Serious harm suffered by a 3-month-old baby boy because of multiple injuries including fractures and bruising of the brain in May 2017. Jack lived with his parents; had been subject to a child protection plan because of risk of neglect before birth. At the time of the injuries, he was subject to both a child protection plan and Interim Supervision Order (ISO). Family were known to multiple agencies; older sibling had been taken into care and adopted. Maternal history of: depression, being a looked-after-child, learning disabilities. Following the identification of the injuries, Jack was made the subject of an Interim Care Order (ICO). Ethnicity or nationality of Jack is not stated. Identifies lessons in relation to effectiveness of assessments; consideration and management of risk; injuries to pre-mobile babies need to be viewed from a perspective of potential risk; consider risk of neglect where a child's weight is varying; need to involve and support fathers; need to share information to allow robust discussion of concerns. Recommendations include: ensure that procedures on pre-birth assessments are consistent, contain guidance on timescales and ensure sufficient challenge; ensure that all agencies understand legal orders and their implications; child protection plans are SMART using tools to measure progress; review and reissue guidance for parents with mental health problems, joint working, and bruising in pre-mobile babies.
      
 Title:  Serious case review into the care of Jack. LSCB: Cambridgeshire and Peterborough Safeguarding Children Partnership Board Author: Jane Scannell Date of publication: 2020  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                                Serious Case Review  into the care of Jack     AUTHOR: JANE SCANNELL DATE: 7TH FEBRUARY 2020   2 Contents                        Page  1. Introduction to SCR         4  2. Process        4  3. Introduction to case       6  4. Summary of key episodes      7   5. Analysis        14  6. Conclusion        32  7. Recommendations           33     8. Glossary         36  9. References          37      3 SERIOUS CASE REVIEW INTO THE CARE OF JACK  1. Introduction 1.1 The subject of this Serious Case Review (SCR) is a baby, Jack, who was 3 months old and living at home with his parents and subject to both a child protection plan and Interim Supervision Order (ISO) when he was found to have suffered injuries including fractures to his skull and his leg. A criminal investigation into Parents’ role in causing these injuries is ongoing. Following the identification of the injuries, Jack was made the subject of an Interim Care Order (ICO) and has been in foster care since leaving hospital.  1.2 The Parents' first child was born 15 months before Jack, had also suffered significant harm whilst in their care and was subsequently adopted prior to Jack’s birth.   2. The Process 2.1 In September 2017 the Chair of the Local Safeguarding Children Board (LSCB) decided that this case met the criteria for a SCR as described in Working Together to Safeguard Children 2015. The reasons for this decision were that Jack had been seriously harmed whilst the subject of a child protection plan and there was cause for concern in the way agencies had worked together to safeguard him.   2.2 The terms of reference were that the review should cover the period from when Jack (then unborn) was made subject of a child protection plan - until the date the Local Authority was granted an Interim Care Order in respect of Jack and he was removed from his parents’ care.   2.3 The terms of reference asked the review to address the following questions:   do assessments and decisions appear to have been reached in an informed way and appropriately assess risk?   did actions accord with assessments and decisions made?   4  were appropriate services offered/provided or relevant enquiries made, in the light of assessments/ plans?  was there appropriate multi agency consideration and continued assessment of risk in this?   was the work in this case consistent with each organisation’s and the LSCB’s policy and procedures (Including bruising in pre mobile babies)?   2.4 Working Together to Safeguard Children 2015 states that SCRs should:  understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;   understand practice from the viewpoint of the individuals and organisations involved at the time, rather than using hindsight;   provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence;  be written in plain English and in a way that can be easily understood by professionals and the public alike  2.5 The agencies involved with the family during the time period covered by the review produced reports of their involvement. A well-supported Practitioner Event was held in January 2018 attended by practitioners from the key agencies who had worked with Jack and his family, together with the authors of the agency reports. This enabled the front-line practitioners who had worked directly with the family at the time Jack was injured to contribute to the review.   2.6 At the outset representatives from the LSCB met with Parents to inform them that a review was being undertaken. Subsequently, efforts have been made to contact parents to enable them to contribute to the review, these have been unsuccessful.  However, some wider family members have taken the opportunity to speak with the lead reviewer. Their contribution has been included into the report where applicable.    5 2.7 The lead reviewer, Jane Scannell, is independent of all professional agencies in Cambridgeshire and has had no previous involvement with, or knowledge of the family who are the subjects of the review. She is a social worker by profession.   3. Introduction to case 3.1   Mother and Father had been in a relationship for several years, having known each other since they were at school together. Mother had had significant involvement with Children’s Social Care (CSC) during her childhood culminating in her becoming a Looked After Child when she was 14. At the time Jack was injured Mother was 20 years old and Father was 22.  3.2   In December 2015 the couple’s first child (Elder Child) was born. There were concerns pre-birth about parent’s housing, life-style cooperation and engagement with agencies and the impact of mother’s learning difficulties. The Local Authority (LA) made an application for a Care Order (CO) when the child was born with a plan for foster care and a community-based assessment but were directed by the court to provide a residential assessment. In February 2016 this placement concluded that, because of the “significant and multiple concerns” about the parents’ ability to safely and consistently meet the baby’s needs, the child needed to be removed from the parent’s care. Care and Placement Orders were obtained in April 2016 and Elder Child was adopted in September 2016.  4. Summary of key episodes prior to and during the period covered by the review  4.1   Key episodes are those periods and events that are judged to be significant to understanding the way that the case developed and was handled.  The term ‘key’ emphasises that they do not form a complete history of the case but are a selection of the activity that occurred and include information to inform the review.    6 Episode 1 - Pre-birth 4.2   Although some of this episode predates the review period, the actions taken prior to the pre-birth child protection conference are included here as they had a significant impact on the trajectory of the case going forward.  4.3   In October 2016 (the month after Elder Child was adopted) CSC were notified by the Midwifery Service that Mother was pregnant again. A pre-birth assessment was initiated and was undertaken by the consultant social worker (CSW1) who had been involved in the assessment and intervention with the Elder Child. The assessment was completed in December 2016.  4.4 The assessment’s conclusion was that there were concerns that this child too could be at risk of significant harm. A child in need (CiN) meeting was held in January and subsequently a strategy discussion between the Police and CSC, held two days later, agreed that the threshold for convening a child protection conference was met.   4.5 Although completed just within the locally defined maximum timeline, the length of time it had taken to complete the assessment and to then hold the subsequent CiN meeting meant that the initial  (pre-birth) case conference was not held until the beginning of February 2017 (by which time Mother was 31 weeks pregnant).   