Injuries to a girl aged under 12-months-old in 2020. Learning includes: professionals should be aware of the lived experiences of the family and create holistic assessments; where there are children within the family who have complex health needs requiring support from and across multiple services there should be a lead professional to coordinate the response of agencies that considers and assesses the needs and demands from within the family; all agencies should understand and recognise the impact that a previous sibling bereavement can have on a family; if a mother states that fathers or men are 'not involved', agencies should use professional curiosity to ensure that they fully explore those people who are associated with a family; when considering reducing or withdrawing any service to a family, health professionals should ensure that the service they are providing is consistent with the level of health pathway; considering historical information and cumulative impact allows professionals to fully understand the family context; holistic assessments need to include a wider picture of the potential stressors for the whole family. Recommendations include: develop a set of standards on early help; ensure that practitioners are appropriately trained in the use of genograms and family mapping; develop a pathway for children for complex health needs; ensure all agencies have an effective identification, assessment, and response to domestic abuse.
      
 Title:  Local child safeguarding practice review: Child G. LSCB: St Helens Safeguarding Children Partnership Author: Wendy Wright and Andy Passey Date of publication: 2021  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                             Local Child Safeguarding Practice Review Child G Review facilitated by: Wendy Wright – Safeguarding Coordinator  Andy Passey – Safeguarding Coordinator OCTOBER 1, 2021                                                                                                                                                                    1 | P a g e    Contents     Page  1.  Context    2 2.  Methodology and Professionals Who Contributed to This Review   2 3.  Family Structure  3 4.  Background 4 5.  What did agencies understand about the children’s living arrangements at the point of which the review period begins. Did these arrangements change during the review period? 5 6.  What was understood by agencies about mothers’ vulnerabilities? (Terms of reference 3) 5 7.  What did agencies understand about the family’s circumstances and the caring roles within the family? (including the role of biological fathers, Partners & Grandparents) (Terms of reference 4 & 5)  7 8.  What services were provided to family members by the agencies involved, during the review period & did the number of agencies working with the family influence the outcomes and impact on the lived experience of Child G and her siblings? (Terms of reference 2, 9, 10)  8 9.  How were Child G’s needs and the risk of harm to which she and her sibling were exposed understood by practitioners and how effective were the actions taken? (Terms of reference 1, 7, 11)  10 10.  How effective was single and multi-agency communication during the review period and how effective were agencies in understanding and overcoming any barriers to engaging with Child Gs family? (Terms of reference 6, 8)  11 11.  To what extent do agencies feel Neglect played a part in this case? If so, what was offered in terms of support? (Terms of reference 12)  12 12.  Did the COVID-19 Pandemic have an effect on the services provided or the family? (Terms of reference 13)  13 13.  Summary  14 14.  Recommendations  14 15.  Appendix  15                                                                                                                                                                    2 | P a g e   1. Context:  This review has been completed further to a referral to the Local Safeguarding Children Partnership Board (LSCP) in mid-2020 by Children’s Social Care as per the processes that are in place. The referral was completed following Child G being admitted to hospital with two skull fractures and multiple bleeds to the brain. To date there has been a number of accounts provided as to how the injuries occurred, none of which have been deemed consistent with the injuries caused. During the production of this report Child G has made a full recovery. As a direct result of the incident Child G and her siblings were removed from the care of their mother and placed with extended family and Local Authority foster carers having become subject to interim care orders. At the time of writing this report care proceedings remain ongoing within the family court alongside a finding of fact hearing in relation to the case.  The LSCP Rapid Review Panel agreed that the threshold was met for a Local Child Safeguarding Practice Review to be conducted. The identified timelines were the partnerships involvement during the 18 months prior to and including the period of Child G sustaining the fractures to her skull. From the initial scoping information, the rapid review group identified the following areas to be considered as part of this review:  How were the Child G’s needs and the risk of harm to which she was exposed understood by practitioners and managers?  Child G and her mother were receiving the support of a number of agencies. How integrated were agencies plans to meet Child G’s needs?  To what extent did agencies understand mothers’ vulnerabilities?  What understanding did agencies have about the fathers of the children and mothers’ subsequent partners?  How thorough was agency understanding in terms of the grandparent’s role within family circumstances especially in relation to the children?  How effective was single and multi-agency communication during the review period?  How effective were single and multi-agency services in promoting Child G’s welfare and in keeping her and her siblings safe?  How effective were agencies in overcoming any barriers to engaging with Child Gs family?  Did the number of agencies working with Child G’s family influence outcomes?  To what extent was Child G’s voice and that of her siblings heard and the lived experience understood?  To what extent was Domestic Abuse a contributory factor in this case? And were agencies overly optimistic about mother’s new partners ability to change?  Where professionals aware of neglect within this family and what was done to support the family?  Was COVID-19 an influencing factor within this case? 2. Methodology and Professionals Who Contributed to This Review: The information available to the review included notes from the Rapid Review Group, merged multi agency chronology, learning summaries provided by all agencies involved with the family and information gathered from a practitioner’s day held in November 2020.  Agencies were requested to complete individual learning summaries which comprised of 14 questions identified by the Local Child Safeguarding Practice Rapid Review Panel.  The following is a list of professionals who contributed to this review by completing the Single Agency Learning Summary Proformas.   Children’s Social Care  PVPU Police  Children’s Hospital Trust  Local Hospital Trust  Adult Mental Health Services  GP Practice  Primary School   Nursery  Community Health Service                                                                                                                                                                    3 | P a g e    3. Family Structure   The relevant family members in this review are: Family Member To be referred to as Subject Child  Child G Twin Sibling 1 Sibling A Sibling 2  Sibling B Sibling 3  Sibling C Sibling 4  Sibling D Mother  Mother Father of Sibling B (No longer in relationship with Mother) Father 1 Father of Sibling C & D (No longer in relationship with Mother) Father 2 Father of Child G & Sibling A (No longer in a relationship with Mother) Father 3 Mothers Partner (no biological link to Child G or Siblings) Partner Maternal Grandfather to Child G & Siblings Maternal Grandfather / Grandfather  When not being cared for in a hospital setting, Child G and Sibling A resided at their home address with their mother and their siblings. Child G’s Mothers Partner also resided at the address on a number of occasions although the exact frequency of his residency remains unclear.  