Death of a 1-week-old in April 2013. Baby A was admitted to hospital following a cardiac arrest and later died, following the withdrawal of life support. Coroner's Inquest concluded no explanation for cause of death. The Crown Prosecution Service took the decision that there would be no criminal proceedings in respect to the death of Baby A. Mother had a history of abusive relationships and had received support for a long-standing heroin addiction for a number of years. Mother was well known to children's social care. Baby A was the subject of a Child Protection Plan at the time of the incident and had been discharged from hospital, post-birth, into the care of maternal grandparents. Mother's eldest child and Child C were also living with maternal grandparents at this time and mother's second eldest child was living with their father. Child C was subject to Child in Need or Child Protection Plans for most of their life prior to the incident. Identifies findings, covering: assessment and planning; collaborative working; practice and professional judgement; and management and supervision. Makes various interagency and single agency recommendations.
      
 Title:  The overview report of the serious case review in respect of: Baby A and Child C. LSCB: Sunderland Safeguarding Children Board Author: Linda Richardson Date of publication: 2014  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        Serious Case Review for Baby A and Child C Published 25 November 2014   Sunderland Safeguarding Children Board (SSCB) is publishing the Serious Case Review Overview Report for Baby A and Child C.  Please note the following documentation which constitutes the whole Serious Case Review:  • SSCB Overview Report  (Document 1) • Why Questions Report by Core Assets (Document 2) • Addendum to the Overview Report (Document 1) • Sunderland Children’s Services Progress Report and single agency Action Plan (Document 3)       2       The Overview Report of the Serious Case Review in  Respect of   Baby A and Child C      This report is the property of the Sunderland Safeguarding Children Board and is confidential.  Its contents, which have been anonymised, may only be shared with appropriate representatives of the recipient agencies for the purpose of improving childcare services and inter-agency working.     The Publication date is 25th November 2014       February 2014    3 Contents  1.  Introduction  1.1. Summary of Circumstances leading to the Serious Case Review 1.2. Decision to hold a Serious Case Review 1.3. Independence 1.4. Serious Case Review Panel 1.5. Methodology 1.6. Publication  2.  Review Process  2.1. Scope of the Review 2.2. Involvement of Local Agencies 2.3. Review Schedule  2.4. Parallel Processes 2.5. Cross Boundary Issues 2.6. Family Engagement in the Serious Case Review 2.7. Workforce Engagement   3.  Family Circumstances  3.1. Genogram 3.2. Family Composition 3.3. Relevant ethnic, cultural or other equality issues 3.4. Background Information 3.5. The Family’s Perspective 3.6. The Experiences of Children within the Household  4. Information known to the agencies  4.1. Introduction 4.2. Prior to Time period under Review 4.3. Time Period under Review  5. Individual Management Reviews (IMRs)  5.1. General Comments 5.2. Children’s Services: Children’s Social Care 5.3. Children’s Services: Primary School and Children’s Centre 5.4. Northumbria Police 5.5. Northumbria Probation 5.6. Health Overview Report 5.7. City Hospitals Sunderland NHS Foundation Trust 5.8. South Tyneside NHS Foundation Trust Community Health Services 5.9. General Practitioner 5.10. Place 1 – Substance Misuse Treatment Provider 5.11. Place 2 Children’s Services    4  6. Further information provided to the Overview Author  7. Critical Analysis • Assessments and Planning  • Multi-Agency Collaboration • Practice and Patterns in Professional Judgement • Management and Supervision • Contextual Issues  8. Findings   9. Conclusion  10. Recommendations  10.1. Multi-Agency Recommendations 10.2. Single Agency Recommendations   Appendix 1    Terms of Reference Appendix 2 Genogram    5 1. Introduction  1.1 Summary of Circumstances leading to the Serious Case Review (SCR)1  1.1.1. LB has a long-standing history of substance misuse and has self reported using cocaine, cannabis and heroin since she was 16 years old.  She has experienced five pregnancies: her eldest child, (Child J), lives with the maternal grandparents and Child P, the second oldest, lives with the birth father.   1.1.2. The third child, Child C, aged 4 at the time of this review, lived with LB until early 2011 when the child was made subject to a Child Protection Plan 2, following concerns about LB’s substance misuse. LB agreed Child C should live with the maternal grandparents until further assessments were concluded. Several months later, Child C returned to live with LB and the Child Protection Plan was changed to a Child in Need Plan3. Three months later, further concerns were raised about LB’s substance misuse and Child C was again made subject to a Child Protection Plan and returned to live with maternal grandparents under Section 204 (s20) of the Children Act 1989. The 4th pregnancy resulted in a miscarriage in 2012. Baby A was born in March 2013.  1.1.3. LB received specialist clinical and community treatment in relation to her drug addiction for several years, but struggled to stay free of illicit drugs for any significant length of time. In summer 2012, LB began a relationship with NX, following his release from prison for selling Class A drugs. She became pregnant but suffered a miscarriage early in the pregnancy. She and NX married later that year and Baby A was born in March 2013.  As a result of continuing concerns about mother’s substance misuse, the baby was made subject to a Child Protection Plan and was discharged from hospital into the care of the maternal grandparents in March 2013, under s20 of the Children Act 1989. The Local Authority continued with plans to pursue care proceedings in respect of Baby A and Child C, both of whom remained in the care of the maternal grandparents.     1.1.4. In late March, Baby A, at one week old was admitted to the local Accident and Emergency Department in a critical condition.  LB reported that she had been feeding Baby A at around 9.00pm. The grandparents were in the home but were not in the room. LB said she had placed Baby A to her chest to wind and cuddle the child and after 5–10 minutes, had noticed the baby was not breathing and appeared limp. Her parents were alerted and the ambulance service was called, during which time the maternal grandfather tried resuscitation.  The baby was still not breathing upon arrival at hospital and was placed on a respirator where breathing was finally restored. There were significant concerns about brain damage given the length of time Baby A had been without oxygen.                                                  1 Names, dates of birth and some family details have been changed to preserve anonymity. 2 When there are concerns that a child is, or may be at risk of significant harm, a multi-agency case conference can decide to make the child subject of a Child Protection Plan. This is to ensure that all parties, including parents, do what is needed to make sure the child is kept safe.  3 When a multi-agency conference believes that a child requires extra support to help his/her developmental needs, a Child in Need Plan will be put in place.   4 Under Section 20 of the Children Act 1989, children and young people can be accommodated by the Local Authority with the consent of those with parental responsibility for the child.   6  1.1.5.  Baby A died early April 2013 following the withdrawal of life support.  1.2. Decision to hold a SCR   1.2.1. Regulation 5 of the Local Safeguarding Children Boards (LSCB) Regulations 2006 requires LSCBs to undertake reviews of serious cases in specified circumstances and to ‘advise the Authority and their Board partners on lessons to be learned’.5  1.2.2. A  SCR is one where:  a) abuse or neglect  of a Child is known or suspected: and b) either – (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the Authority, their Board partners or other relevant persons have worked together to safeguard the child.  1.2.3. A Case Review sub-committee of Sunderland Safeguarding Children Board (SSCB) held a scoping meeting on 24th April 2013 and determined that the circumstances surrounding the death of Baby A met the criteria for holding a SCR. The Independent Chair of the LSCB endorsed the recommendation on the same day and a SCR Panel was established to lead the review.   1.2.4. The decision to hold this SCR was also influenced by the similarities between this case and other reviews relating to babies under the age of one year. The LSCB was concerned about the extent to which lessons from previous reviews did not appear to be impacting positively on front line practice.   1.3. Independence  1.3.1. In order to ensure objective debate and challenge, the LSCB:  • Commissioned an independent person not connected or employed by any of the reporting agencies, to chair the SCR Panel • Commissioned an independent author, not connected or employed by any of the reporting agencies to write the Overview Report • Made it clear to agencies that Individual Management Report (IMR) authors were not to be involved in the case or in its line management • Confirmed that SCR Panel members had no prior involvement with, or line management responsibility for Baby A, Child C and family  1.3.2. The SCR Panel Chair was Cath McEvoy who is currently the Safeguarding Operations Manager for North Tyneside Children’s Services. Ms McEvoy has worked in social work for 24 years in a variety of roles. She has been a Senior Manager within North Tyneside for nine years and has chaired a number of panels as an independent chair around the North East region.  1.3.3. An Overview Report was commissioned from Linda Richardson, an independent safeguarding consultant registered with the Health Care Professionals Council, and who has authored previous SCRs. Mrs Richardson is an accredited reviewer under                                                  5 Working Together to Safeguard Children 2013 HMSO Publication.   7 the Social Care Institute for Excellence (SCIE) Learning Together Programme.  1.3.4. It was agreed that upon submission of all relevant material, the Overview Author, in accordance with the themes outlined in the Terms of Reference appended to this report, would produce the Overview Report to be presented to the LSCB in early 2014.  1.4. Serious Case Review Panel  1.4.1. The SCR Panel consisted of representatives from the following agencies:  • Independent Chair • Northumberland and Tyne and Wear NHS Foundation Trust • Northumberland Probation Trust • Northumbria Police • Sunderland Social Care - Safeguarding Service - Education Safeguarding Team • Sunderland Health, Housing and Adult Services • City Hospitals Sunderland • LSCB Business Manager • LSCB Lay member • Legal Advisor to the LSCB • Public Health Commissioning Manager (Specialist Advisor on Drug and     Alcohol use)  1.5. Methodology  1.5.1. The decision to hold a SCR was taken, some two weeks after the launch on 15th April 2013, of the revised statutory guidance Working Together to Safeguard Children 2013. 6   The SCR Panel decided to undertake the SCR using the methodology outlined in 2010 statutory guidance, being mindful of the need to reflect on the quality of their services and undertake a ‘rigorous, objective analysis’7 as well as exploring systemic influences which may have had a bearing upon practice and decision-making.   1.5.2. The Panel have, throughout this SCR reflected on the chosen methodology and with hindsight have agreed that a sharper, more focussed review in future may remove the need for such a lengthy and detailed report without compromising any of the valuable lessons to be learnt.  1.5.3. A timetable for the SCR was established and circulated to all agencies involved with the family.  Each agency undertook an Individual Management Review (IMR) and was asked to produce a report, which was to offer a critical reflection on that agency’s contact with family members. The IMR reports were submitted to the SCR Panel for scrutiny and challenge before being passed to the independent author for comment in this Overview Report.                                                  6 Working Together to Safeguard Children 2013: Department for Education HMSO. 7 The Munro Review of Child Protection: Final Report May 2011.   8  1.5.4. Three sessions were delivered to IMR authors to explain what the Panel expected in terms of their management review, to check on progress and to offer help and support for the production of good quality, critically reflective reports to the Panel.   1.5.5. SCR Panel meetings and other meetings relating to the SCR process took place on the following dates:   24.04.13 -  Initial Scoping meeting 25.07.13 -  SCR Panel 06.09.13 -  SCR Panel 27.09.13 -  SCR Panel to consider IMRs 07.11.13 -  SCR Panel to consider IMRs 07.11.13 -  Meeting between LSCB Chair, Case Review Chair, Independent Panel Chair, Overview Author to discuss findings and issues from process 16.12.13 –  Meeting between Case Review Chair, Independent Panel Chair, LSCB Business Manager and Overview Author (telephone conference) about findings and recommendations 23.01.14 -  SCR Panel to sign off final draft of Overview Report   1.5.6. The Overview Report addresses the areas identified in the Terms of Reference, but has adopted a more analytical and comprehensive structure in order to draw out clearly the learning from the case. The report examines and evaluates individual professional practice, and offers comment where practice may have been influenced by organisational culture, processes and systems within and between agencies.  1.6. Publication  1.6.1. This review will be published once this report has been accepted by the LSCB.  However, In order to preserve the anonymity for the children in this family, the SCR Panel decided to:  • Use pseudonyms for the names of the children and remove any reference to genders • Avoid the use of exact dates in some reporting  • Avoid any details which would provide information about local services leading to recognition of the children in the review  2. Review Process 2.1. Scope of the Review  2.1.1. The SCR Panel determined that learning could be maximised by reviewing the period from 1st January 2011 – 5th April 2013 as this would allow reflection on practice and decision-making during key periods when Child C was subject to both Child in Need and Child Protection Plans.   2.1.2. Terms of Reference were agreed and these are included in Appendix 1 of this report. These Terms of Reference fall into five distinct categories and the Panel   9 agreed that the independent author should comment on these categories as part of the Overview Report.8 • Assessments and Planning  • Multi-Agency Collaboration • Management and Supervision • Practice and Patterns in Professional Judgement • Contextual Issues  2.2. Involvement of Local Agencies  2.2.1. The following organisations are known to have been involved with the family and have submitted IMRs or information:  Place 1 •••• Place 1 City Council Social Care Safeguarding Service (CSC) •••• A Primary School and Childcare Centre •••• Health  - NHS Foundation Trusts - GP - Midwifery Services - Place 1 Substance Misuse Treatment Provider (P1-SMTP) - Place 1 Clinical Commissioning  Group (CCG) – Health Overview report •••• Health, Housing and Adult Services Drug and Alcohol Team (letter only) •••• Pharmacy (letter only)  Place 2 •••• Place 2 Children’s Services •••• Place 2 Drug and Alcohol Service (letter only) •••• GP (letter only)  •••• Northumbria Police •••• Northumbria Probation Service •••• North East Ambulance Service (letter only)   2.3. Review Schedule  2.3.1. A detailed review schedule was agreed which allowed for the SCR to be completed well within the timescales outlined in statutory guidance. However, the poor quality and delayed IMR submissions from Children’s Social Care (CSC) and Children’s Services Education resulted in the Panel returning these reports and amending the timescales for the SCR. This is commented upon later in the report.   2.3.2. Prior to the Overview Report being submitted to the SCR Panel in January, two family members contacted the Overview Author to request a meeting with the author and the SCR Chair. These meetings took place at the end of January and                                                  8 The SCR Panel was able to reflect on the Terms of Reference throughout the process and concluded that learning would maximized if the detail of these were subsumed in the Overview Report under these five distinct categories.    10 contributed to a further, but necessary delay in the submission of this report to the LSCB.  2.4. Parallel Processes  2.4.1. During the course of this SCR, Panel members were kept informed of the ongoing criminal investigation by the local Police and the arrangements to ensure the safety and wellbeing of Child C.  The Crown Prosecution Service took a decision in May 2013 that there would be no criminal proceedings in respect of the death of Baby A.   2.4.2. Child C was accommodated with Care Proceedings about to be initiated when Baby A died.   2.4.3. The Coroner’s Inquest recorded a narrative verdict on the death of Baby A concluding that there was no explanation for the cause death.  2.5. Cross Boundary Issues  2.5.1. This SCR required some collaboration with another Local Authority a few miles away in (Place 2).  Relevant information across boundaries was shared, although not always in a timely manner. There was however no active involvement by (Place 2) Local Authority in relation to Child C and Baby A. Further information is included in this report.   2.6. Family Engagement in the SCR  2.6.1. Soon after the death of Baby A, the LSCB Business Manager and the Chair of the SCR Panel visited the parents and the maternal grandparents to advise them that a SCR was to take place.  The comments made by the family at that time are included in this report.   2.6.2. Parents of Baby A and Child C and the maternal grandparents were contacted again on three subsequent occasions and were offered various options to contribute to this review. The father and maternal grandmother (MGM) eventually came forward in late December 2013 and meetings took place in mid-January, which importantly allowed this review to consider learning from the family’s perspective.   2.7. Workforce Engagement   2.7.1. The IMR of each agency describes the extent to which staff were involved through interviews. As part of a quality assurance process, the SCR Panel have a system whereby staff and managers are asked to give feedback on their experience of the SCR process and identify what learning they consider to have taken place.   2.7.2. The LSCB has arranged for feedback sessions for staff who worked directly with the family. This is to ensure that all staff who were interviewed are provided with an opportunity to discuss the findings from the SCR and the Panel can explore to what extent the findings are a reflection on general practice across the Authority.  Learning and Improvement workshops for all frontline practitioners have been   11 planned from May 2014. These will take place monthly.  2.7.3. Given concerns of the LSCB about the apparent failure to learn from previous reviews, the Board is now developing a clearer strategy for dissemination and an audit tool to monitor how the Board can be assured that lessons from this and other Case and Serious Case Reviews are embedded into day-to-day practice.  3. Family Circumstances  3.1. A Genogram is provided in Appendix 2.   3.2. Family Composition (and key)  Mother  LB Married NX in December 2011 Lives in Place 1 Child J DoB: 1998 Lives  with Maternal Grandparents Child P DoB: 2002 Lives with Father PS Child C DOB: 2008 Father AH Lives with Maternal Grandparents Baby  A March 2013  died April 2013 Father NX Father to Baby A NX  Lives in Place 1 with LB Maternal Grandfather MGF  Lives in Place  2 Maternal Grandmother MGM  Lives in Place 2 Paternal Great Aunt ST  Lives in Place 2  3.3. Relevant ethnic, cultural or other equality issues  3.3.1. All the agencies identified Baby A, Child C and their parents as White British with English being their first language.  There are no religious beliefs or affiliations recorded. The family live in a relatively deprived area with high unemployment and low-level crime. Parents are known in the community to have been involved in drugs for several years and Police visits and raids are a regular aspect of their lives.   3.3.2. Both maternal grandparents live in Place 2 in their own home, which is comfortable, well-furnished and located within a residential area. Both adults are in paid employment, which involves regular shift work. There are no religious beliefs or specific affiliations recorded.   3.4. Relevant Historical Information - LB  3.4.1. LB had no involvement with social work services in her childhood and reported a positive relationship with her parents until she became pregnant, just before her 16th birthday. Records indicate that LB felt she was not ready to become a parent but her mother refused to sign the consent papers for a termination. LB told social   12 workers that she began using drugs to cope with pressures of caring for her child and ‘mixing with the wrong crowd’. LB’s relationship with the baby’s father ended before Child J was born in 1998.    3.4.2. Child P was born in 2002. Social Care records indicate that Child J and Child P lived with LB and PS, the father of Child P.  However, agency records are confusing as to how long they lived together as a family.  What seems clear is that there were episodes of domestic violence and concerns about drug use, although the impact on the children is not recorded in any detail.  It would appear that both children went to live with maternal grandparents at various times until Child P, aged four years old went to live with PS, the birth father. It seems there was intermittent contact at that time between Child P and LB.  Child J remained living with maternal grandparents under a Residence Order9 and as LB would regularly visit the home of her parents, it is to be assumed that she had ongoing contact with Child J.    3.4.3. Child C was born in 2008 to LB and AH. Reports document concerns about drug use and domestic violence and LB ended the relationship although AH remained living in the area.    3.4.4. Various reports refer to LB’s later relationship with JE. This lasted for approximately three years during which time JE physically abused LB. In November 2010, LB was referred to a Multi-Agency Risk Assessment Conference (MARAC) 10 where she was assessed as being high risk. This assessment was later downgraded to low risk when LB refused to accept Police support or protection.  LB was discharged from MARAC when the relationship with JE ended.   3.4.5. LB has received support for her long-standing heroin addiction from P1-SMTP11  at various times since about 2007.  This involved regular testing and substitute prescribing of Methadone taken under the supervision of a named pharmacist.   3.4.6. LB appeared in Crown Court in February 2007 for an offence of Burglary and received an 18 months Community Order with requirements of Supervision, and a Drug Rehabilitation Order with a requirement to attend a Drug Awareness Programme.   3.5. Involvement of CSC prior to January 2011  3.5.1. A Probation Officer referred LB to CSC in December 2007 following allegations of domestic abuse by AH, father to her unborn baby (Child C).   CSC took no action as records state they were led to believe that she was living in another area at that time. There is nothing to evidence they passed this information on to the area office where LB was reputed to be living. A further referral was made in February 2008 and notes refer to a Core Assessment being undertaken and the unborn Child C being made subject to a Child in Need Plan. In April 2008, an Initial Assessment was undertaken in response to concerns about LB’s drug taking and the impact this                                                  9 A ‘Residence Order’, agreed in court, is used to decide where a child will live, and with whom. 10 Multi-Agency Risk Assessment Conferences (MARACs) are regular local meetings where information about high-risk domestic abuse victims (those at risk of murder or serious harm) is shared between local agencies. 11Which provide pharmacological and psychosocial interventions, with clinical specialism in community alcohol detoxifications and low threshold prescribing.   13 would have on her child.  A decision was taken to continue with the Child in Need Plan. This Plan was discontinued in October 2009.   3.5.2. On 25th August 2010, concerns were again raised about LB’s drug taking.  Records indicate that LB was taking heroin alongside her Methadone prescriptions.  In response to these concerns, a decision was taken to make Child C subject again to a Child in Need Plan. This commenced on 3rd November 2010, two months before the time period for this SCR.   3.6. Relevant Historical Information – NX  3.6.1. NX is the third child born to his parents in Place 1. His father is currently serving a 12-year custodial sentence for rape and sexual assault. According to Probation reports, NX struggles to accept his father’s guilt.  He continues to visit his father in prison.  3.6.2. NX is the father of six children from three previous relationships. According to records, Child B came to live with NX, aged 11.  No records were made available which indicate what contact, if any, NX has had with his other children.  In 2009, NX was arrested and convicted of supplying heroin. He received a five-year prison sentence. NX claimed that he took responsibility for the offence but it was his partner at the time that was dealing in drugs.  NX was released from prison on license in February 2011 after which time he began a relationship with LB.  3.7. Involvement of CSC with children of NX prior to January 2011  3.7.1. No additional information was provided.   3.8. The family’s perspective  3.8.1. The Business Manager of the LSCB and the Chair of the Case Review Sub–Group met with LB, NX and the Grandparents shortly after the death of Baby A. At that meeting, the parents felt they had been unfairly treated and had been asked to ‘jump through hoops’. They said that even when they had done all that had been asked of them, they still ‘lost their children’. They were advised about the possibility of a SCR taking place and assured they would be given an opportunity to contribute to that process.   3.8.2. In January 2014, the Chair of the SCR Panel and the Independent Author met with the MGM at her request.  The meeting lasted for over an hour during which time the SCR process was explained and MGM was given an opportunity to discuss her views about what had happened in her family over the last 2-3 years.  