4.6 The conference agreed that the unborn baby should be subject to a child protection plan because of risk of neglect and also recommended that the LA hold a legal planning meeting. This was duly done (within two days of the case conference) and the legal advice was that the threshold for initiating care proceedings was met.   4.7   As is the policy in Cambridgeshire, the case was brought to CSC’s Threshold and Access to Resources Panel (TARP) but not until the beginning of March (by which time Mother was 35 weeks pregnant). The application, written by CSW1, requested approval to issue court proceedings. It highlighted the evidence from Elder Child’s case but, recognising  7 the need for further assessment given that there had been some indications of change in the Parents’ situation and behaviours, also requested that consideration be given to the assessment either continuing at home once the baby was born under an Interim Supervision Order (ISO) or in foster care (under an Interim Care Order (ICO).  4.8   At the time cases were presented to the TARP by managers, not by allocated workers. In the CSC agency report, the author describes the Group Manager’s understanding of the outcome of the Panel was that “the team were to consider all placement (options)” which included placement with parents as well as a ‘foster to adopt’ placement. However he also stated that his expectation, following the TARP, was that the baby would be placed in a foster to adopt placement as soon as it was born. At the time, decisions made at the TARP were not entered on the case record and there was not a tracking process to follow up the agreed actions as they are now. The minutes from the TARP meeting were not seen by CSW1.  Episode 2 - first six week of Jack’s life (March – May) 4.9   However, when Jack was born in March 2017 (3 weeks after the TARP and 3 weeks before the expected due date) and care proceedings were issued, the care plan put before the court was that Jack would go home in the care of his parents under a Supervision Order. Although not supported by the Cafcass officer allocated to Jack (who had also been the guardian for Elder Child) this plan was agreed by the court and an ISO with a support plan of daily visits was granted. Jack and his parents left hospital and went home in March.   4.10 Initially there were twice daily visits from a range of professionals. The Specialist Midwifery service continued to visit virtually daily until the end of the month, and the Health Visiting (HV) service, social workers and family workers from an externally commissioned service were involved. There was contact with the GP surgery with Jack being taken there because of unexceptional concerns.    8 4.11 At the end of March Mother was prescribed anti-depressants by her GP because of low      mood. Shortly after Jack’s birth, while she was still in hospital, she had had had a similar episode. At the time the consultant had discussed this with psychiatric liaison team who had offered advice and suggested that, should her low mood continue once she was at home, a referral could be made to the Perinatal Mental Health service or the GP could refer her to the Community Mental Health Team (CMHT). However this advice had not been shared with members of the professional network supporting the family and so the GP was not aware of this recent episode or the suggestion that the Perinatal service should become involved. The GP was aware she had experienced similar low mood following Elder Child’s birth.  4.12  A core group meeting held in mid-April, hearing that the family were keeping appointments, that Jack was developing well, that parents were listening to and acting on advice and that paternal grandparents were being supportive, agreed that professional visits could reduce to once a day. A review child protection conference was held as well as a further court hearing and Jack remained subject to a child protection plan and an ISO, with daily professionals’ visits. There were a number of changes in the staff involved in the case: there was a different chair of case conference, the original solicitor retired and CSW2 became the allocated social worker, the in-house Specialist Family Support Service (SFSS), who had not been able to become involved sooner because of capacity issues, took over the parenting assessment work from the commissioned agency. There continued to be changes in the HV involved due to staffing pressures.  4.13 Agency reports and comments at the Practitioner event showed that, although there were no overt significant concerns during this episode, some of the care Jack received from his parents and their behaviours may not have been given the weight they warranted. The CSC agency report states ‘it is clear from recording that parents had been disregarding advice, challenging advice given and requiring significant amount of prompting, avoiding evening visits and refusing to allow observations of bath time’.  9  The impact on practitioners’ perception of risk of the fact Jack was on an ISO and that therefore his wellbeing was under the scrutiny of a court is considered later in this report.  Episode 3 –during which a s47 investigation was undertaken when Jack received an injury to his face (May) 4.14 During the first few weeks of May there were several occasions when the parents were not available for HV visits. Concerns started to further emerge over Jack’s feeding regime with parents speaking of feeding him only every 7-8 hours. Jack was also reported to be suffering from constipation.   4.15 In May the Specialist Family Support (SFS) worker noticed an injury to Jack’s face/mouth which Mother said had been caused by him banging his head against the zip of the top she was wearing. The SFS worker reported this to CSW2 and, because Jack had an appointment with the GP to have his immunisations, it was agreed that Jack should attend this appointment. At the Practitioner event CSW2 explained the thinking was that, if the GP saw the injury and concluded it was a bruise then a child protection medical assessment would be arranged in line with the LSCB’s Bruising in Pre-mobile Babies Protocol.    4.16 Another social worker from the Unit accompanied the family to the GP who confirmed there was a bruise on Jack’s left cheek, a sub conjunctival haemorrhage1 and a small scratch on his forehead and so a child protection medical was arranged.    4.17 The medical took place at the end of the day, in a hospital setting and the parents were reported to have been both upset and angry. The Paediatrician did not get an opportunity to speak with accompanying social worker prior to undertaking the examination and does not recall being told either that Jack was subject to a ISO, or that Elder Child had been adopted, although she knew he was on a child protection plan and was ‘aware care proceedings were likely’.  In discussion with the author of the agency                                                       1 Red eye caused by bleeding behind the sclera (the white part of the eye).  10 report the Paediatrician who examined Jack that day reflected that had she known the full history of concerns which had led to the ISO and child protection plan, she may have completed further investigations at this time.    4.18 The conclusion of the medical was that although it was unusual for a baby to sustain a significant mark from an incident as described, the injury was not inconsistent with the explanation. No blood tests or skeletal surveys were undertaken. A strategy discussion between the CSC and the Police concluded, following receiving a verbal report from the Paediatrician, that there was no role for the Police and that CSC would complete single agency enquiries.   4.19 CSC decided Jack should remain in the care of his parents. CSC practitioners reflected on this decision at the Practitioner Event and felt that their enquires into the injury had been as robust as they could be: medical opinion was that it was possible for the injury to have been caused in the way described, Jack was known to ‘settle’ against Mother’s chest and he could move, but not control, his head. They had not assumed that this would be the decision following the medical assessment and had had a foster placement identified in case it was needed.  