Child G and her siblings had no ongoing contact with their biological fathers during the time period subject to this review. On occasion when Child G & Sibling A were in hospital Maternal Grandfather would take on the caring role for Sibling B & Sibling D.  The family had suffered the bereavement of Sibling C prior to the births of Child G, Sibling A and Sibling D.  Child G is a female child, and she was under 12 months of age at the time she sustained the injury that resulted in this review being undertaken. Her ethnicity is recorded as being white and British.  Learning point 1:  When establishing an understanding of the family structure the reviewers compiled a genogram and held discussions around the family structure within the practitioners meeting. The reviewers found that no agency had a clear recording or understanding of the family structure in its entirety. Through the development of a clear genogram the complexities of the family make up in this case became evident.  The review found that despite agencies involvement no agency recorded the full details of father 1 or father 3 this is in direct contrast to practice standards that some organisations are required to work to. The remaining organisations did not have standards in place. Additionally, the reviewers established that there were a number of unassessed risks within the family network which had not been identified, considered, or appropriately flagged within agencies records. This factor increases the likelihood of risks being overlooked, inaccurate assessment and for the children appropriate support from within a safe family environment not being identified.    Using genograms in social work practice by Hannah Scott (2021) details that a study by Laird et al. (2012) indicated that whilst not used in a high number of cases, those workers who co-created a handwritten genogram with a family (in contrast to the worker completing the system genogram) would include more extensive wider family members. This can be particularly helpful for safety planning using the family network, including Family Group Conferences or exploring Lifelong Links. However, workers must consider the importance of seeking to understand beyond biological family members and the role of family friends and peer relationships, particularly where concerns are present regarding exploitation and extra-familial harm (Firmin, 2019)                                                                                                                                                                            4 | P a g e   3.1 The views of the family  Within any Local Child Safeguarding Practice Review, consideration is always given to obtaining the views of the family in relation to their experiences of working with the agencies involved. In Child G’s case there have been a number of factors that have resulted in the decision being taken not to directly seek the views of Child G or her mother.    For Child G, due to her age the Rapid Review Panel took the decision not to directly speak to her as part of the review. In relation to Child G’s mother and her partner, ongoing investigations, and legal proceedings at the time of completing the report have meant that it has not been possible to involve them directly in the review. However, the mother has been notified of the fact that the review is being undertaken and will be given the opportunity to read the final report prior to publication.        4. Background   At the time of the incident the family were not open to CSC, however Child G, her mother and her siblings were being supported by a significant number of Health professionals working across several Health providers. In addition to this school and nursery were involved with Child G’s older siblings but the family were not open to a coordinated package of Level 2 support.     The family of Child G and her siblings have been known to the multi-agency partnership including Children’s Social Care (CSC) since 2010 just prior to the birth of the eldest sibling. Between 2010 – 2020 there have been 11 referrals made to CSC covering the following areas of concern:   Homelessness / teenage pregnancy  Domestic Abuse between mother and her sibling  Over Chastisement of Sibling B by Aunt.  Risk Uncle poses in relation to alleged sexual abuse (the alleged sexual abuse did not relate to any child subject to this review).  Mother corresponding with a prisoner known for significant Domestic Abuse.  Fabricated/Induced Illness  Loss of a child (Sibling C)  Sibling B being assaulted by Aunt.  Mother being in a relationship with a male whose ex-partner had made allegations of domestic abuse and harassment.  Child G sustaining significant head injury (incident that has led to this review)  These referrals have resulted in a range of outcomes from Child and Family assessments (C&F), Early Help interventions, information signposting and in some cases, there were no further services offered. However, organisations constituting the multiagency partnership over this time period had offered other support and Level 2 support.   The multi-agency partnership from the learning summary, chronologies and practitioner event were aware of a number of factors as listed below:    Mothers mental health, diagnosis of Obsessive-Compulsive Disorder (OCD), depression, and anxiety  The impact on mother of bereavement (Sibling C)  The impact on Sibling B of bereavement (Sibling C)  Mother managing the presenting behaviours of Sibling B  Medical and caring needs of Child G and her twin Sibling A due to prematurity and complex health needs.   Numerous repeated admissions for Child G and Sibling A across two separate hospitals.  Repeated rejection of Early Help Intervention and support  Mother having to live away from the family home whilst Child G and Sibling A were in hospital resulting in Sibling B and Sibling D being cared for by their Grandfather.  Impact on Sibling B’s emotional well-being as a result of mother being away from the family home.                                                                                                                                                                    5 | P a g e    The additional needs of Child G’s older siblings.   Not all agencies were aware of the entirety of the factors affecting the family, as such no one single agency had a full picture of the lived experiences of the children and the family and how these have impacted on the day to day lives given the family were already under a great deal of pressure managing the care of the premature twins who had significant health needs, requiring regular hospital attendance.    Learning point 2: If all agencies had been aware of the picture/lived experiences of the family, this should have led to assessments being completed that were holistic in nature and which clearly evidenced the needs of each family member and any associated risks when needs were not addressed. Resulting in a more tailored package of support being offered to mother and the children.   5. What did agencies understand about the children’s living arrangements at the point of which the review period begins. Did these arrangements change during the review period?   The majority of agencies reported that they generally “believed” the children lived in the family home with mother, and with maternal grandfather on the occasions when the twins were admitted to hospital. Children’s Social Care (CSC) understood that the new partner was also staying in the family home, if not residing there. It was, also acknowledged the twin’s older brothers (Sibling D and Sibling B) had spent large periods of time cared for by Maternal Grandfather historically. When mother was in hospital with the twins maternal Grandfather moved into his daughters’ home to care for Sibling B and Sibling D.   