Serious harm of a 15-year-old girl throughout her childhood. Child Z was taken into care in 2015. She had been on a child protection plan since before birth in 2000. Throughout Child Z's life she was considered to be at risk because of: concerns about parents' capacity to meet the physical, emotional and educational needs of their children; lack of boundaries, including sexual boundaries, within the family; father's mental health and an unwillingness to engage with services. Ethnicity or nationality is not stated. Learning includes: the importance of preserving accessible case records to inform current practice; mental health practitioners should ensure there are robust arrangements to take into account the risks to other family members, especially children when an adult is discharged from a service; police to ensure that custody staff take into account the risks for children when setting bail; ensure that all partner agencies ensure that all relevant agencies are involved in child protection discussions. Makes a number of recommendations including: partner agencies ensure that pathways for escalating child protection issues are maintained until the issue is resolved and ensuring that there are accessible services to children and young people who are victims of abuse or neglect.
      
 Title:  Child Z: serious case review: case summary, review findings, recommendations and responses. LSCB: Central Bedfordshire Safeguarding Children Board Author: Central Bedfordshire Safeguarding Children Board 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.                           1  Child Z – Serious Case Review Case Summary, Review Findings, Recommendations and Responses 1. The case for this Serious Case Review  Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 requires Local Safeguarding Children Boards (LSCBs) to undertake reviews of serious cases. A serious case is defined as one where:   • abuse or neglect of a child is known or suspected; and • 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. • Statutory guidance specifies that ‘seriously harmed’ includes, but is not limited to, cases where the child has sustained • A life-threatening injury • Serious and/or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development. A SCR was first considered with regard to Child Z and her family in May 2014 following a referral to the Central Bedfordshire Safeguarding Children Board (CBSCB) highlighting a number of concerns about the practice of agencies involved with the family.   Whilst it was initially concluded that the case did not meet the threshold for a Serious Case Review, revised guidance on this threshold and the disclosure of further information through the family court proceedings led to a further referral to the CBSCB, requesting that a Serious Case Review be commissioned.  The CBSCB Case Review Group re-considered the case in March 2015, and took the view that Z appeared to have suffered serious harm and recommended that a Serious Case Review should be commissioned.  Alan Caton OBE, Independent Chair of the CBSCB, decided that Z appeared to have been seriously harmed through neglect and possible sexual abuse as a result of failings of multi-agency working whilst being subject to a Child Protection Plan; and accordingly decided that this Serious Case Review should be undertaken.  2  2. The purpose of the Serious Case Review  The terms of reference for this review were to: • Establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children • Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result • Recognise good practice and improve intra and inter-agency working and better safeguard and promote the welfare of children. The Review considered in detail the period from 1 September 1999, when it was first known to agencies that Z’s mother was pregnant with Z to 5 February 2015. Summary information regarding significant events outside of this period was also considered. 3. Contributors to the Serious Case Review  Reports on the involvement of various organisations with Child Z and her family were provided to inform the review.  Specifically, the following bodies provided reports; • Action for Children  • Bedfordshire Clinical Commissioning Group (on behalf of NHS England in respect of primary care services) • Bedfordshire Police • CAFCASS • Central Bedfordshire Council - Access and Inclusion  • Central Bedfordshire Council - Adult Social Care 3  • Central Bedfordshire Council - Children’s Social Care • Central Bedfordshire Council - Legal Services • East London NHS Foundation Trust • Middle School attended by Z • Secondary School attended by Z • South Essex Partnership University NHS Foundation Trust.  4. A Summary of this Case  The Serious Case Review examined the history of the troubled childhood of Child Z, who was known to agencies and subject to a Child Protection Plan since before birth in 2000.   Z’s mother has learning difficulties and had a history of being in a relationship which involved domestic violence prior to her involvement with Z’s father.  There is also history that suggests that she struggled with parenting, with her children from this previous relationship being considered to be at risk of neglect.  Z’s father was ultimately sectioned under sectioned under mental health legislation in August 2014.  From his childhood,  Z’s father demonstrated poor social skills and later reported that he had been a victim of repeated sexual abuse as a child.   