MGM explained she hadn’t been able to make contact earlier as they were still coping with the aftermath of the death of Baby A. Maternal grandfather (MGF) was at work and couldn't meet with us.   3.8.3. Meeting with MGM  MGM acknowledged that her daughter had difficulty in staying away from drugs especially heroin and understood that this had impacted significantly on decisions taken by the authorities in respect of Baby A and Child C.  Nevertheless, MGM   14 believed that her daughter had not been given enough help to stay drug free and that there had not been enough efforts made to explore how LB could have been supported to look after Child C. MGM said she believed that the strong relationship between LB and Child C had also not been recognised.    MGM and her husband are both in employment and have worked shifts for many years. Asked how she managed to work, care for her grandchildren and support her daughter, MGM replied. “Well you just do don’t you”.  She said her sister-in-law was a good support and as a family they had never considered that Child C or Baby A would go to live anywhere else if LB wasn’t allowed to care for them.   MGM described her daughter as a good mother but agreed there were times when she, as a grandparent worried about Child C. She described LB as sometimes appearing ‘sleepy’ and this was when she worried most about her grandchild. She described NX as a good support for LB and thought he should have been considered as a carer for the children. LB sees Child C a couple of times a week but isn’t permitted to take him out or spend time alone with him and this MGM felt, was sad as Child C is close to LB.   She said she could not see a time when Child C would return to LB’s care, as her daughter seems unable to sort out her dependency on drugs.   MGM described Child C as a lovely child, doing well at school, who seems happy to live with grandparents. The child likes seeing mum but now doesn’t expect to go home with her when she leaves.  The relationship between Child C and Child J is a good one.   MGM said care of both children is shared between herself and her husband and her sister helps out as and when needed.   MGM said that when she agreed she would look after Baby A, she had never thought it would be for the long term. She had thought it would just be until LB sorted herself out. She said she had gone to many multi-agency meetings and always believed that LB would end up caring for her children, especially after her marriage to NX.  When Baby A was born, MGM said she didn’t see the social worker and she and her husband went to collect Baby A and LB from the hospital to bring them to her house.  The social worker did not visit and although MGM knew LB couldn’t take the baby out, she was never told not to leave LB alone with the baby.  She said it was never made clear to her what they meant by ‘supervising’ LB’s contact with her baby.    MGM said she had not received any information about the cause of Baby A’s death and did not know what happened. They were upstairs in the house when Child J shouted for help, having found Baby A seeming lifeless.  MGM said the family were devastated by the death. LB had been unable to cope with the loss and MGM suspected she was still taking drugs, although she was always fine when she came to visit Child C, about twice a week.  MGM said she wasn’t surprised that LB had not made plans to meet with us, although she felt that it would be good for LB to do so and she would urge her to get in touch. Child J was still deeply upset at the death of Baby A and is receiving support and help from school.  Asked what might have made a difference to the outcomes for both Child C and Baby A, MGM couldn’t be specific but only reiterated that LB should have received more help when she needed it.     15  MGM did want it recorded that she was deeply unhappy with Children’s Services in [Place 2] when they insisted that Child C be moved from her care after Baby A’s death. She was particularly concerned when they tried to insist that Child J also had to move, although this didn’t happen as Child J refused to move.  Child C went to stay with the Aunt (ST) for a couple of days before moving back. MGM said the social workers were insensitive and had caused the children even more distress.   MGM was advised about the report and when and how it would be published.  She was also informed that a report would be sent by LSCB to her home and she and her husband could also call into the office if she or husband wished to read it just prior to the publication date.  Contact details were passed to MGM for future contact and a request was made for LB to make contact if she felt able to do so.  3.8.4. Meeting with NX, father to Baby A  NX had already spoken with MGM when we arrived and indicated he was clear about the SCR process.  He gave apologies for LB and said she had not been able to face meeting with us. NX said he continues to be concerned about LB and confirmed she still struggles with heroin use, despite her efforts to stay ‘clean’. NX confirmed he neither takes drugs nor drinks alcohol but intended to help and support LB for as long as she needed it.  NX was adamant in his view that neither he nor LB had been given a chance to parent Child C or Baby A. He confirmed he had attended parenting classes as requested, undergone counselling and attended multi-agency meetings but said he never felt the social worker listened or took his wish to care for both children seriously.  He specifically said that the social worker had never observed Child C with LB for any length of time and had she done so, she would have seen the positive caring relationship that LB had with her child.   Asked about sessions with the social worker, NX said there weren’t many three-way meetings and neither he nor LB ever felt really supported by her. He wasn’t able to be more specific but cited times when the social worker (social worker 3) hadn’t kept appointments or had failed to turn up at meetings. He referred to the parental assessment, which had been undertaken and said that both he and LB had been told the assessment was positive but then a decision was still made for Child C to go and live with the MGM.   He felt this decision was never fully explained and expressed his frustrations about the whole process.   NX acknowledged the risks involved in children being around adults who were taking drugs, but said LB always looked after Child C well and with his help, they both could have cared for Child C.  NX said neither he, nor any of his children, had any involvement with social workers and he thought this would have been taken into account when he married LB. It was, he said, much later when he discovered the extent to which CSC were involved in the life of LB and Child C.  For several months he had not been aware of their involvement.  He said LB had not always been honest with him but once he became aware of what was happening, he was   16 determined to get involved.  NX acknowledged he wasn’t always able to attend all the meetings due to ‘other commitments’ but said he had tried to get to these as often as he could.   NX was very annoyed about a hair strand test to which he was subjected some time prior to the death of Baby A. The Overview Author was unaware of this incident.  NX said the test had come back positive for himself but clear for LB. NX had found confirmation that his hair strand could have been contaminated if he was living in the same house as a drug user.  However, his issue was with CSC who had shared that information with members of his wider family. NX was advised to continue with the complaint procedure against the Local Authority and take legal advice in terms of any redress.   NX said he blamed many people for the death of his baby, the social workers, the hospital staff and he also blamed LB. He said this was his last chance to have another child and asked if it was now known exactly what had happened.  NX was unclear about the exact circumstances leading up to Baby A’s death and the author was not able to offer any additional information.   NX said he wanted to challenge the length of time the ambulance took to reach Baby A. He said he had received the phone message that something was wrong when he was in the bath. He had immediately got out of the bath, got dressed and drove from Place 1 to the home of the maternal grandparents in Place 2 and arrived just as the ambulance was drawing up outside. NX queried that it should take so long to respond to a 999 call.  NX was advised this was new information and further enquiries would be made by the Safeguarding Board.  These enquiries revealed that the ambulance arrived nine minutes after the family rang 999, which is one minute outside timescales for the ambulance service to respond to calls of this nature.  Concerns expressed by NX have been shared with the ambulance service.  NX was advised about the SCR report and when and how it would be published.  NX said he would like a copy sent to his address.   Contact details were passed to NX for future contact and a request was made for LB to make contact if she felt able to do so.  3.8.5. The experiences of children within the household   The SCR Panel considered whether it was necessary for the author to speak with any of the above children to ascertain their views. The Panel and the author agreed at the outset, that any information about the children’s views should be ascertained from the IMR reports.    Child C 3.8.6. It is, nevertheless, a striking feature of this review that there have been no attempts by any agency to establish the views of Child C, or seek to understand what life must have been like for this child, moving backwards and forwards between mother and grandparents.  Even from the Children’s Centre and nursery school, there is little information provided which helps the author gather a picture of what Child C was like and how the child coped and importantly, what impact mother’s substance misuse had on the child.  This is a significant omission in all of the reports and   17 particularly so in relation to the IMR from CSC, where it would be expected that the social worker would have had the child’s ‘wishes and feelings’ and also those of the half-siblings firmly at the centre of the assessment processes.   Child J and Child P  3.8.7. There are no significant references to either child in relation to Child C or Baby A, despite the fact that they are family members with whom Child C and Baby A would have had contact.   4. Information known to Agencies  4.1. Introduction  4.1.1. A full, combined chronology was prepared to inform this report, detailing the relevant contact episodes between the children, their parents and extended family members and each agency. Each IMR report and the Health Overview Report included a detailed chronology and a very brief narrative containing information about the agencies’ involvement with the children.   4.1.2. Child C was subject to Child in Need or Child Protection Plans for most of  their life and consequently many multi-agency meetings took place to consider how best the child could be protected and their health and development assured.  This section records and comments upon significant events and work undertaken by professionals in the time periods between these key meetings.  4.1.3. It should be noted that the names used by professionals to describe various multi-agency meetings are neither consistent nor always correct. This report attempts to use the correct name for the meeting even though this might differ from the names used by some agencies in the combined chronology.   4.2. Prior to Time Period Under Review  2002 – 2007  LB’s drug use, her association with drug users and the domestic abuse she suffered from the fathers of her two older children are recorded in CSC and Health agencies’ records.   December 2007 Probation Officer made a referral to CSC in [Place 1] concerned about domestic abuse and impact on unborn Child C. LB was found to be living in [Place 2] at the time so no further action was taken. There is no evidence to suggest this information was passed to [Place 2] by CSC.  February 2008  Probation Officer made a second referral to CSC following concerns about drug use, domestic violence and impact on unborn Child C.  A Core Assessment was undertaken and records indicate that a Child in Need Plan was put in place.  April 2008 Child C was born.   18  April 2008   Initial Assessment. Concerns were raised about mother’s drug taking and the impact on Child C.  May 2008  Child Protection Strategy Meeting. Child C continued to be subject to a Child in Need Plan.  June 2008  Initial Assessment. Child C continued to be subject to a Child in Need Plan.  June 2008 Decision taken to transfer ‘case’ to a CAF12 process for package of services to be identified.  July 2008 Decision taken to return Child C to Child in Need Plan as circumstances ‘are not appropriate’ for CAF team.  October 2009 Child in Need meeting.  Manager’s decision was taken to end Child in Need Plans for Child C. Records indicate this was in response to LB being ‘clean’ from heroin for three months.   August 2010 Initial Assessment. Concerns were raised about mother’s drug taking and the impact on Child C. September 2010 Child Protection enquiries were made following concerns about mother’s drug taking and the impact on Child C. Decision was taken not to progress to an Initial Child Protection meeting. November 2010 Child in Need Plan for Child C implemented.  4.3. Time Period under Review   4.3.1. Child in Need meeting: 6th January 2011  Present: Not clearly documented but LB did not attend and notes refer to social worker, Children’s Centre (nursery) and P1-SMTP. Information pertaining to this meeting has been extracted from notes from other agencies and not from records from CSC, as these were unavailable.  Records refer to:   • LB failing to attend this meeting or keeping planned appointments with Health Visitor, social worker or P1-SMTP                                                  12 The CAF is a standardised approach to conducting an assessment of a child's additional needs and deciding how those needs should be met. http://webarchive.nationalarchives.gov.uk/20080804182823/everychildmatters.gov.uk/deliveringservices/caf/    19 • P1-SMTP advising that they had information that LB was taking Child C out at night to sell drugs • P1-SMTP were advised to liaise with social worker re: testing and progress and asked to confirm reliability of this information  4.3.2. There would appear to have been no discussion around the impact of mother’s actions on Child C and no reference to historical information, which suggests this ‘relapse’ was predictable. There is no recorded discussion about Child C’s attendance at nursery or whether P1-SMTP should have alerted CSC when LB failed to keep her appointments.  This suggests that the Child in Need Plan lacked clarity about the roles and responsibilities of professionals and indicates there was poor collaboration between agencies. The concerns did not generate a home visit despite the fact that no professional had seen Child C since before Christmas.    4.3.3. On 10th January 2011, LB’s previous drug tests were returned to P1-SMTP from the drug testing company and showed a positive result for Methadone and opiates. However, this information was not shared with the social worker until 12th January 2011 following LB’s appointment with P1-SMTP. LB confirmed she was using intravenous heroin – injecting into her groin – and had been for the last four months.  She admitted she was also using other drugs including Diazepam and Amphetamine. LB advised she had last injected heroin some two hours earlier and yet was described by P1-SMTP worker as being ‘coherent’ and seemingly ‘not under the influence’.  This piece of information is important as it is fair to assume that not all professionals would be able to detect that LB was under the influence of opiates, an issue further explored under Section 7. There was no discussion about Child C or how LB was managing to care for her child; this would suggest that the P1-SMTP practitioner did not have the wellbeing of Child C high on her agenda.  4.3.4. P1-SMTP appropriately contacted the social worker and although it is not clear just how much information was shared re: poly-drug use, the social worker was advised about LB’s continuing drug use and that her Methadone dosage was to be increased to support her withdrawal from heroin. The records do not indicate any sharing of information about Child C.     4.3.5. The Health Visitor had another failed appointment on 11th January 2011 and could not gain access when she called to the home.  She contacted the nursery where she learnt that Child C had not attended since before Christmas. LB had made contact with the nursery and advised that Child C had been unwell and this was also the reason why she had not attended the planning meeting on 6th January 2011. The Health Visitor promptly contacted the social worker and followed this up with an e-mail, expressing her concerns that LB was not complying with Child in Need Plans nor keeping agreed appointments. The social worker responded to the e-mail saying she had also visited that day and had not gained contact. She advised the Health Visitor that she was to have supervision the following day.   4.3.6. The social worker met with her line manager on 12th January 2011 and a decision was taken to proceed to a child protection enquiry under Section 47 of the Children   20 Act 198913.  The combined multi-agency chronology indicates that the social worker made a child protection visit later that day where she was introduced to LB’s new partner KR.   LB refuted the suggestion that she took Child C out to buy or deal in drugs although she admitted she was using heroin. LB was informed that a child protection investigation was underway and she was given the option for Child C to stay with the maternal grandparents whilst these continued. The chronology indicates that LB was distressed and concerned about the impact of this decision on her family, although it is not clear whether this referred to her parents or to her immediate family.    4.3.7. No records have been made available to the author which detail how and when Child C was moved to the maternal grandparents’ home or what discussions took place about concerns, care or supervision arrangements.  The status of this arrangement is unclear and as there is no mention in records of a Viability Assessment being undertaken, or whether Child C was to be placed with grandparents under s2014, it must therefore be assumed this move was registered as ‘informal family care’.  This in itself is of some concern as there appears to have been no detailed assessment undertaken to explore whether the grandparents were able or willing to look after Child C and what impact this could have had on Child J.    4.3.8. On 16th January 2011, P1-SMTP received a written copy of an agreement signed by LB in the presence of the social worker, whereby LB agreed not to use illicit substances but would contact her social worker if she were in any difficulty.  A copy of this agreement has not been seen by the author and is not referred to in the CSC IMR.  It is difficult to understand the purpose of this signed agreement if indeed it only related to LB promising not to take drugs. What should have been shared was an agreement between LB, the grandparents and CSC about the care, safety and contact arrangements for Child C and what support the maternal grandparents could expect from the Local Authority.  The Local Authority in [Place 2] should have been informed that Child C was now living in their area.  This information was not shared.  4.3.9. The Health Visitor informed the social worker that she had contacted LB on 16th January 2011 to make an appointment for the following day and had been advised that LB was living with her mother in [Place 2]. There are no records to indicate that the Health Visitor visited the home of the MGM the following day and the issue of why this did not happen is not explored by the IMR author.  Was this because it was out of area?    4.3.10. Upon learning, via e-mail, that a s47 investigation has been initiated, the Health Visitor replied with some general information about Child C, presumably taken from records, as she had not recently seen Child C.  The Health Visitor advised that Child C was up-to-date with immunisations and developmentally within the expected range, although a referral was being made for speech and language                                                  13 Section 47, Children Act 1989 places a duty on the Local Authority to make enquiries if they have information which suggests a child, living in their area, has suffered or is likely to suffer significant harm. 14 Section 20, Children Act 1989 is a voluntary agreement between a Local Authority and a parent where the Local Authority agrees to look after a child or young person.   21 assessment.  She expressed concern about Child C being appropriately stimulated if nursery attendance lapsed due to the distance involved.   4.3.11. The Health Visitor contacted the manager at the Children’s Centre and was advised that Child C usually attended fairly regularly although often arrived late, sometime between 10 and 11. Records about Child C refer to a child who is sociable and confident. The child had not attended since before Christmas and the manager expressed the view that there seemed to have been some ‘family issues’ after Christmas but she did not give or was not asked for more information.  There is no evidence that this information was shared with the social worker.   4.3.12. Whilst information from the combined chronology suggests there were no outstanding matters in relation to background checks of AH, LB or KR, no information appears to have been recorded about the outcome of any assessment.   4.3.13. Records indicate the social worker made another Child Protection visit on 19th January 2011 and saw both LB and Child C. The author presumes this visit took place at the maternal grandparents’ home, but there is no reference to either grandparent being at home. The house was described as clean and appropriate and Child C was recorded as playing quite happily with toys in the corner. LB stressed her commitment to stick to her treatment plan, as she ‘couldn’t lose’ Child C and claimed future tests would be returned negative. It has not been possible to access any records, which indicate whether any discussions with family members took place and there is nothing in the CSC IMR, which indicates any attempt to gather grandparents’ views or assess how the changes may have been affecting Child C and also Child J.   4.3.14. On 21st January 2011, LB tested positive for Cannabis and Methadone. At her appointment with P1-SMTP on 24th January 2011, she tested positive for Methadone and Benzodiaphines, a substance that was not prescribed to her. An oral swab was sent for analysis. LB explained she was living at her mother’s home and it is fair to assume that she was caring for Child C but the P1-SMTP practitioner does not pick up this issue.    4.3.15. On 26th January 2011, the Health Visitor saw Child C at nursery to undertake an assessment. Child C was described as clean and dressed in well-fitting clothes.  Height was on the 0.4th centile and weight on the 2nd centile. At two years nine months, speech was recorded as being immature, but a referral for a speech and language assessment had been made.   4.3.16. Drug tests from LB were returned on 28th January 2011 and indicated a positive result for Buprenorphine, a substance that was not prescribed to her.  P1-SMTP did not contact the social worker with this information  4.3.17. Initial Child Protection Conference (ICPC) 4th February 2011   Present: (Independent Chairperson, LB, P1-SMTP, Nurse, social worker, Health Visitor 1, Police, Children’s Centre.  Records refer to: • Child C doing well developmentally but needing some help with glasses and speech and language   22 • A good relationship noted between Child C and LB and the ongoing support by maternal grandparents was recognised • LB’s attendance at this meeting and ‘three clean tests’ were positively noted • Risks around LB’s continued drug use, her past history, abusive relationships and failing to engage with services   • Child C to be placed on a Child Protection Plan under the category of Neglect  4.3.18. Given LB’s history, the professionals at the Conference were overly optimistic basing their views on incorrect information. Those present were also very naïve about LB’s ability to stay drug free for any significant period of time.  The focus remained on her willingness to engage with services and attend for planned and random testing. There is no recorded discussion about the consequences of LB not keeping to the agreed plan, nor was there any challenge about why, given her past history, she was now more likely to remain drug free than before.  There was no indication why, given that Child C was living with grandparents, they were not present at this Conference. There was no discussion as to the status of this arrangement with grandparents; this is a significant omission and leaves Child C in a vulnerable position.   4.3.19. Between 4th February 2011 and the Core Group meeting on 18th February 2011, LB’s drug treatment was discussed in group supervision at P1-SMTP on 9th February 2011. A plan was identified for continuing work with LB and the practitioner was advised that she should attend all Child Protection meetings.  This was good practice and gave practitioner 3 a clear role.  The Health Visitor liaised with the GP and the required referral was made in respect of Child C’s physical development.  LB continued to test positive for drugs during this period. There is however, no information pertaining to any visits by the social worker to LB or her parents, or to any work undertaken directly with Child C. It is not clear what role the maternal grandparents were expected or willing to take. It appears that LB was living with her parents and taking responsibility for Child C’s care.  4.3.20. On 11th February 2011, LB attended P1-SMTP and talked of taking legal advice to secure contact with her second eldest child, Child P. She expressed frustration that her social worker had failed to keep an appointment the previous week. On 15th February 2011, LB’s test results indicate a positive result for Buprenorphine, a substance that was not prescribed to her.   4.3.21. Core Group meeting 18th February 2011   Present: LB, social worker, Health Visitor, Nursery officer, Nursery Manager. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available.  