Learning point 3: It is clear from conducting this review that although agencies were aware of different people being involved with the family, no agency could clearly define who resided in the property at the specific times of their contact from within the review period.   Agencies were also unable to identify who held caring responsibilities for the children as this did change on number of occasions between 2019 / 2020.     6. What was understood by agencies about mothers’ vulnerabilities? (Terms of reference 3)  The majority of professionals involved during the timeframe of this review were predominantly Health professionals who represented a wide range of specialist health provisions.  When asked about mother’s vulnerabilities all Health professionals were able to identify those related to her mental health, namely anxiety, depression, OCD, and bereavement in relation to the loss of Sibling C.  However, information provided to the review identified that the other agencies involved with the family did not have overarching awareness of mother’s vulnerabilities. This was predominately due to the nature and timing of their contact with the family of Child G.  Despite services being aware of many of mother’s vulnerabilities, little was done to coordinate a package of support for her. It is recognised that the health visitor referred mother to homestart services, however mother declined this service. Also, on one occasion contacted the GP on mother’s behalf, following her running out of medication. Health visitor contacted the GP ensuring a prescription would be available. However, in summary agencies understood mother’s vulnerabilities but didn’t see the impact of those vulnerabilities on the day-to-day parenting of Child G and her siblings. In conclusion there was a lack of professional curiosity by agencies in relation to the presenting vulnerabilities of mother.    The one area that appears to have galvanised the partnership into working together to understand mother’s vulnerability was focused on the receipt of a referral to CSC suggesting she was at risk of domestic abuse by her partner.                                                                                                                                                                     6 | P a g e   This resulted in the agreement of the need for a Claire’s Law disclosure and agreement to share information held to ensure that she had adequate information to make informed choices. The referral also required a C&F (Children and Families assessment) to be completed requiring multi agency consultation and collaboration. The assessment recognised that the relationship was relatively new and was recorded by the social worker as being in its “honeymoon period”. Research would suggest that professionals at this stage should have been alerted to the fact that this was a period of high risk and increased vulnerability due to a number of factors which are highlighted within both the MERIT (Merseyside Risk Identification Toolkit) and Barnardo’s Domestic Violence Risk Identification Matrix. In addition to this the 2016 article Starting a New Relationship After Abuse by DomesticShelters.org, highlights the increased risk when starting a relationship with someone who has previously been a perpetrator of domestic abuse. The article states:    “There isn’t a simple checklist that guarantees a potential partner will be safe, abusive partners are, by definition, manipulative. They can come across as charming and caring.   No matter how charming a person seems, a history of abusive behaviour is cause for concern, as are other red flags. Abuse is a learned behaviour, which means until it is unlearned, a person is likely to have a pattern of abusing multiple partners.”   Within the C&F assessment the focus was on mothers’ partners previous relationships and did not focus on mother’s relationship history to identify any domestic abuse that may have gone unreported which could increase the risk of domestic abuse in future relationships. In addition, the C&F focused on the risk posed to the children in relation to witnessing possible incidents of domestic abuse but did not consider any risk of the children being subjected to violence themselves, or any other forms of abuse or neglect that may become evident. Furthermore, the review found that during the completion of the C&F significant sources of information were not sought.  This may have provided practitioners with an insight in relation to whether there were any concerns during times of increased stress for the family.     Learning point 4: In late 2019, during a discussion regarding the discharge of the twins from hospital it was identified that there were concerns around mother’s presentation and need for additional mental health support through a referral to mental health services. The review found no evidence of this referral being completed despite the identified need. Furthermore, the review found consideration for a re-referral to mental health services was not given any further consideration by the agencies involved with the family in the time period following, even though there were clear signs of mothers increasing stress and anxiety impacting her mental health.      Learning point 5: All agencies should understand/recognise the impact that a previous Sibling Bereavement can have on a family. This should take into consideration not just the impact it may have on their ability to care for other children at the time of the bereavement but also how it may impact the care afforded to any future children. Health services should consider and assess this specifically during any future pregnancies in order to identify any support needs at the earliest opportunity.     Learning point 6: There was no information submitted to the review to demonstrate that Health providers had completed routine enquiries into possible domestic abuse despite these forming part of NICE guidelines and organisational practice guidance. In addition to this during the screening of the referral regarding possible domestic abuse there is no evidence to substantiate that Health providers were specifically asked by CSC about whether routine enquiries around domestic abuse had been completed with mother and what information Health had recorded in response to the enquiries. The 2014 NICE guidelines on Domestic violence and abuse: multi-agency working details that Health and CSC should ask service users whether they have experienced domestic violence and abuse. This should be a routine part of good clinical practice, even where there are no indicators of such violence and abuse.                                                                                                                                                                     7 | P a g e    7. What did agencies understand about the family’s circumstances and the caring roles within the family? (including the role of biological fathers, Partners & Grandparents) (Terms of reference 4 & 5)  Agencies contributing to this review, had limited knowledge of the children’s biological fathers and reported that it was thought there was no ongoing contact between the children and their respective fathers.   