4.20 The HV undertook Jack’s six to eight week post-natal developmental check at the end of May (it was originally due a week earlier but had been postponed by Mother). Parents did not allow Jack to be weighed as they told the HV that he had been weighed by the GP the previous week. Once again the parents spoke of Jack having a feed every 7-8 hours and again the HV emphasised the need for more frequent feeds. When the HV did weigh Jack the following week (beginning of June) he weighed 4.76kg (2nd centile).  At his child protection medical in May his weight had been 4.48kg (9th centile).  Episode 4 - when Jack received a further injury and is later admitted to hospital (June) 4.21 At the beginning of June, Father contacted the CSW2 to inform her that Mother had telephoned him to tell him that Jack had received an injury to his lip when a feeding  11 bottle with milk in it had fallen off a table and knocked his face. He had asked advice from Paternal Grandmother who had advised applying a cold compress and taking Jack to the GP and had Father had made an appointment to see the GP that afternoon. CSW2 went with him and Jack to this appointment where Jack was seen by two GPs who concluded that the injury (on both the inside and outside of his lip) was consistent with the Mother’s explanation and that therefore a paediatrician’s opinion was not needed.  CSC recorded the actions and outcome on the electronic record as a strategy discussion. They did not liaise with the Police until the next day where it was just ‘noted’ on the Police system as, by this time, it had been concluded that the injury had been caused accidently.   4.22 The HV did a routine home visit on the following Monday and noted a ‘small red mark’ over Jack’s left eye and was told by CSW2 it had also been noted by the SSFS worker over the weekend. No further information was obtained or action taken about this. The HV did observe during this visit that ‘mother was reluctant to bring Jack in from his room’ and that ‘parents had little interaction, minimal eye contact and showed few signs of interest in the session’.   4.23 In June a letter containing the outcome of the medical undertaken by the Community Paediatrician during May was received by CSC. In it, the Paediatrician had noted that “if further injuries were caused blood checks and full skeletal would be required”. This letter did not prompt any review or reconsideration of the two injuries Jack was known to have sustained since the child protection medical.  4.24 During a home visit the following week, the HV observed Mother handling Jack ‘very firmly’ and noted that he was ‘quiet and unreceptive to mother’s attentions despite the rough handling’.  His weight had decreased ‘a little’ which prompted another conversation about appropriate feeding regimes, including the need to start weaning at 6 months, and not at a year which Mother felt was appropriate.  4.25 The next day another core group meeting was held. Among the issues discussed was the need for parents to interact more with Jack. The author of the agency report about  12 HV involvement notes that this was a recurring theme at the core group meetings. The meeting also discussed professionals reducing the number of visits per week to ‘allow the parents to be more independent’.  4.26 In the middle of June, Jack was taken to the GP by his parents for his immunisations. The parents told the GP that he had been screaming for two days and that they ‘wondered if he has sprained his ankle’ as it appeared to be bothering him. The GP probed the reason why they suspected this but parents did not provide any explanation about an accident or injury or any further information. The GP’s examination, together with a colleague, (Jack was unclothed) did not identify any “obvious discomfort” or any injuries/marks. The GP arranged to see Jack the next day to review.   4.27 At 9.50 pm on the same day the Police were called by a neighbour to report that the Parents had left Jack alone in the flat and that this was not the first time this had happened. When the Police arrived at 10.16pm they found both parents on the balcony of their flat. The Parents denied having left Jack alone at any time and spoke of having problems with one of their neighbours, implying the report was malicious. The Police Officers saw Jack asleep in his cot and had no concerns for his wellbeing. They made one attempt to follow up with the neighbour who had made the report but were unsuccessful and so were not able to clarify any details – for example how long before the neighbour had phoned the Police had the Parents been out of the flat (if indeed they had) or information about the previous incidents that the neighbour had implied had occurred.   4.28 The attending Police Officers were not aware Jack was subject to a child protection plan. Although the recording system used by the Police’s call handling service contains an “Historical Information” tab where very brief information alerting the call handler to the fact that there is a child protection plan associated with that address exists (to obtain further information, such as the details of the plan, requires a further search) this fact was not passed on to the Officers responding to the call.    13 4.29 In the middle of June, Parents took Jack for a pre-arranged appointment at a hospital in another area regarding an issue with his tongue that had been identified at his 6 week check. The Consultant Surgeon noted a petechial haemorrhage2 on his upper lip. In addition the consultant was concerned by Mother’s report that Jack was having difficulty lying on his back. It was arranged that Jack should be admitted to hospital and child protection procedures were initiated. A medical revealed two injuries to his upper lip, a bruise to his chin, two bruises to his right knee and scab on the back of his head. Jack remained in hospital and a strategy meeting was held the following day. It was agreed that further medical tests were needed and a skeletal survey and a CT (computer tomography) scan were undertaken. Pending the outcome of these tests Jack was made subject to the Police’s Power of Protection3 and supervised contact with his parents was arranged. Further medical tests subsequently revealed ‘multiple healing fractures’ and fracture to the base of his skull with bruising to the front of his brain. Even though Jack was being seen daily by professionals none of the external injuries had been noticed or noted.  4.30 The LA made an application for an ICO which was considered by the court in June. However, because no written medical evidence was presented to the court and the intention was for Jack to remain an in-patient, no order was made but the parents gave an undertaking not to remove Jack from hospital and Police Protection was allowed to lapse. A few days later, the LA returned to court and an ICO was granted and Jack was placed with foster carers.  5. Analysis 5.1 This section considers a number of issues identified in the key episodes and relates them to the questions posed in the terms of reference. These issues can be summarised as the effectiveness of assessments, the understanding of risk, how compatible practice was with policies and procedures and finally, interagency working.                                                        2 A petechial haemorrhage happens when capillaries (tiny blood vessels) bleed and leak blood into the skin causing a small (1-2mm) red or purple spots. 3 Section 46 of the Children Act 1989 allows for a police officer to remove a child from a parent without a court order for a period of up to 72 hours  14  Effectiveness of assessments Pre-birth assessment 5.2 The importance of pre-birth assessments and their potential to set the direction a case takes has long been recognised (Ofsted 2011). In Jack’s case, the pre-birth assessment and work completed by CSW1 was particularly influential in the trajectory that the case took.   5.3 It would generally be considered good practice for a worker who had known the family previously to be allocated when a family is re-referred to CSC. It enables them to build on their previous knowledge, relationships and experience of the family and avoids the risk of ‘starting again’. In this case CSW1, who had been the social worker for Elder Child, was initially the allocated social worker to the family.  