The review established that Z’s father had a series of interventions with mental health services.  It also established that on numerous occasions, concerns about his inappropriate sexual behaviour, particularly in relation to children, were raised with various agencies.  Despite this and the fact that at various points in Chid Z's life child protection investigations, conferences, strategy meetings and full plans were put in place, the lack of co-operation by her parents, ill-informed decision making by professionals and a failure to restrict this father's access to children, led to the conclusion that Child Z was seriously harmed.  4  5. Key findings of the Review  By the time that Z was born there were already well-founded concerns that Z would be at risk of significant harm. The risks identified during the period that Z was on the Child Protection Register between February and June in 2000 ( which remained relevant throughout the period under review) were: a. Parental capacity to meet the physical, emotional and educational needs of their children  b. Lack of boundaries, including sexual boundaries, within the family c. Father’s mental health d. An unwillingness to engage with services. At no point subsequently were there grounds to conclude that the risk of serious harm to Z had been eliminated. Rather, there continued to be a number of events which highlighted risks to the child’s safety, wellbeing and development.   Accordingly, it was predictable that Z would suffer serious harm unless effective action was taken to either significantly reduce the risks to which she was exposed while in the care of parents or to remove Z from that situation.   Over the 15 year period that Z was known to agencies there were a number of opportunities to do this but these were not taken.  The review concluded that there were four critical areas where opportunities were missed: - In Child Protection planning and implementation between 1999 and 2000, at which point the protection plans were discontinued without proper consideration of the risks. - In failing to recognise and respond to the father's mental health issues and the impact of these on the children. - In the inadequate response to repeated concerns that were about sexual activity and potential sexual abuse that were reported to the police and other agencies. - In later child protection processes between 2010 and 2014, which were not effectively implemented until the point at which child Z was taken into care. 5  The review panel has looked at all the factors that have contributed to these issues, which range from the decision of the former Bedfordshire County Council children's social care service to relinquish responsibility for safeguarding Child Z in 2000 through to the impact of accessibility of records , organisational restructuring and IT developments.  The review has investigated each of these factors in detail and made a series of twelve recommendations for action. These relate to training, procedures and guidance, record keeping, mental health services for children who are victims of abuse, enhanced collaboration between professionals involved in child protection.  The recommendations are listed in detail below, together with the actions that have been taken in response to them by various organisations.  Central Bedfordshire Safeguarding Children Board – Response to the SCR for Child Z Learning from the Serious Case Review (Recommendation)  Action that has been taken since the start of the review  and the impact of those measures Continuing work to make children safer and improve the quality of services  1. That the CBSCB review and re-launch their procedures and guidance in respect of sexual activity involving children  CBSCB has reviewed and updated its Under Age Sexual Activity Chapter and this was included within its online procedures in May 2016.   The LSCB has also reviewed and refreshed its Child Sexual Exploitation (CSE) guidance and CSE Risk Assessment Tool. No additional points. 2. That the CBSCB considers whether the training and resources provided for front line practitioners across all agencies adequately equips them to recognise and respond to neglect and emotional abuse, particularly in resistant families, including trigger points for the escalation of intervention.  Since 2013, the overall quality of the service to vulnerable children has improved.  This has been indicated by a significant rise in the percentage of Children’s Services case file audits that conclude that the service provided is good or outstanding – in 2013, most were judged to be inadequate or requiring improvement whilst in 2016 80% are judged good or outstanding.   A pilot of the Graded Care Profile (a tool for assessing neglect) has been successfully tested in Regular case file auditing, and using the learning and improvement opportunities from this activity, is well embedded and ongoing with children’s Services Operations in Central Bedfordshire Council.     An audit on the use of the Graded Care Profile is due to be undertaken during the October 2017. 6  Learning from the Serious Case Review (Recommendation)  Action that has been taken since the start of the review  and the impact of those measures Continuing work to make children safer and improve the quality of services  one Children’s Services Operations locality in Central Bedfordshire.  