The review found that when mother informed agencies that the children’s biological fathers were not involved with the children, agencies did not sufficiently explore the circumstances of mother’s relationships, what had led to the relationships ending or what if any support the fathers provided or could provide to the children? However, School reported that they had previously explored this issue when Sibling B was in an earlier year group. At the time mother stated that his father did not want to be involved in his upbringing. One key missed opportunity for further exploration by school was when Sibling B discussed not seeing his father during a wellbeing session. This could have been a significant factor in terms of his emotional wellbeing and was an opportunity to increase the support network around Sibling B’s mother. The review found that during Sibling B’s counselling sessions Sibling B explored with his counsellor, the people who were a positive influence within his life. It was identified that his grandfather was an important male role model. The report by the NSPCC  Hidden men: learning from case reviews - Summary of risk factors and learning for improved practice around ‘hidden’ men (April 2015) highlights the importance of exploring all hidden males within a family and details that men play a very important role in children’s lives and have a great influence on the children they care for. Despite this, they can be ignored by professionals who sometimes focus almost exclusively on the quality of care children receive from their mothers/female carers.  This was also the case when it came to mothers’ partner, no agency had a clear understanding of mother’s partners circumstances or the specific role that he played in relation to caring for the children. The review found that across agencies there was an awareness of the concerns in relation to the previous allegations of domestic abuse, raised by his ex-partner.  However, this was only as a result of the referral that was made, and agencies being contacted in relation to the Child and Families (C&F) assessment and was not through any enquiries agencies had made during any contact with the family prior to the referral being submitted.   CSC completed a C&F assessment in relation to the potential Domestic Abuse risk posed by mother’s partner, however failed to explore the exact role this partner played in caring for the children. This assessment focused on the circumstances of the referral (the risk he posed to mother) rather than looking at the wider picture. CSC acknowledge within their learning summary that mother’s relationship history was not really understood, and this remains an area that requires further understanding.   The review found that there was also conflicting information between agencies in relation to mother’s partner. For example, Children’s Hospital Trust believed mothers partner was an on/off partner, it was acknowledged he stayed at Children’s Hospital Trust on a number of occasions, but he was reported as not appearing to play a caring role within the family. Whereas 0-19 service and the Local Hospital Trust detailed that mother’s partner seemed to play a much more active role in caring for the children with the mother of Child G referring to him as “Dad”. The more active role that mother’s partner played was also reflected in schools learning summary who stated that Sibling B had spoken of enjoying spending time with mothers’ partner and had been away for weekends with him.  Two of the agencies involved in this review (School and Nursery) had a clear understanding of the role that Grandfather played in supporting and caring for Sibling B and Sibling D whilst their siblings were in hospital. The other agencies that were involved had an awareness of the fact that Grandfather played a supporting role however did not have a clear understanding of the extent of this role.  In conclusion without an understanding of persons involved in the family and their relevant roles in caring for the children the need for support and potential risks cannot be accurately assessed. This gap in assessment then results in the opportunity to provide a tailored support package being missed.                                                                                                                                                                       8 | P a g e   Learning point 7: The theme of hidden males and absent fathers was evident in this case solely due to a lack of professional curiosity. This reflects similar findings within both national/local reviews and the Boroughs multi-agency audits. Agencies need to ensure that they fully explore those people who are associated with a family, the caring roles they may have, circumstances of previous relationships, and the support that absent partners may be able to provide (either physical, emotional, or financial). If a mother states that “they are not involved” agencies should use professional curiosity to develop the discussion around this topic.   8. What services were provided to family members by the agencies involved, during the review period & did the number of agencies working with the family influence the outcomes and impact on the lived experience of Child G and her siblings? (Terms of reference 2, 9, 10)  During the review period there were a number of services provided and offered to the family. The majority of which were in relation to Child G and her twin with little focus on the wider siblings Sibling B and Sibling D.  Community Health services provided support to the family in the form of the health visiting, school nurse, speech and language, physiotherapy, and community dietetics services. The Health Visiting Service provided safe sleep advice, weight monitoring, arrangement of immunisations, development checks, and safe child handling advice all of which was in relation to Child G and her twin. This service included more frequent home visits due to the twin’s level of health need being classed as Universal Plus in line with the Healthy Child Programme (http://www.healthychildprogramme.com).     The Local Hospital Trust provided ante natal care, ongoing support around feeding following the initial discharge from hospital of the twins. This took the form of telephone support, regular home visits, attendance at pre discharge meetings and relevant referrals to other services when necessary.   The children’s hospital trust provided support during the twin’s attendances at hospital via the medical team and provided support via the complex discharge team.  The complex discharge team arranged and managed all of the Multi-Disciplinary Discharge meetings for Child G and her twin (Sibling A).    Throughout the time identified within the review and up until the reported head injuries CSC did not provide a direct service, other than to assess the family. The outcome of assessment was that support at Level 2 should be offered, this was declined by the family. The Level 2 offer was to include awareness raising about domestic abuse.    One of the key messages identified by the 2021 National Panel Annual Report on LCSPRs was that services should consider the reasons for non-engagement in the family and in the response of practitioners and agencies and how to engage, rather than close due to non-engagement. Progress should be evidenced prior to closure, the reasons for closure should be clear and closure should not be viewed simply as the end, that is, there should be clarity about what to do if new concerns emerge.  The GP provided primary care support for the whole family; this included the issuing of prescriptions/advice, and supporting the Secondary Care provision for the twins and Sibling B.  Sibling B was in receipt of Universal Plus School Nursing Service provision and was under the care of Consultant Paediatrician at the Children’s Hospital Trust for asthma. However school provided the main service for Sibling B, recognising the need to support his emotional health due to the impact of bereavement within the family which was felt to be further compounded by mothers absence whilst responding to the health needs of the Child G and her twin (Sibling A). This support was in the form of weekly wellbeing sessions. School referred Sibling B to an external counselling service however his mother was unable to get him to the sessions and Sibling B also refused to attend. As a result, school found a suitable child counsellor for Sibling B to have weekly counselling sessions in school.                                                                                                                                                                      