This meant she was fully aware of the deficits in the care Elder Child had received and the reasons why Elder Child had been adopted the month before the case was referred.   5.4  The CSC agency report states that the pre-birth assessment was ‘very thorough in identifying risks from Mother’s own childhood along with assessments and information known from (Elder Child’s) proceedings’ and it concluded that there were ‘significant concerns….. little change or time to demonstrate learning since (Elder Child’s) removal’.   5.5 In the written information provided to the TARP by CSW1 she requested that consideration be given to applying for ISO in order to test ‘if parents can engage with services’. She noted that they had been engaging with the child protection plan (which by that time had been in place for four weeks). However she also noted that Parents ‘had not learnt from past experiences’ and that even ‘with the highest level of support that can be given’ the parents had not been able ‘bring their parenting ability to a good enough level to ensure (Elder Child’s) basic needs were met in a safe and consistent way’. She included the fact that a referral for a ‘foster to adopt placement’ with Elder Child’s carers had been made. The Group Manager (her line manager) recorded on the  15 same form that he was in agreement with ‘immediate issue of care proceedings and a foster care placement being ready upon discharge from hospital’.   5.6 The decision of the TARP, that proceedings should be issued at birth and ‘placements to be explored’ was understood by the Group Manager (who attended the TARP) to include the option that Jack could go home with his parents and so, when CSW1 subsequently continued to recommend that an ISO be sought, he believed he had the TARP’s permission to agree this. Since the period under review the TARP process has been refined. Cases are presented by allocated workers enabling panel members to discuss the cases with the worker providing the direct input into the families,  the decisions made by the TARP are entered on to the case file and actions agreed are tracked to ensure they are completed in a timely way.  5.7  It is difficult to reconcile how the assessment, and the subsequent views expressed in the case conference, LPM and TARP, resulted in a decision by CSW1, and agreed with by her line manager, to seek an ISO. Even the application to court stated that ‘the parents were not able to meet (Elder Child’s) basic needs or her emotional needs and they were unresponsive to her. The parents’ relationship was volatile and the mother sometimes became frustrated when she was caring for (Elder Child). This meant (Elder Child) was exposed to hostile and angry behaviour’.   5.8 The author of the CSC agency report hypothesised that CSW1 had viewed Parents’ improved attendance at meetings and appointments as engagement and that this, combined with more settled living conditions and an apparently less fractious relationship between the two of them led her to recommend that further assessment could be carried out while Jack was being cared for by his parents at home. This was confirmed in interview when CSW1 confirmed that she ‘could see differences in the parents’ behaviours’.   5.9 Family members spoke of the pressure of how not knowing whether Parents would be allowed to take Jack home had affected them. Given the length of time the pre-birth  16 involvement it would have been expected that they would have been able to have clarity about CSC’s recommendations/plans by the time Jack was born.   5.10 CSW1’s opinion prevailed in court despite the Cafcass officer not supporting the plan.  At the Practitioner Event the Cafcass worker explained the referral had come too late for the case to be included in the Cafcass Plus - a programme that introduces a family court adviser into the pre-proceedings process to either divert cases from entering proceedings or to speed up the process for those who do end up in court. As it was, she had to base her recommendations on what she knew from her involvement with Elder Child and was not able to be in court for the initial hearing. It is therefore not unreasonable to assume the Judge was persuaded by CSW1’s argument given her longer involvement and opportunity to work directly with the parents which the Cafcass officer had not had a chance to do in relation to Jack.  5.11 The decision to recommend the removal of a baby from their parents at birth is a difficult and emotionally charged one. The social worker has to weigh the negative impact on attachment and bonding and the baby’s right to be cared for within their birth family (and in this case, the rights of a learning disabled mother to be given the necessary support) against the risk of harm at a time in a baby’s life they are entirely dependent and very vulnerable. The assessment needs to take into account not only parents’ ability to care for the new-born, albeit with professional support and guidance, but also the prognosis for them to be able to respond to the changing needs as their child grows and develops.   5.12 It is in situations like this that the opportunity provided by supervision to discuss, reflect and challenge opinions and hypotheses with others is especially important. This is necessary however experienced the practitioner, and however well they know the family. The Group Manager’s view that this case did not warrant his ‘specific oversight’ because of how experienced CSW1 was, and because the situation was ‘no different to other cases of this nature’ meant that this case was not discussed in their supervision sessions. In addition the fact that, as a CSW, the worker ‘signed off’ her own  17 assessments meant that the checks and balances which should be inherent in the system were not in play.  Mental Health assessment 5.13 Mother had a history of not wanting to engage in mental health assessments. Reading the agency reports it is possible to identify at least four times (during the period considered) when she was either referred for mental health or associated assessments or had such options discussed with her. Given her vulnerabilities any of these assessments could have been helpful in providing not only a better understanding of her mental health/depression but also of how these, combined with her learning difficulties, impacted on her.   5.14 It was good practice for the consultant at the hospital after Mother had given birth to Jack to liaise with the Psychiatric Liaison team. Although Mother had a history of refusing mental health support, the fact that she was currently in hospital, unclear whether they would be able to take Jack home and worried about her low mood may have made her more receptive had there been a more proactive approach from the psychiatric service at this time. However because Mother was not expressing self-harm ideation the case was considered low risk and therefore warranting advice only to the concerned professionals. The element of risk to the new born baby – who was subject to a child protection plan – did not alter this assessment of risk.   5.15 The  failure to ensure that the recommendations from the Liaison Psychiatric Nurse were passed on to the network working with the family meant that when Mother was upfront with the GP about her low mood/depression, the links to alternative options to address her difficulties were not apparent. Although it is likely, given her pattern of refusing mental health support that Mother would have resisted any referral/support from a more specialist service but the opportunity was not there.  5.16 As it was, the only assessment available that considered the impact of Mother’s learning disability in relation to her mental health and parenting was the psychological assessment completed as part of Elder Child’s court proceedings. Social workers  18 allocated to Mother as a Care Leaver had been pro-active in suggesting that she access services around her mental health needs but she had resisted these suggestions.  5.17 Whilst practitioners were diligent in suggesting to Mother that she should accept counselling in order to come to terms with the loss, to adoption, of Elder Child there was no evidence of consideration of Father’s need for this type of support.  