help. They should have confirmed what supporting networks were available both professional and with his extended family such as his MGF which he spoke about on occasions in conversation with practitioners. The following SPR Recommendation 3 is made: -  SPR Overview Report Recommendation (3) for all Safeguarding Agencies to the Review Recognising the signs and symptoms of neglect, the assessment of risk and enhanced professional curiosity It is recommended that Slough Safeguarding Partnership Board are assured by all safeguarding partner agencies to the Safeguarding Practice Review for Harry, that all staff are reminded to comply with the following: -   26  Knowledge of National and Local Child Protection Policies and Procedures and guidance, utilising the available Slough Neglect Strategy and Tool 2019 to assist in identifying the signs and symptoms of neglect, physical and emotional abuse and to take immediate and necessary action if is required.  To conduct enhanced multi-agency risk assessments to include capturing and analysing the history and family dynamics, to obtain a fuller picture of a child and young person’s life, in order to take immediate and appropriate action.   Professionals must use more professional curiosity and follow up unanswered concerns, questions and inquire into child protection issues, to ensure a satisfactory outcome is obtained and accurately recorded.  To develop an agreed Multi- Agency Home Alone strategy to ensure a consistent approach and expectation of agency action to be taken within Slough.   4.16 Finding 3 - All relevant safeguarding meetings such as ICPC, RCPC, CP, CIN and core group minutes and assessments records must be completed and shared with relevant agencies in a timely way without fail. There should be support for management oversight for chairs of meetings or supervisors, to ensure all actions identified in a child protection case are completed. If an action remains outstanding, the reason why must be assessed and record if there is likely to be any impact on the child if the action is not taken. Agencies must be reminded to take the opportunity to refer possible child protection safeguarding concerns to CSC and agency partners or at the very least call a professionals meeting to communicate and discuss the concerns at the time. Agencies should ensure their recordkeeping practice and systems are effective to ensure records are current and effective to support professional practice. There should be compliance with the SCST CIN guidance and standards.  4.17 If a child subject to previous CP, comes to notice, this should incur additional supervision and scrutiny and where a lead professional is required at the final CIN meeting, one must be appointed.  This will ensure all aspects of a child’s case can be assessed, with all key decisions and available support is considered, together with an accurate record of the action taken and shared if relevant. In the foot infection referral in 2016, the referring school were not invited to the subsequent strategy discussion that followed which should have occurred. Communication and sharing information therefore failed in this respect. Also, if a final CIN closure meeting is not held, as in Harry’s case, supervision should identify the fact and take the necessary action. Minutes of meetings should be completed promptly and shared to all participating and relevant practitioners so that the accuracy of the minutes can be agreed and confirm what actions individual agency practitioners are expected to complete, which the CSC IMR has addressed within their agency recommendations. SCAS could not initially identify the call to TVP and had no record of the home alone incident when Harry made an emergency call. Information within the TVP IMR confirms the incident stemmed from SCAS who called police to Harry who had been found home alone. SCAS have since located the emergency call log and accept there are recordkeeping issues for SCAS which this finding and the following recommendation also applies to. The following SPR Recommendation 4 is made: -  SPR Overview Report Recommendation (4) for all Safeguarding Agencies to the Review Supervision, sharing information, communication and record keeping  27 It is recommended that Slough Safeguarding Practice Review Group are assured by all safeguarding agency partners to the Safeguarding Practice Review for Harry, that: -   Chairs and supervisors will ensure minutes from child protection meetings and assessments are expeditiously shared to relevant agencies and practitioners.  All relevant practitioners and referrers of safeguarding concerns must be invited to meetings and discussions to ensure all child protection concerns are captured and addressed.  All actions agreed at child protection conferences and core groups must be completed. Where actions are not completed, the likely impact on the child of not delivering the actions must be recorded.   Remind staff where there are possible CP concerns that the information must be shared with prompt referrals where concerns are identified.  