Records refer to: • P1-SMTP not attending meeting  • LB advising that her relationship has ended with KR and she was fearful of Child C’s father (AH) • Child C and LB living with the maternal grandparents who it appears were unaware that LB had tested positive for drugs  • Social worker to undertake police checks on all adults having contact with Child C • LB to continue with drug testing    23 • Public Law Outline (PLO) meeting to be held in respect of Care Proceedings for Child C  4.3.22. There appears to have been no challenge to LB in respect of her testing positive for opiates. P1-SMTP did not attend despite an agreement to do so as discussed in practitioner’s supervision session on 9th February 2011. Records also indicate that the social worker agreed to advise the maternal grandparents that LB is continuing to test positive for drugs. It appears from the chronology that they were not aware of this and yet they are presumed to be a protective factor in Child C’s life. There is no explanation as to why these significant family members are not attending any meetings in relation to Child C.  It is also unclear to what extent the MGM was supervising LB’s care of Child C. There is little evidence that the progress of the Core Assessments was discussed at this meeting.   4.3.23. A Child Protection Monitoring visit took place on 24th February 2011 and in the combined chronology, it is noted there were ‘no issues’ in relation to Child C’s social, emotional or behavioural development.  However, these records do refer to Child C sleeping on a pull out bed with LB.  MGM and LB were advised by the social worker that the Core Group’s decision was that the ‘arrangement’ had to continue for a further four weeks to ‘ensure LB cannot relapse’. There are however, no records which explain why the social worker offered this information and where the ‘four week’ timescale came from.     4.3.24. The following day, LB reported to P1-SMTP and had an oral swab taken. It was agreed that they would discuss test results showing positive results for Buprenorphine at next meeting on 4th March 2011. LB talks of difficulties in her relationship with her mother. This was not reported to the social worker.  On 4th March 2011, at her appointment with P1-SMTP, LB described to her practitioner her unhappiness that her social worker had cancelled the last appointment. It is not clear from records whether this refers to a recent cancellation or is the same one LB reported on 11th February 2011.  LB denied any illicit drug use but there is little evidence of any challenge from practitioner 1.  At this stage LB was collecting her prescription daily and asked to be placed on a twice-weekly collection. It was agreed that this would be discussed at next visit. On 8th March 2011 P1-SMTP received a test result, which indicated no illicit substances. The drugs company was asked to recheck the last positive result for LB. On 9th March 2011, LB’s key worker at P1-SMTP was changed for the third time.  4.3.25. The Health Visitor saw LB and Child C on 9th March 2011, although it is not clear where this visit took place.  Child C was recorded as being ‘bright and chatty, sociable and confident’. The Health Visitor described LB’s relationship with Child C as ‘lovely and warm’ but offered no further information, which would help others understand what she meant by this description.  LB advised she has not seen her social worker since she moved house.  This was the first indication that LB had moved and it is unclear how long it had been since LB saw her social worker. Neither the Health nor the CSC authors address this issue in their respective reports, it is significant as reading the chronologies it appears that the Health Visitor was the only practitioner actually ‘working’ with the family.     24 4.3.26. LB attended P1-SMTP on 11th March 2011 and her earlier positive test results were discussed. LB denied using Buprenorphine and stated she didn’t know what this was.  This is highly unlikely given LB’s background but this comment was not challenged. Practitioner 5 did make it clear however, that if she attended every appointment for four weeks and all tests were negative then LB could return to twice-weekly pick-ups [for her Methadone prescriptions].  LB and practitioner 5 agreed that LB would attend P1-SMTP every Friday morning at 10.30am and also when asked to call in for another random test.  This is an example of good practice and had the Child Protection Plan been more focused, this expectation would have been made explicit so all professionals were aware of the arrangement.  Practitioner 5 contacted social worker 2 to discuss the session and was asked to produce the last four months of testing results in preparation for the next Core Group meeting on 18th March 2011.   4.3.27. Core Group meeting 18th March 2011  Present: Not clearly documented but notes refer to LB, P1-SMTP, Health Visitor and social worker. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available.   Records refer to: • Child C benefiting from nursery placement • Child C continuing to live with maternal grandparents • Agreement that a Risk Assessment would be undertaken and completed within two weeks. This appeared to be in relation to Child C staying with LB unsupervised • LB not to have any contact with ex-partner KR • Need for Police checks on grandparents • LB to undergo weekly swab and urine test. (Notes from P1-SMTP, however indicated that a private conversation between practitioner 5 and social worker took place and it was agreed that LB would be subject only to swab tests15.)  It is unclear whether or when LB was informed of this decision  • LB to comply with random drug testing • LB to register Child C with Dentist • LB to register Child C with nursery in Place 2  4.3.28. There is no information contained in the IMR from CSC about this Core Group meeting, either in terms of the information shared or in relation to any dissent or agreed outcomes. It is difficult to understand why the IMR author for CSC, would not explore in detail the effectiveness of these meetings and to what extent they served to secure better outcomes for Child C.  The Core Assessment, and the Risk Assessment related to the adults with whom Child C is in contact were not discussed.  LB and her positive drug tests were not addressed, discussed or challenged.   4.3.29. P1-SMTP received a letter from the drugs testing company indicating that LB’s tests were clear and this appears to set the scene for continuous confusion amongst professionals in future about tests which showed ‘false positives’. This undoubtedly made it easier for LB to subsequently challenge tests, which showed a                                                  15 Swab tests cannot be falsified unlike testing for urine, which could belong to another individual.   25 positive result and created the possibility of doubt in the minds of professionals about the extent of her drug taking.    4.3.30. On 22nd March 2011, the social worker visited LB and Child C, presumably at the grandparents’ home. Records in the combined chronology state that as wider family members were present it was ‘not appropriate’ to discuss the Child Protection Plan.  There is nothing to indicate that the social worker asked to speak with LB or the grandparents on their own. The social worker had last visited four weeks earlier and this was the first visit after the Core Group on the 18th February 2011. It is unclear how LB would have made sense of what was happening given that she and the grandparents had been told in February that Child C would remain with grandparents for another four weeks. Child C was described as talkative throughout visit and was playing with books and toys. Date to start Risk Assessment at nursery was discussed with LB, although it is unclear why such an assessment would ‘start’ at nursery, and not have started at this visit.   4.3.31. P1-SMTP received information on 23rd March 2011 from a client, an ex-partner of LB who made threats to ‘stab and kill’ any service user he saw with her. Practitioner 6 attempted to contact LB several times and she eventually attended alternative P1-SMTP premises with a male substance user who was on a Drug Rehabilitation Requirement Order (DRR). Child C was present.  It is clear at this stage that LB was not co-operating with the Child Protection Plan and was placing Child C at risk by associating with known drug users, but P1-SMTP do not share this information with the social worker and there is no reference to Child C’s behaviour, appearance or wellbeing during the time LB was at these premises.   4.3.32. LB was asked by practitioner 1 on 23rd March 2011 to return the following day for tests, which she did, and she met with practitioner 5.  She was informed about the threats but appeared unconcerned.  She was told that the social worker would be informed about her visit the previous day in the company of adult on a DRR order. LB asked for a reduction of her Methadone, as she wanted to come off drugs completely. She asked to be considered for twice-weekly pick-ups. LB was advised this would be discussed with another practitioner and that she would be contacted to call in the following week for a random test.  There is no mention of the agreement made on 11th March 2011 with practitioner 5 and it is unclear how these agreements were recorded and how different practitioners at P1-SMTP would access these records.   4.3.33. A social worker visit was made at some time the same day to undertake a Risk Assessment. The home was described as clean and well presented. Children’s books and toys were in evidence and Child C’s bedroom was noted to be ‘appropriate’.  If this visit was part of an assessment process it would be expected that detailed notes would be available, but these were not recorded and neither are there references to these in the CSC IMR.   4.3.34. LB test results returned on 26th March 2011 and were positive for heroin and Buprenorphine. This information was not shared with the social worker. LB was called in for random drug testing on 29th March, 30th March and 5th April 2011 but gave excuses as to why she could not attend.  This information was also not shared with the social worker.     26  4.3.35. Child Protection Review Conference 6th April 2011 Present:  Independent Chairperson, LB, Health Visitor 1, social worker 2 and Children’s Centre.  Records refer to: • Nursery advising that Child C presents clean and tidy and is meeting milestones  • LB being concerned at the absence of anyone from P1-SMTP • P1-SMTP’s report. The report expressed the view that LB was not under the influence of substances when she attended her appointments. She was described as presenting well and being communicative, keeping P1-SMTP informed and responding well to treatment. The report refers to a lapse in January 2011 but that LB had attended special key worker appointment regarding lapse prevention • LB was reported as being good at attending her appointments and has been ‘committed to addressing her illicit drug use’ • LB and Child C continuing to live with grandparents until the ‘Child Protection assessment’ was concluded   • An assessment being undertaken in LB’s home  • Child C continuing on Child Protection Plan • Growth to be monitored by nursery, plus monitoring when Child C is wearing glasses • Next meeting 14th April 2011  4.3.36. The report from P1-SMTP is overly optimistic, factually incorrect and failed to address LB’s lack of co-operation with random drug testing agreed at the Core meeting on 18th March 2011. The Independent Chairperson had telephone contact with P1-SMTP in relation to non–attendance at Child Protection Conference and was advised that practitioner 4 was on sick leave.   4.3.37. The Independent Chairperson was advised that LB’s mother was questioning the validity of drug testing and LB was receiving mixed messages from P1-SMTP. It is possible that this is a typing error as there is nothing in any records, which indicates the Independent Chairperson, had a conversation with the maternal grandparents. It is possible that LB herself raised the query about the validity of drug testing. There appears to have been a challenge by the Independent Chairperson about the failure of P1-SMTP to arrange random sampling and yet from P1-SMTP records, it is clear that LB was asked to attend for random drug tests but that she failed to attend or respond to calls from practitioners on several occasions.  There is clear evidence of inconsistent practice by professionals – LB is advised at meetings, and appears to agree, that she must attend for planned and random drug testing. However, when she fails to comply, she is not robustly challenged or informed about the consequences of her failing to comply with the requirements in the Child Protection Plan. This is a pattern evident in all LB’s contact with professionals, a pattern that continues to be repeated until the death of Baby A in April 2013.   4.3.38. The Review Conference notes refer to the various ‘tasks’, which have been ‘achieved’ since the Initial Conference in early February. However, there is little discussion as to what ‘achieved’ means and scant evidence that any of these will lead to sustained and improved outcomes for Child C.     27 4.3.39. LB attended P1-SMTP on 7th April 2011 and there was discussion about reducing the Methadone prescription and LB moving to a twice weekly pick up.  There was no reference to the agreement made between practitioner 5 and LB on 11th March 2011.  4.3.40. Social worker records refer to an assessment session on 7th April 2011, but it is unclear where this assessment visit took place. The report provided to the Review Conference on 6th April 2011, refers to ‘assessments taking place in LB’s home’, this would imply that LB is taking Child C to her home. If the meeting did not take place at LB’s home, then there was little value in assessing LB’s parenting skills when she was living with her parents.  The issue of how best to assess LB’s parenting skills should have been addressed at the Initial Child Protection Conference and the details discussed in depth at the subsequent Core Group meeting.   4.3.41. The social worker records refer to LB and Child C both being observed and that Child C responded well to LB. The house was described as appropriate with ‘toys and books’ in evidence. Child C was ‘smart and happy to talk’ and was wearing glasses, encouraged by LB.  The phrase ‘toys and book in evidence’ is beginning to be used too often and without any further information becomes meaningless.   4.3.42. Core Group meeting 14th April 2011 (Information Sharing meeting)  Present: LB, Health Visitor and Children’s Centre worker. This should have been a Core Group meeting, but it appeared that only LB, the Health Visitor, and the key worker from the Children’s Centre attended the meeting. The social worker did not attend and therefore the meeting was designated as an ‘information meeting’.   LB was described as very unhappy with the non-attendance of other professionals.  The Health Visitor agreed to write to P1-SMTP and the Team Manager of CSC to express concerns about the failure of these agencies to ensure representation. There would appear to be no minutes of this meeting but records from Health Visitor notes, and from the Children’s Centre refer to the speech and language appointment for Child C sent mistakenly to Children’s Centre, LB reported that she continued to attend appointments and her results were clean and LB also shared that the Police raided her home the previous week but no drugs had been found. There is no indication that there was any discussion about Child C or where this child was when the Police raided the home.  4.3.43. Between 14th April 2011 and the Core Group held on the 12th May 2011, discussions took place between the Independent Chairperson, CSC and the manager of P1-SMTP around safeguarding responsibilities and the importance of managerial oversight and regular attendance at meetings. This was an appropriate challenge by the Independent Chairperson and led to improved attendance at future meetings.   4.3.44. On 4th May 2011, a Child Protection Monitoring visit took place at LB’s home. It is unclear when a decision or an agreement had been made that Child C could stay/visit LB at her own home. Records describe Child C as playing in the garden so ‘not appropriate’ to discuss concerns but ‘no issues’ with presentation.  It is   28 difficult not to assume that these visits are purely functional in that they allow the recording of a ‘visit’ to be made prior to a multi-disciplinary meeting. There are no records that outline the purpose, content or outcome of this or any other visit. This is not only poor practice, it is practice which leaves Child C vulnerable and gives mixed messages to LB about the purpose of these visits.   4.3.45. LB has not been tested since 27th April 2011.  4.3.46. Core Group meeting 12th May 2011 Present: Not clearly documented but notes refer to LB, Health Visitor, social worker and Children’s Centre. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available.   Records refer to: • Child C doing well and assessed as being age appropriate in terms of  development • LB being advised about importance of her attending sessions at P1-SMTP • LB’s explanation about her missed appointments and her confusion about when she was to be tested over Easter period • Social worker leaving on 20th May 2011 but advising that outcome of Risk Assessment would be available for a sharing of information meeting on 19th May 2011 • LB being advised by social worker that if she associated with [named] adults 1 or 2, this would adversely impact on Risk Assessment • Information from P1-SMTP suggests that LB has tested for Methadone only since January 2011, but missed appointments are not addressed and neither is the positive test result on 26th March 2011  • Next Core Group meeting 9th June 2011  4.3.47. Between 12th May 2011 and the Core Group meeting on 9th June 2011, LB failed to keep her agreed appointments for drug testing. On one visit to P1-SMTP, she expressed her frustrations to practitioners and described feeling down and dejected. She said that she had done everything that had been asked of her and yet she did not feel her situation was progressing.  This is an understandable point made by LB given that her missed appointments do not appear to have been challenged by other professionals and she was present at the last meeting to hear P1-SMTP confirm tests indicated she had been free from illicit drug use since January.  LB expressed concern over the uncertainty about what was happening and the impact this was having not just on Child C but also on Child J. LB was advised by her practitioner at P1-SMTP that she must demonstrate compliance through attending for regular and random drug testing. LB was also advised that she would have another Key Worker at P1-SMTP. This would be her third change of worker in five months.   4.3.48. LB was not given any information about her new social worker and there were no social work visits during this time period.  Despite the information shared at the Core Group meeting on 12th May 2011, the meeting to discuss the outcome of the Risk Assessment on 19th May 2011 was cancelled and the outcome of the assessment was not subsequently shared with LB or any professional. It would appear this assessment had been ‘lost’ if indeed it was ever undertaken.  The absence of a robust and qualitative Risk Assessment at this stage was a significant   29 failing, which led to poor quality decision-making and confirmational bias on the part of professionals, an issue explored, further in Section 7.   4.3.49. During this period, the Health Visitor noted LB’s demeanour and LB is described in records as being ‘down, agitated and not herself’. LB’s history of having deep vein thrombosis (DVT) was discussed and LB was advised to seek medical attention and ensure that her own health needs were not neglected. There was continuing confusion as to who was the new social worker and attempts by the Health Visitor to find out more information were unsuccessful. The Health Visitor was unable to confirm arrangements for the Core Group meeting, which had been planned for the 9th June 2011. This is evidence of a lack of managerial oversight. This was a child subject to a Child Protection Plan and arrangements should have been made earlier to allocate the case to another social worker and as a matter of good practice, to arrange a handover visit.  Significantly, the social worker that was leaving had a supervision session two days before she was to leave her post, her first such session in three months.   4.3.50. There is little in the records to suggest there were any major concerns about Child C. The child appeared to be meeting milestones and was often described as a happy sociable child.  It is of some concern that there was so little information about Child C and how the child’s care was managed when his grandparents were working shifts.   4.3.51. Core Group meeting 9th June 2011 This meeting took place as planned on 9th June 2011, attended only by nursery staff, LB and the Health Visitor.  LB was recorded as being upset and distressed at the non-attendance again of a social worker and P1-SMTP. There were no apologies from P1-SMTP and no explanation as to why there was no representation from CSC. The Health Visitor attempted to contact CSC but was unsuccessful in finding out what had happened.  This is very poor practice and highlights that the support and facilitation of Core Group processes are not working. This again gives mixed and unclear messages to LB. There are no records of any discussion about Child C at this meeting. Neither of these issues were explored in the IMR report for CSC.    4.3.52. Between 9th June 2011 and the next Core Group meeting on the 24th June 2011, another social worker was allocated to the family (social worker 3), but it would appear that there was no introductory or transfer visit to LB, Child C or maternal grandparents.  According to records, LB was advised by P1-SMTP of the name of her social worker and the date of the next Core meeting.  Social worker 3 visited the nursery on the morning of the 24th June 2011 where Child C’s relationship with mother was described as positive.   4.3.53. The Health Visitor persisted in her attempts to find out date and time of Core Group meeting. She left messages for the social worker, which were not returned. When contact was eventually made on 23rd June 2011, the Health Visitor was informed the Core Group would possibly take place the following day, but this could not be confirmed.   The Core Group meeting did however go ahead on the 24th June 2011 but without the Health Visitor in attendance.     30 4.3.54. LB did not attend for any appointments with P1-SMTP during this time period. Whilst there was conversation between the social worker and the practitioner at P1-SMTP, LB’s failure to keep to regular appointments was not discussed.  4.3.55. Core Group meeting 24th June 2011 Present: P1-SMTP, Nurse, LB, social worker 3 and Children’s Centre.  Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available.   Records refer to: • Child C doing well, developmentally and socially, described as being a confident child. Had been toilet trained by LB and always appeared clean and well dressed  • LB said Child C had bonded well with Child J but she was concerned that both children were getting used to being cared for full-time by her and she was worried about the effect it would have on both children when she and Child C returned home in the near future • LB’s view that the living arrangements were an additional pressure on her parents and LB feeling she had done all that was asked of her and no progress appeared to have been made • P1-SMTP felt LB was coping well with her treatment but needed to be aware of how her feelings and frustrations might make it difficult for her not resume her drug use • The Risk Assessment, which would confirm whether Child C could live with LB in her own, had not been completed  • Social worker said that all plans were being satisfactorily progressed. LB’s next appointment with social worker was 28th June 2011 • Next Core Group meeting was agreed for 21st July 2011  4.3.56. There is significant evidence of professional complacency here, which suggests that members of the Core Group were unclear about their roles and the function and purpose of Core Group meetings. Whilst LB was not challenged about her failure to attend for regular and random drug testing, neither was there any professional challenge about individual agency performance. There is no recorded challenge at this meeting in respect of the long-awaited Risk Assessment, originally expected by mid-April, and neither was there a clear understanding about what factors would indicate sufficient progress so Child C could return home to live with LB. The role of grandparents as protective factors was not considered in any sense and it is unclear to what extent they were involved in caring for Child C.  There is a sense of the same meeting being repeated over and over again with the same goals being identified but little to evidence that any progress was being made.   In this respect LB’s frustrations and comments are quite understandable.  What remains clear is that the focus was on mother and not on the safety and welfare of Child C.   4.3.57. Between 24th June 2011 and the next Core Group meeting on 21st July 2011, LB failed to keep her appointments at P1-SMTP and test results on an earlier swab indicated the presence of opiates. This information was not however shared with the social worker at the time. Practitioner 10 sought to keep in contact with LB, reminding her of the need to comply with the Child Protection Plan and the Treatment Plan.  LB had face-to-face contact on 19th July 2011 where she again   31 voiced her frustrations at everything taking so long. There is no evidence of challenge in respect of LB’s missed appointments.   4.3.58. During this period, the Health Visitor wrote formally to the social worker expressing concerns about the Core Group meetings, the absence of the Risk Assessment and the general drift and delay in moving things forward.  The letter was copied to the Team Manager in CSC and the Health Visitor’s own line manager. This was good practice.  4.3.59. Core Group meeting 21st July 2011 Present: P1-SMTP, LB, social worker and Children’s Centre.   Records refer to: • LB’s frustration at not being able to move to her home and having to take two buses to take Child C to nursery  • Child C continuing to thrive, displaying good social skills and development • P1-SMTP report that LB’s treatment continues to progress and she was engaging well. LB had recently reduced Methadone with no reported ill effects and continued to provide samples, which ‘proved’ she was free from illicit drugs • Health Visitor’s concern about the absent Risk Assessment. The completed Risk Assessment had been forwarded to a Team Manager who was on sick leave. Social worker agreed to locate this and forward to Core Group members for comments • Agreement was reached that if Risk Assessment was satisfactory then Child C could return home with LB and that this ‘case’ had taken too long to conclude  4.3.60. The minutes for this Core Group were made available to the author. They are shocking in terms of their brevity and lack of focus and analysis.  