9 | P a g e   The review established that Sibling D appeared to have significant health needs that were being addressed by primary, secondary, and tertiary health services culminating in an assessment to establish if there were any additional needs. Referrals to SALT and community dietetics were made as a result of the assessment findings however, in early 2019 Sibling D was discharged from the Community Dietetics as a direct result of not being taken to appointments and by mid 2019 there was no service offer to him. This appears to be as a direct result of not being taken to appointments. Additionally, there were no professionals able to demonstrate an understanding of Sibling D’s needs with the exception of nursery who report that Grandad was his main carer, and it was established that any concerns they discussed with him were addressed. It is the opinion of the reviewers that Sibling D was very much a “hidden child” further to the birth of the twins in 2019.  The review found that when Early Help was offered by Schools, 0-19 Service, and CSC it was predominantly offered in isolation with no previous understanding of when or what had been offered by other services. When this support was declined as mother stated that she had sufficient professionals involved little further exploration was completed to overcome the barriers to accepting the support.   Information submitted to the review demonstrated that Health Services were the predominant service provider throughout the review period specifically in relation to the twins. It is clear that there was limited coordination to support the family to navigate the complexity and competing demands placed on them by Health providers who in the main worked in isolation. The one opportunity that did arise to provide this coordination was missed as further discussions across Health agencies concluded that it was not warranted as the family had sufficient support. This decision did not recognise that mother was pulled between the caring roles of the twins and the caring needs for Sibling B and Sibling D i.e. there was no consideration given by the professionals involved in relation to the logistics of how mother was managing to meet and address all the needs within the family. The reviewers are of the opinion that had this been considered by professionals and a coordinated approach introduced the pressures on the family and anxieties could have been reduced.    The reflection at the practitioner event concluded similarly; noting that without a coordinated approach the number of professionals involved does not necessarily equate to successful intervention or positive outcomes for a family as was the case in this review. Therefore, it was concluded that it would have been best practice to have identified a lead professional from within the Health Services to ensure that the services being provided were understood and coordinated.    The review found that despite the complex health needs of Child G and her twin Sibling A, agencies did not consider that a referral to the Children with Disabilities team was needed. Such a referral may have allowed for mother to gain access to specialist support including respite, housing needs, finances, and access to associated charities.   The review identified that the 0-19 service reduced their level of contact with the family in mid 2020. The 0-19 service following discussions with mother ceased their weekly visits and agreed that their next contact with the family would be when Child G and her twin (Sibling A) required their 10-month developmental checks.  The level of contact agreed was found to be inconsistent with the health pathway to which they were open (namely Universal Plus).    In summary the large number of services involved with the family did not have a negative impact on Child G. However, when looking at the needs of the older siblings the review found they were at times overlooked following the birth of the twins, with no one agency clearly understanding their lived experience. The reviewers felt that health services were predominantly focused on the complex health needs of the twins.   Learning point 8:  Where there are children within the family who have complex health needs requiring support from and across multiple services there should be a Lead Professional to coordinate the response of agencies that considers and assesses the needs/demands from within the family. This approach should ensure that all outcomes for all children within a family are met.                                                                                                                                                                     10 | P a g e    Learning point 9:  When considering reducing or withdrawing any service to a family, Health professionals should ensure that the service they are providing is consistent with the level of Health pathway to which the family are open (as defined by the Healthy Child Programme). Any decision to change the level of Health pathway that a family is open to should be supported through appropriate assessment and management oversight.     9. How were Child G’s needs and the risk of harm to which she and her sibling were exposed understood by practitioners and how effective were the actions taken? (Terms of reference 1, 7, 11) Child Gs health needs are clearly documented, and she is known to have complex health needs originating at birth. No agency had identified this family to be at risk of harm and were in the main receiving single agency support above that of universal need.  Information available to the review shows that there were potential risk factors as follows: physical abuse, Domestic Abuse and mental health issues affecting both mother and one of the siblings. The Rapid Review Group identified the possibility of neglect being a feature within the family, this is discussed later in the report.  Physical Abuse: In early 2020 a referral was made to CSC in relation to Sibling B sustaining injuries following falling off his uncles’ bike; the referral also detailed that his Aunt had caused a separate injury by digging her nails in to his arm. No further action was recorded, however the circumstances around Aunt causing the injury were not explored nor recorded.  This was a missed opportunity by CSC to assess and understand any risk to which the children were exposed to within the wider family network. Following school being notified by CSC that the referral would not reach Level 3, school did speak with Sibling B’s mother in regard to an EHAT, however, this was declined.  Domestic Abuse: Good practice would state that when practitioners assess a case in relation to domestic abuse, they should use their organisational policies such as routine enquiries.  The review found no evidence that such routine enquiries had been completed in the case of Child G.  When looking at Domestic Abuse (DA) no agency as part of their learning summaries or from the practitioner day identified DA as being a part of the identified risk relating to the family. This was up until receiving the referral from a neighbouring Local Authority in early 2020 where there were concerns raised around domestic abuse perpetrated by mother’s partner in his previous relationship.  CSC acted appropriately in that the family received an assessment. The assessment concluded that threshold was not met for statutory intervention as there was no evidence that the children had been exposed to any form of domestic abuse with no reported incidents. The social worker (SW) did acknowledge within the assessment that the risk in relation to the partner should not be dismissed but that this relationship was in the early phases and that abuse may not have yet manifested itself.  