Following a child protection step down, a final CIN meeting must always take place and the role of lead professional to support the child going forward, should be appointed.    There is audit compliance with CP procedures on CP and CIN plans and step-down processes.  Practitioners should be made aware of the SCST CIN guidance which is now in place and for all agencies to use and comply with the guidance for consistency of professional practice.  Agencies should ensure their recordkeeping systems are robust, accurate and efficient for purpose and staff are complying with policy.  4.18 Finding 4 - In respect of the TVP issues in this particular MASH. The TVP IMR Author informs the review that the approach of those police departments involved with child protection (i.e. MASH and CAIU) have since evolved to be more professionally curious and to consider such cases in a wider context, due to the concerns and potential for missed information and action required in child protection cases. TVP have made a recommendation to this SPR for TVP to reassess its process for the handling of case conference notes and review police action within the MASH. This will be an opportunity to look into the function and resource capacity of the MASH to ensure standards of safeguarding children and young people are maintained to expectations. There is therefore no requirement for a SPR Recommendation, as TVP are addressing this finding.   4.19 KLOE 3 - Were partners sharing information appropriately and formally, both during the  times when Harry was and was not subject to a child protection plan?   4.20 This KLOE refers to sharing information which has been addressed within the narrative in Chapter 3 and within KLOE 2, in Finding 3 and SPR Recommendation 4 above.  4.21 KLOE 4 - Where an agency had a concern, were the procedures followed to address that  concern including the application of escalation procedures where appropriate? 4.22 What were the issues in this case? This SPR has identified a requirement to highlight to professionals working together that they must take account of another agencies concerns and opinions. Policies and procedures as well as the Pan-Berkshire Multi-Agency Child Protection Dispute Resolution Procedures (which has been updated and referred to below in 2019), are current and were not always followed. Every agency who reports a safeguarding issue must be given the respect  28 and receive an effective response, to ensure any request for help and support in a CP case is addressed and appropriate action taken if found necessary. The relationship between the school DDSL and the SW broke down with disagreements, leaving the school feeling undermined with the SW and CSC response. The focus was on a relationship between two professionals rather that maintaining focus on Harry. Even though this was of a short duration in comparison to the period under review, the school believed CSC were not supporting them. CSC did not appear to have had the same issue with Harry’s mother which the school had, whereas the school were seeing Harry daily, highlighting concerns which his mother clearly resented. The SW it is believed, was not taking the view of the school who believed the SW was appeasing his mother. It became necessary for the HT to raise a record of concerns against the SW and had to wait until December 2016, some three months later for a response from the SW manager. CSC were emailed again about the response and made a formal complaint, which escalated to the CEO of SCST and forwarded onto the Head of Operations (HO) who made a visit to the school. The HO listened to the school’s concerns and promised an investigation as they felt unsupported. The school never received an outcome. Adopting the dispute resolution procedure should negate the need for an agency to make a formal complaint against another. The following finding and themes have been identified: -   4.23 Finding 5. Professionals working together, compliance to policies and procedures and escalation processes.   4.24 What should be considered? Considering agencies are working to the same ends, they need to work together. The delay in responding to the initial school concern is unacceptable and after the visit by senior management and the promise of an investigation the outcome should have been reported to the school. Therefore, when an agency has an issue or complaint, agencies should use the Berkshire Escalation Process for Professionals with Safeguarding Concerns. This policy was reviewed and was updated in April 2019. It is now the called ‘Resolving Professional Disagreement and Escalation.’8 The resolution processes must be treated expeditiously. Harry’s mother and her dislike of the school came between the working professionals and took the focus off of Harry. It is not unreasonable to make sure that in future, school staff are listened to and their opinions taken seriously. The school raised an issue with the SPR Independent Author regarding cases which do not meet thresholds (addressed in KLOE 1 and Recommendation 2 below). It was also an opportunity due to the concerns for the school or any safeguarding practitioner to call a multi-agency professional meeting to discuss the concerns, of the advice ignored by Harry’s mother, safeguarding concerns and the relationship the school had with her and the CSC, to maintain the focus on the child protection and thus keeping Harry at the centre of concern. The following SPR Recommendation 5 applies: - SPR Overview Report Recommendation (5) for all Safeguarding Agencies to the Review Professionals working together, compliance to policies and procedures and escalation processes.  