It is significant that there were more details about this meeting in records from other agencies than are provided in the minutes provided by the social worker as chairperson. It is unclear how those present could conclude, without a completed Risk Assessment or the absent Core Assessment that Child C could return home providing ‘the Risk Assessment was satisfactory’. For children subject to a Child Protection Plan, any analysis of risk should be a multi-disciplinary process in which all professionals and parents participate. The actions agreed in this meeting suggests that the Risk Assessment was considered to ‘belong’ to CSC and any recommendations were foregone conclusions not requiring input or challenge from other key parties. It is difficult to understand exactly what progress had been made and what was different from previous concerns highlighted earlier in the year. There is evidence here of questionable decision-making and again points to the dangers of Child Protection Plans lacking focus and direction.   4.3.61. Between 21st July 2011 and the Core Group meeting on the 17th August 2011, LB tested positive for opiates but denied any illicit drug use. She suggested that her self-medication - co-codamol - for her DVT was probably interfering with results.  P1-SMTP later rang LB to advise that the drug company had later confirmed that this test should in fact have shown a negative result. LB claimed she could not understand how the original test proved positive for opiates and was described as being relieved to hear this result. There was no challenge to LB during this   32 conversation in respect of her failure to keep her appointments at P1-SMTP. This information was not shared with the social worker.  4.3.62. A Child Protection Monitoring visit took place on 25th July 2011. LB shared her frustrations about her previous social worker not keeping in touch. She also raised the issues of minutes of Core Group meeting going to wrong address, despite all previous minutes being addressed correctly.   The social worker is recorded to have discussed the ‘assessment’ with LB but there are no details provided in relation to this conversation.  The home was described as being clean and well presented with more than enough food in the home. LB referred to wear and tear in her carpet and this suggests that the visit took place in LB’s home and indicates that Child C was spending time at LB’s home. Child C was described as playing with B, a female adult friend of LB’s.  It is highly likely that this person was the daughter of NX.   4.3.63. NX was released from prison having served 25 months of a five year sentence for supplying Class A drugs.  4.3.64. The Health Visitor saw Child C and LB at the Children’s Centre and LB reported positively on her engagement with P1-SMTP, although this was not substantiated from an external source.  Both mother and child continued to live with maternal grandparents, although the Health Visitor had not seen Child C at the grandparents’ home.    4.3.65. Core Group meeting 17th August 2011 Present:  social worker, Children Centre Key Worker, and Health Visitor Not present:  LB, P1-SMTP worker.   Records refer to: • Social worker sharing with meeting that the Risk Assessment is ‘missing’ • LB not present as she was taking her children on a trip • No concerns from professionals about LB’s parenting  • LB testing negative for drugs • Those present are advised by Health Visitor that LB has new boyfriend [NX] who has been to prison for drug dealing, although he denies using drugs • Reference to the need for him to be assessed • An agreement that social worker start rehabilitation plan for Child C to be returned to LB’s care    4.3.66. The minutes provided by CSC are even shorter than minutes from the previous meeting and the date is incorrect.  Since the last meeting LB had missed appointments and the ‘missing’ Risk and Core Assessments had not materialised.  It is difficult to understand why the professionals at this meeting agreed to continue with the rehabilitation plan without seeing or discussing a Risk Assessment and, significantly, without LB being present. There would appear to have been no challenge to this decision.  Undoubtedly, there was firm-ground intelligence to suggest that Child C was doing well, meeting milestones and developing physically and emotionally. What was not addressed however was the fact that Child C was living with grandparents so the issue of LB’s parenting remains an unknown factor. Furthermore, there is considerable naivety, accompanied by a degree of optimism about LB being allegedly ‘drug free’.  Random drug sampling for LB had not proved conclusively that she was not using drugs as she had consistently and persistently failed to attend for these tests when requested.   The additional risk factor of a   33 boyfriend on Licence for drug offences seriously questions LB’s ability to remove herself from the drug community, but this appears to have been only a minor consideration according to the notes from the meeting.    4.3.67. Between 17th August 2011 and the Child Protection Review Conference on 2nd September 2011, practitioner 10 contacted LB to discuss her non-attendance at appointments.  LB had left a message saying she was unable to keep her appointment on 22nd August 2011 as she was seeing a solicitor about access to Child P and was discussing the situation with her social worker later that day.   LB was challenged about this with practitioner 10 advising that he had tried to contact the social worker and a voice message had confirmed she was on leave from 18th August 2011 until 29th August 2011. LB however, was insistent that she had an appointment with her social worker and according to records from CSC; a Child Protection Monitoring visit did take place on 22nd August 2011. It is possible that the social worker made this visit just prior to taking leave, although this is not an issue referred to or explored by the IMR author. The author of the Health Overview report however, refers to the answer machine message as evidence that LB was not being honest when she said she had an appointment with her social worker later that day.     4.3.68. There are several comments in reports, which refer to LB being ‘manipulative’ and not to be trusted. Yet, professionals regularly took the word of LB without checking back with others to confirm what they had been told. There is also evidence, which suggests that LB was actually truthful on some occasions about when she was taking drugs – she admitted several times to P1-SMTP about what she was doing and whilst she was adept at providing excuses for non-attendance for drug testing, she rarely missed her appointment at multi-agency meetings.   4.3.69. Whilst records pertaining to LB’s drug use go back to 2007, there is little information and analysis provided about the impact of this on Child C. It must be questioned therefore whether a negative impact was assumed because LB was a drug user, as opposed to a negative impact being identified following careful observation and assessment.  Without further detail in relation to Child C or LB’s previous children, the presence of professional bias16 must be considered as a factor alongside the possibility of LB’s engagement with professionals being seen as ‘disguised compliance’17.   4.3.70. Following the social worker visit on 22nd August 2011, LB and Child C were described as ‘fine’ and the plan for rehabilitation was discussed with LB being informed that at the next Child Protection Review Conference, Child C would come off the Child Protection Plan and move to a Child in Need Plan. LB reluctantly shared the name of NX but said she only saw him at weekends when Child C was not present.  Clearly, the social worker was confident that the decision of the Review Conference would support the views of the Core Group and the message to LB was unequivocal despite the presence of another male adult in the life of Child                                                  16 Professional bias occurs when professionals hold onto a particular view about a situation or an individual and do not consider other alternatives, which may challenge this view.  17 ‘Disguised compliance’ involves a parent or carer giving the appearance of co-operating with professionals to avoid raising suspicions, to allay professional concerns and ultimately to diffuse professional intervention.   34 C and one who had clear links to the drug community.  There was no discussion around grandparents and how they were coping with having LB and Child C living with them and importantly, what their views were about LB having ‘sole’ care of Child C and returning to live with them at home.  This is very poor practice.  4.3.71. The Probation Officer for NX discussed with him the impact of his offending on his children.  NX did not discuss his developing relationship with LB and it is not clear whether information about past and present relationships would as a matter of routine, have been explored during this session.   4.3.72. Child Protection Review Conference 2nd September 2011 Present:   Independent Chairperson, LB, social worker, Health Visitor, P1-SMTP. Staff from Children’s Centre are not in attendance.   Records refer to: • Risk Assessment on LB’s ex-partner had been ‘lost’ in the system but was deemed to be no longer necessary as they did not have any contact with Child C • Social worker had visited LB at her home and noted no issues with Child C in terms of behaviour or development • Agreement that a Risk Assessment on NX would be required if the relationship with LB developed • Positive reports in respect of Child C’s development and wellbeing. Minor physical problems with speech and hearing had been addressed • LB had not attended her appointments with P1-SMTP for almost four weeks although she apparently kept in regular contact with her key worker Decisions taken: - Child C be removed from Child Protection Plan to Child in Need status - LB to move back home within two weeks with Child C - Social worker 3 to continue involvement to offer stability and consistency - Core Group/Planning meetings to be held every four weeks - LB to engage with P1-SMTP, keeping all appointment and providing tests - Health Visitor to make follow-up meeting with LB at next Core Group Meeting - Representation from Child C’s new nursery to join Core Group - Work with the family not to cease without agreement from all professionals  4.3.73. It is unclear how a decision could be taken to return a child back to mother’s care without the completion or sight of a risk assessment.  Furthermore, despite the requirement for LB to attend for regular drug testing, she had not attended for almost four weeks. The decisions taken at this review meeting appear to have been endorsed by those present without challenge.    4.3.74. The combined chronology however, refers to the Health Visitor notes in which she refers to ‘professional anxieties’ about the decision to change Child C’s status from Child Protection to Child in Need. The Health Overview report refers to the Health Visitor’s attempt to challenge this decision, which was overruled by the Independent   35 Chairperson, but this information is not contained in either the combined chronology or the Health IMR report.   4.3.75. There is no reference to any assessment of LB’s parenting ability or capacities and the Core Assessment had still not been shared with any professionals, if indeed it had been concluded. It is difficult to understand exactly what had changed since Child C was made subject a Child Protection Plan in February. Child C was then reported to be developing well and meeting milestones, there were no concerns about their behaviour or health and LB continued to struggle with her drug addiction. Whatever the tests may indicate, past history of LB’s addiction and research available about addictive behaviours would suggest that the risk of lapse or relapse was ever-present. Consequently, it would have been more appropriate for professionals to consider how Child C could be kept safe rather than the broader focus of making sure that LB was drug free.   4.3.76. Child in Need meeting 15th September 2011 Present:  social worker, Health Visitor and P1-SMTP. Records refer to: • LB’s continuing non-attendance at P1-SMTP • Risks of LB not engaging with P1-SMTP were acknowledged • Noted that Child C had one known contact with NX • Meeting rescheduled as LB was not present   4.3.77. Between 15th September 2011 and the Child in Need planning meeting on 22nd September 2011, LB was contacted by P1-SMTP about her missed appointments and why she did not attend Core Group meeting. LB said that she forgot about the meeting. NX discussed with his Probation Officer the effect of his father’s conviction on his family. He reported he was living at his mother’s home.  The developing relationship with LB was not mentioned.   4.3.78. The Health Visitor rearranged a visit and agreed to see LB and Child C at Children’s Centre instead of LB’s home. There is no explanation for this change in arrangements but this was a missed opportunity – the Health Visitor should have been curious about the change in arrangements and ensured that a home visit took place given that Child C had only recently moved back to live with LB.    4.3.79. The social worker visited LB and saw Child C at home.  LB said that Child C was finding it difficult to adjust to the new nursery and became physically ill on arrival so LB had kept the child at home.  LB was reminded about the importance of keeping appointments. LB acknowledged this. She advised the social worker her relationship with NX was progressing and agreed that NX would need to be assessed given his contact with LB. Also agreed that the new nursery should be informed of Child C’s Child in Need status. LB had clearly arranged a transfer to a new nursery near her home and understood the reason for staff there to be informed about Child C’s Child in Need status.   4.3.80. Child in Need meeting 22nd September 2011 Present: LB, social worker, Health Visitor and P1-SMTP. It is not clear why there is no representation from Child C’s new nursery.  Records refer to: • LB sharing information about NX   36 • LB being advised that NX was not to stay overnight until Police checks had been complete • LB not fully engaging with P1-SMTP, she missed four appointments but a recent urinalysis tested positive for Methadone only  • LB agreed to keep appointments with P1-SMTP • Child C was unable to settle at new nursery  • LB to keep Core Group informed  4.3.81. There was no challenge to LB in respect of her missed appointments and again a surprising degree of optimism and naivety is apparent.  There was no discussion around whether the missed appointments could be an excuse to mask drug taking or to what extent urinalysis was the best test on which to base a view that LB was drug free. The roles of P1-SMTP as specialist in this field does not appear to have been used as a resource to assist the professionals develop their knowledge around this issue.   4.3.82. There is no reference to a Child in Need Plan, no goals or targets were identified and no discussion around how best agencies could work together to support LB and ensure Child C was well and safe in her care.  The minutes of this meeting briefly refer to a list of actions and statements and are an example of very poor practice in terms of understanding the role and function of professionals supporting a Child in Need Plan. It is apparent upon reading the various IMR reports that many practitioners did not know the name of the meetings they were attending or their related terms of reference.  As there was never any clear challenge to the ineffectiveness of these meetings, this suggests that the poor practice highlighted in this SCR may well reflect practice elsewhere in the Authority.    4.3.83. Between 22nd September 2011 and the next Child in Need meeting on 20th October 2011, LB tested positive for opiates on two occasions, but she denied illicit drug use, despite the tests results being confirmed by the Drug Testing Service. A urinalysis for one of these tests indicated only the presence of Methadone suggesting either [another] flaw in the drug testing process or that the urine samples provided by LB were not hers.  LB kept one appointment with P1-SMTP on 3rd October 2011 and insisted she was drug free explaining that she would not use heroin ‘this close to the case being closed’. At an appointment with P1-SMTP the following day, LB again denied using illicit drugs and an agreement was reached that LB’s prescription for Methadone would be gradually decreased and would be reviewed at a later date. LB agreed to keep appointments with practitioner 10 on Tuesdays and Fridays.     4.3.84. In supervision, practitioner 10 confirmed he was unsure whether LB was going through a difficult time but expressed concerns and highlighted the pattern of LB’s disengagement with services when pressure was removed.  A subsequent test result for LB showed presence of opiates and Methadone. Practitioner 10 then tried to contact LB on at least six occasions following her non-attendance for drug testing.  This information was not shared with the social worker.  4.3.85. Just before the meeting on 20th October 2011, LB contacted her key worker at P1-SMTP to explain she had been to visit Child P in [another area]. This information was neither shared nor clarified.   37  4.3.86. The Police received information alleging that NX was harassing his former partner and mother of his children.  This allegation was taken seriously and a notification was sent through to CSC. It would appear that this information did not trigger a link to LB and Child C.  4.3.87. The Health Visitor made a home visit on 7th October 2011 to assess Child C’s health and development. No concerns were identified. Child C was reported to be well settled into nursery. LB talked about recent test results and again insisted she was drug free.  It would have been difficult for the Health Visitor to challenge this statement, as there had been no information circulated from P1-SMTP about LB’s tests. This left the Health Visitor having to accept LB’s version of what was happening and reduced the impact of joined up interventions by agencies. A discussion took place about Child P who is living with their father elsewhere.    4.3.88. Child in Need meeting 20th October 2011 Present:  Not documented but notes make reference to: LB, social worker 3, Health Visitor and Practitioner 10, P1-SMTP. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available.   Records refers to:  • Information that LB was pregnant by current partner but had not booked with GP or Midwife as she planned to change GP • LB and partner are happy with news and will marry soon • LB advised she was to stay with grandparents for a while as their shift patterns meant they needed help with Child J. LB will also care for Child C at same time • LB reported that Child P now lives with father some distance away in [another area] but LB will have contact every holiday • Health Visitor reported no concerns re Child C’s welfare or progression. Developmental tests show Child C is developing as expected • Practitioner 10 advised that LB had not attended since 4th October 2011 despite requirement for her to attend twice a week. LB’s last two swabs tested positive for heroin • LB denied taking illicit drugs and insisted tests were ‘wrong’. Practitioner 10 asserts that recent events suggest a relapse. LB advised that solicitor had said she is not legally obliged to take these tests. However, LB acknowledged why she was required to take these • LB advised that her new partner is willing to work with her and help her treatment  • Decision that Child C would remain on Child in Need Plan • Social worker 3 apologised for not visiting since last meeting. The Risk Assessment on NX is still outstanding and this would be progressed as a matter of some urgency  • LB agreed to engage fully with P1-SMTP and treatment plan and attend twice a week on Tuesday and Friday • LB to register with GP and have pregnancy confirmed • Next Core Group meeting 16th November 2011    38 4.3.89. There is again little evidence of challenge and focus from this meeting.  Without any plan or contingency agreements, interventions were piecemeal and there is a sense that professionals were repeating the same actions recorded in previous meetings and yet optimistically, expecting a different outcome in relation to LB’s engagement with services and her ability to remain drug free.    4.3.90. Between 20th October 2011 and the next Child in Need meeting on 16th November 2011, LB registered with new GP surgery and her Methadone treatment was noted.  Whilst the notes clearly indicate that LB already had three children there was no check to ascertain where these children were living. This information should have been routinely collected.  LB’s pregnancy was confirmed and notes indicate a referral was made to the Community Midwife, although there was no referral letter. The Health Visitor contacted the Specialist Substance Misuse Midwife (SSMM) and discussed the situation re: LB and her unborn child.    4.3.91. A visit by the Health Visitor on the 8th November 2011 was recorded. The house was described as clean and warm.  Child C had gained only a little weight but LB insisted that the family and Child C had a nutritional diet. LB advised that she had been attending her appointments with P1-SMTP and that NX had stayed over the previous night. There was no challenge by the Health Visitor about this overnight stay despite the agreement made at the meeting on 22nd September 2011. Had the Health Visitor been more sceptical she may have assumed that NX stayed there more often than LB was saying and took the opportunity to explore this whilst she was there.  LB’s pregnancy and health needs were discussed and LB was advised about dangers of smoking when pregnant.   4.3.92. P1-SMTP were persistent in their efforts to make contact with LB who failed to keep any appointments with them until 15th November 2011. On this occasion she arrived at P1-SMTP premises with a friend and saw practitioner 9. Child C also accompanied LB to this appointment and was described as looking physically well and acting appropriate for that age. LB‘s pregnancy was recorded as being obvious and practitioner 9 was informed that the expected delivery date was 18th June 2012.   4.3.93. In response to a challenge about non-attendance, LB said she had been threatened at her last visit to the pharmacy to collect her Methadone prescription and was fearful about returning. She had also recently been robbed but had not contacted the Police. No further explanations were forthcoming.  It was noted that LB had been out of treatment since 4th November 2011 and LB stated she had been buying Methadone off the streets but had not been taking heroin.  She was unable to give a urine sample but gave an oral swab and was asked to return that afternoon for an appointment with a Doctor who would reinstate the treatment plan. LB was advised that a urine sample would be necessary.  LB asked to collect her prescription from a different pharmacy and she was informed that she would be required to attend on a daily basis to collect her medication.    4.3.94. P1-SMTP were advised by another P1-SMTP that LB had been in custody three nights previously but had been released without charge. However, whilst there she had twice tested positive for opiates. Conversations between P1-SMTP and SSMM highlighted P1-SMTP’s ‘grave’ concerns about LB being ‘off script’ and the impact this could have on her unborn child. P1-SMTP made a Child Protection referral to   39 CSC on 15th November 2011. It is unclear whether they discussed this referral with the social worker.   4.3.95. This information was later shared with the Health Visitor who made an unannounced visit but did not make contact with LB. There are records, which detail good information sharing between P1-SMTP, Health Visitor, the Community Midwife and the SSMM. The Health Visitor contacted social worker 3 and outlined her concerns that LB was not complying with Child in Need plan and expressed the view that in her opinion the Child Protection threshold has been reached. Social worker 3 agreed with this view and a decision was taken to discuss this further at the next planning meeting.  The Health Visitor appears to be co-ordinating contacts and ensuring various colleagues are kept informed. This is to be applauded, as without this persistence, it is possible that the social worker would not have picked up the growing number of concerns.   4.3.96. Following this conversation, social worker 3 made an unannounced visit on 14th November 2011. LB stated that she had ‘given up’. She alleged that someone was threatening her when she arrived to collect her prescription and that she had been buying Methadone off the street.  LB advised social worker 3 that she and NX were arrested on 11th November 2011 for conspiring to sell Class A drugs but no drugs were found and no further action was taken. LB gave conflicting explanations about this incident.   It would be expected that this information would prompt further discussion and challenge from social worker 3, especially in relation to the impact on Child C. However, there are no records, which confirm such a conversation took place.  4.3.97. At this stage, the social worker should have contacted the Police to gather more information about the arrest as she only had LB’s version of what had happened.  The Police clearly did not consider it relevant to inform CSC about their actions so it must be assumed that neither LB nor NX were with Child C when they were arrested.   4.3.98. Child in Need meeting 16th November 2011 Present: Not clearly documented but notes make reference to: Health Visitor, LB, practitioner 10, and P1-SMTP. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available. Records refer to: • LB failing to take Child C to a planned appointment  • LB giving ‘inconsistent’ information regarding care of Child C • LB was tearful, irritated and threatened to leave meeting saying that ‘minds had been made up’ • Child C was agitated at meeting, but was clean and appropriately dressed • Child C has poor weight gain – only 12 ozs in five months • LB had not attended for testing as agreed. LB claimed this was due to harassment by another P1-SMTP service user • P1-SMTP confirmed that LB had tested positive for heroin the previous day but reported she was now back on ‘script’ and ‘appeared stable’  • LB had admitted injecting heroin whilst Child C was at school and also buying Methadone   40 • LB recently arrested for supplying Class A drugs though claimed this was a misunderstanding. LB had £600 in her possession at time • Meeting suspended due to Child C’s agitation but LB advised that as she was not complying with agreed plan, the Child Protection Plan would be resumed if the social worker manager agreed • This was explained to LB as needing to keep unborn child and Child C safe. Records indicated that LB understood this  4.3.99. Even given a clear indication by LB that she is taking heroin, the notes from this meeting suggest a paralysis on the part of the professionals and particularly the social worker. The term ‘appears stable’ seems overly optimistic given LB had been using heroin 24 hours earlier. The concerns shared with the social worker before the meeting on the 16th November 2011 should have alerted her to discuss these with her line manager before the meeting so a plan of action was ready to discuss with LB. Child C clearly left the meeting with mother and returned to live in an almost identical situation which had in January, pre-empted the child’s move to the maternal grandparents’ home.  