Health contribution to assessments 5.18 Pre- birth, and for some weeks after Jack was born, Mother received services from a Specialist Mid-wife from the vulnerable mothers’ team. The specialist Mid-wife provided all the ante-natal care in the family’s home. Mother’s improved engagement with this service was cited frequently as evidence of greater engagement during this pregnancy compared with her first but, given that minimal effort was required from her to access the service it is questionable how valid this was as evidence of positive progress.  5.19 The HVs’ role and contribution to the parenting assessment was compromised to a degree by the changes in personnel involved. At the Practitioner Event the individuals involved spoke of how they felt that they were just ‘filling in the gaps’ in the care/visiting plan rather than using their specialist skills and being integral to the assessment. The child protection plan included little specific interventions from HV other than to ‘visit regularly to monitor and promote health and development as he grows and develops’.  Learnings/findings  No matter the level of experience or seniority of the social worker they need to have the opportunity of reflection and challenge provided by supervision, especially when they are making potentially high risk decisions. Case work supervision must be as available to CSWs as to other case-holding staff.   Assessments completed by CSWs need to have further scrutiny and independent sign off.  19   Timeliness is not just a matter of meeting prescribed timescales. Assessments, and other actions/meetings need to be completed in time to allow for planning, engagement of identified resources etc. and in the case of pre-birth assessments so that parents (and professionals) know well in time what the arrangements will be once the child is born.   In cases eligible for Cafcass Plus, CSC need to refer early enough (by 30 weeks) to enable Cafcass be involved in the pre-proceedings work.   When the Psychiatric Liaison service is asked for and provides advice about an inpatient the Psychiatric Liaison practitioner needs to ensure this communicated in writing to the GP. When the Psychiatric Liaison team are aware that CSC are involved with the family, this information also needs to be shared with CSC.   Especially during the perinatal period, any consideration of a parent’s mental health needs to explicitly take account of the potential risk to the baby.   Workers need to consider emotional impact of life experiences (adoption of Elder Child in this case) on fathers as much as on mothers and ensure that they too are made aware of/offered support.   Consideration and management of risk Identification of risk 5.20 Prior to his birth the risks to Jack were based on the risks identified during Elder Child’s short time in Parents’ care and were generally considered to be ‘not so much the risk of physical harm, but of emotional harm and neglect’ (Cafcass). Was there sufficient alertness in the network to other possible risks? At the Practitioner Event it was apparent that CSW2 had reflected on this and felt that the, apparently minor, injuries Jack had not been “given a loud enough voice”. It would appear that the professionals involved were, like the CSW1, persuaded by the fact that Parents were, albeit not very  20 happily, allowing the daily visits was evidence that they were engaging effectively in the protection plan.  5.21 However, there were indicators that the care Jack was receiving was posing a risk to his wellbeing. Concerns about his feeding regime and reported constipation were noted, as was Mother’s reluctance to accept advice and to allow observation of him being bathed. As time passed there were more times when the family were not available for professionals’ visits. These factors were not drawn together and used to inform whether the protection plan was working.   5.22 When Jack was born (slightly early at 37 weeks gestation) he weighed 2630g which placed him slightly below the 25th centile. During the first three months of his life Jack’s weight (when recorded) fluctuated between the ninth and second centile. However neither this drop nor the fluctuation was identified and so their potential as indicators of concerns (about the care Jack was receiving) was not recognised. (A previous serious case review in Cambridgeshire (2015) identified concerns about professionals not recognising concerns about a child’s weight as evidencing risk of harm.) Although the child protection plan included a requirement for the HV to ‘monitor and promote (Jack’s) health and development’ it was not specific about the need to regularly weigh him - and measure his length and head circumference. Because Jack was weighed by different people and in different settings – at home, at his child protection medical and at the GP surgery – a consistent picture was not obtained.   5.23  Another area of risk for Jack was the quality of the relationship between his parents and their individual ability to moderate their behaviours. Also included in this area of risk was the impact of Mother’s learning disability – on her ability to understand concerns and to comprehend the modifications in behaviour and lifestyle she was being asked to make.   5.24 Staff who had previously worked with Mother providing leaving care services, were clear that although she was very capable with day to day living tasks such as household chores and personal care, her learning disability was apparent in her ability to process  21 information and make decisions. The psychologist’s report undertaken during the care proceedings for Elder Sibling stated that she had ‘severe impairment across all areas of executive function’ and a Special Educational Needs (SEN) assessment in 2011 identified that she has an IQ of 66 indicating ‘extremely low intelligence’. Staff also reflected that she was difficult to reason with, especially when angry and that she could be quite aggressive. Health records noted that “throughout her life (she) has used ‘attitude’ and behaviour to mask the level of understanding she has”.   5.25 The child protection plan makes little reference to the need to cater for Mother’s learning disability. The pre-birth plan had an action for a referral to be made to the Learning Difficulties Service to “assess the best way for agencies to communicate with (Mother) and to look at strategies to help (Mother) to remember information”. Mother had had some involvement with this service around the time she had Elder Child but was felt to “quite borderline” as to whether she met their criteria for involvement and there was no involvement from them during the period under review.  5.26 The HVs’ agency report acknowledges that, although the HVs involved were aware that Mother had some learning needs, they had not read Elder Child’s records and so were not aware of the degree of disability she had. The summary of the work completed by the SFSS makes no reference to how their work addressed Mother’s learning needs, other than referring to some reading material being provided in large print format.  5.27 It is also not clear how much domestic abuse was a feature of the relationship although it is apparent that there were incidents at times during their relationship. The fractious behaviour that led to concerns during the time Elder Child was in Parents’ care was clearly still evident as the child protection plan referred to the agreement with Parents that they would not ‘expose Jack to arguments or shouting’.  5.28 Although the court did agree an ISO, it was with an exceptional amount of support visits. The order was for twice daily visits for at least the first week and then daily visits for at least a month. The fact that this level of visiting continued for longer suggests there was a degree of concern about what would happen if the visits reduced.    22  5.29 There was little comment in the agency reports about the quality of the child protection plan - the tool against which decisions would be made about the progress the parents were making in their care of Jack. The plan produced as a result of the review child protection conference in April specifies actions that will be taken by those involved, including Parents but there is no mention of what deficits/concerns these actions were addressing. Or indeed, of what was going well which the plan would build on and enhance. This is consistent with the findings made during Ofsted’s focused visit to CSC in March 2018 which found that ‘some plans are more action-focused, with little evidence of being developed with families’.  