It is recommended that Slough Safeguarding Partnership are assured by all safeguarding agency partners to the Safeguarding Practice Review for Harry that: -                                                            8 Berkshire ‘Resolving Professional Disagreement and Escalation Policy.’ 2019  29  In practice, every agency and practitioners should be treated with respect, and their contributions are given equal weight and status as other professionals.   All agencies should comply with the Pan-Berkshire - Resolving Professional Disagreement and Escalation Policy (April 2019) in resolving disputes between agencies and safeguarding professionals. Professionals should respond as expeditiously as possible, ensuring any issues are addressed with the referrer.  4.25 KLOE 5 - Was there an element of “professional accommodation” to Harry’s situation? (In  other words, did professionals get used to Harry’s situation which might have affected their perception of his condition and toleration of his home circumstances? 4.26 What were the issues in this case? Generally, agencies to the review identified that there was a lack of professional accommodation to Harry’s situation. Harry’s defensive and sometime inconsistent accounts to reasonable requests from school staff who, only had Harry’s welfare at heart, were difficult and his mother was particularly demanding. There are clear elements of his mother’s control which worried Harry as to how his mother would react when concerns were discovered and raised by school staff. She was evidently strict with him, but his home life was never properly assessed from the information submitted to this review. She appeared to be compliant with the SW and the GP but that did not make Harry safe. Mother had displayed a varied and superficial compliance dependent on who she interacted with. There was no professional accommodation from the perspective of the school.   4.27 This report suggests there were elements of disguised compliance such as when Harry’s mother was given appropriate safeguarding advice not to leave Harry home alone but, she continued to do so. The Primary Care IMR is of the opinion there should not be too much emphasis and weight placed on the GP’s assessment of Harry when considering the degree of neglect and the mitigation of the related risks. His mother always presented well to the surgery and the appointments were only for 10 minutes duration. As the CCG state, there were no reports from primary care about safeguarding concerns but acknowledges learning for the GP practice in their IMR to the SPR. Harry’s mother when dealing with Harry’s SW appeared compliant, but this was not the case with her interaction with the school.   4.28 The school stated, his mother was extremely aggressive (a trait from her youth) towards another young girl at school. Furthermore, his mother told the school she had shown Harry his birthday presents but since he had lied to her (no details), she was no longer giving him the gifts but will provide him educational books to read. The school provided books for him which the mother appeared grateful for and agreed to take another book titled “boy in the dress.” Harry’s mother subsequently accused the school of encouraging him to become a transvestite because of the title of the book. The GP treated Harry and his mother regularly, mainly related to his skin infection. The CCG IMR Author suggests the reoccurrence of his skin infection was ‘normal’ in their opinion. It was not seen as a related cause and again when there was a delay in Harry receiving treatment for his infected foot injury where neglect was not considered. The CSC team manager’s summary at the conclusions of the SW’s C&F assessment regarding the robustness of the assessment that Harry was not at risk of significant harm considering Harrys’ history and concerns identified, this SPR suggests these highlighted comments could possibly be an element of professional accommodation.  