Non-accidental injuries to 6-week-old Child J, sustained on at least two separate occasions. Child L, aged 5-months, half-sister to Child J, had sustained a mouth injury and bruising 10 months earlier and had been subject to a Child Protection enquiry but after a Child and Family assessment the case was closed. Both parents of Child J had traumatic backgrounds. They were offered extra support with enhanced health visiting, teenage pregnancy programme, housing, benefit and educational issues but the couple were unable to take advantage of this help. Seven health visitors were involved with the family as well as others offering other services. Child J was found to have bruising by the GP; further examination at the hospital found multiple rib and a leg fractures. As result of injuries to younger child, both were removed from the home and Care proceedings began. Issues identified include: the need for practitioners to be aware of the significance of early life experiences, drug use and mental health problems in parents and their impact on the children; the need to understand normal child development which would have improved the quality of decision making; inter-agency cooperation; the need for effective supervision and managerial oversight. Examples of good practice were noted by the GP, the housing support worker and the health visiting service. Recommendations include strengthening interagency procedures for the police, children's social care, housing providers and the NHS Foundation Trust. Please note that this report was written in June 2016 but was published in February 2017.
      
 Title:  Serious case review: overview report: Child L and Child J. LSCB: Somerset Safeguarding Children Board Author: Mark Dalton Date of publication: 2017  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.                                       SERIOUS CASE REVIEW  OVERVIEW REPORT                  Lead reviewer: Mark Dalton                                                                                June 2016 FINAL – June 2016 Page 2 of 45 Table of Contents  1. Introduction ............................................................................................................. 4 Circumstances leading to this Serious Case Review .............................................. 4 2. The Serious Case Review Process ........................................................................ 5 Scope and Terms of Reference for each agency ................................................... 6 Practitioner Involvement ......................................................................................... 6 Family Involvement ................................................................................................. 7 3. Background Information ......................................................................................... 8 Family Structure...................................................................................................... 8 Family Context ........................................................................................................ 8 Analysis – Family Context ...................................................................................... 9 Antenatal care – (Child L) ..................................................................................... 10 Analysis – Antenatal care ..................................................................................... 10 Birth and postnatal care ........................................................................................ 11 Analysis – Birth and postnatal care....................................................................... 12 4. Narrative account of injuries - first incident April 2014 (Child L) ........................... 12 Analysis - Narrative account of injuries - first incident April 2014 (Child L) ........... 16 5. Significant events May 2014 – February 2015 ..................................................... 18 6. Narrative account of injuries - second incident February 2015 (Child J) .............. 19 Analysis - second incident February 2015 ............................................................ 20 7. Summary .............................................................................................................. 21 (a) The effectiveness of multi-agency identification, analysis and management of the risk of physical abuse and why the risk was managed in that way. ......... 21 (b) The effectiveness of multi-agency information sharing arrangements and any identified ‘system’ barriers to achieving effective identification and management of risk. .......................................................................................... 22 (c) The quality of risk assessments and validity of any tools or processes used to identify protective factors as well as risk factors. .................................. 23 (d) The quality and impact of multi-agency planning, decision and review processes used to promote improved outcomes for children. ........................... 24 (e) The impact and quality of professional supervision and its contribution to securing child-centred practice.......................................................................... 24 (f) The application of ‘thresholds’ and the degree of shared understanding and agreement across the partnership of those thresholds. ............................. 25 (g) Any ‘cultural practice norms’ that could impact on the professional network’s capacity to deliver child-centred practice including responses to safeguarding children under 1 years of age. ..................................................... 26 (h) The degree to which multi-agency practice in the field of risk and harm to children under 1 year of age is informed by evidence and research ................. 27 FINAL – June 2016 Page 3 of 45 (i) The degree to which the multi-agency system operated with the child at the heart of its intervention, including addressing issues of diversity and what needs to change to increase the responsiveness of the system? ..................... 28 8. Lessons learned ................................................................................................... 29 Understanding Family History ........................................................................... 29 Understanding Normal Child Development ....................................................... 29 Liaison between agencies working with the same family .................................. 30 Overreliance on self-reporting ........................................................................... 31 The need for effective supervision and managerial oversight ........................... 31 Examples of Good Practice ............................................................................... 32 9. Recommendations ............................................................................................... 33 Somerset Safeguarding Children Board ............................................................... 33 Inter-agency procedures ................................................................................... 33 Shared recommendation for all agencies ............................................................. 34 Avon and Somerset Police ................................................................................ 34 Childrens Social Care ........................................................................................... 34 Housing Providers ................................................................................................ 34 10. Single-agency recommendations ....................................................................... 35 Avon and Somerset Police ................................................................................ 35 Joint recommendation for Police and Children’s Social Care ............................ 35 Children’s Social Care ....................................................................................... 35 Knightstone Housing Association ...................................................................... 36 Somerset Partnership NHS Foundation Trust ................................................... 36 Somerset Clinical Commissioning Group .......................................................... 37 Yarlington Housing Group ................................................................................. 37 Yeovil District Hospital NHS Foundation Trust .................................................. 37 Appendix 1 ............................................................................................................ 38    1. Introduction  1.1 The two subjects of this review are infant half-sisters who, at the time of their injuries, lived with their young parents in a large town in the south of the county. All family members are white British.  1.2 This review was prompted by the discovery of bruising to Child J by her GP at a routine six weeks check in February 2015.  Further investigations revealed in addition to the bruising, six broken ribs and a fractured tibia.  The injuries were consistent with non-accidental injuries sustained on at least two separate occasions.    1.3 Ten months earlier the older child - Child L was also subject to a Child Protection enquiry (also known as a Section 47 enquiry) after she presented at hospital with an injury to her mouth; a torn frenum, she was 5 months old at the time of the injury.  The cause of this injury remains unexplained, however, it was accepted that this is an unusual injury and the likelihood of a non-accidental cause needed to be considered.  1.4 Throughout their lives the children had lived with their birth mother Ms Q and the father of the second child Mr P.  The father of the older child Mr S played no part in the upbringing of the children and Ms Q’s relationship with him had ended before the birth of Child L.  1.5 As a result of the injuries to the younger child both children were accommodated and Care proceedings commenced in February 2015.  Circumstances leading to this Serious Case Review  1.6 The decision to hold a Serious Case Review (SCR) was made by the Chair of the Somerset LSCB on 12th April 2015 following a recommendation from the Learning and Improvement sub group.   1.7 The case meets the criteria for a serious case review as set out in the principles contained in Working Together 2015.1    1.8 The Learning and Improvement sub-group also considered that “working together” (i.e. inter-agency relationship) issues had been identified as a factor in this case and others involving very young children, and there was evidence that the potential for serious harm to the children existed. The group concluded that a                                             1 LSCB’s to undertake reviews of serious cases in specified circumstances.  (1)(e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1) (e) a serious case is one where:   (a) abuse or neglect of a child is known or suspected; and   (b) either - (i) the child has died; or (ii) the child has 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. FINAL – June 2016 Page 5 of 45 Serious Case Review was the most appropriate type of review to elicit learning to improve multi-agency safeguarding arrangements in Somerset. 2. The Serious Case Review Process  2.1 The method used to undertake this serious case review has been influenced by research and experience of other reviews and sought to incorporate aspects that are designed to improve the dissemination of lessons to front line practitioners in an efficient and timely way.  2.2 A Serious Case Review panel was established to guide the process, critically review the Individual Management Reviews (IMR’s) and support the Overview Report Author.  2.3 Individual management reviews were commissioned from the constituent agencies and these were followed up with a practitioner seminar that brought together front line practitioners from the constituent agencies and members of the SCR panel.  All practitioners were able to read the IMR’s from all agencies.  This event enabled those involved in the case to reflect on the decisions and actions they had taken, and to collectively consider ways in which children could be better protected in the future   2.4 Individual management reports received from the following agencies:  Avon and Somerset Police   Knightstone Housing Association  Somerset Children’s Social Care  Somerset Clinical Commissioning Group  Somerset Partnership NHS Foundation Trust  Yarlington Housing Group  Yeovil District Hospital NHS Foundation Trust  2.5 Initially an IMR from Turning Point (drug and alcohol misuse services) had also been requested, however, examination of their records showed only two contacts with one of the parents during the period under review, therefore the SCR panel accepted that their involvement had little to offer the review process.  2.6 In addition a practitioner’s seminar was arranged to allow those with first-hand experience of the case the opportunity to consider the IMR’s and contribute their own observations and experiences of working with the family.  2.7 A Case Review Panel was formed consisting of the following:  FINAL – June 2016 Page 6 of 45 Deputy Director of Quality, Patient Safety and Governance (Chair of Panel) - Somerset Clinical Commissioning Group Business manager - Somerset LSCB Detective Chief Inspector - Avon and Somerset Constabulary Designated Doctor for Safeguarding Children - Somerset Clinical Commissioning Group Designated nurse- Somerset Clinical Commissioning Group Named nurse - Yeovil District Hospital NHS Foundation Trust Operations manager - Children’s Social Care Somerset County Council   2.8 An independent lead reviewer and overview author with a background in children’s social care was appointed.  Mark Dalton is a qualified and experienced Social Worker who has worked with children and families for 30 years.  He is an experienced overview report author who has worked with both children and adult safeguarding boards.  Scope and Terms of Reference for each agency   2.9 It was agreed that the period under review should be from the first presentation in pregnancy of the older child in November 2013 through to the significant injuries to the younger child in February 2015.   The terms of reference are attached at appendix 1.   Practitioner Involvement  2.10 The practitioner seminar was attended by 25 practitioners and managers who were a representative sample of the constituent agencies who routinely work together on cases such as this.2    2.11 This group were able to provide insights into the practicalities of delivering services to the family as well as contextual knowledge of the range of services and how they relate to each other.  Their openness, insight and critical analysis have greatly assisted in the completion of this report.  2.12 The involvement of practitioners supports the rapid dissemination of good practice and lessons learned from the review.  