There was no discussion at this meeting about the need for any safety planning for Child C and this highlights yet again the failure to place Child C at the centre of these interventions.  It might also be questioned why there was no managerial presence at any of these meetings, especially given the inexperience of the social worker involved.   4.3.100. Between 16th November 2011 and Child Protection Strategy meeting on 24th November 2011, results from the swab taken from LB on 15th November 2011 showed positive testing for heroin, opiates and Methadone.  4.3.101. LB miscarried her baby on 19th November 2011.   4.3.102. LB attended an appointment at P1-SMTP three days later and rearranged her appointment to collect her Methadone prescription. She advised that her mother was arriving to look after Child C as she was still distressed and finding it difficult to accept she was no longer pregnant.   4.3.103. Child Protection Strategy Meeting 24th November 2011 Present: Not clearly documented but notes make reference to: Health Visitor, Police, social worker, Nursery and practitioner 12 (on behalf of practitioner 10), P1-SMTP. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available.   Records refer to: • Background information and Police checks  • Questions over whether Child C was with LB when she was arrested • Concerns raised over drug use and dealing from home address • Concerns raised that partner of LB is possibly supplying drugs to his eldest child and to LB • Daughter of LB’s partner is often in household and is collecting Child C from nursery • Social worker to discuss with LB that she allows Child C to live with grandparents on an s20 (voluntary placement). Grandparents to be involved in this discussion. If LB does not agree then Court proceedings will commence   41 • Child Protection proceedings to be commenced. Initial Child Protection Conference to be held in 15 days • Situation to be discussed with Legal Team  4.3.104. The Police provided additional information, which suggested there were concerns about the possibility of LB and NX being involved in supplying Class A drugs.  There was little information about Child C shared at this meeting and the risks to the child’s welfare and safety were not made explicit. Plans were not made to ensure the child was kept safe whilst further enquiries were made.  Neither was there a record of any discussion or reference to LB’s miscarriage and to what extent if any, this may have been linked with or attributed to, her drug taking.   4.3.105. Between 24th November 2011 and the Initial Child Protection Conference on 14th December 2011, LB withdrew consent for Child C to again live with the maternal grandparents, explaining that as her parents worked full-time, this would require her to move to [Place 2] so she could care for Child C. LB did not want to do this given her relationship with NX. A decision was taken that the social worker would visit on a daily basis until the Child Protection Conference in five days’ time.  However, two days later Child C was staying with grandparents as LB had been ‘detained’ in hospital after needing medical care after her miscarriage.  There are no records to advise how long Child C stayed with grandparents but by 5th December 2011, the child was recorded as being seen at home with his mother.   4.3.106. The CSC report states that a legal briefing took place sometime after the strategy meeting but before the Child Protection Conference. The Local Authority was advised they did not have enough evidence for an application to remove Child C on an Interim Care Order and a decision was therefore taken to instigate Public Law Outline (PLO)18 procedures.   4.3.107. LB did not keep appointments with P1-SMTP or take Child C for a paediatric appointment. This was the second missed appointment for Child C.  LB left a voice message for the Health Visitor explaining she was very busy as wedding to NX was going ahead on 9th December 2011.  4.3.108. A planned visit by the Health Visitor on 5th December 2011 found LB keen to talk about her forthcoming wedding but not the Child Protection concerns raised at the last meeting. Child C was recorded as not being their normal happy self, had a runny nose and LB said the child had been off school for two weeks due to having a cold.  This does not appear to have been challenged by the Health Visitor who was informed that the eldest child of NX (17 years) was asleep upstairs.  LB said she was collecting Methadone daily and refused to accept that her lifestyle posed a risk to Child C. Records indicate the Health Visitor was of the view that LB did not appear to be under the influence of drugs.                                                    18 Public Law Proceedings are commenced under section 31 of the Children Act 1989 where the Local Authority takes the view that it is no longer possible to safeguard and promote the welfare of the Child promoting his/her upbringing by his/her family without a care or supervision order.   42 4.3.109. Practitioner 10 attempted to contact social worker 3 to discuss his concern that LB had not attended for testing since 16th November 2011. These concerns had been discussed in a supervision session and he was encouraged to persist in trying to contact social worker 3 to query how Child C was being protected whilst still in the care of LB.  4.3.110. NX and LB were married on 9th December 2011.  4.3.111. Child C continued to attend nursery every afternoon but usually arrived late. There were no behavioural issues although records continued to refer to a delay in speech and language.  NX informed his Probation Officer of his marriage and LB’s miscarriage and was told that the Offender Manager will have to make contact with CSC as he is on Licence.  NX replied that he did not believe they are involved.   4.3.112. Initial Child Protection Conference 14th December 2011 Present: Not clearly documented but notes make reference to: LB, Health Visitor, social worker, Nursery and practitioner 12 (on behalf of practitioner 10), P1-SMTP • LB admits smoking heroin whilst Child C is at nursery • Notes refer to there being no therapeutic work with LB since May 2011 due to LB’s ‘disengagement’  • Views expressed that LB is not honest with services • No record of information from Legal Services • LB to keep all appointments relating to Child C’s health • Should be a written agreement as to who will take and collect Child C from Nursery • Child C to be subject of a Child Protection Plan under the category of Neglect due to: - LB’s continuing to test positive for drugs - Recent marriage to NX and unassessed risks posed by this relationship - LB inability to impose boundaries on Child C - LB minimising professional concerns • First Core Group meeting 20th December 2011  4.3.113. This was the third time that Child C had been on a ‘Child Protection Plan’ but like previous occasions, the plan was simply a list of tasks to be achieved within a given period. There was no attempt at clearly defining expected outcomes and no way of reviewing or monitoring progress.  For example, notes describe that LB and NX were to ‘fully engage with Children’s Services’ but the notes failed to say for what purpose, what this entailed, why it benefited Child C and how this ‘engagement’ would be reviewed and measured.  There is a sense of this being almost a ‘start again’ process19 with all previous knowledge about professional interventions and LB’s ways of responding to these being ignored. Once again, the focus related mainly to LB and NX and drug taking.                                                    19 This is a situation where children suffered long term neglect and children’s social care fail to take account of past history and they adopted a  ‘start again’ approach’ Brandon et al Biennial Review 2003- 2005.   43 4.3.114. On 20th December 2011, LB attended for urine test at P1-SMTP. This tested positive for Methadone only.    4.3.115. A PLO meeting was held on 20th December 2011. The Senior Solicitor for the Local Authority forwarded a Pre-Proceedings letter to the author. LB attended this meeting and was advised that if the outlined concerns were not addressed then the Local Authority would proceed with Care Proceedings in order to safeguard and protect Child C.  It is unclear whether these were additional concerns or those identified in the Child Protection Plan.  4.3.116. Core Group meeting 20th December 2011 - held in LB’s home Present: Not clearly documented but notes make reference to: LB, NX, Health Visitor, social worker, and practitioner 10, P1-SMTP. Information pertaining to this meeting has been extracted from notes from P1-SMTP records.   Records refer to: • Child C seen as bright and sociable and interacting well with both LB and NX • Information re: NX’s back ground shared with his permission – he has served 28 months of a five year sentence for supply of Class A drugs • Agreed that NX’s Probation Officer would be asked to join Core Group • LB and NX agreed to a Parenting Assessment, which would conclude in March 2012. This would be undertaken by social worker who would also visit family twice a month • LB to attend P1-SMTP twice weekly for planned and random urine testing • LB happy to engage with Child Protection Plan  4.3.117. There remained vagueness to these plans, a point already addressed several times previously in this report.  The focus remained mainly on the adults and not on Child C. There was no discussion about the need for safety plans for Child C, which given his age and vulnerability was a serious omission. LB and NX agreed to take part in a three month Parenting Assessment. It was not made explicit exactly what professionals were looking for, how their parenting would actually be assessed and what would be involved. There was also a lack of curiosity from professionals as to what this assessment would entail and what model would be used in the process.  4.3.118. Between 20th December 2011 and 11th January 2012, LB did not collect her Methadone prescription and was out of ‘script’.  She was contacted by P1-SMTP and attended an appointment on 28th December 2011 as agreed. LB advised she had been using ‘left over’ Methadone and was advised that this was not acceptable as this would count as illicit drug use. Urinalysis tested positive for Methadone only.  LB later attended Doctor’s appointment and was given a new prescription to be collected daily.   A further test on 30th December 2011 also tested for Methadone only. LB attended three further sessions with P1-SMTP and was noted to be in a good mood and feeling positive.  Tests were positive only for Methadone.   4.3.119. The Health Visitor made a home visit and appeared to have a productive discussion with LB, discussing the Child Protection Plan and consequences for Child C if LB did not keep to agreements.   LB appeared to understand this. Health Visitor was also able to discuss the impact on Child C when LB was taking drugs.  Health Visitor later had supervision and reported that in her view NX may have been a positive influence for LB. She was urged to persist in obtaining copies of assessments especially in relation to NX.     44  4.3.120. A Child Protection Monitoring visit took place on 11th January 2012. Social worker 3 saw Child C who presented as ‘fine’ and ‘very talkative’ and showed social worker 3 his room.  Written agreements and assessment sessions were discussed with LB who was reminded that failure to keep to the plans would be considered as a risk factor to Child C.  Records do not indicate whether NX was present and it must be assumed he was not party to these discussions. There was a distinct lack of engagement with NX, notwithstanding the absent Risk Assessment agreed earlier in the year. There was clear evidence that NX was now part of Child C’s life and yet there appears to be very little effort made to engage him. There is a substantive body of research20,21 highlighting the marked failure of health and social care professionals to engage with fathers and men in the lives of children where there are child protection concerns; this knowledge should have alerted professionals to the need to take a more pro-active stance in seeking to find out more about NX, although it may have been assumed this would have been achieved through the Parenting Assessment.  4.3.121. Child C is attending school but often arrives late. Reports indicate that child appears happy to attend school. Speech and language development was being addressed.  4.3.122. Core Group meeting 23rd January 2012 Present: Health Visitor, Class teacher and Headteacher, social worker, P1-SMTP and LB. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available. Reports refer to: • Issues around Child C’s weight  • P1-SMTP confirmed that LB had attended all sessions and tests showed negative results for opiates or other drugs   • LB discussing her emotions and being open with P1-SMTP worker • LB advised that Child P was staying with her at weekends. Those present agreed that care of Child P would be included in the Parenting Assessment. • Records note that LB now has care of all three children on Sunday afternoons • Social worker advised that there were no current concerns and notes refer to professionals remarks that Child C appears to be thriving physically, emotionally and socially  4.3.123. The fact that LB now has care of all three children at times fails to raise any concerns. Professionals appeared reassured by the social worker comments.   4.3.124. Between 23rd January 2012 and 9th February 2012, LB tested positive for illegal substances and informed P1-SMTP that NX’s eldest child  had been banned from home as she was using Cocaine. P1-SMTP discussed LB’s recent lapse but this was not shared with social worker. Social worker 3 made a home visit on the same day but LB’s recent tests were not discussed. Social worker 3 arranged to visit the following week to pursue the assessment.  This presumably means the Parenting Assessment.                                                   20 Scourfield, J. (2001) Constructing men in child protection work, Men and Masculinities.  21 Improving the engagement of fathers in child protection (2010) National Institute for Social care and research.   45  4.3.125. Child Protection Monitoring visit 9th February 2012 Social worker arrived for Child Protection visit. LB had written it down for following day. Child C was present and house was clean and tidy. LB advised that NX’s daughter had started using drugs and so she is no longer allowed in their house. Session rearranged for 13th February 2012.  4.3.126. LB’s tests from 9th February 2012 confirm presence of opiates, heroin and Methadone. P1-SMTP asked the Drug Testing Service for confirmation of result. Practitioner 16 at P1-SMTP informed practitioner 10 that clients had identified LB as a drug dealer who had a driver who waited in the car while she was dealing.  Practitioner 10 tried to contact social worker 3 but was unsuccessful. It might have been useful if P1-SMTP had also e-mailed social worker with this information given there was a monitoring visit taking place the following day.  It would also have been useful if the social worker had made contact with P1-SMTP prior to her visit to learn more about LB’s recent engagement with P1-SMTP.  This is evidence of poor collaboration and solo working of agencies.   4.3.127. Child Protection Monitoring Visit 13th February 2012 • Social worker visited. Saw Child C who was asleep • LB was getting ready for visit to solicitor • House clean and tidy and social worker recorded ‘no issues to note’  4.3.128. There is so little information provided from this and other visits that it is difficult to ascertain their purpose. There is no information recorded which relates to a plan of any sort and the visit has the appearance of a brief visit to check that nothing untoward has happened. This is extremely poor practice and raises a question about social work intervention and what this actually means. There is little to evidence that any ‘social work’ is undertaken with LB. The failure to be clear about the purpose and planned outcomes for each visit suggests that the social worker was merely monitoring what was happening rather than actively seeking to achieve change through the social work relationship.  It is possible that other professionals assumed that there was more to these social work visits than actually took place but this was never discussed or challenged in multi-agency meetings and highlights the ineffectiveness of the plans made to protect Child C.   4.3.129. Supervision of the social workers is recorded as happening only four times during the period under review. It is questionable as to how the work undertaken by social worker 2 and social worker 3 was monitored and supported and what opportunities took place for reflective practice.  The lack of managerial oversight is also significant given that a Letter before Proceedings had been issued and LB had been formally advised of the implications of not adhering to agreements. It is clear that there was no understanding between agencies or amongst professionals as to what behaviours or actions would trigger an [earlier] application to court to begin Care Proceedings.   46  4.3.130. Core Group meeting 20th February 2012 Present: Health Visitor, Class teacher and Headteacher, social worker, P1-SMTP and LB. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available.  Records refer to: • Social worker 3 informed Core group that the Parenting Assessment was progressing as planned  • Information shared about NX’s eldest child being asked to leave the home due to drug use  • Discussion about accessing help from P1-SMTP for NX’s eldest child  • LB disputing results of recent drug tests. P1-SMTP confirming that urinalysis showed presence of Methadone only • LB being advised that NX’s daughter was not to have unsupervised contact access to Child C • LB did not want NX’s Probation Officer to attend group but was informed this was required. LB advised that NX should also attend • Child C attending nursery late every day but was described as bright and lively but still small for  age  • LB informed those present that NX will adopt Child C on 21st February 2012 • After LB had left meeting, information was shared by P1-SMTP that a service user alleged that LB was dealing in drugs in [another] area  • Social worker to pursue this  4.3.131. Between 20th February 2012 and Child Protection Review meeting on 2nd March 2012, Northumbria Police call at LB’s house following referral from a drug dependency centre concerned about Child C and LB’s drug addiction. Police note house clean with lots of food and Child C well and ‘outgoing‘. LB and NX not pleased but accepted visit as routine.   According to the combined chronology Police undertake a ‘welfare visit’ the following day, but it is highly likely that this is one and the same visit.   4.3.132. Child Protection Review meeting 2nd March 2012 Present: Health Visitor, Class teacher and Headteacher, social worker, P1-SMTP and LB.  Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available.   Records refer to: • Parenting Assessment completed on 22nd February 2012 and this was recorded as ‘positive’ • Health Visitor reported that Child C’s weight is still low but there are no [other] physical problems.  Referral to be made to dietician. Other milestones achieved • Nursery reports no educational difficulties. Child C is sociable and can form ‘strong bonds’ but punctuality is still an issue • P1-SMTP treatment plan for LB continues but LB disputed a recent result, which tested positive for heroin. P1-SMTP will discuss Methadone reduction at LB’s request • LB is required to have oral swabs not urine tests • Assessments in relation to NX’s daughter continue • Child C to continue on Child Protection Plan under category of Neglect   47 • After LB left room, information is shared that LB and NX are still under surveillance, as Police believe they are dealing in drugs and are monitoring the household  4.3.133. The information from Northumbria Police does not appear to have raised concerns and no action or immediate home visit was made. A further PLO meeting was planned for 13th March 2012.  The feedback from the social worker that the Parenting Assessment was ‘positive’ is puzzling given the information recorded from this and previous meetings.  It was clearly not shared with or circulated to other professionals and there is no recorded discussion about the conclusion of this assessment.   4.3.134. Core Group meeting 15th March 2012 Present: Not clearly documented but notes make reference to: Health Visitor, social worker, (who had returned previous day from leave of absence), and practitioner 10, P1-SMTP. Apologies were received from LB. Information pertaining to this meeting has been extracted from notes from other agencies as records from CSC were not available.  Records refer to: • LB gave apologies for her absence as she had to seek medical attention for her DVT - Health Visitor to contact hospital to see if LB sought medical attention • Child C had attended eye clinic and needs to continue to wear glasses • Still attending school but arrives late, three absences due to illness • Child C talks at nursery about NX’s daughter sleeping at their house • P1-SMTP advise that LB has not been tested since 2nd March 2012 • Information shared that LB accessing needle exchange services in [area]  • PLO meeting planned for 13th March 2012 had to be rearranged. Now planned for 2nd April 2012 • Conflicting information about LB engaging with drug services • Suggestion that LB may be pregnant (although it is unclear whether this was information shared by LB and with whom)   4.3.135. Records suggest that LB was seen in nursery after this meeting and P1-SMTP opportunistically took mouth swab. P1-SMTP records note there was no-one else present and LB willingly agreed to the test.  It is unclear why the PLO meeting was adjourned for a further two weeks given the information shared at this meeting and previous meetings.   4.3.136. Between 15th March 2012 and 2nd April 2012, Health Visitor confirms that LB did not attend hospital appointment for DVT on 15th March 2012. Results from the swab taken by P1-SMTP on 15th March 2012 showed positive for heroin, opiates and Methadone. This does not appear to have been shared with social worker 3.  LB attends for an appointment with practitioner 11 on 20th March 2012 in the presence of a friend and Child C. LB was described as looking well and admitted to recently smoking heroin. There are no records of any challenge or any observations concerning Child C. This information was shared with social worker 3 the following day who stated that ‘care proceedings would be instigated’ to remove Child C from the family home if LB did not agree to place Child C with MGM.     48 4.3.137. Social worker made a home visit on the same day and LB was asked to agree to Child C going to live with MGM. LB was upset but reluctantly agreed and Child C was voluntarily accommodated under s20 of the Children Act 1989.  LB rang her mother and explained about testing positive for heroin. It would appear that social worker 3 took Child C to grandparents’ home on 21st March 2012 and records indicate the child appeared unperturbed during the journey. The situation was discussed with the MGM and she confirmed that she could care for Child C for a few days until she returned to work, after which time Child C would have to be cared for by the paternal aunt, ST. Social worker advised that transport to and from nursery would be arranged, as would relevant checks on ST.  Aunt later telephoned to confirm her agreement with this plan and indicated they wanted to make sure Child C stayed in the family until things were ‘sorted’.   4.3.138. On the same day a Regulation 2422 Assessment was started. There is no evidence that a Viability Assessment had been undertaken, perhaps because it was assumed that as Child C has lived with grandparents previously it was not required. The Regulation 24 Assessment should have been completed within 16 weeks but in July 2012, the Fostering Officer records that the maternal grandparents ‘do not feel the need for the in-depth assessment needed for relatives now’ and consequently the assessment on the maternal grandparents remained incomplete with no checks undertaken with the home Local Authority and significantly no liaison with social worker 3 in respect of information about family background and family dynamics.  The Fostering Officer could not state why this assessment was incomplete and the IMR author does not explore this in any detail. Checks have now been introduced to make it more difficult for this error to happen in the future.   4.3.139. Social worker 3 received a call from MGM on 26th March 2012 saying she was unsure whether she or the aunt could look after Child C for longer than a few days.  Social worker agreed a visit to discuss.  It is not clear when or if this visit took place and the reservations from the MGM and aunt do not appear to have been shared with colleagues in the Fostering Team or with the line manager despite their importance and significance.   4.3.140. Test results from 15th March 2012 on LB confirmed positive for heroin, Codeine, and Morphine. P1-SMTP made telephone contact with LB after non-attendance and received text message from LB blaming P1-SMTP for telling social worker about her drug use. LB claimed to have lost trust in P1-SMTP. Social worker 3 contacted P1-SMTP asking for full chronology of LB’s treatment plan and her engagement with it. This was forwarded to social worker 3 on 29th March 2012.  4.3.141. The Safeguarding Nurse read the minutes from Conference and Core Group and in supervision session discussed her growing concerns with Health Visitor. The Health Visitor was requested to put concerns in writing to social worker 3 so they are available for the PLO meeting.                                                    22 A ‘Regulation 24 assessment relates to the temporary approval of a relative, friend or other person connected with a child where the Local Authority is satisfied that certain conditions have been met.     49 4.3.142. The Health Visitor wrote to social worker 3 asking for clarity around a number of issues relating to assessments, boundaries for Child C and LB supervising contact between Child C and NX’s eldest child.    