30  SPR Comment: The C&F assessment was reviewed for the purposes of this review. The view of the SPR is that the assessment was not robust. It would appear the answers Harry’s mother gave when questioned regarding safeguarding concerns were accepted with little challenge. A capacity test concluded that Harry should not be left unattended as he was unable to give the right answer when asked what he would do in the event of a fire. The assessment also does not say whether the further work identified with Harry to teach him how to respond appropriately in an emergency, was conducted. It is not recorded whether the neighbours confirmed there was a satisfactory agreement in place when he was left home alone. The poor relationship his mother had with the school is highlighted. She said she felt targeted and tarnished given her history and was struggling to repair her relationship with the school. There was only advice given to Harry’s mother to try to improve her relationship with them. It is known from the school, the SW did not consult with the school regarding the assessment findings before the conclusion of the assessment, in order to resolve the issue between Harry’s mother and the school. A professionals meeting with agency partners should have been considered to discuss the wider impact on Harry before closing his case to SCST.   4.29 Harry’s mother, on two significant occasions would not consent to a child protection medical examination of Harry. The first occurrence was when he sustained a significant infected wound to his foot and again at the disclosure of the significant injuries which resulted in the current police investigation and this SPR. The mother finally agreed with much persuasion in the first instance for the medical as the wound needed hospital treatment and Harry himself wanted to go to hospital for the wound to be treated. In the circumstances of this current case and because Harry had been taken into police protection, CSC made the decision and agreed to allow a CP medical for Harry without his mother’s consent. The following findings and themes have therefore been identified: -  4.30 Finding 6.  Further Multi - Agency training in disguised and varied compliance.  4.31 Finding 7.  Child Protection Medical Examinations.  4.32 What should be considered? Finding 6 - Training in dealing with confrontational parents or guardians must be made to instil confidence and support for practitioners This should include concerns regarding Harry’s silence and posing the question whether there were any elements of his mother grooming his responses to practitioner’s scrutiny. From his presentation, comments and answers made to practitioners, as disclosed within the narrative in Chapter 3, this is highly likely. Where these situations are suspected or exist, all local and national policy and procedures need to be enacted to ensure the welfare of the child remains paramount. Threshold training has already been implemented within Slough, but it should be open to all safeguarding partners as the school particularly asked it to be open to CSC.   4.33 In dealing with confrontational parents, as in this case, a family needs to be appointed with an experienced SW. Practitioners should not be diverted off course if a parent or guardian is difficult. Where a parent does not wish to be challenged and who becomes defensive, it is imperative that practitioners still continue to take all necessary action to protect the health and welfare of a child or young person. Safeguarding action taken must be recorded, assessed and checked for accuracy and  31 referred or shared in the appropriate way. Practitioners must be aware that a parent or guardian can be telling different things to different professionals. Therefore, there is a need to ensure a joined-up approach by professionals, mindful of disguised compliance of a parent or guardian who purports to comply or varies their compliance when interacting with practitioners, especially when there are repeated and ongoing concerns. Recommendation 6 below, will go towards mitigating professional accommodation when dealing with difficult parents who could intimidate or manipulate some practitioners. The following SPR Recommendation 6 applies: - SPR Overview Report Recommendation (6) for all Safeguarding Agencies to the Review Multi- Agency training in disguised and varied compliance.  It is recommended that Slough Safeguarding Practice Review Group are assured by all safeguarding agency partners to the Safeguarding Practice Review for Harry, ensure: -  Staff should always consider disguised or varied compliance in any safeguarding case and to take appropriate action.  Staff are supported and trained in dealing with difficult and confrontational parents or guardians and who may be grooming a child and young person’s responses to practitioner’s scrutiny.   