The Graded Care Profile supports practitioners in being clear about when the care of children is inadequate, assisting authoritative challenge and support to families. Multi-agency partners such as South Essex Partnership Trust (SEPT) have also taken part with in the Graded Care Profile Pilot.   The Graded Care Profile is now being rolled out further across Social Work and Early Help Teams.  CBSCB currently provides multi-agency training in relation to resistant families. A review carried out in relation to the impact of this training highlighted impact in relation to three key areas - messages taken into practice, strengthened child centred practice and specific examples of enhanced team practice. A strong legacy from the training is a heightened awareness of the need to “think family”, maintain a high level of professional curiosity about the ‘real life’ experience of children in the family and strengthen collaboration with other professional colleagues and agencies.  CBSCB offers an E-learning Course on the topic of Neglect, which is available to all staff from all agencies across Central Bedfordshire and is free to access.  All practitioners and managers in Children’s Services Operations will  begin training in  Motivational Interviewing, to enhance their skills in assessing and engaging with families who are resistant to change.  Training began in September 2016, and most staff and managers have had training and briefings.  This learning programme is ongoing.     7  Learning from the Serious Case Review (Recommendation)  Action that has been taken since the start of the review  and the impact of those measures Continuing work to make children safer and improve the quality of services   In addition the CBSCB has completed a multi-agency audit in relation to neglect cases to identify any further multi-agency learning and training needs and since November 2016 has been delivering a face to face training course ‘Understanding the impact of abuse and neglect on children’  On the 30th March 2017 a Pan Bedfordshire LSCB Conference focusing on tackling Neglect was held with 340 practitioners attending.   3. That all partner agencies ensure that the importance of preserving accessible case records to inform current practice when recommissioning or restructuring services and when implementing IT developments is embedded in their organisational memory.  Within Children’s Services Operations any transitional arrangements are carefully assessed in terms of risk at regular Mosaic (electronic case records system) Optimisation meetings.   This means that the full history of a family is available for Children’s Services Operations staff.  Within Health Services this is addressed via contractual arrangements from the Bedfordshire Clinical Commissioning Group with its contracts with the service providers. Following the Serious Case Review health providers within Bedfordshire have completed the Goddard Checklist which includes clarity around preserving records.  SEPT has confirmed there is a policy in place to retain child records for 25 years in accordance No additional points. 8  Learning from the Serious Case Review (Recommendation)  Action that has been taken since the start of the review  and the impact of those measures Continuing work to make children safer and improve the quality of services  with NHS Information Standards.  ELFT has transferred all patient records from April 2015 onto its electronic patient records system (RiO). ELFT’s Health Records Policy includes a section on the Goddard Enquiry.  The Goddard Enquiry: This is an enquiry that was set up after investigations in 2012 and 2013 into the activities of Jimmy Saville. Dame Lowell Goddard was appointed chair in September 2014 however the enquiry faltered several times. Professor Alexis Jay OBE has taken over as Chair and set out a plan of action for the Committee through to the end of 2018. All that is being said of the future is that it is hoped to make serious progress by the end of 2020. A letter was sent to all CEOs of Trusts in July 2015 stating that until The Goddard Enquiry had finished its deliberations Trusts were to put the destruction of records in any format on hold.  The enquiry’s remit broadens as it progresses and it is felt that it will necessarily include adults of today and tomorrow who were children at the time that the enquiry began. Accordingly archiving of all documentation to our contracted secure storage facilities may continue but the deletion of those records is on hold. 9  Learning from the Serious Case Review (Recommendation)  Action that has been taken since the start of the review  and the impact of those measures Continuing work to make children safer and improve the quality of services   Within the Police all records are kept electronically and retained in accordance with the Management of Police Information and CPIA disclosure rules. There is a specific plan in place to ensure records are retained, although legacy systems might become harder to access in the future, but this is a risk around general software/hardware development. There is a very low risk of not accessing these records in the future.  4. That Bedfordshire Police ensure that their custody staff, when setting bail conditions for individuals who may pose a risk to children, take into account all children to which person has access and if applicable coordinate this with other processes addressing risk to the children.  