Research indications suggest that the greater the involvement in practitioners in the review process, the more likely it is that those practitioners will take learning away from events such as the practitioner seminar, and also be more interested in reading the completed overview report, participating in further training and sharing the learning with colleagues. The Learning and Improvement framework within Working Together                                             2 Attendance at the event was as follows: Midwives – 6, Health Visitors 3, Nursery Nurses – 3, Named Nurse for Safeguarding – 3, Designated Doctor for Safeguarding – 1, Medical Director – 1, Police – 3, Childrens Social Care – 3, Housing – 1, LSCB – 1. FINAL – June 2016 Page 7 of 45 to Safeguard Children3 states the expectation that Serious Case Reviews should be conducted within an organisational culture of continuous improvement and learning from experience. There is a considerable body of national evidence that the direct involvement of frontline practitioners improves the quality of learning and the transfer of those lessons into frontline practice.  Family Involvement   2.13 The relationship between the family and professionals and the influence the family had on professional decision-making has been shown to be an important consideration in understanding the decision making in all cases. In the case under review there were times experienced professionals; well versed in the policies and procedures of their agencies deviated from the agreed and expected course of action, and the Review sought to understand why this happened.  2.14 Workload, availability and quality of supervision, information sharing (both between agencies and within different departments of large and complex agencies) and recording difficulties are important factors in explaining why atypical decisions were sometimes made.  However, an equally important factor would seem to be the family’s influence on professional behaviour. Although this young and vulnerable couple lacked formal power their behaviour influenced professional decision-making. For example, the fact that they sought help when children were injured and presented as caring and concerned was seen as a positive and reassuring factor. On other occasions the overwhelming nature of the multiple problems they faced would divert professionals from focusing on the primary reason for their visit i.e. the care of the children.   2.15 Perhaps the most important reality check on whether professionals have an effective working relationship as think they have is whether there is any tangible change that the parents made as a result of interventions, e.g. they would agree to change their smoking habits within the home, yet the evidence would suggest that they did not.   2.16 This is not to say the parents were being consciously deceitful or manipulative, nonetheless situations arose which caused professionals to be unduly over optimistic based on no evidence other than the parents expressed willingness to comply with a professional’s plan.  2.17 The mother of both children and father of Child J have been invited to meet with the Overview Report author on three occasions to discuss their experience of working with agencies in Somerset, however they have not agreed to do this and their views are not represented in this report.                                             3 Working Together to safeguard Children 2015. p72. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/419595/Working_Together_to_Safeguard_Children.pdf FINAL – June 2016 Page 8 of 45 3. Background Information Family Structure  3.1 During the period under review the family consisted of the following members:  Ms Q - mother of both children Mr P -  father of Child J (the youngest child) Child L -  oldest daughter Child J -  youngest daughter.  Mr S the father of the oldest child played no part in the family at the time in question. Family Context  3.2 In order to understand the circumstances in which the children were injured. It is necessary to have some appreciation of the background and challenges faced by their parents.   3.3 This environmental information has been shown to be relevant for those conducting risk assessments and it places some parameters around what could realistically be expected of the parents in terms of taking up offers of help and following advice from professionals. 4  3.4 Ms Q the mother of the children had a disrupted adolescence with a history of growing up in a violent household and witnessing domestic abuse between her mother and stepfather.  Because of this she left the family home aged 16 and lived for short periods in hostel accommodation and with other family members.  3.5 On two occasions Ms Q had presented in Somerset as homeless; in May 2012 when she was provided with Hostel accommodation and December 2012, when she requested that she be “Looked After” as she had no money and wanted support.  The social work assessment noted the following concerns:  Deteriorating mental health (including an overdose)  Risk of pregnancy and STD’s (including two miscarriages) o Homelessness.  3.6 Unfortunately she was not assessed as meeting the threshold for support in terms of her vulnerability at the time.   3.7 In April 2013 she left the area and lived with Mr S the father of her oldest child in a neighbouring authority.  Mr S has a complex and disrupted family background.  As an individual he had long-standing problems controlling his behaviour and anger and had received support for this throughout his childhood.                                              4 Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003–2005. Brandon M, Belderson P, Warren, C, Howe D, Gardner R, Dodsworth J, Black J. p58. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/182302/DFE-RBX-10-08.pdf  FINAL – June 2016 Page 9 of 45  3.8 He became known to health services in Somerset whilst living in hostel accommodation in January 2013.  At that time he was concerned that his inability to control his temper was likely to result in him losing his accommodation.  After an initial mental health assessment further involvement ceased and he returned to live with his mother in a neighbouring area.  3.9 During the time the young couple lived together there were several instances of significant domestic abuse, which occurred while Ms Q was pregnant with her oldest child.  These incidents, not only included an assault by Mr S, but latterly an assault by another family member as well.  3.10 Having made an initial disclosure of physical abuse at the hands of her partner, Ms Q was reluctant to provide any further details, which made it impossible for the Police to pursue a formal complaint any further.  She also informed the Police in July 2013 that the relationship with Mr S had ended. Apart from one attempt to contact her through her family, this is the last known contact between Ms Q and Mr S.  3.11 The relationship between Ms Q and Mr P, the father of the second child, began following her return to Somerset. It is recorded that she attended the local hospital emergency department on 15th July 2013 with him, and most professionals assumed that he was the birth father.   3.12 Mr P also had a number of significant issues in his background. His mother died when he was aged 16 and both he and his sister suffered an extreme grief reaction. This manifested itself in outbursts of anger and some antisocial and criminal behaviour that resulted in a Police record for public order and assault offences.  Although there were referrals for therapeutic support for him these were not followed up.    3.13 By August 2013 Ms Q and Mr P were presenting as a couple to Somerset Health Services (midwifery and health visiting).  This was relatively soon after the mother’s relationship with Mr S had ended.   Analysis – Family Context  3.14 The decision not to offer support to Ms Q support as a Homeless young person in January 2013 was an incorrect decision and did not fulfil the local authority’s statutory responsibility towards her. The local authority took the view that because Ms Q had previously lived independently on two occasions and her mother was prepared to offer accommodation she did not meet the criteria for being considered “vulnerable”.  However, it failed to take into account that the attempts at living independently had not been successful; and Ms Q had suffered two miscarriages and taken a deliberate overdose whilst in hostel accommodation.  It also overlooked the reason for her leaving home in the first place was the abusive and violent relationship with her stepfather. Under these circumstances it would not be reasonable to expect her to return to an abusive household. FINAL – June 2016 Page 10 of 45  3.15 The significance of the early life trauma affecting parenting ability of young parents is widely known (see below p25). Information about early life experiences and family background should be included in risk assessments.  Issues regarding the collation of data for family health needs assessments may need to be addressed by neighbouring authorities where service users cross County boundaries. However, this can also be a problem for different departments within agencies – at the time of this review Health Visitors could not see adult mental health records on the RIO electronic record system, or access CAMHS records, for example. This meant that a full picture of the individual backgrounds of the parents was not available to any of the services trying to work with them. It is also clear that professionals did not adopt a significant level of professional curiosity that would perhaps have identified Mr P’s status within the family.   Antenatal care – (Child L)  3.16 Concerns about the vulnerabilities of Ms Q and Mr P were recognised and shared between the health visiting service, midwifery and the GP during August 2013. These concerns prompted some referrals for additional services; including adult mental health services for Mr P.  In addition to his traumatic events in his background, he had disclosed to his GP that he had been hearing voices telling him to harm himself. This problem had apparently arisen since he had given up using cannabis.  Attempts to engage him in mental health services were unsuccessful and he was referred back to his GP.   3.17 In November 2013 a Family Health Needs Assessment was completed by the Health Visitor. The assessment identified vulnerabilities of the couple; particularly their traumatic backgrounds and ongoing housing issues. The assessment resulted in a decision to offer the Teenage Pregnancy Programme; an enhanced level of Health Visitor support.  3.18 The Family Health Needs Assessment did not include any information from clinical mental health records, but relied on self-reporting by the couple.  Therefore, while Mr P had mentioned his drug use, he suggested this was historic and no longer an issue. However, his ongoing cannabis use would severely affect his participation with services offered to support him  Analysis – Antenatal care   3.19 Collectively, Health Services had a strong grasp of the abilities and risk factors for this young couple. Offers of additional support included the enhanced health visiting service, teenage pregnancy programme and individual counselling for Mr P.  Ms Q and Mr P were also receiving high level of support with housing, benefit and educational issues from their Housing Support Worker. However, there is a sense of the professionals making all the running and focussing on process rather than outcomes; whether through lack of motivation or lack of ability the couple were unable to take advantage of the help that was offered. The lack of progress was possibly disguised by their apparent willingness to accept help. A FINAL – June 2016 Page 11 of 45 further complication was the number of staff involved in delivering the service; a total of seven individual Health Visitors were involved with the family with differing degrees of engagement. Although all staff accessed their bi-monthly clinical casework supervision it is difficult to see how a composite picture of the family’s behaviour could have emerged through this process.  3.20 The influence of Mr P’s cannabis use was not assessed as he was in denial about the extent of his habit. A characteristic of his drug use was that he would give differing accounts of his use to different professionals; he informed his GP and Psychiatrists that he had given up, but told the Mental Health Worker that he was regularly smoking cannabis daily and was addicted. During the Family Needs Assessment Mr P had acknowledged his previous drug use, but maintained that this was in the past and he was making “a fresh start”. A conversation between the Health Visitor and other health professionals with the Housing Support Worker would have been helpful at this point and provided a more realistic assessment of the extent of his drug use.  3.21 The risk factors suggesting a degree of disguised compliance5 were in evidence prior to the birth of Child L in November 2013, and the appearance of cooperation continued in the working relationship with all professionals.   Challenging disguised compliance is rarely clear-cut and can be a difficult area of practice; professionals may feel unsure it is the correct analysis of service user behaviour.  However, consideration of the lack of progress in areas identified in the Health Visitor assessment and compiling a chronology of involvement would have provided sufficient reason to check their perception of the family with other agencies.  Fundamentally, this is a function of the supervisory process; to challenge beliefs about apparent changes and seek evidence of actual progress. Birth and postnatal care  3.22 Four days after her birth Child L was admitted to the SCBU (special care baby unit) with a raised temperature and rash.  The observations of the parenting capacity raised concerns about the degree of support the mother would require in the future and also the “overpowering” behaviour from Mr P towards Ms Q.    3.23 These observations were recorded in a “Concerns Diary” by the SCBU Team which unfortunately was never shared with the Health Visitor or GP following discharge.  The concerns were reported verbally to the Health Visitor who recorded them in the clinical records but this information was neither shared nor discussed with anyone else. It can be argued that at a time of great stress – such as the admission of a baby to the SCBU - allowances must be made about a parent’s presentation.  However, the behaviour which had been observed on the SCBU needed to be placed in the context of young inexperienced parents who had traumatic and disruptive childhoods. These observations had a significance in that they corroborated some of the concerns highlighted in the Family Needs Assessment which suggested that they would need a higher level of coordinated support.                                              