As such, mother was supported to request and receive information under the Claires Law Disclosure.  The family were offered Level 2 support which was refused; all information was shared with partner agencies.  Mental Health issues: Both mother and Sibling B suffered from Mental Health issues. Agencies had an awareness of mother’s mental health (OCD, depression and anxiety) yet no agency reported that they had clearly assessed how these concerns may or may not have impacted the care afforded to Child G or her siblings.  The review established that across the agencies the indicators of increasing stress for mother such as, an inability to cope with the twins’ health issues and a heavy reliance on Health professionals was not clearly understood or assessed from a single or multi agency perspective in terms of how they impacted on mothers’ ability to parent Child G and her siblings.                                                                                                                                                                       11 | P a g e   The information presented shows Sibling B intermittently presented with aggressive behaviour. This suggests there may have been mental health difficulties, but it does not appear to have been considered by agencies in terms of its increased impact on the family. Counselling was put in place by School however a full assessment may have been more appropriate. School took steps to address this by completing a referral to CAMHS for an assessment and support, however, this referral was rejected. The review notes that the anxiety of Sibling B would appear to correlate with the birth of the twins - the impact of the twin’s complex health needs may have led to Sibling B being overlooked.  Learning point 10: The completion of Accurate risk assessments means a more effective agency response and ultimately better outcomes for children and families. Considering historical information and cumulative impact allows professionals to fully understand the family context.   10. How effective was single and multi-agency communication during the review period and how effective were agencies in understanding and overcoming any barriers to engaging with Child Gs family? (Terms of reference 6, 8) The learning summaries reflected that, agencies generally worked well together to ensure that the safety and health needs of the children were met. At the time of the incident all agencies worked together to ensure that all children were immediately safeguarded. Previous audits and reviews would evidence that this is reflective of practice in St Helens. The agencies involved acted efficiently and effectively, the fact that the incident occurred during a weekend period did not impact or lead to drift or delay in this case. In the past national serious case reviews have talked about the difficulties experienced when dealing with an incident during the “out of hours” period however, this was not evident in this case.       Sibling B’s school detailed that the multi-agency communication was impacted by the fact that the younger siblings did not attend school. As there was no EHAT in place for the family school did not receive or request information from partner agencies. The way in which they overcame this barrier was to speak directly to mother or through communicating with the Education Welfare Officer who had direct involvement with the family.   Sibling D’s nursery had limited communication with outside agencies other than when assessments or screening was completed by CSC.  The nursery adhered robustly to their safeguarding procedures and this meant that they would only communicate with outside agencies when specific safeguarding concerns were raised. Within the nursery there were daily conversations held between staff where concerns would be discussed, reported, and recorded.   Children Social Care was found to have liaised with all professionals currently involved with the family during the two assessment periods. CSC sought information for the completion of screening/ assessments however the outcomes of the these were not consistently fed back to the agencies from whom the information had been sought.  In relation to the health services involved with the family there were some examples of good communication within health services which was specifically in relation to the twins. These examples of effective communication were achieved through multi-disciplinary discharge meetings that were arranged and managed via the Children’s Hospital Trust. The paediatric liaison service was also used to facilitate communication in this case. This service shared information with the Health Visitors, Midwives, GP’s, and the Family Nurse Partnership following attendances at A&E, acute services and discharge from hospital to support the continuity of care.   The review found that Child G, her siblings, and mother crossed primary, secondary, and tertiary care services with numerous health providers all using different electronic health record systems with no one single system collating all of the information. When we look at information sharing with some organisations as in this case the HV, SN and adult mental health all had the same electronic system however did not triangulate any of that information.                                                                                                                                                                      12 | P a g e   Due to these complexities and the barriers that that they create, there is a reliance on a health professional as in this case taking the lead for the child and families health needs to support a co-ordinated plan working with the parents. What should have happened in this case is that health practitioners knew the difficulties the family experienced, the level of health need and the potential stress and pressures on the family but didn’t work with mother to pull that together in a joint health EHAT enabling all to see the bigger picture around the need for support.  The reviewers found barriers to communication and information sharing to be a factor in relation to Fabricated or Induced Illness (FII). In 2018 concerns of FII were raised in relation to Sibling D and again in 2019 in relation to Child G and Sibling A. The initial concern by the children’s hospital trust resulted in there being no evidence to substantiate a finding of FII. The screening of the further anonymous referral in 2019 made no mention or reference to the FII referral or outcome for Sibling D in 2018. This demonstrates that there was no triangulation of the information held within the different health systems.   The review found no evidence of communication or coordination between the different internal departments within the Children’s Hospital Trust which during the time period of this review had all of the children within the family open to their hospital services.   When looking at communication between agencies it was also evident that General Data Protection Regulation (GDPR), and consent acted as a barrier to communication. Agencies become hesitant to request and share information as Child G’s mother had declined Level 2 support and there was no EHAT in place. The Information sharing Advice for practitioners providing safeguarding services to children, young people, parents and carers (July 2018) details that GDPR, Data Protection Act 2018 and human rights law are not barriers to justified information sharing, but provide a framework to ensure that personal information about living individuals is shared appropriately.   The review also identified that when one of the predominant health services involved with the family reduced their level of contact ceasing the weekly visits to the family there was no documented contact with other agencies (in particular other health services) involved to inform them of the fact that they would be reducing their involvement, or to inform them of the advice that they had given to the mother during their last contact.   