Custody Sergeants have been reminded of their responsibilities to consider all children that may be at risk. Beds Police Custody Sergeants make bail decisions based on the advice of investigating officers and by conducting a risk assessment considering all available information. Where Custody staff are made aware of risks the conditions set will be designed to mitigate that risk. Custody Inspectors will be asked to consider appropriate conditions during regular Custody Record audits.  In relation to the recent Bail Act changes, Bedfordshire Police has given guidance to staff that the presumption against bail for most cases will not count in relation to child safeguarding cases. This is to ensure the limited protection available through the imposition of bail conditions is not lost.  5. That commissioners and providers of CAMHS NHS Bedfordshire Clinical Commissioning Group, ELFT and CAMHS will work in partnership with 10  Learning from the Serious Case Review (Recommendation)  Action that has been taken since the start of the review  and the impact of those measures Continuing work to make children safer and improve the quality of services  ensure that appropriate and accessible services are available to children and young people who are victims of abuse or neglect.  through their commissioning arrangements with East London Foundation Trust who provide the CAMHS Service has addressed this issue. A new structure has been implemented and a Single Point of Access (SPOA) has been put in place to develop a consistent and clinically led screening process and triage for all CAMHS referrals. Waiting times within Bedfordshire have been reduced and a new 7 day week crisis service has also been commissioned.  ELFT staff have attended training regarding child sexual exploitation.  In addition there is now a dedicated Looked After Children Service Team within the CAMHS service.  CHUMS, Bedfordshire Open Door, Sorted and Relate to create an integrated SPOA for CAMHS services. 6. That CBC ensures that all of their Social Care and Legal Services staff are aware of their responsibilities in respect of legal planning and able to effectively interface with each other.  All staff and managers in Children’s Services Operations and Legal Services have been briefed on the learning from this SCR, including clarity around the respective roles of each service.   Cases in formal pre-proceedings process are jointly reviewed by Consultant Social Worker and Legal Services Manager.   This learning will continue to be regularly revisited and tested in routine case file audits of Children’s Services case files. 7. That the CBSCB and CBC include within their training provision information on differing standards of proof in criminal and civil Newly qualified social workers are provided with learning sessions by experienced team managers and the Legal Services Manager on legal work.  This issue will be revisited in the ongoing staff learning sessions facilitated by the Consultant Social Workers. 11  Learning from the Serious Case Review (Recommendation)  Action that has been taken since the start of the review  and the impact of those measures Continuing work to make children safer and improve the quality of services  proceedings and the relationship of these to child protection practice. This includes addressing the differing standards of proof in criminal and civil proceedings and the relationship of these to child protection practice. All managers have briefed staff on the learning from their SCR including this issue.  The burden of proof is included within the current CBSCB module two training.    The burden of proof has also been included within the single agency training for SEPT staff and is reinforced through supervision.  8. All partner agencies should ensure that their pathways for escalating child protection issues, including those from routine audit processes, ensure that senior manager oversight and supervision is maintained until the issue is fully resolved.  Within Children’s Services Operations all managers have been briefed on the learning from this SCR in terms of the need for evidenced follow through to make sure that concerns about child protection issues are resolved.  SEPT has clear internal structure to escalate concerns supported by LSCB escalation protocol. SEPT’s 0-19 Team Service have also strengthened processes for Team Leader oversight, supported by caseload monitoring tool, and supervision.   In relation to the Police the current escalation policy has been reviewed and is still appropriate and but needs to be consistently used. Therefore guidance has been sent to all senior managers in the Public Protection departments within the The Audit Manager and Head of Professional Standards for Children’s Services Operations provides oversight and challenge to monitoring progress and outcomes when child protection issues are raised in routine audits.  12  Learning from the Serious Case Review (Recommendation)  Action that has been taken since the start of the review  and the impact of those measures Continuing work to make children safer and improve the quality of services  Police.      ELFT have confirmed that escalation pathways within their organisation are in place.  9. That the CBSCB sponsor a multi-agency task and finish group to develop and embed a ‘Think Family Approach’ across children’s and adult services when working with parents with mental health difficulties. In particular this should include robust arrangements for the assessment of risk to children from parents and carers with mental health difficulties including when an adult is discharged from a service.  