5 Disguised Compliance. https://www.nspcc.org.uk/globalassets/documents/information-service/factsheet-disguised-compliance1.pdf  FINAL – June 2016 Page 12 of 45 3.24 The pattern of enhanced health visiting that was established prior to the birth continued throughout December 2013 and into the New Year.  There were concerns about feeding problems and safe sleeping for the baby.  In particular the Health Visitor was concerned that the couple were attempting to wean their baby at 11 weeks old.  In the light of this, it is perhaps unsurprising that the parents attended the Emergency Department with the baby and the GP surgery with respiratory and feeding problems on several occasions in February and March 2014. Analysis – Birth and postnatal care   3.25 In terms of good practice, the liaison between health visiting, community nursery nurse and hospital was effective, enabling consistent advice to be given to the parents regarding feeding and some other practical difficulties.  With the benefit of hindsight, it can be seen that giving advice had little or no impact in changing their behaviour; they continued to attempt to wean the baby in spite of very clear messages that she was too young and ignored the safe sleeping advice. At no point did any agency raise the question about whether the standard or parenting was placing the children at risk and critically review the information that was held on the family.   3.26 The couple were adept at diverting professionals concern and introducing new issues to distract attention from subjects they found difficult.  With numerous ongoing problems regarding housing, benefits and training courses, in addition to their individual health needs, it was relatively easy to distract the focus from the care of their daughter.  3.27 The accurate analysis of risk requires information from a variety of sources and knowledge of the individuals over a period of time. The Family Needs Assessment undertaken by the Health Visitor in November 2013 was a good start this process. However, the limitations also need to be recognised, the information was largely based on self-reporting and did not have input from other services that were engaged with Ms Q and Mr P or had previous knowledge of them. There were sufficient signs that the parents struggled to provide a level of basic care. This is a common occurrence in families where there is a history of drug problems, poor housing mental health issues and relationship difficulties.6  4. Narrative account of injuries - first incident April 2014 (Child L)  4.1 On the 21st of April 2014 (Easter Bank Holiday Monday) Ms Q telephoned the NHS non-emergency service because Child L had bleeding from her upper gum. They were advised to take her to the Emergency Department and she was admitted via ambulance. On examination she was found to have a torn upper frenum described as a “deep laceration to the inside of her upper lip”. There was                                             6 Children’s Needs – Parenting Capacity. Child abuse: Parental mental illness, learning disability, substance misuse, and domestic violence. Cleaver H, Unell I, Aldgate J. 2011. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/182095/DFE-00108-2011-Childrens_Needs_Parenting_Capacity.pdf FINAL – June 2016 Page 13 of 45 no explanation given for this injury and its cause has never been ascertained.  In the course of the medical examination the following day the mother drew attention to small red marks on Child L’s left torso.  Ms Q explained to the doctor that these had been observed by the Health Visitor two weeks earlier who had accepted that they may have been self-inflicted by Child L. The parents had previously told the Health Visitor that Child L pinched herself whilst sitting in the bath.  The Health Visitor observed the red marks and recorded that they are “four small pinch marks the size of Child L’s fingers”, she did not inform any other professional about the bruises, and accepted that they had been caused as her parents had suggested. After a full examination, no additional injuries were discovered.  During the admission the Health Visitor and Named Doctor for Safeguarding Children were consulted about the future plan of care.  4.2 A referral to Children’s Social Care was made on 22nd April 2014 by the Hospital and the Police were subsequently informed by Social Care about the incident. A strategy discussion took place over the telephone between a locum Team Manager from Social Care and the Police. There was no direct participation from doctors or the Health Visitor during the discussion. The medical opinion shared with the Police from Social Care was recorded by the Police as advising “it is unlikely that the baby caused the injury to herself but this does not necessarily imply that it was non-accidental”.  The fact that the medical opinion was reported to the strategy as third party information means that the concerns may have been diluted.  What should have been made clear was that even an accidental injury to a child of 5 months is potentially serious and needed further investigation.  4.3 The result of the strategy discussion was that Police and Social Care agreed there would be no further investigation of the injury and a Child and Family assessment would be undertaken by Social Care. Concerns appear to have been allayed by the parents seeking medical attention, their demeanour at the hospital (described as appropriate and concerned for their daughter’s welfare) and the small size of the injury.  4.4 On 23rd of April 2014, the Health Visitor received planned clinical supervision and had the opportunity to discuss the case in depth with the Named Nurse. In the course of this supervision they accessed the mother and her partner’s clinical records and identified a number of risks that were not previously known to the Health Visitor or the Hospital.  The information around Mr P’s mental health problems and other factors were promptly shared with Children’s Social Care.  4.5 Coincidentally, Mr P attended his first face-to-face mental health assessment on the same day.  He discussed hearing voices, which he identified as that of his deceased mother.  The psychiatrist believed that Mr P was suffering from a drug-induced psychosis and added an anti-psychotic drug to his existing prescription for anti-depressants.  The details of the change in his prescription were given to his GP and he was discharged with no follow-up.  4.6 On 24th April 2014, the Named Nurse contacted Children’s Social Care to share her concerns about the known risk factors and specified the following:  these were young parents aged 18 and 21 years FINAL – June 2016 Page 14 of 45  previous bruising had been observed by the Health Visitor  concerns raised by Midwifery in the initial post Natal period regarding Mr P’s overbearing attitude  the mother’s postnatal depression requiring medication  Child L’s previous admission for a choking episode aged 10 weeks  Mr P’s first mental health assessment when he disclosed hearing voices, being aggressive and wanting to hurt someone  Mr P’s second assessment when a diagnosis of probable drug induced psychosis was made.  4.7 The Named Nurse also requested consideration of an initial child protection case conference. This would have been a useful forum for agencies to pool their information, learn from the experience of others in working with the family and clarify actual risk factors. The opinion from Childrens Social Care was that the parents were cooperative and had sought medical advice and therefore a Child in Need assessment was more appropriate.   4.8 The Named Nurse liaised with the Named Doctor at the hospital regarding the need for further clinical tests, including a skeletal survey, as would normally be undertaken during a Section 47 enquiry; these tests were carried out on 25th April 2014 and came back clear.  4.9 A further telephone strategy discussion was held between the Police and the locum Team Manager for Social Care on 24th April 2014 following receipt of the information from the Named Nurse.  Again, no one from health was invited to participate in this discussion, but it was agreed that the case would now proceed as a single agency Section 47 investigation to be undertaken by Children’s Social Care.   4.10 The subsequent investigation was superficial and of poor quality. There were a number of reasons that contributed to this; the social worker in question was inexperienced in child protection work and lacked appropriate training.  The Children’s Services Department was in the process of re-structuring at this time and managing a high turnover of staff, with a correspondingly over reliance on agency workers and high caseloads. There was an absence of supervision and managerial oversight of the case.7  4.11 Whilst no explanation of the torn frenum was provided at the time, subsequently in the course of investigating a separate incident of non-accidental injury to Child                                             7 The Ofsted Inspection of services for children in need of help and protection, children looked after and care leavers March 2015 found: “A legacy of continual changes within the senior leadership team over the past ten years, a pattern of instability across the workforce, an over-reliance on the use of agency staff and an absence of effective partnership working have led to a service that has struggled to draw together a cohesive and strategic approach to improve services for children. Throughout this time, poor management oversight throughout all levels of the organisation, weak practice, stagnation in early help and a culture that managers and Social Workers say has inhibited change have been allowed to permeate into children’s services. These are seriously affecting the lives of children and families”. p36 http://reports.ofsted.gov.uk/sites/default/files/documents/local_authority_reports/somerset/054_Single%20inspection%20of%20LA%20children%27s%20services%20and%20review%20of%20the%20LSCB%20as%20pdf.pdf  FINAL – June 2016 Page 15 of 45 L’s sibling 10 months later, her mother would suggest that the injury had occurred whilst Mr P fed her.   4.12 The outcome of the Social Care assessment was a series of weak recommendations dependent on the cooperation and motivation of the parents.  Previous experience would suggest that these recommendations were unlikely to be acted upon. The assessment concludes with “what needs to happen” as follows: 1. Mr P to continue to take his anti-psychotic medication 2. Both parents to jointly attend parenting classes 3. Parents to seek professional advice if they have any concerns about Child L’s well-being.  4.13 The Social Worker had also informed the Health Visitor that he planned to convene a professionals meeting to discuss the case, although this did not take place.  4.14 The Social Worker had also contacted mental health services requesting medical information in relation to Mr P, and an opinion on the significance of the diagnosis in relation to the risk to the children and his parenting skills.  Although Mr P’s mental health had been assessed as recently as 23rd of April 2014, it was agreed that a further in-depth assessment was required to specifically consider his parenting capacity and current medication.  4.15 The mental health assessment took place on 15th May 2014, Mr P was in a positive mood, having been informed that Children’s Social Care had ceased involvement with his family (although they would not formally close the case until June, there was no further contact from Social Care with the family after the 14th May). However, the psychiatric assessment diagnosed that Mr P was more than likely suffering a significant mental health problem - a prolonged bereavement reaction and symptoms that may turn out to be schizophrenia.  In addition to increasing Mr P’s anti-depressant medication a referral for further support and assessment was made.  The assessment report was sent to the GP, but not Children’s Social Care - who were in the process of closing the case.  4.16 At the point of closure the Children Social Care Operations Manager reviewed the case and requested more information be documented on the case file in relation to the decision-making process.  4.17 The case was further reviewed by a senior manager who recommended that the Social Worker shared his assessment with the Health Visitor, GP and Children’s Centre and that he was satisfied that parents have engaged with the children centre before closure. It was further recommended that a Team around the Child (TAC) meeting be held as part of a formal step down from Children’s Social Care.  4.18 It is now clear that the assessment was not shared, and the other key agency, the Health Visiting service was not aware of the plan for a TAC meeting.  In any event the TAC meeting did not take place and the parents did not engage with the Children Centre prior to the case being closed to Social Care in June 2014. FINAL – June 2016 Page 16 of 45  Analysis - Narrative account of injuries - first incident April 2014 (Child L)  4.19 A number of health professionals involved in this review noted that there can sometimes be an additional pressure to discharge patients over a Bank Holiday because of pressure on available beds and resources. The discharge was made without further reference to Childrens Social Care or the Health Visiting service, while neither agency had any concerns at that time, it would have been good practice to check and also reinforce their opinion that the injury to the frenum was serious and needed further investigation.  As was subsequently shown the Somerset Partnership Named Nurse was able to identify several significant concerns when she reviewed the case information two days later.  In any event the discharge process was not a substitute for a multi-agency strategy discussion/meeting while the child was still in a place of safety.  4.20 On this occasion the strategy “meeting” consisted of a telephone discussion between the Police Officer and the Children’s Social Care Locum Team Manager. There was no consideration given to this being a face-to-face meeting and inviting other professionals who knew the family to participate. In addition, there was no definitive shared record of the meeting distributed to professionals working with the family.  4.21 The additional information provided by the Named Nurse on 24th April was a missed opportunity to reconvene the strategy discussion as a face-to-face meeting.  The subsequent single agency Section 47 investigation appears to have been half-hearted and there is no evidence of any robust enquiry into how the torn frenum or the bruising to Child L had occurred.   4.22 In practice it would be more usual for an unexplained injury to a 5-month old baby to be the subject of a joint Police and Social Care investigation.  