4.3.143. NX asked to be considered as main carer for Child C but social worker 3 advised this was not possible due to his background. Social worker 3 began a dialogue with NX’s Probation Officer who stated that NX appeared unaware of situation with CSC. Concerns about Child C were shared.  Probation Officer advised that NX was not a drug user and expressed view that he is low risk to children.   4.3.144. On 28th March 2012, the Placement and Resources Panel (PARP) agreed to Child C being placed with maternal grandparents. Although the CSC IMR states that a Risk Assessment was attached to the paperwork, this related to the risk posed by the placement itself rather than any analysis focused on the risk posed to the children if they remained living with their parent. This template has now been amended to include the reason why the placement is needed and any actual or perceived risk to the child if there is contact with the parent.   4.3.145. It is perhaps significant to note that the Panel did not comment on the incomplete Fostering Assessment, if indeed they noticed.   4.3.146. CSC IMR records that the Parenting Assessment on LB and NX was concluded on 2nd February 2012 and the Assessment recommendation was that Child C should continue to be cared for by the maternal grandparents and Care Proceedings would be initiated.  It is unclear why this report appears to contradict the feedback given by the social worker in early March, which described the Parenting Assessment as ‘positive.’ The report is over 20 pages long but most of the content is extracted from files and records and simply replicates historical information already known to professionals.  There is no reference to the fact that LB may be pregnant.  There is a brief analysis consisting of one side of A4, which leads to the conclusion that the Local Authority should pursue Care Proceedings. It is a very poor analysis and contributes little in terms of assessing parental capacities of either LB or NX.   4.3.147. PLO meeting 2nd April 2012. No details were provided of this meeting other than a record stating that Care Plans should be provided by 16th April 2012. It is unclear whether LB’s pregnancy was mentioned.  4.3.148. In early April, following several texts and calls, P1-SMTP contact social worker 3 concerned about LB’s disengagement with services and discussing P1-SMTP having to close case given LB’s engagement was only on a voluntary basis. A Child Protection Monitoring visit was made on 10th April 2012 at grandparents’ home. LB, NX and grandparents were present but LB and NX stayed only a few minutes to sign paperwork. Child C was seen and described as looking well. There is no discussion recorded about telephone conversation on 26th March 2012 and no records are made of any discussion with the grandparents.  It is unclear whether they were made aware of the need for them to be fully assessed as kinship carers.   4.3.149. A Looked after Child Initial Health Assessment was undertaken on 11th April 2012. Records describe Child C as confident and independent, progressing well developmentally and no concerns were identified.  A Child Protection Monitoring   50 visit took place on 16th April 2012, noted that Child C was well presented and there were no concerns recorded.   4.3.150. LB made contact with P1-SMTP on 16th April 2012 saying she would like to come in for an appointment later that week and asked to see practitioner 5. However, on the same day LB’s GP was contacted advising that LB had dropped out of treatment and was no longer receiving medication from P1-SMTP.  4.3.151. Core Group meeting 17th April 2012 Present: Not documented but notes make reference to: [replacement] Health Visitor 2, LB and social worker. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available. Records refer to:  • Temporary Health Visitor 2 attending in place of Health Visitor 1  • LB expressing a wish to re-engage with P1-SMTP • Child C reported to be expressing emotionally distressing behaviour when with LB who has unlimited access. NX also visits at grandparents’ home • CSC plan to seek Supervision Order  • Conference date to be brought forward for discontinuation of the Child Protection  4.3.152. There was no discussion about Child C’s behaviour but the records infer that Child C’s distress was a result of the ‘unlimited’ contact with LB. While this may have been a factor, other possibilities e.g. separation and loss of contact with mother were not explored.   4.3.153. Between 17th April 2012 and the Review Child Protection Conference on 30th May 2012, the Local Authority instigated Care Proceedings in respect of Child C. Social worker 3 visited maternal grandparents and was informed that neither grandparent wanted to be full-time carers as they both worked and the aunt, ST was covering childcare to help out. This discussion and its outcome were not recorded in any detail and although a ‘fostering visit’ was scheduled for 11th May 2012, there is no record of this visit taking place in the combined chronology or in the IMR report. The Local Authority where Child C was living was not notified that a child subject to a Child Protection Plan had moved into their area.  4.3.154. NX discussed the situation with his Probation Officer and reported that he was motivated to work to help LB get Child C returned to her.   4.3.155. A Child Protection Monitoring visit took place on 14th May 2012 and social worker 3 recorded that Child C was unwell but wanted to go to school so social worker 3 transported the child to nursery. No other information was available regarding this visit.   4.3.156. Core Group meeting 15th May 2012 cancelled. No details are provided.  4.3.157. On 29th May 2012 Child C was made subject to an Interim Supervision Order. The Child Protection Plan was ended at the Looked After Child review, which took place the following day.    51 4.3.158. Looked After Child Review 30th May 2012.  Information extracted from CSC records. Present: Independent Chairperson, social worker, Probation Officer, School The minutes from this meeting were not made available to the author. No details are available from other agencies other than notes extracted from the Probation IMR, which states that Child C was to stay with grandparents.   The Health Overview report indicates that Health Visitor 2 was advised on 11th June 2012 that a Review Child Protection Conference had taken place on 30th May 2012 and a decision taken that Child C was now a Looked After Child. There is no explanation or discussion of this decision in the CSC IMR.  In many cases where a child who is the subject of a Child Protection Plan becomes Looked After, it is no longer necessary to maintain the Child Protection Plan. However, given that Child C remained living with family members and had regular contact with LB, it may have been advisable to continue with the Child Protection Plan. In the absence of any detail or information in the CSC IMR, the rationale for this decision is unclear. The group was advised that a Kinship Assessment was underway for the maternal grandparents. The ‘shared’ care between grandparents and aunt was not discussed.  4.3.159. LB attended Drug Service 2 and tests are positive for Methadone only. LB expressed concern about Methadone use and discussed trying alternative therapies. She was referred to different services.   4.3.160. The temporary Health Visitor visited Child C at maternal grandparents’ home on 19th June 2012 and recorded that Child C was eating breakfast and ‘presented well’, although MGM said Child C was showing some signs of anxiety and was nail biting.  Maternal grandparents noted to be caring for all three of LB’s children. The issue of maternal grandparents indicating they could not care for Child C on a long-term basis does not appear to have been addressed.  4.3.161. Care Planning meeting 20th June 2012 Present: Not clearly documented but notes refer to LB, Health Visitor, social worker, Nursery staff. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available. Records refer to: • Child C showing signs of anxiety, biting nails and sleepwalking. LB was upset by this information. Said she and Child C had never been apart before  • Records note that this arrangement would ‘not be for too long’  • Maternal grandparents had been assessed as foster carers • An advocates meeting to take place on 27th June 2012 and a Court Hearing on 3rd July 2012 • LB using a private drug testing company. CSC required hair strand testing   • LB asked for NX to be assessed as a carer for Child C  4.3.162. Between 20th June 2012 and 16th July 2012, LB confirms to Drug Service 2 that she is still using heroin and is struggling to stop. She said she had informed CSC and her solicitor. She was advised that being open with professionals was important. The drug service made an appointment for her to see a doctor four days later and recommended she sought treatment for an infected site on her arm. LB kept the appointment and agreed a new treatment plan.  Tests were negative for opiates. LB   52 attended one other appointment but cancelled and rearranged a third as a result of ‘childcare’ difficulties.   4.3.163. Child C was noted to be presenting well at school, receiving additional help for maths and literacy and also receiving information about Stranger Danger given the number of adults collecting the child from school.   The fact that this was a Looked After Child appears to have been overlooked and left Child C in a very vulnerable position. This issue should have been highlighted and explored by the IMR author.   4.3.164. Care Planning meeting 16th July 2012 Present:  LB, NX, Health Visitor, Probation Officer, social worker, Headteacher, and School Nurse. Information pertaining to this meeting has been extracted from notes from other agencies and not from records from CSC.  Records refer to: • School has concerns about different people collecting Child C • Attendance is good and Child C is a described as happy child, intervention for listening and attention skills are continuing • LB and NX are to have a psychological assessment but remain concerned about pending Court Proceedings and when Child C can be returned to their care  • Concerns about LB’s drug use and missed appointments are noted   • NX will be assessed as a carer for Child C  4.3.165. There was no information about Kinship Assessment on maternal grandparents and any comment or challenge regarding the plan to assess NX as a carer for Child C, despite the outcome of the Parenting Assessment completed three months earlier.   4.3.166. Between 16th July 2012 and the Care Planning meeting scheduled for 13th August 2012, LB was offered a revised treatment plan, which did not involve Methadone. She admitted she was still using heroin. LB talked to her advisor about her feelings and concerns and was reminded about the need for Child C to be kept safe.  The increased stress on LB in relation to the pending Court case was noted.  Upon collecting medication at the pharmacy, LB tried to conceal some medication in a bag, (as opposed to taking the medication on site) and when challenged said she might be pregnant and the dosage made her sick. A pregnancy test confirmed that she was pregnant.  This information was promptly shared with the Drug Testing Service and LB was asked to attend for another appointment the following day. There was no contact between drug service and the social worker during this period. The doctor did however contact LB’s GP to advise of their involvement and stress the need for careful prescribing.   4.3.167. LB continues to miss planned appointments with drug service 2.  4.3.168. Care Planning meeting 13th August 2012 at GP surgery Present: Not clearly documented but notes refer to LB, Health Visitor, Drug Service Worker and Clinical Co-ordinator from Drug Service 2. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available.   Records refer to: • LB confirming her pregnancy  • LB not wanting to engage with P1-SMTP but agreeing to liaise with SSMM (Specialist Substance Misuse Midwife)     53 • Psychological Assessment to be undertaken in respect of Court Hearing  • Court Hearing in November 2012  • Health Visitor to contact SSMM • Child C continue to live with grandparents  4.3.169. Drug service 2 referred LB back to P1-SMTP where she attended a Doctor’s Review on 6th September 2012.  LB attended a first meeting with Community Midwife. LB referred to Consultant-led clinic for vulnerable women.  Issues around DVT were not recorded although Midwife obtained a detailed history, including LB’s drug use.  There is no reference to any contact with SSMM.   4.3.170. A supervision session is noted in the combined chronology for CSC, although this session is not referred to in the CSC IMR report.  The author assumes this session refers to supervision between social worker 3 and her Team Manager (SS). The notes refer to the need to follow Unborn Baby Procedures and state that three sessions have been completed in relation to NX’s Parenting Assessment.  There is also a note, which relates to recordings and where these should be stored on the system.  The social worker was advised that hair strand testing should be a requirement for LB.  4.3.171. A Looked After Child Review on 12th September 2012 is recorded in the combined chronology but it is likely that the information in these records referred to a conversation between the Community Midwife and the Health Visitor, possibly in preparation for a forthcoming Review.  Records refer to the Health Visitor being informed that any referral to the SSMM needed to go through the GP. It was also confirmed that the maternal grandparents were not planning to apply for a Residence Order in respect of Child C.  The Health Visitor formally handed over the care of Child C due to their age, to the School Nurse.  4.3.172. By the 14th September 2012 LB had again dropped out of treatment but P1-SMTP continued to maintain contact due to her pregnancy, despite LB continuing to engage and disengage herself from the services offered.   4.3.173. Documentation from P1-SMTP indicates LB’s continued drug use and missed appointments between 12th September 2012 and 7th November 2012. During this period, Health Visitor 1 transferred Child C to School Nursing Service and a handover summary was shared and signed. A new Health Visitor was allocated to the family in respect of the unborn child, with Health Visitor 1 declining to continue work with family citing ‘this was the right time for a change’. This demonstrates good reflective practice with the Health Visitor acknowledging that long-standing work with a family may not always be in the interests of either the family or the worker. The Community Midwife made a referral to CSC, copied to the Named Nurse and Midwife, the SSMM and Health Visitor 3, presumably expressing concerns about LB’s drug use and the impact on the unborn baby.   4.3.174. According to the CSC report, this referral triggered an ‘Initial Assessment’ by social worker 3 on unborn Baby A. However, the Assessment was not signed off by a manager or entered onto the case management system by social worker 3. This Assessment should have been completed within 45 days but in fact was not completed until early February 2013, which is significantly outside timescales.    54  4.3.175. The School Nurse arrived for a Care Planning meeting on the 18th October 2012 but no meeting had been organised. She is informed several days later that the next meeting will take place on 7th November 2012.  This is not the first time there has been confusion about meetings; this highlights the importance of meetings being properly co-ordinated if they are to be effective in any way and highlights again the absence of any managerial oversight.  4.3.176. Court Hearing October 2012. No details of this Hearing have been provided to the author. However, records in the CSC IMR suggest that it was at this Hearing that a decision was taken that LB and NX should be subject to psychological assessments.   4.3.177. Care Team meeting/Pre-Birth Multi-Agency meeting 7th November 2012  Present: LB, P1-SMTP, School Nurse, Midwife, Deputy Head, social worker.  Records refer to: • Information reviewed by agencies • LB paying for private counselling sessions  - no further information is sought or provided • Information shared from Court Hearing, which required that LB starts drug counselling for three months and she and partner undergo a psychological assessment.   • LB admitting to still using heroin and agreed twice a week testing • No significant concerns re: Child C at school or in relation to his wellbeing or development although concentration and retention of information is an issue • LB has daily-supervised contact with Child C at her mother’s home  • Social worker reported she has observed contact and has no concerns about the relationship between LB and Child C • (Fostering) and Adoption Panel will take place on 12th November 2012 • LB is 15 weeks pregnant  • Health Visitor asked about plans for the unborn baby and was informed these could not be confirmed that day but a pre-birth conference would take place on 5th December 2012  4.3.178. The author of the IMR report for CSC refers to not being able to locate the notes from this meeting. However, the Overview Author was sent a copy of the notes written by social worker 3, although other requested minutes were not forwarded. This highlights a systemic failure in the organisation if significant records cannot be easily located and retrieved.  Whilst problems with the information systems in Local Authorities are well documented, this issue nevertheless can significantly impact on practice and decision-making.   4.3.179. Maternal grandparents were approved as Connected Carers for Child C on 12th November 2012 and the decision approved by the Local Authority on 20th November 2012.  4.3.180. Looked After Child review 14th November 2012 Present: Not clearly documented but notes refer to LB, NX, MGM, Independent Chairperson 1, Health Visitor 2, P1-SMTP and School Nurse. Information pertaining   55 to this meeting has been extracted from notes from other agencies, as records from CSC were not available.   Records refer to: • Independent Chairperson 1 (chair) reviewing the Care Plan for Child C who remains on an Interim Supervision Order • LB and NX being advised that there were two possible outcomes in relation to Child C: the child could return to the care of LB full-time or would continue to live with grandparents • Independent Chairperson being advised of LB’s pregnancy although this was noted at the Care Planning meeting in August 2012 • LB has daily contact with Child C under supervision and advised she is paying for regular sessions with psychiatrist. Social worker 3 agreed to look into this • NX asked if he could have unsupervised contact with Child C. Social worker 3 agreed to look into this • Concern raised about the number of different practitioners LB sees at P1-SMTP  4.3.181. On the 9th November 2012, the Health Visitor has telephone supervision and advises her line manager that the unborn baby would be ‘integrated into the ongoing Care Proceedings for Child C’. Given, that a child must be born before Care Proceedings can be instigated, it is unclear whether this was a misunderstanding on the part of the Health Visitor or she had been given misleading information by the social worker. The Health Visitor is reminded by her supervisor to make sure there are timely birth and conference arrangements to safeguard the unborn baby.   4.3.182. NX’s eldest child was arrested in November 2012 on suspicion of possession of drugs.  She was found to have drugs hidden in underwear.  4.3.183. Between 14th November 2012 and the Care Planning meeting on 5th December 2012, LB continued to miss appointments at P1-SMTP and they contacted the SSMM to share their concerns.  There is evidence of good information sharing between health colleagues and P1-SMTP.   4.3.184. The Health Visitor’s supervisor discussed concerns regarding Child C and the unborn baby with her line manager – the Safeguarding Nurse Advisor on 28th November 2012.  She was advised that the Unborn Procedures should be followed and these would likely lead to an Initial Child Protection Conference.  The supervisor was also advised to ensure that the Health Visitor liaised with the social worker to ensure these procedures were followed.  Given the delay and drift already evident, concerns should have been escalated at this stage and discussions initiated at more senior level.    4.3.185. The SSMM was unsuccessful in her attempts to contact LB regarding missed appointments.  4.3.186. Care Planning Meeting 5th December 2012 Present:  Social worker, Midwife, Health Visitor, Student Nurse, School.  CSC records refer to: • LB had kidney infection and did not attend. NX had work commitments   56 • No significant concerns about Child C although concentration appears to be an issue. LB asked to sign an Individual Education Plan for Child C • No goals or progress were identified in these brief notes  Notes from other agencies refer to: • LB continuing to use heroin • Unborn baby placed on ‘system’ in line with procedures • Child Protection proceedings to be instigated when LB has reached 26-week gestation. A Case Conference will be arranged • NX to be assessed as carer for baby • Risk identified and remain unchanged • Initial Assessment to be carried out in relation to unborn child  4.3.187. Between 5th December 2012 and 5th February 2013, LB continued to avoid testing but admitted to still using heroin. Practitioner 18 discussed with practitioner 17 the need to check urine samples with pregnancy testing to ensure the urine samples belong to LB. NX told his Probation Officer that he and LB were doing all they could to prove they could care for Child C, but he was expecting that the arrangements with the maternal grandparents would continue long-term with LB and NX having contact.   The assessment for NX to be carer for his baby when born remained outstanding.  It is difficult not to question whether the Parenting Assessment/Carer Assessment/psychiatric tests etc., were platitudes intended to diffuse the concerns and anxieties of LB and NX. It is understandable that LB and NX perceived they were being asked to jump ‘through hoops’ without any realistic hope of Child C and their baby being allowed to live them.   4.3.188. Team Manager 3 in CSC confirms on 13th December 2012 that they will progress to an Unborn Baby Conference due to serious concerns about LB’s unborn baby and the fact that Care Proceedings were already underway in respect of Child C.    4.3.189. Records suggest that Child C was at home with LB and NX on Christmas Eve but there are no records to confirm whether this arrangement had been discussed or agreed with the social worker. On 26th December 2012, LB attended A and E department of local hospital with a swelling in her leg which showed evidence of DVT. She was advised to attend Maternity Unit after treatment with anti-coagulants but failed to attend.  The Delivery Suite Co-Ordinator tried unsuccessfully to contact LB but her calls and messages went unanswered.  Several attempts made by the Community Midwife and the SSMM to contact LB were unsuccessful and notes through the door were not possible as letterbox was sealed from inside.  These efforts demonstrate persistency and good practice. Concerns increased as it became evident that the unborn baby was at high risk due to LB’s DVT and anaemia.  LB failed to follow up treatment.  P1-SMTP received a telephone call from social worker 3 to advise that the Care Planning Meeting due to take place on 8th January 2013 was cancelled.  The reason for this is not clear and is not picked up by the IMR author for CSC.  4.3.190. LB continued to avoid antenatal and P1-SMTP appointments.  P1-SMTP are informed that LB had attended a needle exchange service and obtained needles under her maiden name and were informed that LB was injecting into her groin. P1-SMTP shared concerns with social worker 3 who advised she would inform the   57 Local Authority Solicitor. Social worker 3 telephoned LB to discuss concerns but her phone was answered by someone else. Social worker 3 contacted NX to advise of missed appointments and growing concerns. NX claimed not to know about these and said he would get LB to get in touch.   4.3.191. LB attended high-risk clinic on 15th January 2013 and was advised by Consultant that he planned to deliver her baby at 38 weeks. At this point LB was 28+ weeks. LB was advised about importance of keeping appointments and was described as looking unwell and low in mood. She admitted recent use of heroin. LB said she had no recent contact with social worker.   4.3.192. There are no details in CSC IMR about the Court Hearing on 16th January 2013, but P1-SMTP records indicate that LB contacted them to advise that NX had been in Court to hear that the baby will be removed at birth and she had until 2nd April 2013 to ‘turn things around’.  4.3.193. The Health Visitor made an antenatal visit on 18th January 2013. LB was not in but NX was at home.   The Health Visitor completed the necessary paperwork with NX and offered to return if LB would like a visit.   This was the first recorded opportunity that a professional other than the Probation Officer has had to talk with NX, and whilst NX helped the Health Visitor to compile a genogram and complete the Family Health Assessment Tool, there is no record to suggest that this opportunity was used to discuss professional concerns and the increased vulnerability of his unborn child, especially in relation to the higher risk of Sudden Infant Death Syndrome.    NX’s eldest daughter was present and records indicate her baby was due the following month in February 2013. Social worker 3 was not advised that LB was not present for this visit.    4.3.194. LB attended a P1-SMTP appointment three days later on 21st January 2013 and confirmed she had recently used heroin. She blamed the social worker for this as she stated it was her way of coping with the stress of learning that her baby would be removed at birth and NX would not be allowed to care for his child.  LB was clearly challenged by practitioner 18 at P1-SMTP and given an unambiguous message about the damage to unborn babies of continued drug use. LB was advised that P1-SMTP would contact the social worker to advise of LB’s continued use of heroin.  NX and LB attended another appointment at P1-SMTP on 25th January 2013 and NX stated he believed that social worker 3 held a grudge against himself and LB.  On 4th February 2013, LB was contacted by practitioner 18 to ask if she would like an oral swab test prior to the meeting the following day. LB refused but agreed to a urine test.  4.3.195. Care Team Meeting and Pre-Birth Multi-Agency Meeting   5th February 2013  Present: LB, NX, P1-SMTP, School, Health Visitor, and social worker 3.  