4.34 Finding 7 - At the practitioner’s event, there was a request for the SPR to consider seeking legal advice and clarity from Slough Legal Services in order to agree an understanding between Health, Police and CSC. This is regarding obtaining consent for child protection medical examinations and action to be taken if a parent or guardian refuses to give consent. In Harry’s case, it was well managed by professionals within this review on the two occasions it arose. If no parental consent is forthcoming, the usual process would to be for the Local Authority to make an application to the court for an Interim Care Order or Emergency Protection Order. This did not happen in Harry’s case as the SCST took the view he was in Police Protection and it is suggested, assumed temporary parental consent to allow Harry’s CP Medical. In fact, no parental consent is required if it is felt that a medical examination and treatment is needed in an emergency which it is suggested, it was an emergency in Harry’s case. SCST considered the welfare of Harry was paramount and the subsequent hospitalisation and diagnosis of the significant injuries he sustained would go to support that the action required for a medical and treatment of his injuries was urgent. What would help is to make it clear in child protection training that when parents refuse a medical, in each case there is a range of options which should be explored, including legal advice. The following SPR Recommendation 7 applies: - SPR Overview Report Recommendation (7) for Slough Borough Council Legal Service Child Protection Medical Examinations  It is recommended that Slough Safeguarding Partnership, should include within child protection training, the range of options practitioners can take, including legal advice, when a parent or guardian refuses consent to a child protection medical and added to the Pan Berkshire policies and procedures as a result of the learning from this SPR.  32            Chapter 5 5  Conclusions 5.1 This SPR Overview Report for Harry is Slough Safeguarding Partnership Board’s response to establish future learning to provide child protection safeguarding within the Slough Borough Council area.  5.2 Predictability and Preventability 5.3 Predictability - The circumstances of this SPR for Harry outlines persistent child protection concerns of possible neglect of Harry since birth until the incident in January 2019 when this review was commissioned. Due to his family background and child protection history, the likelihood Harry would be a victim of neglect was predictable as signs and symptoms of neglect existed throughout his 11 years of age at the time. There were elements of his mother possibly showing disguised compliance when interacting with some professionals particularly when Harry was subject to CP, CIN plans and C&F assessment. His school had persistent safeguarding concerns of his mother’s care.  Advice given to her regarding addressing Harry’s chronic skin condition, the promptness of treatment of injuries and the requirement not to leave him alone, were made to sustain improvements to her child’s life, but she failed to comply with the advice. Neglect and the possibility of physical and emotional abuse is considered predictable in Harry’s case. 5.4 Preventability - The significant and extensive injuries Harry sustained in January 2019 may have been mitigated if the learning as identified in this review was being carried out. Although neglect was predictable, the persistent injuries Harry presented to the GP and within school were never fully explored as to the causation, not assisted by Harry and his mother’s inconsistent accounts. The outcome of the current police investigation and if any criminal proceedings are instigated, will determine whether Harry was subject to physical abuse by his mother. The view of  33 the SPR is there were previous warnings and clear signs and symptoms not only of neglect, but as suggested above, physical and emotional abuse which was never fully assessed when attempting to understand Harry’s life with his mother. The opinion of the SPR therefore is that Harry’s case could have been prevented, which the learning and recommendations from this review will hopefully address for future learning.  Particularly as previous work with the family when Harry was subject to CP and CIN plans, there appeared compliance by Harry’s mother to care and provide for Harry. 5.5 Engagement with professionals - Practitioners Event 5.6 A Practitioners Event was held that was well received and attended by agency practitioners involved in the SPR. The issues submitted for discussion were elicited from the analysis of agency submissions including the KLOE’s and practitioner’s own views and opinions at the event. The information received was taken into consideration and analysed within Professional Practice using the KLOE’s, and subject to the Findings and SPR OV Report Recommendations in Chapter 4.  5.7 Participation of Harry’s family  5.8 Harry’s Mother and Father were not offered the opportunity to participate in the review due to the fact that Mother was subject to a police investigation of Harry’s neglect and physical abuse and it would not be appropriate at this stage of proceedings. The exact details and location of his Father is unconfirmed. He was, however, not part of Harry’s life during the scoping period of the SPR. Professionals did not capture or further consider Harry’s MGP’s either by contact or through his CP and CIN plans or in the C&F assessment. The views of the family have not been incorporated in the report. Therefore, questions as to the care and support that could have been provided to Harry have not been obtained from them. The voice of Harry’s mother is captured throughout the SPR and is subject to extensive comment within the report.  