5.30 There are few specifics in the child protection plan against which it could be evaluated as being effective in ensuring the care that Jack was receiving was safe and appropriate. It was the Core Group’s responsibility to develop the outline plan in to a detailed working tool. This task would have been easier had the child protection plan included measurable objectives for change and ways of evaluating whether those changes had taken place (i.e. using the Graded Care Profile, a tool that is being incorporated in to use in practice in Cambridgeshire).  Impact of the Interim Supervision Order 5.31 The review has considered whether the fact the court granted an ISO rather than an order which would give the LA parental responsibility - influenced workers’ perception of the level of risk Jack was exposed to. There was uncertainty in the professional network about the status of the Order, with some staff assuming that it offered more protection than a child protection plan and others unaware of its implications. What was more influential on staffs’ understanding was the fact that a court, based on the information put before it, had agreed, with conditions, that Parents could care for Jack at home. At the Practitioner Event staff who had been involved with Elder Child reflected that they had been surprised by this but assumed that, as it had been agreed by the court, it was well-considered decision and would be overseen by the legal  23 system. There was an implicit understanding that the risk was being managed through the court process and practitioners did not realise this was not the case.  Implications of changes in the professional network 5.32 A feature of the case was the number of changes in the personnel working with the family. Although the initial CSW was the same worker as the one who had worked with the family during the involvement with the Elder Child, she left the authority and CSW2 was allocated to the case in mid-April. A total of four different Health Visitors worked with the Family during the period under review; there was a change of case conference chair between the initial and review child protection conference; because of lack of capacity in the in-house SFSS, an external agency was commissioned to undertake pre-birth parenting support and the in-house service became involved again in mid-April. The LA legal advisor who was involved in the initial application to court retired prior to the hearing in April.   5.33 These changes may have contributed to lack of a cohesive view/understanding of the care Jack was receiving and of the effectiveness of the child protection plan. It was noticeable that several of the reports or statements about the plan’s progress contained contradictory information and the CSC agency report author notes that ‘triangulation of information does not appear to have been undertaken’. This is likely to have been compounded by the changes in personnel involved in the case.  5.34 The family also reflected that not only was there a high number of visits to their home by professionals but the numbers and the changes in personnel added to the pressure they felt under. They also felt this contributed to them receiving what they felt were mixed messages over feeding and general care issues.   Police call out 5.35 The Police Officers who responded to the neighbour’s call about Jack being left alone in the flat were unaware that this was a baby on child protection plan. Had they had this knowledge they might have been more curious about why the neighbour had told the  24 call handler that she had seen them leaving Jack alone before. It may have made them less willing to accept, without further confirmation, the parents’ explanation that the report was malicious.    5.36 The Police call handlers’ screen shows them a great deal of information about the address and people involved when they are responding to a referral. There is a risk that, unless the police officer who is responding to the referral specifically asks them to check ‘Historic Information’ (where the information that the child is subject to a child protection plan is recorded) it can be missed. On this occasion the call handler did not inform the officers of the plan and they did not ask.  5.37 It is unlikely that the Police Officers would have been able to tell that Jack had suffered injury (by the time they saw him he would have already experienced the fractures that were subsequently discovered) but had they known he was identified as a child at risk of harm they may have been more assiduous in following up the allegation that Jack had been left alone before with the neighbour as well as ensuring that the allocated social worker was informed in a timely way.   Learning/findings   The fluctuation or loss of weight in a child could have a range of causes, however professionals must always consider the risk of neglect in the family where Childrens weight is varying. This has been a learning point from previous SCRs in this area and further work needs to be undertaken across the professional body to support professionals in considering neglect or other safeguarding risks as a cause for weight change.   When there are concerns about neglect and the quality of care a young baby is receiving there should be frequent measurements of length, head circumference, and weight, using the same pair of scales and by the same professional to enable a clearer analysis of growth patterns.   25  There is a lack of understanding in the professional network about court orders – their powers, limitations etc. Staff from agencies other than CSC would welcome information further information/training on this.   There are a variety of tools that can be used by core group members to inform and measure progress and which can also help practitioners see patterns in behaviours and incidents and help triangulate information and observations. These include the Graded Care Profile, chronologies and genograms. They are especially useful at times where there are changes of staff involved.   It is essential that Police Officers responding to calls need, at the very least, to be aware whether any children in the household are subject to child protection plan at the time when they are attending the call. Call handlers need to be alert to the “Historic Information” tab and the significance of a child being subject to a child protection plan.  Working within policies and procedures Pre-birth procedures 5.38 The referral to CSC by Midwifery Services for a Pre-birth assessment was timely and reflects improved practice from a previous SCR undertaken by the Board (2014) which identified that referrals were not being made until 24 weeks in to the pregnancy. The current LSCB procedures do not specify the timing but do emphasise the need not to delay. However, this promptness was compromised by the delay in completing the assessment and convening the subsequent meetings.   5.39 The assessment process was not compliant with either Cambridgeshire’s Safeguarding Children Board’s Multi-agency Pre-birth Procedures or with CSC’s own internal procedure for pre-birth assessments. The former states that where a referral indicates that the unborn child may be at risk of significant harm a strategy meeting including the Community midwife or Maternity Services, Health visitor, Police, Social worker and any other professionals as appropriate should be convened to determine, among other  26 things, the particular requirements of the pre-birth Single Assessment and whether a Section 47 Enquiry needs to be initiated. CSC’s internal procedure states that the assessment MUST (sic) be completed within 35 days with a child in need meeting held prior to the completion of the assessment and, should the assessment identify that an initial child protection conference is needed a strategy meeting should be held.   5.40 Good practice would suggest that, when possible (i.e. if the referral is timely) the case conference should be at about 24 weeks into the pregnancy to allow for a premature birth, to avoid the parents having to experience a potentially difficult experience too near the birth and to allow for planning and necessary interventions. The CSC Pre-birth Procedure states it should be held at 23/24 weeks. However the LSCB’s Practice Guidance on Child Protection Conferences states that Pre-birth child protection conferences should normally be held after the 24th week of pregnancy and not less than 6 weeks prior to the expected delivery date. DfE’s statutory guidance - Court Orders and Pre-Proceedings for LAs (2014) emphasises that when the LA is considering proceedings shortly after birth, the letter before proceedings4  should ideally be sent at or before 24 weeks.    