Undated CSC records refer to: • LB’s continued use of opiates  • P1-SMTP now only doing oral swabs  • HV’s meeting with NX • Child C doing well with 94% attendance at school • NX asking P1-SMTP if he could attend a drug abuse awareness course   58 • Social worker 3 to follow up information from the parenting class that NX completed  Notes from other agencies refer to:  • Social worker 3 stating that the Initial Assessment was complete and there would be an Unborn Baby Conference held within two weeks (Health records) • Next Court date was 6th February 2013, though this would likely be adjourned • LB and NX described as challenging and arguing that social worker 3 only focused on the negatives in the family and had advised NX that the only way he could care for his baby would be to leave LB.  Social worker 3 disputed that she had said that to NX (P1-SMTP records) • Plan outlined for unborn baby (Health records)   4.3.196. Notes extracted from other agencies records refer to a Child Protection Plan being outlined but the Overview Author has not had sight of these, despite requests being made for copies of all minutes. The information recorded in paragraph 4.3.189 above highlights the importance of maintaining careful records of meetings. The CSC notes do not mention unborn Baby A despite the meeting being called a pre-birth meeting, yet records from P1-SMTP and Health clearly indicate some information was shared.   The Unborn Baby Conference was well overdue and no explanation was offered and no challenge recorded. It is possible that the Care Planning meeting on the 5th December 2012 was considered by CSC to be the Pre-Birth conference, but this confusion only serves to highlight that social worker 3 was unclear about procedures and her line manager should have identified this.   4.3.197. Between 5th February 2013 and 7th March 2013, LB tests were contradictory and there were suspicions recorded that LB was submitting someone else’s urine for testing.  NX continued to attend a drug awareness course and a parenting awareness course and attended P1-SMTP with LB for at least three of her appointments with P1-SMTP. LB attended her antenatal appointments.    4.3.198. Social worker 3 received a call from SSMM on 13th February 2013, confirming she was able to attend the Initial Child Protection Conference on 28th February 2013. Although social worker 3 had not requested a Conference she nevertheless informed other professionals and as she was unable to attend on the said date, arranged for another colleague to attend on her behalf.   4.3.199. According to the combined chronology, a supervision session took place between social worker 3 and her manager on 26th February 2013, the day before social worker 3 took a two-week leave of absence. Records in the chronology refer to social worker 3 being informed by her manager that the pre-birth assessments should be written up and birth arrangements confirmed, but there is no evidence at this stage that the pre-birth assessment had been completed. The Unborn Baby Child Protection Conference for Baby A was already outside timescales.   4.3.200. In the IMR report, however, the author confirms having sight of the supervision record for social worker 3 which took place in February, but writes ‘Neither Child C nor unborn Baby A were discussed during February’s supervision’. This significant discrepancy is neither challenged nor addressed by the IMR author and leads the   59 SCR Panel to conclude that the IMR report was written without reference to the combined chronology.   4.3.201. The Child Protection Conference confirmed by social worker 3 before her leave, did not take place when it became evident that the planned Conference was actually for another family with the same surname.  An Operational Manager subsequently proceeded to request an Initial Child Protection meeting in respect of unborn Baby A.  This was planned for 15th March 2013, the day after social worker 3 was to return from leave.   4.3.202. Care Planning meeting/ Pre-Birth Multi-Agency meeting 6th March 2013  Present: LB, NX, P1-SMTP, School.  Incomplete draft minutes (written by a social worker covering for social worker 3) refer to:  • Child C still attending school and has good attendance. Described as a happy child willing to try new activities. Child C is on special needs register but developing well, although has some problems with concentration • No Birth Plan being available, No ICPC report shared. PLO - no assessment commenced    • Both parents attending joint counselling with P1-SMTP which ends on 15th March 2013  • LB and NX express frustration at the way their ‘case’ is being managed. Said that social worker had not attended any contact sessions to ‘observe parenting’. Parents do not know what plan is for baby • They are given information about the complaints procedures  4.3.203. Despite the birth being imminent - LB was in her 36th week of pregnancy - the Initial Child Protection Conference had still not taken place and consequently no birth arrangements were agreed. The pre-birth assessment had not been completed or shared with any professional. There is a strong sense of drift here with neither the social worker nor her line manager acting with any urgency.  There have been no visits with parents to discuss the Local Authority’s position and no record of any contact with the maternal grandparents to discuss Child C and the future.   4.3.204. The absence of any birth arrangements was discussed in supervision between Health Visitor 3 and the Safeguarding Nurse Advisor. Health Visitor 3 was asked to urgently liaise with Midwife and social worker 3 in regard to these arrangements.  At this stage, the Safeguarding Nurse Advisor should have escalated her concerns to a more senior manager in CSC especially given the number of times this issue had been raised both on an individual basis in supervision and in multi-agency meetings.   4.3.205. Practitioner 18 from P1-SMTP shared her report with LB and explained why she would be recommending that the baby be made subject to a Child Protection Plan.  4.3.206. Records in the combined chronology indicate that a fraught telephone call took place on 14th March 2013 between a social worker and LB.  LB refused a meeting at her mother’s home to discuss the conference report and was distressed and angry when advised that the baby would be removed from her care at birth.  LB advised that her mother would not let that happen and ended the telephone conversation.  It is not clear if this social worker was social worker 3 who had returned to work only that day, or a colleague standing in for her.     60  4.3.207. Initial Child Protection Conference 15th March 2013   Present: LB, NX and their legal representatives, Health Visitor, SSMM, Midwife, P1-SMTP, social worker, Legal, Independent Chairperson.   Records refer to:  • Confidential information shared at Conference prior to LB and solicitor arriving at meeting. Information about NX’s father was withheld  • Court Proceedings being underway in respect of Child C  • Independent Chairperson expressed concern about lack of information in relation to LB’s health care, especially in relation to her DVT  • P1-SMTP were asked to provide confirmation about results of testing • Social worker shared information about concerns and LB’s long and sustained history of drug use, her disengagement with services and her repeated failure to regularly keep appointments with P1-SMTP and remain drug free for any significant length of time  • Those at the Conference were told that LB had failed to put the needs of her unborn child first and had continued to use illicit drugs throughout her pregnancy • Risks identified and all professionals agreed that even ‘given the strengths’ the unborn baby should be made subject to a Child Protection Plan under the category of Neglect • NX had requested again to be assessed as carer for baby. LB asked that her parents also be assessed as carers • Social worker advised that CSC would be going to Court to remove baby at birth: however LB agreed that baby could go and live with grandparents. Her mother had sent a letter confirming that she would agree to this arrangement Records indicated desired outcomes: - LB to be clean and sober from all illegal substances: Ongoing - NX to gain clear understanding on needs of children: by 1st April 2013 - Birth plan to be produced and shared with professionals: within two days - Care Proceedings to be initiated immediately after birth to ensure baby is safe: by first core group meeting - NX to continue to attend drug awareness course so he can understand more about heroin use: ongoing - LB and NX to complete psychological assessment: by 26th March 2013 - Placement for unborn baby confirmed within four days - All health appointments to be kept by LB: ongoing   4.3.208. This meeting was delayed by 90 minutes, as the social work report was not prepared. Social worker 3 had in fact returned from a two-week leave of absence only the previous day and would have been unaware that the Conference was taking place. It would not be expected that she would be up-to-date with events and would certainly not have had time to prepare a Conference report. This issue should have been addressed prior to the Conference and suggests once again a serious lack of managerial oversight.  A pre-birth assessment had still not been completed.   61  4.3.209. Core Group meeting 18th March 2013  Present: LB, SSMM, and social worker.  Records refer to: • Birth arrangements agreed • Baby will be induced and NX will be present at birth.  Only named family members would be allowed to visit  • LB will breast feed and will be given support to do this  • Upon discharge, the baby will be placed in care of maternal grandparents on a s20. They will supervise all contact between LB and the baby. LB will stay with her aunt so she can be close to the baby  • If LB tests positive for any illicit drugs, then all contacts with the baby would be supervised by CSC • LB would be tested before and after her admission to hospital  4.3.210. The plan lacks key detail about communication between agencies and how LB would be monitored whilst in hospital and crucially the extent to which the maternal grandparents would be able to supervise LB’s contact with her baby. There was no discussion about Child C. Notes refer rather optimistically to the changed attitude of LB and NX.   LB tests results on the same day indicated the presence of opiates, but these were not discussed with LB when she next attended an appointment at P1-SMTP two days later.   4.3.211. The CSC report states there was no written Risk Assessment completed in respect of Baby A, the inference being that some sort of Risk Assessment was undertaken but it was not recorded. A Regulation 24 Assessment should have been completed in respect of this placement and this would have included a Risk Assessment. The Placements and Resources Panel (PARP) should also have been advised about the placement so information about Child C’s placement was known.  The IMR author notes that further work has been undertaken to ensure there is now greater clarity about when it is necessary for social workers to attend PARP.  However, the Local Authority in [Place 2] where the maternal grandparents lived should also have been informed that Baby A was being moving into their area.    4.3.212. NX’s mother was given permission to visit but not once the baby was discharged.  NX asked social worker 3 how long LB had to produce clean tests before she could take care of the baby. This answer to this question, if given, was unrecorded.   4.3.213. SSMM followed up with social worker 3 her concern about supervision of LB whilst in hospital and explained that there may only be two staff on duty. Social worker 3 advised that as it was a controlled environment she was satisfied with that level of supervision but she would talk to her manager.  SSMM could have challenged this decision but it is possible that she was waiting for social worker 3 to come back with her manager’s decision.  Social worker 3, however, did not make that call, and SSMM should have escalated her concern at that point. The SSMM entered a note in hospital records to ensure that toxicology reports were performed on admission and on discharge.  This did not happen and is a serious omission as LB could have been using drugs whilst in hospital.  LB was receiving a daily prescription of Buprenorphine from P1-SMTP, which was collected at a specified pharmacy.    62 4.3.214. LB gave birth to Baby A in late March (Day 0) and was admitted to the postnatal ward for 72 hours so Baby A could be monitored and checked for Neonatal Abstinence Syndrome. LB was helped to breastfeed and the baby was given top-up feeds.  There is no reference to the baby being transferred to the Neonatal Unit, which given the safeguarding concerns would have been advisable.  The Emergency Duty Team were informed of the birth so the social worker could be informed as soon as possible.  There are no records to indicate which family members visited, but social worker 3 was noted to have attended on Day 3 although she had no discussions with any ward staff regarding LB and the care of her baby.   4.3.215. LB and the baby were discharged on Day 4. LB advised ‘she was unable to stay’ and left without receiving her medication and prescriptions and without being subjected to any toxicology tests, despite notes placed on her records. P1-SMTP were not contacted about her discharge and LB returned home without her prescribed medication leaving both Baby A and LB in a very vulnerable position.    4.3.216. Records do not state who collected LB and Baby A or how they travelled to the maternal grandparents’ home, although MGM provided this information much later.  Social worker 3 was not involved in the discharge arrangements but in line with procedures, she should have made a home visit that day.  Given that Baby A was a child subject to a Child Protection Plan, it is of concern that the social worker did not visit on day of discharge or visited Baby A at the home of the maternal grandparents. The IMR author does not comment on this practice or explore why social worker 3 did not visit or even if she knew the procedures required her to do so.    4.3.217. LB’s GP was sent discharge information and the postnatal transfer letter and Postnatal Vulnerability Assessment, which advised that Baby A was subject to a Child Protection Plan. However, given that the baby was to live with maternal grandparents, this information should have been sent to the GP practice in the area where Baby A would live.   4.3.218. LB and Baby A were seen by the Community Midwife on Day 6 at the home of the maternal grandparents where both were present and LB was observed to be feeding Baby A with formula milk. LB said that Baby A was also taking 2-3 ozs of breast milk every two or three hours. Baby A was weighed and noted to have lost 12% of birth weight; arrangements were made to reweigh the baby within the next 24–48 hours, although in line with the Community Health Surveillance (CHS) guidelines 23  for managing weight loss in newborn babies, Baby A should automatically have been seen every day for 10 days.  Given mother’s substance misuse, this weight loss could have been an indicator of neonatal abstinence withdrawal and should have alerted the Community Midwife to potential risks.  4.3.219. At this visit, it would have been appropriate for the Community Midwife to share with the maternal grandparents and LB, the risks related to co-sleeping and Sudden Infant Death Syndrome (SIDS) for newborn babies, especially in relation to babies born to mothers known to be drug users.  The ‘Give Me Room to Breathe’                                                  23 CHS Guidelines “Prevention and Management of Excessive Weight loss in the Breast fed Newborn”.   63 campaign had been launched in 2011 and provided important information about sleeping arrangements for young babies.  It is unclear why the Community Midwife did not share this information with LB and her parents, especially as Baby A was a vulnerable baby and therefore a high risk. If this information was shared, it was not recorded. LB and her parents were given a number to contact Midwifery staff should they have any concerns.    4.3.220. P1-SMTP contacted LB late March and advised her that the test results from two tests taken earlier in the month had been confirmed as positive for heroin and this would be included in Court reports.  LB was distressed and said she was going to lose everything. P1-SMTP attempted to contact social worker 3 but received no answer so e-mailed the information to her.   4.3.221. P1-SMTP contacted SSMM to advise that LB had not waited at the pharmacy for her medication. They also stated that they had been unaware that LB had been discharged from hospital and had learnt of this when they rang LB to discuss her medication. LB had contacted the pharmacy that ascertained that she had not been prescribed any medication from the hospital but she was unwilling to wait for a prescription to be arranged. LB later attended the maternity unit for medical checks and told the Midwife that the pharmacy had been unable to dispense her medication, as the hospital had not arranged a prescription for her on discharge.  The Midwife talked with a Consultant but LB was advised they could not arrange a hospital prescription, as there was no way of confirming whether LB had medication from elsewhere. By this time, it was afternoon on Easter Saturday so the pharmacy would not be open for another three days. Upon reading reports, there is a sense that LB may have desperately been trying to get hold of some medication although she was clearly too impatient to wait at the pharmacy for a prescription.   4.3.222. Baby A, aged one week, was admitted to Paediatric Intensive Care Unit at the Royal Victoria Infirmary following a cardiac arrest and was reported to be in a critical condition.  Baby A was not breathing upon arrival at hospital but breathing was finally restored via a respirator. However, given the length of time without oxygen, the medical staff advised there would be brain damage.   4.3.223. The necessary paperwork for Baby A to be placed with the maternal grandparents under s20 had not been completed, alongside a failure to notify key people and services, including the CSC in the area where Baby A was living.  Social worker 3 had claimed she was unaware of what had to be done although her manager contradicted this and stated she had advised social worker 3 and had assumed the necessary paperwork had been completed.  The implication of this is that when Baby A was admitted to hospital, it was not known they were a Looked After Child and neither was the Local Authority aware that a Looked After Child had moved into their area.    4.3.224. A Strategy Meeting was held on 2nd April 2013 attended by key agencies.  At the meeting, information was shared about the events leading up to Baby A’s admission to hospital.  Baby A had suffered a catastrophic collapse whilst unsupervised in LB’s care.  LB had explained that she was feeding Baby A and had pulled the baby to her chest for winding and after 5–10 minutes realised the baby had stopped breathing and called for help from her parents who were upstairs. Her   64 eldest child, J however reported coming into the room and seeing Baby A lying over LB’s knee and looking pale. LB appeared drowsy.   4.3.225. The decisions made at the meetings were that:   • LB and NX could have two hours supervised contact each day at hospital, including weekends • Contact between LB, NX and Child C to be supervised until further work was undertaken with maternal grandparents • Maternal grandparents and J to have open access to Baby A  4.3.226. Baby A died early April 2013 following the withdrawal of life support.    5. Individual Management Reviews (IMRs)  5.1. General Comments  5.1.1. It is crucial that professionals and organisations protecting children reflect on the quality of their services and learn from their own practice and that of others. Working Together to Safeguard Children 2013 states ‘Good practice should be shared so that there is a growing understanding of what works well. Conversely, when things go wrong there needs to be a rigorous, objective analysis of what happened and why, so that important lessons can be learnt and services improved to reduce the risk of future harm to children.   These processes should be transparent, with findings of reviews shared publicly. The findings are not only important for the professionals involved locally in cases. Everyone across the country has an interest in understanding both what works well and also why things can go wrong’.   5.1.2. The LSCB Business Manager and the SCR Panel offered direction and assistance to the IMR authors, and stressed the importance of reports being quality assured and signed off by senior managers before the final submission. The SCR Panel considered that some reports were below the expected standard and were left to pragmatically accept some of these even after further rewrites and amendments.  5.1.3. Although the quality of the submitted IMR reports varies, they are all largely descriptive documents with very little evidence of critical reflection. It is apparent that the IMR authors were not skilled or well practiced in writing analytical reports and confused presentation of facts and descriptions of practice with analysis and critical reflection. In order to qualify as a ‘critical’ review, authors are required to go beyond simple descriptions of what happened and critically examine practice and procedures, not passively accepting everything that has been read or was said, but questioning, evaluating, making judgements, finding connections and identifying any patterns or themes. In this way the analysis aims to contribute to both organisational learning and the development of professional practice within a single agency. This is an area the LSCB should consider as a matter of some urgency especially given the very poor quality of reports received from key statutory agencies where detailed analysis of data is essential for strong performance and good quality services.   65   5.1.4. There were no outstanding IMRs. Whilst some authors described poor practice and identified various shortcomings and occasionally the steps taken to remedy these, they often failed to explore the possibility of any systemic factors, which may have impacted upon practice, performance or outcomes across other areas in the organisation. Consequently, learning where it occurred remained person centred rather than system centred. This was reflected in the nature and type of the recommendations made which focused largely on the need for better training, improved procedures and further reviews [of services, systems or practice].   5.1.5. Some of the authors of the IMR reports were not appropriately qualified and/or sufficiently experienced to effectively undertake a management review within their own agency. This posed particular challenges where individuals were placed in the position of having to question the practice of their senior managers.   5.1.6. Given the poor quality of the IMRs it is clear that within Sunderland, there is a worrying lack of understanding on the part of senior managers across all agencies about their responsibility to sign off and quality assure IMR reports. None of the IMRs received by the author had the signatures of senior managers, and this raises questions for the Overview Author and the LSCB as to whether they agree with, and will progress, the recommendations made. Sunderland LSCB procedures makes clear that IMR reports should be signed off by a Senior Manager in the organisation prior to submission to the SCR Panel and in doing so they confirm the report meets required standards and the contents and recommendations are acknowledged and accepted by the organisation.     5.1.7. The process of individual agency quality assurance became an identified concern during this Review as it became apparent that some of those tasked with undertaking the quality assurance of reports may not have had a full understanding of the requirements of that role. In future, it may be of benefit if a briefing session is held with those responsible for quality assuring single agency reports relating to SCRs.  Multi-Agency Recommendation 1     5.1.8. Not one of the IMR reports which contributed to this review provided the author with a pen picture of Child C. Whilst there are some descriptions about Child C’s physical development and educational needs, there is very little to help create a picture of what Child C was like; how the child felt about what was happening and what impact the mother’s drug addiction actually had on the child’s attachment and emotional development. It is worth noting Lord Laming’s comments that although made in 2009 are pertinent to this and every other SCR.     ‘the failure of all professionals to see the situation from the child’s perspective and experience; to see and speak to the children; to listen to what they said, to observe how they were and to take serious account of their views in supporting their needs is probably the single most consistent failure in safeguarding work with children’    5.1.9. It is not acceptable to note that Child C  ‘was only three or only four’, there are a myriad of different ways professionals can gather information about how a child,   66 even as young as Child C, was feeling about things happening around them.  The failure to consider the child’s experience is a significant omission in these IMR reports.    Further brief comments on individual IMR reports are made below.   5.2. Children’s Services: Children’s Social Care (CSC)   5.2.1. The copy of this IMR report made available to the Overview Author is unsigned by a senior manager in the organisation. The SCR Panel reservedly and reluctantly accepted this report, given that it had already been submitted late and was re-submitted following substantial amendments.   5.2.2. The IMR was assigned to a principal social worker who also worked as an independent practitioner assessing prospective adopters and foster carers. It is the view of the Overview Author that this practitioner had neither the experience nor the seniority to undertake the IMR on behalf of CSC. It is of concern to note that despite three layers of management above the principal social work post, there was no other individual who could undertake the Review.  The delays in this report being submitted and accepted by the SCR Panel and the frequent and many amendments to it, suggest a lack of senior managerial oversight and commitment to the SCR process that is of some concern.  It should be noted that amendments to the IMR report were being sent through to the Overview Author as late as two weeks before the Overview Report was due to be submitted.  This is an issue that must be addressed between the LSCB Chair, the Director of Children’s Services and the Chief Executive as a matter of some urgency.  5.2.3. As the key statutory agency, it would have been useful if more detail had been provided about concerns identified in 2009 – 2011, even though this was outside the time period of this review.  