5.9 Culture and Diversity 5.10 This review identified Harry followed the Muslim faith and when he became a Slough Looked after Child (LAC) the foster placement was unaware of his religious culture which should not occur in future placements. Otherwise culture and diversity was not an issue identified within this SPR. 5.11 Previous SPR’s and initiatives 5.12  The NSPCC database for previous SCR and SPR’s was reviewed. There are similar learning as outlined in the analysis of the KLOE’s and SPR Recommendations in Chapter 4. This supports the fact that lessons are not being learnt. The SPR action plan which follows this report should ensure the learning is appropriately disseminated and the lessons are learnt, forming professional practice for the future of child protection in Slough. 5.13 Conclusions  5.14 Harry is now safe, and his health and well-being have considerably improved since he went into care. The SPR had no concerns about how agencies responded to concerns presented in January 2019. Correct child protection procedures were followed at that time which this SPR confirms.  5.15 The SPR reviewed the long-term cumulative effect of his neglect and abuse, in addition to the presence of numerous injuries amounting to serious harm. Specifically, why Harry was living in  34 such conditions for such a long time. There is a need to improve working together and information sharing, learning about neglect, the cumulative nature of neglect and abuse and the necessity to respond swiftly to prevent delay and long-term harm of a child or young person.  5.16  A Slough Multi-Agency Neglect Strategy and Tool 2019 has been published with intensive multi-agency training implemented. Learning from this review will identify what more can be done to make and better inform practice improvements as it is planned for the strategy to be reviewed and updated again in the summer of 2020. 5.17 Safeguarding practice in Slough was rated inadequate (from 2013 until March 2019 when Slough was inspected by Ofsted and rated as requires improvement to be good with a number of recommendations made as a result of the inspection. The school believes that overall, schools were left wanting during this period. This SPR cannot realistically address this view as it is outside the remit of the terms of reference. The review, however, has actively listened to agencies and practitioners involved in the SPR and has attempted to address and improve working relationships, particularly as highlighted in the disagreement between the school and CSC, through Recommendation 5 in Chapter 4.  5.18 Submission 5.19 This SPR overview report for Harry is submitted to Slough Safeguarding Partnership to consider the findings and to promulgate the recommendations for learning to ensure the health and wellbeing of children and young people in the Slough Local Authority area.               35            Appendix 1 - Bibliography and Glossary Bibliography - Additional to the foot notes in the report, the following legislation, documentation and guidance was consulted for the process of completing this SPR: -  Guidance Department for Education database. Working Together to Safeguard Children 2015 and 2018.  Care Quality Commission (2010) Guidance about compliance: Essential standards of quality and safety.  Slough Borough Council, Safeguarding Partnership Board website. Bullying in UK Schools – House of Commons Library, February 2020, a briefing paper discusses the prevalence of bullying amongst pupils in schools across the UK, and policies to prevent and tackle bullying in English, Welsh, Scottish and Northern Irish schools.   Serious Case and Safeguarding Practice Reviews NSPCC database for previous SCR’s and SPR’s - 2015 to 2020.           36                    Appendix 2- Glossary CCG  Clinical Commissioning Group C&F Children and Families  CP Child Protection CPP Child Protection Plan CPS Crown Prosecution Service CSC Children’s Social Care CIN Child in Need DSL Designated Safeguarding Lead  ED Emergency Department FSW Family Support Worker HOS Head of Service IA Initial Assessment  ICO Interim Care Order ICPC Initial Child Protection Conference IMR Individual Management Reviews IA Independent Author LAC Looked after Child MASH Multi-Agency Safeguarding Hub MGF Maternal Grandfather MGM Maternal Grandmother NFA No Further Action PP Police Protection   37                                         PVP Protecting Vulnerable People RCPC Review Child Protection Conference RR Rapid Review SCAS South Central Ambulance Service  SCST Slough Children’s Services Trust SD Strategy Discussion SM Strategy Meeting SO Supervision Order SPB Safeguarding Practice Board SPR (G) Safeguarding Practice Review (Group) SW Social Worker TVP Thames Valley Police TOR Terms of Reference  YOT Youth Offending Team WTSC Working together to Safeguard Children 