5.41 The impact of the delay in this case was that the parents were unclear about what the LA’s plans post birth were and the professional network were equally unsure - ‘there were two very different plans being discussed…one that if (parents) achieve a lot during this time they will take their baby home and two that an Interim Care Order will be sought at birth’.  (Midwifery Service Agency Report). This uncertainty would have impacted on the parents’ emotional wellbeing - “they hoped, but didn’t believe, they would take Jack home, they didn’t know plans” (Midwife at Practitioner Event) and was no doubt a contributor to the low mood mother was reported to be experiencing while in hospital which prompted the discussion with the liaison psychiatric team.                                                        4 Letter before proceedings is formal written notice that proceedings are likely and lists the concerns, the support and what parents have to do to avoid this action being taken   27 Bruising in Pre-mobile Babies Protocol  5.42 The CSCB’s, in common with many other LSCBs’, Child Protection Procedures contain this protocol. It exists because bruising is the commonest presenting feature of physical abuse in children who are not yet independently mobile (Ofsted 2011).  The CSCB protocol makes it clear that it applies not only to bruising but also to ‘otherwise suspicious marks’.  A Consultant Oral and Maxillofacial Surgeon recognised the significance of a bruise in a pre-mobile baby and appropriately responded when he saw Jack in June.  5.43 The protocol is ‘necessarily directive’ and requires that any pre-mobile baby with a bruise (or otherwise suspicious marks) be referred to CSC and ‘for a senior paediatric opinion where there is no obvious medical cause’.   5.44 On neither occasion Jack was seen with bruises was the protocol followed. On the first occasion the CSW agreed he should go to the GP initially and on the second occasion neither CSW2 nor either of the GPs who examined him recognised that the protocol should be applied – because the injury Jack had sustained had no medical cause. The fact they thought the explanation was consistent with the injury was irrelevant.   5.45 The protocol also requires the relevant paediatrician to liaise with Children Social Care with regard to the outcome of the assessment as soon as it is completed. In this case, following the medical assessment, the paediatrician did speak to CSW2 who recorded the details of the discussion on the strategy meeting form. However the written report, which was not received by CSC until two weeks after the examination had taken place, contained additional information about having further investigations (blood tests and a skeletal survey) should Jack be injured again. By the time the letter arrived, this had happened.   5.46 The GPs who examined Jack at the beginning of June could not have known about this recommendation at the time they saw Jack. It is debatable whether this made any difference to the sequence of events. As the injury to Jack’s mouth was accepted as  28 being caused accidently and because the professionals involved had not identified that the Bruising in Pre-mobile Babies procedure should be instigated, it is unlikely that they would have referred for these additional investigations. Whether they would have shown any indications that Jack was being subjected to physical harm can only be conjectured.  Strategy meetings 5.47 Working Together 2015 and the Board’s Child Protection Procedures are clear that health colleagues should participate in strategy discussions and meetings. In this case some of the strategy discussions that took place prior to Jack being admitted to hospital in June only involved CSC and the Police. It would appear that some of them were more about facilitating a process i.e. enabling the pre-birth case conference to be legitimately convened, than being a meaningful exchange of information and professional views and an opportunity to plan any ongoing enquiries needed.   5.48 Had a strategy meeting been held after the medical assessment undertaken after Jack injured his face in May the Consultant Paediatrician would have been fully informed of the concerns around the family and made her decision whether or not to undertake further tests with more context. Other attendees would have known not only how unusual she thought the injury was from its reported mechanism but also that she recommended that further tests should be undertaken should Jack receive further injuries. This may have influenced decisions taken when Jack received the next injury.  5.49 There was no strategy meeting or discussion held as a result of Jack’s mouth being injured in June (during Episode 4). The social work unit recorded the activity on a strategy meeting form but, in light of the GPs’ opinion that the injury was consistent with the explanation, decided that they would complete a single agency enquiry without discussing it with their Police colleagues.   Learning/findings  29  Not following the Pre-birth protocol created unnecessary delay which was unfair on parents, and caused uncertainty/confusion in some of the professional network. It is not clear that delay was used usefully to inform the assessment of how the parents would cope.    Although it is good to allow for professional discretion, it would be helpful for the LSCB’s Pre-Birth procedures to include more clarity about timing of strategy discussions and the completion of assessments. Information on the timing of the pre-birth conference and PLO process needs to be within this protocol.    The CSC’s Procedures Manual’s Pre-Birth Procedure – Safeguarding Process is not compatible with the process described in the LSCB’s procedure.   The title of the Bruising in Pre-mobile Babies Protocol may distract practitioners from the fact that the protocol requires any ‘suspicious marks’ to be treated in the same way. There would greater clarity if the title was less specific about the nature of injury it applied to.     Pre-mobile babies are particularly vulnerable. Any pre-mobile baby already identified as being at risk of harm and in need of a child protection plan has additional vulnerabilities and any injury/mark should always warrant a senior paediatric opinion.    Strategy meetings are not consistently being convened to the requirements of Working Together and this means that decisions risk being made without full contextual information.   Full contextual information needs to be shared with medical practitioners undertaking child protection medicals and doctors need to need to ensure they have sufficient time to speak with social workers prior to undertaking the examination.    Reports from child protection medical assessments need to be provided in a timely way. If they contain additional/different information than that given verbally at the  30 conclusion of the assessment this needs to be highlighted and brought to the recipients’ attention.  Interagency working 5.50 A strong child protection system is characterised by confident, mature partnerships between the front line practitioners supporting families. There was an impressive commitment from agencies to providing the initial two, and subsequent daily, visits.  5.51 There were no obvious barriers to communication revealed either in the agency reports or by the staff who attended the Practitioner Event and it was evident that staff had established relationships and shared information and were not working in ‘silos’. Core group meetings took place regularly although the changes in the HVs and general capacity issues in the service meant that this key service was not always represented.                                                                                                                                                                                    