The need for a Think Family Approach (children and adult services) task and finish group has been identified from this SCR and Child A.  This is in respect of making sure that there is effective communication and decision making for the children of parents with mental health difficulties and possible or known learning difficulties.  The Principal Social Workers for Adult Social Care and Children’s Services Operations now have an established dialogue to develop processes to improve collaborative working and trouble shoot when problems are emerging that may be detrimental to the welfare and safety of children. Task and Finish Groups have been completed to improve collaborative working between ELFT, CBC Adult Social Care and Children’s Services Operations.  The Pan Bedfordshire Protocol between Children’s Services and Adult Mental Health Services is currently being updated.  10. That the CBSCB consider whether their procedures and the practice of partner agencies adequately ensure that all relevant agencies are engaged in strategy discussions and where appropriate remain engaged with child protection investigations.  The recent (March 2016) Joint Targeted Area Inspection (JTAI) provided a detailed independent regulatory review of decision making in the Access and Referral Service for Children’s Services Operations and concluded that the service provided to families was of a good quality.  The inspection concluded that information sharing; multi-agency analysis and threshold decisions in strategy discussions were sound.  There was good awareness and competence in understanding the issues of child sexual abuse (signs and symptoms), in particular, but not exclusively, in respect of Central Bedfordshire Council Children’s Services Operations contributes actively to ongoing Pan Bedfordshire service development around child sexual abuse and neglect.  Central Bedfordshire has proceeded with an updated and more effective chid sexual exploitation risk assessment tool, as agreed during the March 2016 JTAI inspection.    13  Learning from the Serious Case Review (Recommendation)  Action that has been taken since the start of the review  and the impact of those measures Continuing work to make children safer and improve the quality of services  child sexual exploitation.  ‘The single point of access safeguarding hub and social care assessment teams effectively provide a timely response to the range of problems that children and young people experience. In particular, children and young people generally receive high quality services at the first point of contact with children’s social care.’ Ofsted, the Care Quality Commission (CQC), HMI Constabulary (HMIC) and HMI Probation (HMI Probation) May 2016  In relation to SEPT, safeguarding policy and procedures, training and supervision inform and reinforce staff of their responsibility to full participate in strategy and child protection conferences both ICPC & RCPC. Recent inspections/audit has acknowledged SEPT professional participation at these meetings.    In addition the CBSCB has developed and implemented a Policy and Procedure Group to oversee the reviewing and updating of its online procedures. The procedure for Child Protection Enquiries has been reviewed.  11. That CBC should ensure that all Child Protection Plans are stand-alone documents which include all of the actions required by the The Chairs of Child Protection Case Conferences and all managers in Children’s Services Operations are clear that all Child Protection Plans are stand The Chairs of Child Protection Case Conferences introduced a Strengthening Families approach to Child Protection Case Conferences in the last 14  Learning from the Serious Case Review (Recommendation)  Action that has been taken since the start of the review  and the impact of those measures Continuing work to make children safer and improve the quality of services  professional network and the family concerned, along with clear milestones and contingency arrangements for lack of progress with the plan.  alone documents.  They have been reminded of the risk of confusion for the professional network and family if there are multiple documents.   They are also clear that all plans need to be outcomes, impact and child focused. quarter of 2016.  This has meant that Child Protection Case Conferences, and the plans created, will provide high support and high challenge to families and professionals by being really explicit about what people are worried about, what needs to change, by when, what the signs might be if the plan is not working, and what will happen if it is evident that the welfare and safety of the children is not being secured.  Feedback from surveyed professionals and parents has indicated high satisfaction rates with the Strengthening Families approach to Child Protection Case Conferences in CBC.  12. That the CBSCB disseminate the learning from this Review to staff across the partnership.  CBSCB in conjunction with the two other LSCBs in Bedfordshire provide multi-agency briefing events on a quarterly basis for front line practitioners in to share the learning from Serious Case Reviews.  LCSB Training courses are also updated as necessary following case reviews with any appropriate learning.  Learning is also disseminated through newsletters and briefing documents. To continue the dissemination of learning from case reviews.  