The two agencies have distinct roles in these circumstances:  “The Section 47 Enquiry and assessment must be led by a qualified social worker from Children's social care, who will be responsible for its coordination and completion. The social worker must consult with other agencies involved with the child and family to obtain a fuller picture of the circumstances of all children in the household, identifying parenting strengths and any risk factors. Enquiries may also need to cover children in other households with whom the alleged offender may have had contact. All agencies consulted are responsible for providing information to assist.  At the same time, where there is a joint investigation, the Police will have to establish the facts about any offence that may have been committed against a child and collect evidence as they lead the criminal investigation.”8                                              8   Somerset Safeguarding Board Procedures Manual.  http://www.proceduresonline.com/swcpp/somerset/p_ch_protection_enq.html?zoom_highlight=joint+Section+47#single_age_jnt  FINAL – June 2016 Page 17 of 45  In this case it would seem that the medical opinion shared at the strategy discussion was interpreted as indicating that medical professionals were not saying that that the injuries to Child L were non-accidental and therefore the initial section 47 investigation could be undertaken solely by Social Care. There is no information in either the Police or Social Care records to suggest that the medical opinions were explored further or put in the context of the earlier bruising.   4.23 This case illustrates the importance of professionals being able to challenge medical opinion; the NSPCC national review of Serious Case Reviews has found that too much emphasis is often given to medical evidence. The reluctance of doctors to explicitly attribute injuries to child abuse can be interpreted as evidence that abuse had not taken place despite the police (and other agencies) having contextual information about families that would strongly suggest abuse had taken place.9  4.24 There appears to have been an under appreciation of the significance of the injury to the frenum.10  Whilst this may have been a small injury it is a significant one in that it could not possibly have been self-inflicted and can be indicative of poor or negligent care as well as non-accidental injury. The baby had a history of feeding problems, some of which had prompted contact with health services in the recent past. This history of these presentations alongside the recorded concerns about premature weaning suggests some lines of enquiry that should have been further explored.  4.25 The bruises to the baby’s torso that the Health Visitor had seen on 7th April were also significant as it is not possible that they were self-inflicted. Many professionals, particularly health staff know the mnemonic “children who don’t cruise don’t bruise” and the phrase is quoted several times in different IMR’s. It is generally accepted that bruising in pre-mobile babies is very unusual11.    4.26 The case closure process within Social Care was premature in that it ignored the worrying information about Mr P’s mental health and ongoing drug use and took place before a professionals meeting had been called or the results of Mr P’s mental health assessment were known.   4.27 There is no record that Children’s Social Care was aware that Ms Q was again pregnant and had booked in with midwifery services on 1st May 2014.   In addition, an appropriate parenting class had not been identified, in fact it would seem that a suitable class did not exist and the Housing Support Worker had sought advice from the Health Visitor in identifying a suitable group for them to attend.                                              9 https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/police/  10 A tear to the frenum is not a definite indicator of a deliberate injury; however, if it is the result of an accident it would be reasonable to expect the parents to remember how the injury occurred. Ten months later, during the investigation of injuries to Child J, Ms Q did provide a possible explanation of the injury. 11 CORE-INFO Bruises on children. http://www.nspcc.org.uk/globalassets/documents/advice-and-info/core-info-bruises-children.pdf  FINAL – June 2016 Page 18 of 45 4.28 The Social Care plan, such as it was, depended heavily on the parent’s agreement to take up offers of voluntary support and the case was closed with no evidence that any part of the plan was in place.  It would seem that the family were motivated to get social services out of their lives and would agree to virtually anything to achieve this. 5. Significant events May 2014 – February 2015  5.1 The confirmation of the mother being pregnant with her second child in early May was a significant event. Ms Q had a history of difficulties in her previous pregnancy and she had also decided to stop taking her anti-depressants for fear of the effect on her new baby.  5.2 As had been the case with her first pregnancy, in her second pregnancy Ms Q had an above average number of maternity contacts.  During these contacts she would at times complain about the lack of support from her partner and at times that they had considered splitting up, the main reason for this had been Mr P’s continued cannabis use - including times when he had been in sole charge of Child L.  5.3 Following the second mental health assessment for Mr P on 15th May 2014 there was a short period of concerted engagement between Mr P and mental health services. This assessment specifically addressed the issue of Mr P’s ability as a parent and stated that: “Nothing Mr P said during the assessment raised our concerns in relation to safeguarding concerns about Mr P’s step-daughter”. The conclusion of the assessment was that Mr P was possibly suffering a mental health problem; a prolonged bereavement reaction and symptoms which may turn out to be schizophrenia.  He was prescribed an anti-depressant and a referral made to the Early Psychosis Team for further support and assessment.    5.4 The clinical assessment was followed up by a Mental Health Worker from the STEP Team (Somerset Team for Early Psychosis) who undertook a further assessment at home on 2nd July 2014. The assessment noted a number of stress factors including debt, low income and unemployment, the second pregnancy, arguments, anxiety, hypervigilance and panic attacks. The worker also noted that Mr P was “heavily addicted” to cannabis, and despite assurances given to his GP, Health Visitor and consultant psychiatrist he had not reduced his intake. He was also changing his medication and was no longer taking anti-depressants regularly.  Despite the identification of these stress factors Mr P’s parenting style was described as “warm and caring”.  5.5 Mr P failed to attend a follow-up appointment with his psychiatrist to review his medication on 15th July 2014. The psychiatrist considered further appointments were unnecessary, particularly as Mr P was now seeing the STEP Team and no further appointments were made.  5.6 This is significant information that should have been shared with the Health Visitor or the Trust’s Safeguarding Children Team. The potential risks to Child L identified from these stress factors were not discussed in the course of the FINAL – June 2016 Page 19 of 45 assessment and it would have been helpful to share the Mental Health Worker’s observations with others working with the family.  5.7 In fact there was only one referral to the Somerset Partnership Trust Safeguarding Children Team by Adult Mental Health Services throughout the period of this review in spite of the number of concerns highlighted by both the Psychiatrist and Mental Health Workers assessments of Mr P.  The Trust’s policy is clear; if staff have concerns about children they should discuss their concerns with a member of the Safeguarding Children Team.  It would seem that once again the professionals were overly optimistic about the likely impact of Mr P’s ability to control his drug use and engage with mental health services.  5.8 Mr P next had direct contact with the STEP worker in September 2014, there appeared to have been some definite improvements; Mr P claims to have stopped taking cannabis completely and no longer had psychotic feelings. As a result his relationship with Ms Q has also improved and they have attended parenting classes together in August. Mr P was discharged from the STEP Team to the care of his GP on 8th September 2014.  5.9 An important source of support for the family during this time was the Housing Support Worker.  This person had a long-standing relationship with Ms Q; having first met her in 2012 as a homeless 16-year-old in hostel accommodation.  Records suggest that Ms Q and Mr P were possibly more open and frank with her than they were with the other professionals involved with their family.  5.10 It is unfortunate that the potential positive benefits of this relationship were not fully appreciated by Children’s Social Care or the Health Visitor; equally there was no sign that the Support Worker appreciated the concerns that other agencies had for the care of the children.  The Housing Support Worker should have been considered and supported as a Lead Professional for the family.  6. Narrative account of injuries - second incident February 2015 (Child J)  6.1 On 4th February 2015 Child J (born December 2014) was seen in the morning at home by the Health Visitor and a student nurse.  The visit was noted to be positive a one; both children seemed well and happy and the parents relaxed and positive.  Child J was observed naked and weighed and measured.  6.2 Later the same day Child J was taken by her mother and maternal grandmother to her GP for her 6-week assessment. In the course of the examination the GP noted faint bruising to Child J’s back and head, and questioned Ms Q and her grandmother about how bruises had occurred. He was not convinced by the explanations that they had been caused accidentally and referred Child J to hospital for further assessment.  Child J was taken to the Accident and Emergency Dept. of the local Hospital at approximately 6:00pm that evening. The Emergency Duty Team held an initial strategy discussion with the Police where it was agreed that Child J would remain in the hospital and a Child protection medical examination and skeletal survey would take place. FINAL – June 2016 Page 20 of 45  6.3 Further examination identified multiple rib fractures and a fracture to her left tibia. The dating of the fractures suggested that they occurred on at least two separate occasions. A face to face strategy meeting chaired by the Children’s Social Care Team Manager and attended by the allocated Social Worker, Safeguarding Lead Nurse, two Police Officers, Consultant Paediatrician and a nurse was held on 6th February 2015.  Both parents were formally interviewed and some possible explanations for the bruising to have occurred accidentally were offered. However, there was no explanation for the injuries to Child J’s ribs or leg. Due to the seriousness of the injuries sustained to Child J and taking into account a previous Child Protection enquiry relating to Child L alongside concerns about parenting ability, it was agreed there was a significant risk of harm to both children and they should be taken into care.  6.4 The option of agreeing to voluntary accommodation was given to the parents, with the contingency plan that if they would not agree the Police would use a Police Protection Order to secure the immediate safety of the children and Children’s Social Care would seek a Care Order.  6.5 A decision was made not to proceed to an initial Child Protection Case Conference because the children were protected by the Looked After regulations and there was no plan to return them to their parent’s care without a full and thorough assessment.  Analysis - second incident February 2015   6.6 The decision making and subsequent investigation following the injury to Child J was more thorough and competent than the one that had occurred in April 2014 after the injuries to Child L.  The process benefitted from a face to face strategy meeting that was attended by relevant professionals. The meeting was able to review the results of the medical examination and also take into account the previous unexplained injury to Child L.  Information about the background of the parents was also available to the meeting.  6.7 The “danger statement”12 within the assessment summarises the risks as follows:  ‘Somerset Children's Social Care is seriously concerned about [Child J] who suffered non accidental injuries whilst in the care of her parents. [Child J] was 7 weeks and 6 days when she suffered these injuries. Medical report states that uncommon and unexplained bruises in a 7 weeks old non mobile baby likely non-accidental injury. [Child J shows evidence of multiple soft tissue injuries (face and back bruising) and bony fractures (multiple ribs, and tibial metaphysis) which are consistent with non -accidental injuries sustained on at least two separate occasions. There is no evidence of any condition(s), which would make her                                             12 A “danger statement” is an integral part of the Signs of Safety approach adopted by Somerset Childrens Services. It should be a clear, understandable and jargon free description of the child protection concerns. FINAL – June 2016 Page 21 of 45 particularly susceptible to bruising or bone fractures. The explanation provided for the injuries is inconsistent with clinical findings We are concerned because there is no clear explanation as to how [Child J] sustained these injuries and it is not clear at present who is in the pool of perpetrators, hence extended family members were not considered at this time to care for these children.   Historically [Child L] (she was five months old) suffered physical harm and injuries while in the care of her parents and explanation given at the time was inconsistent with medical findings.   We are concerned about this pattern of behaviour and lack of plausible explanation. We are concerned that both children were exposed to such risk of physical harm and even likelihood of death. We are concerned about parents' possible mental health and uncertainty about father's taking medication as instructed. Lastly, historical concern that [Mr P] was drinking excessively and using cannabis and this linking to his mental health as discussed in this report.’  6.8 The strategy meeting concluded with clear directions about future actions and further review of the plan.  It is clear that liaison between agencies was much improved and there was a consensus about the outcome in terms of protecting the children. 7. Summary  7.1 This section of the report will seek to address the key specific issues highlighted in the terms of reference (see Appendix 1).  (a) The effectiveness of multi-agency identification, analysis and management of the risk of physical abuse and why the risk was managed in that way.  7.2 The risk of physical abuse was not seriously addressed until the second non-accidental injury had been discovered in February 2015.  