5.52 However, despite the core groups being held regularly, is it is apparent that there was information known to some members of the network and not to others. Additionally it is not apparent that there was robust discussion about concerns. Indeed, the injuries that Jack was known to have sustained (and which had been deemed to have been caused accidently) were not even discussed at the core group meetings.  5.53 The CSC report notes that ‘no concerns’ were highlighted at the May core group meeting and yet it was clear from the recording that parents had been disregarding or challenging advice, requiring significant amounts of prompting, avoiding evening visits and refusing to allow observation of bath time.   5.54 Core Groups have a pivotal role in enabling communication between key practitioners and ensuring they are aware of every aspect of how the protection plan is working. No specific reason for why the core group involved with Jack did not identify that the child protection plan was not being effective was highlighted by agency report authors. The conclusion is therefore that the lack of a SMART (specific, measurable, achievable,  31 realistic and timely) plan and the changes in the personnel involved were contributory factors.   5.55 S.47 strategy meetings are the other procedural way of enabling information sharing. The fact that no strategy meetings were convened until Jack was admitted to hospital meant that this opportunity was not available.  Learning/findings  Information about s47 investigations that have occurred between core group meetings needs to be discussed at the next meetings to ensure there is an awareness and understanding of the details and outcome both within the professional network but also in the family.   The core group needs to focus on risk - what is going well, what the concerns continue to be and what is going to be done to address them. Practitioners need to feel confident in challenging both colleagues and family members as necessary.    The importance of strategy meetings in sharing information.  6. Conclusion 6.1 There are unique advantages to a child who grows up within their birth family and the decision to separate a new-born and their parents is extremely emotive. It is important that even when parents have not been successful in parenting a previous child, the decision is approached with an open mind.  Nevertheless the benefits need to be balanced against the risk of harm. It is salutary to consider the lived experience of Jack for the short time he was in the care of his parents. Although there were times when his parents appeared to be attentive and caring, during the first three months of his life he was injured, lost weight, was reported to be screaming for lengthy periods and observed to be roughly handled.    32 6.2 The trajectory for the way events unfurled was set in place by the recommendation that Parents should have the opportunity to demonstrate that they had changed sufficiently in the eleven months since Elder Child had been removed from their care.  This was a particularly vulnerable young family. Mother has a learning disability and had also experienced poor and abusive parenting herself. She was a care leaver. The relationship between the parents was known to be fractious at times. They had recently had their first baby removed from their care.   6.3 It was a high risk decision to recommend the assessment to continue while the Parents cared for Jack at home. There are both procedural and operational checks and balances within the system, the function of which is to challenge and review the optimism of the recommendation. These include supervision, legal advice, the TARP, the court’s and Cafcass’ involvement and multi-agency meetings. However these systems did not have the effect of overriding the recommendation, thus allowing Jack to go home with his parents and subsequently experiencing poor care and being injured.   6.4 There were a number of contributors that inhibited or otherwise compromised professionals from seeing a more accurate picture of the care Jack was receiving including changes in staff involved, uncertainty about the scope of a Supervision Order, a failure to recognise that there was a risk of physical harm and lack of adherence to policies and procedures.  6.5 Any injuries to pre-mobile babies need to be viewed from a perspective of potential risk. When that baby is already identified as being at risk of significant harm, the need to be especially alert to the fact that marks, which may otherwise not be considered suspicious, may be indicative of physical harm is particularly pertinent. Procedures and protocols need to be clear, explicit and adhered to.  7. Recommendations It is recognised that actions have already been taken in relation to some of the individual agency's identified learning. In addition agency reports included a number of  33 recommendations which this review endorses. The purpose of providing additional recommendations is to ensure that all professionals in the partner agencies of the LSCB are confident that the areas identified as of concern in this review are addressed.  Recommendation 1  The LSCB and CSC should ensure that their respective procedures on pre-birth assessments are consistent and contain guidance on timescales.   Recommendation 2  The LSCB should seek confirmation that CSC processes ensure that the supervision of, and the signing off of assessments, ensures that there is sufficient challenge and opportunity for reflective discussion.   Recommendation 3  The LSCB must ensure that professionals from all agencies are aware of the different legal orders available to CSC and their implications.   Recommendation 4  The LSCB should seek assurance that child protection plans are SMART and consider the use of tools such as the Graded Care Profile, where appropriate, to enable progress to be measured.   Recommendation 5  The LSCB should review and reissue the guidance ‘Safeguarding Children who have a Parent or Carer with Mental Health Problems. Guidance for Effective Joint Working’ ensuring that perinatal needs are appropriately addressed.   Recommendation 6  The LSCB should review and reissue the Bruising in Pre-mobile Babies Protocol. The protocol should make it clear that when pre-mobile baby who is subject to a child protection plan has any injury it should be referred for a paediatrician’s assessment.   34  Recommendation 7  The LSCB should assure itself that reports of medical assessments are being provided in a timely way and that expectations in the content is being met.   Recommendation 8  The LSCB should seek assurances from Cambridgeshire Police that call handlers understand the significance of a child being subject to a child protection plan and that there are effective systems in place to ensure that they always notify officers when their ‘Historical Information’ indicates that a child living at the address they are despatching the officers to is subject to child protection plan.   Recommendation 9  The LSCB should review the multi-agency training it provides on working with learning disabled parents to ensure practitioners have appropriate knowledge and skills and know how to access resources to support their work.      35 Glossary   Cafcass Child and Family Court Advisory Support Service  CCS  Cambridgeshire Community Services NHS Trust   CiN  Child(ren) in Need  CO   Care Order  CMHT  Community Mental Health Team  CSC   Children Social Care  CSW   Consultant Social Worker  DfE  Department for Education  GP  General Practitioner  HV  Health Visitor  ICO  Interim Care Order  ISO   Interim Supervision Order  LA  Local Authority  LPM   Legal Planning Meeting  LSCB  Local Safeguarding Children Board  SCR  Serious Case Review  SEN  Special Educational Needs  SFSS  Specialist Family Support Service  SO  Supervision Order  TARP  Threshold and Resource Panel       36 References    Child and Family Single Assessment Framework. Cambridgeshire County Council. March 2015  Ages of concern: learning lessons from serious case reviews: A thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to March 2011. Ofsted 2011  Court Orders and Pre-Proceedings. Statutory guidance for LAs. Department for Education 2014  Working Together to Safeguard Children HM Government 2015 Letter to Executive Director: People and Communities following focussed visit. Ofsted April 2018                                                  