Learning point 11: Practitioners within CSC should ensure that they share the outcomes of any assessment with the agencies who they have sought information from as part of the assessment. This should then be clearly documented within each agency relevant systems detailing what has been shared, who it was by, who it was shared with and why.     Learning point 12: Agencies should ensure that they utilise the information they hold on their own recording systems in relation to the whole family and not just the information they hold in relation to the member of the family that they ongoing involvement with.    11. To what extent do agencies feel Neglect played a part in this case? If so, what was offered in terms of support? (Terms of reference 12)  The Rapid Review Panel felt that the case presented elements of chronic neglect, this was not identified within multi agency learning summaries or within the practitioner’s event. None of the agencies identified any concerns around neglect throughout their involvement as such no specific support was offered in relation to neglect.   This is not to say that neglect wasn’t a feature within this case, and it is worthy of note that agencies; particularly health, did not consider the wider picture that would have led to the possibility of neglect being a feature. The search for health needs and the facilitation to meet those needs is a fundamental principle within the provision of health services. However, in this case it is evident that there is a lack of this principle in places. For instance, not assessing the impact of mother’s mental health on her ability to meet the demands of caring for premature twins, the burden of premature baby feeding regimes, SEND issues and the ever-growing demands upon mother as main carer for the children. There was                                                                                                                                                                    13 | P a g e   little professional oversight in relation to giving thought to the added weight of mother having to deal with her own health issues whilst co-ordinating and attending to the array of health needs and interventions that that children were experiencing.   In conclusion professionals assumed that neglect was not a feature in this case however this assumption was not based in sound assessment utilising locally agreed tools and resources such as EHAT, GCP2 to support analysis.  Health agencies held information which should have prompted practitioners to explore themes such as possible neglect i.e. around the children’s growth charts to identify where they were residing at the times when there were peaks and drops in weight (home vs hospital), missed maternal mental health appointments, missed child health appointments and the root cause of sibling’s behavioural issues. As these factors were not fully explored the reviewers were unable to conclude whether the children were subjected to neglect and whether any possible neglect was through omission or commission.   Learning point 13:  To be holistic assessments need to include a wider picture of the potential stressors for the whole family. Where there are identified levels of health and development needs and gaps in those needs being met practitioners should recognise these as possible indicators of neglect. This should then be assessed through the use of locally agreed tools and resources such as EHAT and GCP2.    12. Did the COVID-19 Pandemic have an effect on the services provided or the family? (Terms of reference 13) In relation to the impact of the COVID-19 pandemic on the services provided the review found that generally critical business was maintained by services for the family, in some cases the service maintained direct visits to the family and in other cases this took place virtually.  The 0-19 service stated that the Health Visitor had direct contact with the family during home visits however, these then predominately became by telephone during the COVID-19 Pandemic prior to level of intervention by the Health Visitor being reduced in mid 2020. This change in direct contact was consistent with the processes put in place by the 0-19 service as at the time there was no compelling clinical or safeguarding need identified in relation to the family of Child G. Upon reflection it was identified that this would have impacted on Health Visitor observing/assessing the children in the care of their mother in the family home. Coupled with this, given the recent referral around alleged domestic abuse in relation to mothers partner the reduction of direct contact also reduced the opportunity for the Health Visitor to go into the property and observe any possible increased tensions within the household which may have been an indicator of domestic abuse. The April 2020 report Family violence and COVID-19: Increased vulnerability and reduced options for support by Kim Usher et al explores this factor and states:  “Isolation paired with psychological and economic stressors accompanying the pandemic as well as potential increases in negative coping mechanisms (e.g. excessive alcohol consumption) can come together in a perfect storm to trigger an unprecedented wave of family violence (van Gelder et al. 2020). Substance misuse, financial strain, and isolation are all well-known domestic abuse risk factors (Richards 2009). During isolation, there are also fewer opportunities for people living with family violence to call for help. Isolation also helps to keep the abuse hidden with physical or emotional signs of family violence and abuse less visible to others (Stark 2009).” Within the practitioner’s event it was identified that during the COVID-19 pandemic the family of Child G did not meet the threshold as a priority family for the Community Nurse Service as they were not in need of clinical nursing intervention. This threshold was implemented by the Community Nurse team to manage which families needed to have continued face to face visits. Despite this the nurse involved with the family of Child G was not constrained by process or procedure and used her professional judgement to override this and continue to complete face to face visits to ensure that the support received by the family was maintained.  During the COVID-19 pandemic Child G’s mother made the decision to keep her older children off nursery and school provision due to the vulnerability of the twins. School endeavoured to continue to try and maintain regular visual contact with Sibling B working together with EWO to provide almost daily                                                                                                                                                                    14 | P a g e   visits to the family. The wellbeing sessions for Sibling B did not take place during COVID-19 pandemic due to the ongoing restrictions.   The COVID-19 pandemic resulted in a reduction of the oversight professionals had of the family. Not all professionals explored how the pandemic may have impacted the family directly. Given mothers history of mental health specifically in relation to her high level of anxiety and intrusive thoughts of the family becoming ill and dying, the COVID-19 crisis would have had significant impact which should have been explored as it may have identified increased risk around her ability to care for her children. This exploration would have enabled services to assess whether there was any need for additional support. This factor was also evident in relation to Sibling B who’s wellbeing sessions were not completed due to the pandemic. Given the concerns around Sibling B’s emotional wellbeing, plans should have been put into place by practitioners to allow the emotional wellbeing sessions to continue either via telephone or virtually. The review does however, acknowledge that EWO did continue to make home visits and phone calls during this period to enable them to check on the wellbeing of Sibling B. Practitioners should ensure that they take into account how external factors may impact on a family either directly or indirectly. 