The potential for an injury to occur through negligent or clumsy parenting was known to health professionals based on their observations of the parenting from the midwifery staff present at the birth of Child L onwards.   7.3 The initial unexplained injuries to Child L – the bruising to her torso noted on 7th April 2014 – were initially accepted by the Health Visitor as self-inflicted.  A possible explanation why the Health Visitor went along with the explanation is the visit followed Child L’s 3 nights’ admission to hospital with suspected gastroenteritis and her focus was on this presenting issue rather than wider concerns.  She may also have been reassured by Ms Q bringing the marks to her attention. Crucially the Health Visitor did not share the information with anyone else, so there was no opportunity for challenge or second thoughts about the explanation. This was clearly an error of judgement that has been recognised and reflected on by the person concerned. FINAL – June 2016 Page 22 of 45  7.4 Apart from an initial request to change health visitor (the basis of Ms Q’s objection to her first health visitor was she “kept bringing the past up”), relationships with health visitors appeared positive, although in hindsight it can be seen that advice given was often not taken (e.g. premature weaning, smoking around the baby).  In addition, the parents were not honest or consistent about the extent of Mr P’s drug use or their use of medication, and gave different information to the Health Visitor and Housing Support Worker about these issues.  7.5 Although there was some liaison between the Housing Support Worker and Mental Health Worker this did not constitute a case discussion. The information that Mr P had smoked cannabis whilst in sole charge of Child L and as a result the couple had separated should have been shared with the Health Visitor and referred to Childrens Social Care.  7.6 A case discussion between professionals at virtually any juncture would have been helpful; there are several key events in the period under review, when an exchange of information and an agreement on a shared strategy may have resulted in constructive working relationship with the family. It is important to note that there are no procedural or protocol reasons why professionals cannot communicate directly, and there are several instances in the Early Help guidance, Childrens Services procedures and Somerset LSCB’s Core procedures where the need to consult with other professionals is mentioned.  7.7 Initially there were thought to be problems in accessing case records between different departments within health, and the Health Visitor was unaware that she could see Mr P’s mental health case records. However, even if this had been possible it is unlikely to have prompted a different response because the perception at the time was that the family were cooperating and to a large extent doing as well, or better, than professionals had expected.    7.8 A referral to the Somerset Partnership Trust’s Safeguarding Team by the Mental Health Worker was required under the Trust’s policy in the light of the information they had about Mr P’s drug use and potential effect on his ability as a parent. This would have led to a referral to Social Care and resulted in an earlier recognition of the concerns regarding the care of Child L.  (b) The effectiveness of multi-agency information sharing arrangements and any identified ‘system’ barriers to achieving effective identification and management of risk.  7.9 Information sharing between services within the same sector was generally effective; between Midwifery and Health Visitor and Hospital and Community Health Services.  However, this was not the case at this time between health visiting and adult mental health services.  Health Visiting staff were unaware that they could access adult mental health client records - which proved to be the source of much relevant information when they were eventually accessed during the health visitor’s supervision session on 23rd April 2014.   FINAL – June 2016 Page 23 of 45  7.10 The engagement of GP practices in effective safeguarding arrangements is often a challenge. In this case the Practice were sent several important pieces of information including a mental health assessments and changes to medication. In addition the GP had the most complete understanding of the history of Ms Q and Mr P of any professional. Yet the GP was not involved or consulted in the decision making regarding any of the strategy discussions.  7.11 Multiagency information sharing arrangements are governed in a long-established information sharing protocol and the multiagency child protection procedures. The key task for Social Care following the strategy discussions with regard to information sharing was to ensure that the decisions and actions were recorded and ensure they were disseminated to the agencies involved with the family. This did not happen following either of the two strategy discussions following the injury to Child L in April 2014.    7.12 A further concern is the failure by managers and supervisors to use the Escalation Policy to address inter-agency concerns. Somerset LSCB now has a Conflict Resolution Policy13 and at the time of this review a multi-agency “Escalation Policy; Resolution of professional disagreements in work relating to the safety of children” was available. This would have been a formal way of addressing the concerns about the lack of responsiveness from Childrens Social Care.   (c) The quality of risk assessments and validity of any tools or processes used to identify protective factors as well as risk factors.  7.13 Mr P was assessed by mental health professionals several times prior to and during the period under review, although these should not be considered as “risk assessments” in the context of his ability to care for young children. Their significance could be said to be that they diagnosed a need for further treatment that was never taken up.  This becomes a pattern of behaviour which would have been useful for subsequent assessments to be aware of; because later interventions were predicated on accepting the parent’s agreement to do something at face value without following up they had actually complied with an agreed course of action.  7.14 With regard to Ms Q and Mr P as parents, the Health Visitor completed an antenatal Family Health Needs Assessment in November 2013; however the completion of this assessment led to Ms Q requesting a change of Health Visitor following the birth of Child L as the assessment had upset her by raking up the past.    7.15 On reflection there are several reasons why this might have not been the best course of action; almost by definition, an assessment in this context is based on knowledge of the person over a period of time and past behaviour being the best predictor of future behaviour. Therefore, the assessment must to some degree                                             13 http://www.proceduresonline.com/swcpp/somerset/p_conflict_res.html?zoom_highlight=escalation FINAL – June 2016 Page 24 of 45 “rake up” the past - and this would have been part of the process whichever health visitor had undertaken it. However, the primary objective was seen as preserving the relationship between the family and health services and a new health visitor was allocated.  7.16 The assessments from mental health professionals and health visiting services should have formed a major component of the social care assessments. The first assessment following the injuries to Child L were recorded as a child and family assessment, but at the point it was undertaken it had been designated a Section 47 enquiry.  This report has been described by Social Care as inadequate (the report does not consider the histories of the parents and the on-going drug and alcohol issues); although these inadequacies were recognised by both the operations and strategic managers their suggestions for improving the report did not fundamentally address its failings.  (d) The quality and impact of multi-agency planning, decision and review processes used to promote improved outcomes for children.  7.17 This case is characterised by a lack of multiagency planning and is clearly not compliant with national and local guidance.14  Although some information had been exchanged between agencies, this was usually verbally and not backed up in writing.  Following the discovery of the injury to Child L the Somerset Partnership Named Nurse had requested consideration be given to an initial Child Protection Conference.  Following their Section 47 enquiry, Social Care, did not believe that the case met the threshold for a Child Protection Conference and no other meeting was arranged. Within Social Care’s plan, there is reference to a Team Around the Child (TAC) meeting but this was never arranged.    7.18 However the option remained for other agencies to escalate their concerns if they were unhappy with the decision, or to exercise their own professional responsibility and convene a meeting themselves. It is likely that two forces were in play which influenced the decision-making; firstly there was the apparent cooperation of the family and their expressed willingness to work with professionals, secondly, there may have been an over accommodation to the difficulties within Childrens Social Care, leading to lowered expectations about what could realistically be delivered.  (e) The impact and quality of professional supervision and its contribution to securing child-centred practice.  7.19 This review did not identify any systemic barriers to the identification and management of risk.  The case illustrates both positively and negatively the centrality of well-informed and challenging supervision in managing and identifying risk.                                              14 Working Together 2015  http://www.workingtogetheronline.co.uk/   and Somerset LSCB Child Protection Procedures http://www.proceduresonline.com/swcpp/somerset/index.html  FINAL – June 2016 Page 25 of 45 7.20 The supervision of the Health Visitor by the Named Nurse on 23rd April enabled the Health Visitor to place in context two episodes of unexplained injuries and recognise the history of mental health concerns as a significant risk factor.  Most significantly the process of supervision enabled the decision about the bruises to Child L to be re-visited and the explanation that they were self-inflicted finally discounted.   This crucial information was shared with Social Care the same day.  7.21 Unfortunately the lack of supervision for the allocated social worker had a correspondingly negative effect on the management of the case.  The significance of the information from the Health Visitor did not prompt a face to face strategy discussion.  Although the case status was revised from a child in need to a single agency Section 47 investigation there is no discernible difference in the approach adopted by the Social Worker or their manager.  7.22 The subsequent Section 47 is regarded as inadequate by the Social Care IMR author and its conclusions were not shared with other agencies.  The multi-agency requirements for single agency Section 47 investigations require Social Care to invite other professionals to contribute and comment on any plans, record decisions on the case record and ensure that all the professionals involved are aware of the decisions about the case.  However there is no evidence that this happened on this occasion.  7.23 The management oversight of Section 47 enquiries is an important check and balance built into the procedure but this did not occur until the case was closed on 9th June.  (f) The application of ‘thresholds’ and the degree of shared understanding and agreement across the partnership of those thresholds.  7.24 There are three distinct occasions where thresholds appear to have been an issue in this case.  7.25 Firstly the extent to which Ms Q met the threshold under the Southwark judgement in January 2013.  The Southwark Ruling15 requires the local authority’s duty to provide accommodation to homeless and vulnerable young people under the age of 18 (a Child in Need) seems not to have been applied as Ms Q was not considered vulnerable by the operations manager.   7.26 However, because Ms Q had had to live in two hostels and taken an overdose she should have been considered to be a vulnerable young woman and accommodated, and not have been expected to live in a household where there had been known violence.  7.27 Secondly the decision to deliver the teenage pregnancy programme was made by the Health Visitor in November 2013 – this is an enhanced programme of                                             15 Judgments - R (on the application of G) (FC) (Appellant) v London Borough of Southwark (Respondents) - http://www.publications.parliament.uk/pa/ld200809/ldjudgmt/jd090520/appg-1.htm and Somerset Childrens Services Guidance. http://www.proceduresonline.com/somerset/cs/chapters/p_prov_acc_16_17s.html  FINAL – June 2016 Page 26 of 45 support and home visiting aimed at addressing some of the typical problems that young parents face16.  Unfortunately, Ms Q felt that she couldn’t work with this Health Visitor as she had “raked up the past” during the Family Health Needs Assessment and a new Health Visitor was introduced.  Given that a pre-requisite of delivering the programme is building a trusting relationship with the parents, this was an understandable decision, but the cost may have been the first-hand knowledge of the significance of the family background.  7.28 Thirdly the decision regarding whether Child L was a child in need, or a child in need of protection; both strategy discussions held in respect of Child L were telephone discussions held after the decision to discharge her home had been made.  Her admission during a three-day Bank Holiday had also compounded the problems of resources being stretched, lack of a child abuse specialist reviewing the injuries, no awareness of previous concerns in the Hospital records (documented by the Hospital when Ms Q was seen for her booking in appointment) or the concerns of the Health Visitor.  7.29 For these reasons the view that Police and Social Care had gained from the Hospital was that the level of medical concern was low; medical professionals were not saying the injury was non-accidental and the parents had sought medical intervention and acted appropriately. The family was supported by appropriate professionals and had no history with Children’s Social Care.  7.30 In spite of the additional concerning information provided by the Named Nurse two days later the case remained a single agency investigation. The rationale for this was that whilst there was now a different interpretation of the bruising to Child L, there was no further information relating to the cause of the injury and the skeletal survey had not indicated any further injuries.  Medical professionals were not saying these were non-accidental injuries and Police accepted that the initial investigation could be progressed by medical staff and Children’s Social Care. The decision-making lacked the sceptical enquiring mind set necessary to review accounts of injuries and how they were caused.     (g) Any ‘cultural practice norms’ that could impact on the professional network’s capacity to deliver child-centred practice including responses to safeguarding children under 1 years of age.  7.31 At the time the injuries to Child L was discovered Children’s Social Care was going through major change and upheaval; which led to higher than usual caseloads, reliance on agency workers and a turnover of staff.  As a result corners were being cut in terms of practice and supervision.                                              16 “Evidence shows that young mothers and their babies experience poorer health outcomes in comparison to general maternal health. Young mothers are more likely to smoke during pregnancy, less likely to breastfeed and more likely to have post-natal depression. This is often compounded by the fact that many young parents come from the most deprived areas.” Somerset Intelligence. http://www.somersetintelligence.org.uk/pregnancy-maternity.html#youngparents  FINAL – June 2016 Page 27 of 45 7.32 This may have resulted in a tacit acceptance of the difficulties within Children’s Social Care, leading to lower expectations from partner agencies.  There is no evidence that other agencies escalated their concerns about the decision making within Childrens Social Care, although there were a number of occasions when this would have been appropriate.  (h) The degree to which multi-agency practice in the field of risk and harm to children under 1 year of age is informed by evidence and research    7.33 The list of risk factors identified by the Somerset Partnership Named Nurse on 24th April, comprised:   The relatively young age of the parents -  aged 18 and 21 years  Previous concerns about the care of Child L - the bruising noticed by the health visitor and the “choking episode” 10 weeks  Concerns raised by Midwifery colleagues in the initial post-natal period regarding Mr P's "over bearing" attitude to Ms Q  Ms Q's depression in the immediate post-natal period requiring ante depressants  Mr P's Mental Health where he had disclosed hearing voices, being aggressive and wanting to hurt someone and also the possibility of "drug induced psychosis"   7.34 All of these factors have been identified as significant both in the biennial studies of serious case reviews and in other focused research.  This list is helpful in that it also possibly identifies the existence of the “toxic trio” of risk factors; drug dependency, mental health issues and domestic abuse. Although the evidence of domestic abuse was not strong; this had been an issue in Ms Q’s family and a previous relationship and warranted further exploration.  Research shows that the risk of children being abused within the first thirteen months of life is fourteen times higher when parents have been abused themselves as children, are under 21 years old, have a history of mental illness or depression and are living with a violent adult.17  7.35 Health staff were aware of the significance of early life experiences,18 drug use and mental health problems; although these concerns were shared with Social Care they did not appear to have an impact on subsequent multi agency decision-making.   7.36 Following the children and families assessment the risk factors had been reduced to:   Mr P to continue to take his anti-psychotic medication                                             17 Risk factors of parents abused as children: a mediational analysis of the intergenerational continuity of child maltreatment (Part 1).’ Journal of Psychology and Psychiatry 46, 1, 47–57. 2005. Dixon L., Browne K.D., Hamilton-Giacritsis, C 18 All Babies Count: prevention and Protection for Vulnerable babies. http://www.nspcc.org.uk/globalassets/documents/research-reports/all-babies-count-prevention-protection-vulnerable-babies-report.pdf  FINAL – June 2016 Page 28 of 45  Ms Q and Mr P to jointly attend parenting classes  Ms Q and Mr P to seek professional advice if they have any concerns about Child L’s wellbeing  7.37 The risk factors had been externalised and addressing problems had become dependent on taking medication regularly, attending a group and promising to contact the health visitor or GP if they were concerned.  As a plan for managing risk this is completely inadequate because it fails to recognise the psychological barriers and lack of motivation in the couple. Their primary motivation was to get professionals (social workers) out of their lives. It is significant that Mr P’s mood was noticeably better when he heard that Children’s Social Care was closing the case.  7.38 An explicit discussion about the possible disguised compliance exhibited by the family would have been useful and enabled professionals to review their contact with the family and consider what they were actually achieving.   7.39 The phrase “Children who don’t cruise don’t bruise” is a useful reminder of the improbability of a five-month old being responsible for their own bruising.  Its significance is mentioned in two Health IMRs (Somerset Partnership and CCG) and also referred to by the Police.   7.40 The GP demonstrated a high level of vigilance and decisiveness in referring Child J for further examination following discovery of the bruises.  He was not dissuaded from this course of action by the explanations for the bruising offered by the parents.  (i) The degree to which the multi-agency system operated with the child at the heart of its intervention, including addressing issues of diversity and what needs to change to increase the responsiveness of the system?  7.41 It could be argued that the needs of the parents led to a lack of focus on the needs of the children - it can be difficult to separate the two and requires a co-ordinated approach which was missing in this case. The parents had an advocate and supporter in the Housing Support Worker, who attempted to address a wide range of issues including welfare benefits, further education, and health issues in addition to tenancy and accommodation problems.  7.42 However many of the staff involved reflected that their focus on the welfare of the children had sometimes been lost by the other seemingly pressing needs of the parents.    7.43 In contrast to the earlier single agency investigation, the involvement of the Police in the second investigation had a positive effect in protecting the children and even resulted in a possible explanation for the previous injury to Child L.  The explanations for the bruising to Child J offered by the family have been properly considered by the Police and subject to further testing.  Although these explanations are unlikely, they have not been completely ruled out. FINAL – June 2016 Page 29 of 45 8. Lessons learned  8.1 The lessons for practice in this case are neither unique nor uncommon amongst the findings of serious case reviews. Injuries to children under the age of one who are cared for by young parents with a history of their own challenges and difficulties are proportionally overrepresented as the subjects of serious case reviews.  Understanding Family History  There is an extensive body of research which shows that a range of problems can impair parents’ ability to meet the needs of their children. These include, but are not restricted to, poor mental health, problem drug and alcohol use, learning disability and domestic abuse. Serious case reviews continually emphasise the importance of understanding and acting on concerns about children’s safety and welfare when living in households where these types of parental problems are present (Brandon et al., 2008; 2009; 2010).19  8.2 The Family Health Needs Assessment pro-forma followed by the Health Visitor and the Child and Family Assessment guidance used by Social Care20 make some reference to family history but do not emphasise why this information is relevant particularly in the case of young parents with babies and how their own early life experiences will affect their ability as parents.    8.3 It is clear that knowledge of the “assessment triangle” is not enough21; in addition the current guidance is focussed on situations where the children can be an active participant in the review and the reliance of the “signs of safety model” in formulating safety plans supposes a level of parental cooperation that cannot be assumed.  8.4 It is important that practitioners are aware of the significance of family history in forming their assessments and how this will affect not only on risk assessments but also on the ability of individuals to cooperate with a plan.  Understanding Normal Child Development                                               19 Assessing Parental Capacity to Change when Children are on the Edge of Care: an overview of current research evidence.  Ward H, Brown R and Hyde-Dryden G June 2014 p 37. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/330332/RR369_Assessing_parental_capacity_to_change_Final.pdf  20 http://www.proceduresonline.com/somerset/cs/chapters/p_assessment.html#develop  21 Assessment Triangle – the three domains of assessment are described in Framework for the Assessment of Children in Need and their Families. 2000. http://webarchive.nationalarchives.gov.uk/20130401151715/https:/www.education.gov.uk/publications/eOrderingDownload/Framework%20for%20the%20assessment%20of%20children%20in%20need%20and%20their%20families.pdf  FINAL – June 2016 Page 30 of 45 An understanding of normal development in childhood is an essential component of child protection practice. Overall, there is a dearth of child development teaching on professional courses for those who will be working with children.22  8.5 A greater understanding of normal child development for the Social Work staff and Police Officers would have improved the quality of the decision making at the point of the strategy meetings and prompted Police and Social Care to challenge the medical opinion and would potentially have led to a more informed assessment regarding the likely cause of the injuries.  8.6 In this case the doctor’s opinion regarding the parent’s presentation was given as much weight as their opinion as to the probable cause of the injuries. These opinions seemed to have influenced the first impression the family made on the social worker – and these impressions are notoriously difficult to revise unless one is challenged to do so.   8.7 Recent analysis23 into serious case reviews has also shown several examples of agencies such as the police and social care wrongly interpreting medical opinion as definitive, when it should be seen as one of a range of possible explanations. The need to discuss differing perceptions of the family and possible explanations for an injury is recognised as important and again underlines the importance of face-to-face strategy meetings involving more than two agencies. At this time there appears to have been an over reliance on strategy discussions rather than strategy meetings  Liaison between agencies working with the same family  8.8 Inter-agency communication is a perennial issue raised by serious case reviews and child protection research. 24 The event which would potentially have made the biggest difference was the face to face meeting as requested by the Named Nurse on 23rd April 2014 (although she had requested an initial child protection conference, any professional meeting would have been helpful at that point).  However efficient information systems become in the future at allowing access to records, there is no substitute for direct inter personal dialogue.  8.9 The practitioners who participated in this review all recognised that a face to face meeting was preferable and showed a willingness to facilitate these meetings where possible; neither distance or workload were seen as reasons for not holding a face to face meeting.  It is important therefore that the workload of the social care manager or any other professional should not be the reason that face to face meetings are replaced by telephone discussions.                                              22 New learning from serious case reviews: a two year report for 2009-2011. Brandon M, Sidebotham P, Bailey S, Belderson P, Hawley C, Ellis C & Megson M. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/198919/DFE-RB226_Research_Brief.pdf  23 Unpublished research undertaken as part of the Learning into Practice (LiPP) a DfE sponsored project to improve the quality of SCR’s. (see http://www.scie.org.uk/LiPP/ for further details) 24 Working Together to Safeguard Children, 2015; Munroe Review of Child Protection, 2011. FINAL – June 2016 Page 31 of 45 Overreliance on self-reporting    A delicate balance needs to be struck to avoid neglecting relationships with parents; becoming too involved with needy adults; or getting so caught up in a family’s chaotic situation that attention is diverted away from the child (Brandon et al, 2009; Turney et al, 2011). Practitioners can also meet with outright hostility or ‘disguised compliance’ from adults who appear to be cooperating but are not, ultimately, able and/or willing to change.  To confront these difficulties, practitioners should maintain an attitude of ‘healthy scepticism’ and ‘respectful uncertainty’ when interacting with families. They also need the time and space to reflect and discuss the situation with people who can offer a fresh perspective and challenge their assumptions and beliefs. They may receive this support from supervisors, peers or external consultants (Trotter, 2008; Turney et al, 2011).25   8.10 Through the process of this review it has become apparent that all the information necessary to produce an in-depth assessment was known to various agencies.  This information was never joined up and each assessment effectively re-started the process.   8.11 Unfortunately because practitioners did not work together there was no opportunity to corroborate or verify information. A scepticism towards unlikely explanations is a useful skill to develop. There is a risk of a “start again syndrome” becoming established where significant events are dismissed without proper investigation because they do not fit in with the agreed plan.26  The need for effective supervision and managerial oversight   8.12 The lack of effective supervision has been referred to numerous times in this review, it is important to specify why this is considered such a crucial area for learning and should be considered by all agencies.    