13. Summary From reviewing the evidence contained within the learning summaries, the practitioner event it is clear this was a family who needed help and support. There was a lack of multi-agency coordination and understanding of what the lack of engagement with the early help provision meant to the family and how this may have increased stressors within the family. Due to insufficient professional curiosity, not all practitioners in this case had a clear understanding of the factors that cumulatively impacted on the family. Factors such as the number of health appointments, maternal mental health needs, including the death of her child all had significant impact. When coupled with the emotional and health needs of the siblings this would have increased mother’s anxieties reducing her ability to respond to the needs of the children.   It is the opinion of the reviewers that the family would have benefitted from the allocation of a lead professional who would have been able to coordinate services, relative to the children’s complex needs.  No single agency appeared to have had a clear understanding of who the family members were, or significant the others involved with these children and what caring roles were provided and by who. Neglect was not clearly identified by practitioners involved in the case which resulted in a significant area of unassessed and unaddressed risk. Practitioners should be aware that Neglect does not always present in the typical forms and in some cases will need further exploration past these forms before it can be discounted.  14. Recommendations  Recommendation 1  For the Safeguarding Children Partnership to facilitate the development of a set of practice standards when it comes to how we offer early help across the multi-agency partnership. As a minimum these standards should detail the need for practitioners to discuss with a family and appropriately record the key points outlined below:   What exactly Early Help is and any common misconceptions.  Why Early Help is being offered (Signs of Safety format)?  What support can be offered and the possible format it will take?  What the potential impact on the children and the family may be if no support is accepted?  The reason why Early Help has been declined by the family and what efforts were made to overcome this barrier?  Recommendation 2                                                                                                                                                                    15 | P a g e    The Safeguarding Children Partnership working with the Health Forum should identify an ongoing training and refresher training program to ensure all front-line practitioners across the multiple health services are trained in the Early Help provision and EHAT completion. This should be supported through an auditing process of cases that have been identified for Early Help.     Recommendation 3  The Safeguarding Children Partnership working in conjunction with the Health Forum (and ultimately commissioning services) should look to develop a pathway for children and families with complex health needs to ensure that when there is a relevant need an allocated lead health professional is identified. This will then ensure a coordinated approach from Health providers and enable a greater understanding of how the health needs of all of the children impact the family holistically.  It would also provide a single point of contact for partner agencies when they are seeking information around a family.   Recommendation 4  For the Safeguarding Children Partnership to seek assurance from all agencies that practitioners are appropriately trained in the use of genograms/family mapping (as per Signs of Safety model). This should be supported through an ongoing audit process within each agency to ensure that genograms/family mapping are being utilised and updated across cases in accordance with organisational practice standards.  This will support an understanding of significant relationships within a family.  Recommendation 5 For the Safeguarding Children Partnership to seek assurance from all agencies about their practice in relation to the identification, assessment, and response to domestic abuse. For health service this would be to include adherence to NICE guidance and routine enquiries.  Recommendation 6 For the Safeguarding Children Partnership to seek assurance from 0-19 service and integrated commissioners that the correct application of the Healthy Child Programme threshold is consistently applied with oversight from team leaders. This should then be reflected within the Health records and any changes to the levels of intervention i.e. step up or step down to be recorded with clear rationale (this should be supported through a programme of audit/dip sample).  15. Appendix  Working with the whole family: What case files tell us about social work practices. Laird, S., Morris, K., Archard, P., & Clawson, R. (2017)  https://doi.org/10.1111/cfs.12349  From genograms to peer group mapping: introducing peer relationships into social work assessment and intervention, Families, Relationships and Societies by Firmin, C (2019) - https://www.ingentaconnect.com/content/tpp/frs/2019/00000008/00000002/art00004  Using genograms in social work practice 18/02/2021 by Hannah Scott - https://www.researchinpractice.org.uk/children/news-views/2021/february/using-genograms-in-social-work-practice/  Healthy Child Programme - http://www.healthychildprogramme.com  Information sharing Advice for practitioners providing safeguarding services to children, young people, parents and carers July 2018 -                                                                                                                                                                     16 | P a g e   https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/721581/Information_sharing_advice_practitioners_safeguarding_services.pdf  Request information under Clare's Law: Make a Domestic Violence Disclosure Scheme (DVDS) application - https://www.merseyside.police.uk/advice/advice-and-information/daa/domestic-abuse/alpha2/request-information-under-clares-law/  NSPCC Domestic abuse: learning from case review – June 2020 https://learning.nspcc.org.uk/media/1335/learning-from-case-reviews_domestic-abuse.pdf  Annual review of LCSPRs and rapid reviews by Jonathan Dickens, Julie Taylor, Joanna Garstang, Nutmeg Hallett, Natasha Rennolds & Penny Sorensen - March 2021 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/984770/Annual_review_of_LCSPRs_and_rapid_reviews.pdf  Hidden men: learning from case reviews - Summary of risk factors and learning for improved practice around ‘hidden’ men - April 2015 https://learning.nspcc.org.uk/media/1341/learning-from-case-reviews_hidden-men.pdf  Family violence and COVID-19: Increased vulnerability and reduced options for support by  Kim Usher AM, RN PhD FACMHN, Navjot Bhullar BA(Hons) MA, MPhil, PhD MAPS, Joanne Durkin PgDip MA, Naomi Gyamfi BSc (Hons) MSc, Debra Jackson AO, RN PhD FACN SFHEA MRSNZ - April 2020 https://onlinelibrary.wiley.com/doi/full/10.1111/inm.12735  Barnardo’s Domestic Violence Risk Identification Matrix https://www.cafcass.gov.uk/download/6629/  NICE Recognising and responding to domestic violence and abuse https://www.nice.org.uk/about/nice-communities/social-care/quick-guides/recognising-and-responding-to-domestic-violence-and-abuse  https://www.nice.org.uk/Media/Default/About/NICE-Communities/Social-care/quick-guides/recognising-responding-domestic-violence-abuse-quick-guide.pdf  NICE guidelines on Domestic violence and abuse: multi-agency working - 2014 https://www.nice.org.uk/guidance/ph50  Starting a New Relationship After Abuse by DomesticShelters.org - May 2016 https://www.domesticshelters.org/articles/relationships/starting-a-new-relationship-after-abuse   