8.13 Supervision is necessary to achieve the following:   not accepting at face value what the parents or others in the family said  questioning by individual professionals and agencies of their own and others’ views, decisions and actions  ensuring that there was an effective intervention by the respective agency                                              25 Assessing children and families An NSPCC factsheet. February 2014 https://www.nspcc.org.uk/globalassets/documents/information-service/factsheet-assessing-children-families.pdf  26 Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003–2005. http://webarchive.nationalarchives.gov.uk/20130401151715/https://www.education.gov.uk/publications/eorderingdownload/dcsf-rr023.pdf  FINAL – June 2016 Page 32 of 45 8.14 There is some evidence that practitioners had been affected by ‘rule of optimism’.   There is a tendency by social workers and health workers towards rationalisation and under-responsiveness in certain situations. In these conditions, workers focus on adults’ strengths, rationalise evidence to the contrary and interpret data in the light of this optimistic view. They confuse participation by parents with cooperation.27  8.15 The primary way professionals have their perceptions of a family challenged is through supervision – it could be said there is also a need for a “healthy scepticism” in supervision as well.   8.16 Supervision is the cornerstone of effective practice; not only in terms of providing guidance, support and challenge for staff, but also in intervening when the inter-agency system fails to respond adequately. Supervisors could have used the Escalation Policy on several occasions when agencies disagreed over important issues such as the need for a case conference. Examples of Good Practice  8.17 In conducting a serious case review it is important to remember that the primary purpose is learning from the case.  It is important therefore to note examples of good practice and ensure that the review endorses these where it finds them. The following examples of good practice have been noted:   The GP raising concerns about Child J, having noticed bruising.  The housing support worker providing continuity of care to Ms Q  The health visiting service in maintaining a relationship and responding flexibly to the needs of the family Inclusion of Mr P in interventions; a frequent finding in case reviews is that the male partner is excluded, or absent from work with the family                                                  27 Learning lessons from serious case reviews 2009–2010 Ofsted 2010. http://www.workingtogetheronline.co.uk/documents/learning_lessons_from_serious_case_reviews_20092010.pdf  FINAL – June 2016 Page 33 of 45 9. Recommendations Somerset Safeguarding Children Board  Inter-agency procedures  9.1 The LSCB should regularly review the interagency procedures to ensure that the procedures are strengthened in specific areas:   a) Information about bruising - nationally several LSCB’s include practice guidance regarding the significance of bruising in pre-mobile babies. Somerset LSCB should consider including guidance on bruising and other forms of non-accidental injury to children in the Practice Guidance section of its online procedures 28  b) Strategy meetings - the current procedures suggest that telephone strategy discussions may be adequate in some situations.  The benefits of a face-to-face meeting were overwhelmingly endorsed by the practitioners who attended the professional’s seminar held in the course of this review. Clearly in a large county such as Somerset there will be occasions when they are the only option. However, in cases where:  there is medical information which needs to be explored,  certain agencies hold information not available to others and   the injury is unexplained,   a face-to-face meeting should take place unless this will cause unacceptable delay which may endanger the child. Consideration could be given to the use of Video conferencing to avoid delay      9.2 Therefore the current guidance could be strengthened to:  a) provide guidance about when a face-to-face meeting should be held.  b) standardise how the decisions made at the strategy meeting are recorded and who will take responsibility for sharing this information with agencies, who participated and those involved in the case but unable to attend.  c) recognise that there is a professional responsibility to use the Conflict Resolution procedure when agreed decisions are not adhered to without adequate explanation.  9.3  The LSCB should introduce a programme of multi-agency audits in key areas (such as attendance at Strategy meetings or Hospital discharge meetings for example) to better understand the issues around compliance with these procedures.                                              28 For example, Nottingham shire and Nottingham City SCB procedures: http://nottinghamshirescb.proceduresonline.com/guides/p_bruising_babies.html See also NICE guidance on Child maltreatment: when to suspect maltreatment in under 16's. https://www.nice.org.uk/guidance/CG89/chapter/1-Guidance  FINAL – June 2016 Page 34 of 45 Shared recommendation for all agencies  9.4. In terms of working in partnership with other organizations, all strategy discussions/meetings should involve Children’s Social Care, the Police, Health and other bodies as appropriate, in particular the referring agency.    9.5 Where young parents are a cause for concern then the housing agency or housing support staff may have significant information to assess risk and should be included in strategy discussions/meetings.   9.6 The LSCB should ensure that all agencies ensure that their staff are aware of the escalation policy and when it should be used.  Avon and Somerset Police  9.7 Avon and Somerset Police should ensure that all Police Officers involved in Child protection investigation will have sufficient understanding of child development to challenge information given in Strategy Meetings and Case Conferences.  Childrens Social Care  9.8 Review the guidance on child and family assessments to ensure that it is applicable to families with babies and young children. This guidance should also include information and advice about disguised compliance  9.9 Social Care staff responsible for convening child protection strategy meetings should ensure that invitations to attend, or contribute by other means, are sent to all of the relevant professionals who have knowledge of the child or family.  9.10  Guidance on undertaking child and family assessments with vulnerable young parents needs to be given to all staff to enable them to take into account the vulnerability of the young parent and remain focussed on the needs of the child.  Housing Providers  9.11 Housing Support Workers should be given training and support to enable them to consider the impact that tenants' lifestyles and behaviour are likely to be having on their children. They should also attend specific Child Protection training to ensure they have knowledge of their responsibilities to work with other agencies.     FINAL – June 2016 Page 35 of 45 10. Single-agency recommendations.  The following single agency recommendations were included in the individual management reviews and therefore endorsed by senior staff within that organisation. Some additional recommendations have been made as a result of the review process and agreed by the LSCB. The LSCB’s role is to hold these organisations to account in terms of implementing their agreed recommendations. Avon and Somerset Police  1. Avon and Somerset Police should remind all child protection investigators, and investigation managers, that the recording of decisions made, and their rationale, is an essential part of the good governance of investigations. The Police should agree a timescale for this with the LSCB with the expectation that it will be completed within 6 months of the endorsement by the LSCB of this Review.  2. Quality assurance should be tested through standard management practices, and the opportunity for decisions to be re-evaluated where necessary should also be in evidence. The Force should consider dip sampling of records over and above its reliance on good supervision. Joint recommendation for Police and Children’s Social Care  3. A senior Avon and Somerset Police manager should meet with senior colleagues in Somerset Children’s Social Care manager to explore and agree ways of ensuring their representatives in Strategy Discussions are able to be sure that all relevant information has been shared. They should also explore how information available may be effectively tested and identify information required e.g. adding trigger questions like ‘how is the information verified?’ to recording templates. This should happen as soon as possible.   Children’s Social Care  4. All Child and Family assessments must include all aspects of the assessment framework and consultation with relevant partners.  5. Managers should support staff to undertake chronologies which meet the agreed standard.  6. Managers should ensure risk is re-assessed and signed off by them and recorded as a manager’s Decision and Action record.   7. Operations managers should clarify ‘step down’ process at point of closure of cases with partner agencies.  8. Strategic Managers audit group (Children's Social Care) will review the circumstances and supports in place for all homeless 16 and 17 year olds, known to the service, addressing any deficits so that all these young people have suitable accommodation and a level of support appropriate to their needs.   FINAL – June 2016 Page 36 of 45 Knightstone Housing Association  9. Revise support paperwork to include section for acknowledging if children are present and any observations about them.   10. Further training for managers in Safeguarding children will be provided to ensure that supervision includes regular discussion about any safeguarding concerns, so that managers can give appropriate support and to ensure safeguarding is discussed at all supervision sessions as a standing item.  11. Maintaining the quality of contemporaneous notes will be addressed with individual staff member and managers will check files as part of regular one to one supervision sessions.  Somerset Partnership NHS Foundation Trust  12. Somerset Partnership will provide formal feedback to all staff involved in this case to ensure staff will have learnt lessons from the incident with the aim of improving the quality and safety of services provided to vulnerable children and their families.  13. The ongoing roll out of Level 3 training to Adult Mental Health staff will continue and include the lessons from this Serious Case Review and specifically include information sharing responsibilities where parents or carer are accessing support and how this impacts on their ability to look after their child.  14. All levels of Trust Safeguarding Children and Child Protection training will include the lessons from this Serious Case Review and focus specifically on the importance of review and analysis of historic information as part of health needs assessment.  15. The Trust will develop a Level 3 training module in relation to “Professional Curiosity” and will include strategies for helping staff ask difficult questions and “think the unthinkable”.  16. The ongoing assimilation of the “Think child, think parent, think family” approach across the Trust will continue and a clinical audit of professionals records will be instigated to ensure children’s needs are considered during the assessment and provision of ongoing care to adults by Trust staff.  17. The Trust will re-launch the “non-cruisers don’t bruise” advice to staff and ensure any incidents where this process is not applied are thoroughly reviewed with the staff concerned to identify any further lessons to be learned.  18. Cases where escalation is required, particularly those where there is disagreement regarding thresholds, will continue to be reported via the Trust Incident Reporting DATIX system to ensure a high level of scrutiny across the Trust governance systems.  The current agreed process of sharing such incidents with senior Children’s Social Care managers will continue to ensure maximum learning is achieved by all professional groups.   FINAL – June 2016 Page 37 of 45 Somerset Clinical Commissioning Group   19. The good practice of the GP in identifying subtle signs that could have easily been missed and responded immediately, will be used as a case exemplar and shared with other GP practices.   20. The CCG Safeguarding Team will continue to stress the importance of using screening questions, and practicing professional curiosity. This should always be a part of any training package.  21. Review the management of domestic abuse when women present to A&E departments.  22. The GP practice should review the arrangements for review of discharge letters from accident and emergency by the practice where domestic abuse has been identified and consider the follow up, multi-disciplinary discussion and risk assessment in line with good practice in domestic abuse management.  23. The GP practice should review the arrangements for coding of domestic abuse in patient records  Yarlington Housing Group  24. Review Safeguarding policy and procedures and update regularly in line with legislative or best practice changes.  Yeovil District Hospital NHS Foundation Trust  25. Single agency training should highlight the importance of all Yeovil District Hospital NHS Foundation Trust staff regularly asking service users whether they are experiencing domestic abuse, particularly in pregnancy.  This should be a routine part of good clinical practice, even when there are no indicators for abuse. Staff should also ascertain the legal parental status of all adults accompanying children to Hospital  26. A Significant Event meeting should take place with all Yeovil District Hospital NHS Foundation Trust staff involved in this case, to discuss the issues involved and to identify any individual learning required from the individuals involved.  27. The lessons learnt from this review will be disseminated to the individuals directly involved with the case and the wider organization, illustrating the concerns identified and reiterating best practice processes.  The relevant local and national policies and guidelines should be referenced and their usage reiterated to all staff.   FINAL – June 2016 Page 38 of 45 Appendix 129  Somerset Local Safeguarding Children Board  Terms of Reference for Serious Case Review  Child L and Child J   Decision to hold the Serious Case Review The decision to hold a Serious Case Review (SCR) was made by the Chair of the Somerset LSCB on 12.04.15 following a recommendation from the Learning and Improvement sub group held on the 24.03.15. As a result of the LSCB Chair’s decision, agencies were requested to secure their records.  The Learning and Improvement sub group concluded that the mandatory SCR criteria outlined in Working Together 2015 were not met in that the serious harm test had not been evidenced i.e., there has not been serious and/or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development. However, the group considered the history of this case, the “working together” issues that had been identified in this and other cases involving very young children and the potential for serious harm that existed and concluded that a Serious Case Review was the most appropriate type of review to elicit learning to improve multi-agency safeguarding arrangements in Somerset.  The Serious Case Review will be carried out in accordance with Chapter 4 of Working Together to Safeguard Children 2015.  Parallel investigation/enquiries  No other parallel investigations or reviews of practice have been commissioned in respect of these incidents  A criminal investigation is being carried out and both parents have been re-bailed for 29th July to allow the Police to carry out further investigation (as at 06.05.15). The Serious Case Review will not necessarily be formally or fully completed until the conclusion of criminal proceedings however the LSCB will ensure any necessary delay in concluding the Serious Case Review has no impact on using the identified learning to improve practice and outcomes for children, young people and families.  Family Involvement   The panel will ensure that members of the family will be sensitively invited to contribute to the review.   In the first instance, mother and step father/father will be notified of the review and contacted by the Independent Chair of the Panel or their nominee to facilitate their contribution to the review.                                               29 Identifying details have been removed from this document. FINAL – June 2016 Page 39 of 45  The timing of this dialogue will be agreed with the Police and the Crown Prosecution Service to ensure that evidence for any future criminal proceedings is not compromised.   Practitioner Involvement   All agencies are expected to secure the views of practitioners involved in working with the children and family to inform single agency learning.  The Independent Lead Reviewer will ensure the views of the multi-agency practitioner group are sought and used to identify ‘system’ learning during the progress of the review and to support the quality of the learning identified in the Overview Report.  Commissioning the Independent Lead Reviewer.  Somerset LSCB will commission an independent person with appropriate experience to produce an overview report that will be published in full in line with Working Together to Safeguard Children 2015.  Mark Dalton has been appointed as the Independent Lead Reviewer.  Chair of Serious Case Review Panel - Deputy Director of Quality, Patient Safety & Governance, CCG (Panel Chair)  A contract for each of the above roles is in place and clearly defines expectations.  Time period over which events should be reviewed   Agencies should review all relevant records relating to the subject child and all individuals listed at section 3 from the birth of CHILD L to the date CHILD L and CHILD J were accommodated.    The date of February 2015 has been determined as the end of the review period because there are no identified concerns in respect of the subject children or any other child (ren) beyond this date.    10.0 Organisations to be involved   The following agencies should review all relevant records relating to the subject child and all individuals (i.e. family members):  Avon and Somerset Constabulary Turning Point Somerset County Council – getset (Early Help Service) and Children’s Social Work Services Somerset Clinical Commissioning Group Yeovil District Hospital  Somerset Partnership NHS Foundation Trust Knightstone Housing   The following agencies will form the Serious Case Review Panel: FINAL – June 2016 Page 40 of 45  Avon and Somerset Constabulary Somerset County Council – Children’s Social Work Services  Somerset clinical commissioning group  Somerset Partnership NHS Foundation Trust Musgrove Park Hospital  In addition, the following post holders will be part of the Serious Case Review Panel:  LSCB Board Manager  The Serious Case Review Panel Chairperson, in conjunction with the Lead Reviewer, will as required identify any additional expertise required to support a robust and comprehensive learning process.  Individual Management Reviews   All authors of Individual Management Review reports must submit evidence of authorisation and ownership of the Individual Management Reviews and be signed off by the senior officer in the organisation who has commissioned the report, challenged and quality assured its content and accepted the findings.  The senior officer must have the authority for ensuring that the learning and recommendations of both the individual management review and where appropriate the overview report are acted on in a timely way.  Timescales for submission of IMRs  Chronologies should be submitted by 4th September 2015  Upon receipt of chronologies, and to assist the Overview Report author, a common system of referencing professionals involved will be agreed and used in all relevant documentation e.g. Health Visitor 1, Health Visitor 2, GP 1, Social Worker 1.    This system of referencing will be used in the Overview Report so as to preserve the anonymity of professionals involved in working with the child and his family.  IMR authors are requested to submit their completed reports by 18th September 2015    Information Sharing  All statutory partners of the LSCB have signed up to an information-sharing protocol that permits the sharing of information between agencies for the purposes of serious case reviews.  A copy can be made available on request.  All information and correspondence in respect of the serious case review should be transmitted securely and the preferred method is secure email30.                                               30 If any agency does not have arrangements to communicate via secure email, contact should be made with LSCB Board Manager to identify and agree an alternative safe method. FINAL – June 2016 Page 41 of 45 Terms of reference for each agency  1. To review all relevant records relating to subject children, mother and father/step-father and establish the facts of the case in relation to each individual agency  2. Construct a comprehensive chronology of involvement by the organisation and/or professional(s) in contact with the subject children and the family agencies in respect of issues of:  Concern or indicators of child abuse or neglect  Capacity to parent/ provide safe care  Domestic Abuse and any other criminal activity   Substance abuse and its impact  3. To review any agency records from any 3rd Sector service, or adult services not known of at the time of setting the terms of reference.   4. Briefly summarise those key points reached, opportunities for assessment and decisions reached in the case, the services offered and/or provided to the children and family, at each point and any other action taken for the period identified in point 9 above.  5. To complete an Individual Management Report which looks systematically, openly and critically at individual and organisational practice to see how the risk of physical harm was identified and addressed and why the risk was managed in that way.  6. To determine whether the case indicates that changes could and should be made and, if so, to identify how those changes will be brought about and what outcomes would be sought as a consequence.   7. To summarise practice and ‘system’ learning for the organisation including good practice.  8. To identify key actions required to support improved safeguarding practice and translate into specific recommendations.  9. To establish a clear outcome focused action plan for individual agency implementation as a consequence of any recommendations.   Guidance can be found below.  Overview report   1. The Overview report will be published in full and should be produced in a manner that focuses on the professional involvement and inter-agency working with the family as opposed to the detailed history and experiences of the lives of the subject child or others referred to in section 3.  The report should identify the key inter-agency ‘system’ learning, good practice and specifically address:  FINAL – June 2016 Page 42 of 45 (a) The effectiveness of multi-agency identification, analysis and management of the risk of physical abuse and why the risk was managed in that way.  (b) The effectiveness of multi-agency information sharing arrangements and any identified ‘system’ barriers to achieving effective identification and management of risk.  (c) The quality of risk assessments and validity of any tools or processes used to identify protective factors as well as risk factors.  (d) The quality and impact of multi-agency planning, decision and review processes used to promote improved outcomes for children.  (e) The impact and quality of professional supervision and its contribution to securing child-centred practice.  (f) The application of ‘thresholds’ and the degree of shared understanding and agreement across the partnership of those thresholds.  (g) Any ‘cultural practice norms’ that could impact on the professional network’s capacity to deliver child-centred practice including responses to safeguarding children under 1 years of age.  (h) The degree to which multi-agency practice in the field of risk and harm to children under 1 years of age is informed by evidence and research    (i) The degree to which the multi-agency system operated with the child at the heart of its intervention, including addressing issues of diversity and what needs to change to increase the responsiveness of the system?   2. Compile an integrated chronology of involvement with the child and family on the part of all relevant organisations, professionals and others who have contributed to the review process. Note specifically in the chronology each occasion on which the child(ren) was seen, if the child(ren) was seen.   3. The findings from this SCR should be considered alongside learning from local SCRs as well as those conducted elsewhere and should take account of findings from relevant research and the socio-economic background of the family and their community.  4. To assess the quality of learning, identified by each agency submitting an IMR and the response to that learning.  5. To establish a multi-agency action plan as a consequence from any ‘system’ issues arising from the overview report.   FINAL – June 2016 Page 43 of 45 6. To undertake all the above actions by November 2015 and present findings to Somerset LSCB in December 2015   Media Strategy  In accordance with Somerset LSCB Communication Strategy, any media enquiries in respect of the Serious Case Review will be managed by the Local Authority communications team in conjunction with constituent partner agencies.  Review  To ensure a dynamic learning process, these Terms of Reference will be reviewed by the Serious Case Review Panel under the leadership of the Serious Case Review Chairperson after an analysis of the single agency chronologies has been completed as well as in the event that any new information emerges during the course of the Serious Case Review     Endorsed by: Learning and Improvement Panel    Approved by: Sally Halls LSCB Chairperson          FINAL – June 2016 Page 44 of 45 IMR Guidance  The analysis should cover the following case specific issues:   (a) Whether the needs of the children and family were identified by the agencies that were in contact with the children and the family and responded to appropriately and identify any ‘system’ issues impacting on the individual workers ability to identify need and risk.     (b) Were practitioners aware of, focussed on and sensitive to the needs of the children in their work, knowledgeable about potential indictors of abuse or neglect and authoritative in acting on concerns or information so as to promote the children’s welfare; including making referrals to other agencies?  (c) Whether the threshold criteria used to access services was known, understood and applied by those working with the children and family so as to provide the right support at the right time to the children and the family.  (d) When, and in what way, were the children’s wishes and feelings ascertained and taken account of when making decisions about the provision of children’s services. Was this information recorded?   (e) Did the agencies consider the racial, cultural, religious, and linguistic identity of the children or the family and any associated implications within the assessment, planning and provision of services?  (f) Did the agencies consider whether the developmental stage/ chronological age as well as abilities or disabilities of the children had an impact on their situation and any associated implications within the assessment, planning and provision of services?  (g) Did agencies consider whether the abilities or disabilities of the adults had an impact on their situation and any associated implications within the assessment, planning provision and review of services?  (h) Were previous concerns known, understood and analysed as part of the risk assessment and was the cumulative impact of risk for each child actively identified and addressed?  (i) Was historical information about the family available to those working with and/or allocated to the family and were the household compositions known, understood and reviewed in light of known risk indicators/ information?  (j) What weight was given to those protective factors identified by practitioners and how was this balanced with identified risks in terms of assessments and plans  (k) Did the assessments and decisions appear to have been reached in an informed, child-centred and professional way and were they underpinned by research, risk indicators and child development?  FINAL – June 2016 Page 45 of 45 (l) Were appropriate services offered/ provided to support improved outcomes for the children, or relevant enquiries made, in the light of assessments and did a lack of resources have any bearing on the management of the case?  (m) Whether outcome focused planning and review processes supported and underpinned service provision; including the management of risk.  (n) Whether agency recording promotes the management of risk via: - Comprehensive recording of the names (and date of births of adult members) - A chronology - A genogram - Accurate knowledge of the household composition - Analysis of risk - Outcome focused plans - Supervision records  (o) Whether practitioners worked together to identify, analyse and manage risk and respond to any ‘system’ challenges that impact on inter-agency working.  (p) Was there evidence of accurate and timely information-sharing and liaison between agencies within the County and across borders?  (q) Were established internal and interagency procedures followed including escalation and dispute resolution and did they make a difference?   (r) Did the organisation have in place arrangements, policies (including supervision) and procedures for safeguarding and promoting the welfare of children and acting on and/or escalating concerns about their welfare?  (s) Were adequate supervision and line management arrangements in respective agencies in place to support child-centred practice and were they adhered to?   