Although there are references to  ‘concerns and neglect’ there is very little information provided in the IMR, which helps the reader, understand the evidence which led to these conclusions, other than the fact that LB was a drug user.    5.2.4. The author attempts to review practice across three service areas, CSC, Fostering Service and the work of the Independent Reviewing Officers.  Learning would have been enhanced had the reviews of each of these services been undertaken separately or at least presented in three different reports/sections.   5.2.5. Whilst there are references in the CSC IMR report to pressures of work there are few details which relate to any broader contextual issues, which may have impacted upon practice.  Issues, for example, such as the need to recruit social workers from overseas, the challenges in retrieving information from the case management system and the high caseloads of Independent Chairperson(s).  These are missed opportunities to examine and highlight where organisational factors may have impacted on performance, especially for example in relation to the restructuring of front line services in 2012.  5.2.6. Figures from national research highlight a continuing rise in the number of referrals, Initial Assessments and Core Assessments between 2009 and 2011 across other   67 Local Authorities but these influences, if they impacted on services in Sunderland are not explored.   5.2.7. The recommendations, of which there are 25, focus predominantly on training, amending procedures and reviewing processes. It is concerning to note that some of the recommendations relate to what might be regarded as expected practice such as the need for Operational Managers to discuss vulnerable babies in supervision sessions and workers needing to follow procedures. Without the IMR author exploring why these practices do not happen routinely, the recommendation and others like it, become a tick box exercise in which the lessons, although identified, are not well understood and therefore not embedded into operational practice. This has significant implications for CSC and should also be addressed as a matter of some urgency.  5.2.8. The IMR report is largely descriptive and fails to offer a critical analysis of practice and systems in CSC. Whilst the author does identify some areas where practice falls below expected or required standards, there are few attempts to explore why certain actions or decisions are taken or what systemic factors may have influenced practice.  In particular the following questions are not explored in any depth and as such offer opportunities for learning and improving practice are severely curtailed. Further urgent consideration should be given to consider: • Why were managerial oversight and supervision arrangements so inadequate, given the LSCB had undertaken an exercise relating to supervision in the recent past? • Given that effective records contribute to better outcomes for children, why were records, minutes and plans of key meetings not available and why, when some were submitted, were they so poor? • Why are arrangements for chairing and note taking at various meetings so inadequate?  • Why are the training opportunities provided to frontline practitioners and the learning from research and reviews not leading to improved practice? • High caseloads are known to be linked with practice that leaves children vulnerable. Are senior managers aware of areas/teams where caseloads are unacceptably high?  • What factors mitigated against expected practice in this case?  • The inadequacy of Independent Reviewing Officer resources has been raised by the LSCB on a number of occasions, why has there been no effective action to date?  5.2.9. Given, these issues are related to practice and systems with the lead agency and as such should be addressed as a matter of some urgency. Multi-Agency Recommendation 2  5.3. Children’s Services: Primary School and Childcare Centre  5.3.1. The SCR Panel reservedly accepted this report, it having been substantially amended following the first submission. There is no signature on the IMR report to indicate it has been accepted by a senior manager.     68 5.3.2. The SCR Panel had expressed concerns about the selected author of this report given her lack of expertise in Child Protection and the lack of seniority in the organisation.  This author required considerable support in writing this report and it is to her credit that she persevered and eventually submitted the report by the extended deadline.  However, it is concerning that the [organisation] fails to recognise just how important these reports are in terms of improving practice and achieving better outcomes for children.   5.3.3. It is evident that the author is unfamiliar with the SCR process and with Child Protection and Child in Need procedures in general. The report contains a vast amount of information and the author has clearly been vigilant in following up gaps and areas of uncertainty.  It is in this IMR that there are the first, albeit brief references to Child C, whom the child likes and what toys are favourites. The author refers several times, appropriately to the view that within a multi-agency context, it is the mother and not Child C who is the centre of focus.    5.3.4. What is missing in this report is the reflection and critical challenge. On page 23 for example, the Teaching Assistant working with Child C advises the [IMR] author that she is only there to support the child in terms of academic needs.  This statement should have been challenged and the individual asked about the extent to which she understood her safeguarding responsibilities.  It would then have been useful to explore to what extent, if any, this view of safeguarding [as being someone else’s responsibility] was commonplace across the school and the Authority and the implications of this for children in Sunderland.   5.3.5. Although the author does try to address a number of identified failings, such as the poor recording practices and the failure to ensure appropriate and timely sharing of records when Child C is subject to a Child Protection Plan, the author does not explore what gets in the way of these practices occurring routinely.   5.3.6. There are seven unnumbered recommendations and although these follow the template provided by the LSCB, they do not provide any information about the intended impact of the recommendation. This makes it difficult for action plans to be measured against improved outcomes for children and young people.   5.3.7. The Overview Author would advise strengthening the recommendation, which relates to Child Protection files and records.   5.4. Northumbria Police   5.4.1. The Police IMR was written by the Major Crime Review Advisor, whose role is to conduct Management Reviews within Northumbria Police. The extent of this author’s experience is not recorded but it is fair to assume given her role, that the IMR author is suitably qualified to undertake the independent management review for this agency.  There is no signature on the IMR report to indicate it has been accepted by a senior manager.   5.4.2. The IMR report was submitted on time but the SCR Panel were concerned to note there were no lessons to be learnt and questioned the absence of any recommendations.  A revised report was submitted which the SCR Panel accepted.    69  5.4.3. The report is brief and addresses the key points. However, further reflection and exploration of the importance of good liaison between statutory agencies where families with children are under surveillance would have been useful.   5.4.4. There is one recommendation that appropriately highlights the importance of Police Officers attending Initial Child Protection Conferences and the IMR confirms that action has already been taken by Northumbria Police to address this issue.    5.5. Northumbria Probation   5.5.1. The author of IMR report is a Reviewing Manager for Northumbria Probation Trust and is suitably qualified and experienced to have undertaken this review. There is no signature on the IMR report to indicate it has been accepted by a senior manager.   5.5.2. The author provides a brief description of the work undertaken by the service clearly highlighting where practice fell below expected standards and the steps that have been taken to remedy this.  The author does not explore however, whether the issues of concern, such as recording, risk assessments and lack of home visits might also be happening elsewhere in the Probation Service and this leaves the review lacking in any critical analysis of why the ‘experienced’ Probation Officer failed to undertake, what the author considers to be some basic tasks.   5.5.3. The author explores the difficulties of not having good quality minutes of Core Groups circulated promptly and suggests that a pro-forma to be used for Probation staff.  However, the issue of why the concerns about the minutes were not escalated to senior managers is not explored.  There is reference to a Child Protection Register and it is not clear to which register this refers, given that this is terminology is no longer used for children requiring protection.   5.5.4. An exploration of the Probation Officer’s role in Core Groups would have been useful in that the knowledge, held by and given to the Probation Officer in this case was of considerable significance in respect of NX’s role within in the family of LB.   5.5.5. There are three recommendations, which are too vague, and although there are references to some changes in future policy these are not described or explained.   5.6. Health Overview Report   5.6.1. This report was written by the Head of Safeguarding for Sunderland NHS CCG who was appropriately experienced and well qualified to undertake the review.  The report was submitted on time and accepted by the SCR Panel.    5.6.2. The IMR author highlights that clear lessons are to be learnt from this review and identifies areas where practice needs to develop. The author stresses the importance of good quality supervision in Health Visiting, Midwifery and Drug Treatment Services to minimise the chances of bias and errors in reasoning occurring, but like other authors there is no real explanation as to why this kind of supervision does not happen routinely.  The author does however, infer in the   70 concluding section that inappropriate staffing and a lack of resource may impact on health practitioner’s ability to deliver robust and effective services.  5.6.3. The recommendations from the individual health IMR authors are endorsed by the Health Overview Author who makes a further ten appropriate recommendations.   5.6.4. The Overview Author would suggest a recommendation that supervising personnel are reminded about the LSCB’s escalation policy.   5.7. City Hospitals Sunderland NHS Foundation Trust   5.7.1. This IMR report was undertaken by a Senior Midwife who confirmed she had no prior involvement with the family as either a practitioner or a manager and was appropriately experienced to undertake this review.  There is no signature on the IMR report to indicate it has been accepted by a senior manager.   5.7.2. The report provides clear information about contact with LB and Baby A and the author offers some thought as to why some practices did or did not happen, for example the problems about where notes about safe sleeping were located on breast feeding records and how short staffed units would make it difficult for LB to be properly monitored whilst in hospital. However, there is no discussion as to whether the midwifery team did enough to ensure that LB and her parents were fully informed about the risks to Baby A.    5.7.3. There are no references made by the author to previous reviews in Sunderland where vulnerable babies have been injured or died. The author does not comment on to what extent, if any, the learning from those reviews impacted on current practice or is linked to the recommendations included in this report.  5.8. South Tyneside NHS Foundation Trust Community Health Services (includes School Nursing and Health Visiting Services)   5.8.1. The IMR author of this IMR report is a Lead Nurse Safeguarding (Named Nurse) and has substantial experience in safeguarding children within health settings and has been involved in other SCRs for another Local Authority.   5.8.2. The report provides detailed information about the involvement of practitioners from the Community Health Services with Child C and Baby A, LB and NX. The author stresses the consistent level of support offered by Health Visiting Services to this family but, for example, fails to explore why concerns were never escalated to a higher level within CSC.  There are no references to learning from previous SCRs even though, like this review, they related to the death or neglect of vulnerable babies.   5.8.3. The IMR author does however, highlight that the team in which the Health Visitors were working was under considerable strain due to pressure of work and being short staffed.  This, the author reports, was remedied when additional appointments were made to the team.  Also, during the period of this review, the author states there was a national drive to improve services within the health sector through the standardisation of activities and processes.  The IMR author notes the significance   71 this had for the Health Visitor role, especially the introduction of the Early Warning Assessment Tool and acknowledges the impact this would have had on workloads.    5.8.4. The author makes five recommendations which are too vague and do not state specific outcomes. The Overview Author would advise on a sixth recommendation, which relates to the timely use of the LSCB’s escalation policy.   5.8.5. There is no signature on the IMR report to indicate it has been accepted by a senior manager.  5.9. General Practitioner  5.9.1. This IMR was undertaken jointly by the Named GP Safeguarding Children and a Designated Doctor for Child Protection, neither of whom had any clinical involvement with Child C or Baby A, prior to Baby’s admission to Paediatric Intensive Care Unit in April 2013.   5.9.2. The report confirms that the GP had limited involvement with any safeguarding processes for Child C or Baby A.  LB was however noted on their records as being a vulnerable woman with a history of domestic abuse and substance abuse.  However, this information clearly ‘flagged’ on records did not prompt a referral to CSC when she became pregnant or when she sought support for insomnia.   The authors appropriately comment that ‘there was distinct lack of social enquiry for the family’ but there is no discussion around this issue and whether it is a regular feature of this Practice or others in the area.   The authors do not explore the relationship between Midwives and GP although they do point out that the GP appeared to see the child processes as being the responsibility of other members of the Primary Health Care Team.  The issue of the GP failing to submit a report to the Child Protection Conference in March 2013 is noted.  5.9.3. The authors propose eight recommendations all of which are endorsed by the Health Overview Author.   5.10. Place 1 – Substance Misuse Treatment Provider  5.10.1. An independent consultant undertook the IMR for P1-SMTP with experience in Chairing and writing SCRs. There is no signature on the IMR report to indicate it has been accepted by a senior manager.  5.10.2. The report is largely descriptive and whilst this provides some useful information, there is an absence of any critical analysis. It would have been helpful to explore some of the challenges faced by P1-SMTP in offering a service to LB and yet also being expected to be aware of the needs of Child C. There is at times, a stark difference amongst the practitioners in terms of how they work and this issue is not explored.  5.10.3. There is little critical reflection on there being so many different practitioners working with LB and the fact that this seemed to allow her to dictate her treatment and the times she would come in for testing.    72 5.10.4. An exploration of the value of drug testing would have been helpful and brought much to the debate about the validity of this approach when working with parents who misuse substances and where there are children involved.   5.10.5. The safeguarding supervision appears to be of a good standard and this is to be commended, although comments by the author as to why the practice of some practitioners failed to meet the required standards would have been helpful.  5.10.6. The author makes four recommendations. A fifth recommendation should include the need for P1-SMTP to examine how it ensures that staff remain child focussed in their work with substance users who are parents.  5.11. Place 2 Children’s Services   5.11.1. This report was written by the Strategic Manager Safeguarding Children in [Place 2] Children’s Services. There was limited involvement for this Authority with either Child C or Baby A. Nevertheless, the IMR author identifies, two key lessons in relation to this SCR; the need for liaison and good communication sharing between professionals when children are moved across Local Authority boundaries and secondly when a child is moved into an area under a Child Protection Plan, the host Authority should be notified of any Strategy Meetings and take action if such notifications do not occur.    5.11.2. The IMR author makes three recommendations related to the involvement of [Place 2] Local Authority with this family, which are relevant.    6.  Further information provided to the Overview Author 6.1. The LSCB provided details of three previous reviews to the Overview Author. These had been undertaken between 2011 and 2013 and were held in relation to the death, injury or neglect of three babies under the age of one. The LSCB had, in response to the findings from these reviews, delivered a series of workshops to frontline practitioners to disseminate the lessons learnt and to highlight practice issues in relation to working with families with vulnerable babies and where domestic violence and substance misuse were evident.  6.2. Following the death of Baby A, the LSCB were concerned to note that there were many similarities with previous reviews and were anxious to examine why changes in practice did not appear to have taken place or had not been sustained.  The Overview Author was asked to consider this issue as part of the Overview Report.   7. Critical Analysis   7.1. This analysis is based on discussions in the SCR Panel, the individual agency contributions to the Review and the author’s own contributions and research. The analysis also takes into account significant information provided by the LSCB   73 relating to previous reviews with similar circumstances to those relating to the death of Baby A.   7.2. The SCR Panel and the LSCB Chair decided to undertake this SCR in line with previous guidance published in 2010. This process required each agency to undertake a management review of their involvement with the family and produce an individual agency report to contribute to the Review process.  There are however shortcomings in this process which have been acknowledged by the LSCB and the Department for Education. The revised 2013 statutory guidance encourages a more systemic way of undertaking Reviews and allows scope for LSCBs to consider other more effective ways of learning.     7.3. The aim of a systems approach to Case and Serious Case reviews is not limited to understanding and describing what happened but is also about asking why particular actions or decisions made sense at the time and what factors influenced those actions. The IMR authors for this review were asked to consider these factors in their reports but in general, the reports fail to address these issues from a systemic perspective.   7.4. The Overview Author has considered all of the Terms of Reference, and with agreement of the SCR Panel, offer comments in this section under five specific headings: • Assessments and Planning  • Multi-Agency Collaboration • Practice and Patterns in Professional Judgement • Management and Supervision • Contextual Issues  7.5. Where specific issues of failings have been identified, these are recorded as Findings and underpin the recommendations made later in this report.   7.6. Assessments and Planning   Finding 1  The absence of any robust multi-agency assessments to inform the development of good quality plans and decision-making left Child C and subsequently Baby A vulnerable.   Finding 2 Without skilled and experienced chairs, the multi-agency meetings lacked focus and direction leading to unspecified outcomes and poor reviews of progress.   Assessments 7.6.1. There is increasing concern about the negative effects on children when parents or other members of their households abuse alcohol or drugs or engage in other illegal drug-related activity. 24 A consistent finding across all biennial reviews of                                                  24 Hidden Harm: Responding to the Needs of Children of Problem Drug Users (2003) – a report of an inquiry by the Advisory Council on the Misuse of Drugs London: Home Office.     74 completed SCRs is of a significant proportion of children in households where one or both parents misuse illicit drugs and/or alcohol. 25    The original analysis conducted for the NSPCC in 2011 estimates that 19,500 babies less than one year old were living with a parent who has used Class A drugs in the last year. 26   7.6.2. It is acknowledged that not all substance users have problems with parenting. However in many cases, it is necessary to make an assessment which includes the substance use and behaviour of the parents, and any impact from this upon their parenting capacity, before deciding what help, if any is required, and whether Child Protection Procedures should be initiated. The purpose of any assessment is to assess the effects of substance misuse upon a parent’s ability to maintain consistent and adequate care for their child.  ‘There is a reasonable basis in research to suggest that a child whose parent is misusing substances is at increased risk. Substance misuse can demand a significant proportion of a parent’s time, money and energy, which will unavoidably reduce resources available to the child. Substance misuse may also put the child at an increased risk of neglect and emotional, physical or sexual abuse, either by the parent or because the child becomes more vulnerable to abuse by others.’ (V Lewis 1997) 7.6.3. The idea of professional or organisational assessment is an inherent feature of social work practice. Indeed it is considered ‘a core social work skill’ (Crisp et al, 2003, p iv) and as identified in the above text is fundamental to safeguarding children whose parents misuse illegal substances.  A key feature of this review is the number of assessments, which were lost, mislaid or simply never completed by CSC.  Yet, it is these assessments, which were essential for the development of robust plans and quality decision making in relation to Child C and Baby A.   7.6.4. It should be noted at this point that, with the exception of a Parenting Assessment dated 26th March 2013, neither the author nor the SCR Panel have seen any of the Assessments undertaken by CSC and which are referred to in some reports. Neither, it would seem have the IMR authors had sight of these or if they have, they failed to comment on either the quality or the content of the assessments.   7.6.5. At the outset of the time period under review, Child C was subject to a Child in Need Plan.   7.6.6. Child C has been the subject of various assessments since birth and it is of concern that the detail of these is not referred to in the CSC IMR report.  There is evidence to suggest that a negative view was established about LB’s parenting capacity and her drug use as early as 2008 and that view does not appear to have changed. Research27 into human reasoning tells us that once a judgement has been formed it becomes very difficult for people to re-evaluate it or accept any evidence that challenges it. The pattern of responding to LB would also support this thinking as all of the interventions, repeated time and time again, focused on one aspect of her                                                  25Neglect and Serious Case Reviews University of East Anglia, (2012). 26 All Babies Count NSPCC Publication. 27 Human Reasoning and Cognitive Science Bradford Books Keith Stenning (2012).    75 behaviour - substance misuse and the need for regular testing, so it could be seen that she was not using illicit drugs.  The assumption, without any clear assessment, was that if LB could ‘prove’ she was not using drugs, her child could be safely returned to her care.  7.6.7. In the IMR reports, frequent references are made to this child, which imply that when living with LB, the child’s needs were neglected, yet what this means is unclear. Other records point to the fact that the child’s developmental milestones were generally met, the child was lively and active and had a strong attachment to LB and home conditions were adequate.   7.6.8. The decision to make Child C subject to a Child Protection Plan in February 2011 under the category of Neglect, was made on the basis of LB’s ‘lifestyle and her failing to engage with services.’  It was decided, appropriately, that a Core Assessment28 should be undertaken by the social worker and LB agreed that Child C would remain at the home of the maternal grandparents until this assessment was completed. The Conference also requested that a risk assessment (in relation to adults in contact with LB) was also completed.   7.6.9. At the Child Protection Review meeting in April 2011 however, neither assessment materialised and no challenges were made or questions asked by the Independent Chairperson about their absence or progress. However, notes of that review meeting state ‘Core assessment to be undertaken… and completed by April 2011’, suggesting that elements of these minutes were cut and pasted from the February document and/or that a discussions about the assessments had taken place but were not recorded.  Both options are poor practice and the IMR author for CSC does not comment on this practice or offer any explanation for it.  It is simply noted in the IMR report that in terms of the risk assessment the Team Manager could ‘not recollect why it did not take place’.  The Core Group was eventually advised in July 2011, that the risk assessment agreed in February, had been forwarded to a senior manager who was on sick leave and the document could not be located. Several weeks later the group was informed that the assessment was ‘lost’.  7.6.10. There are several more references to the need for assessments throughout this time period which then never materialise or were not progressed:  when LB first began her relationship with NX; when they married; when NX asked to be a carer for Child C and when he asked to be a carer for Baby A.  At various times Health Visitor 1 tenaciously questioned progress about the agreed assessments but this did not have any impact. At this point concerns should have been escalated to a more senior level using the LSCB’s escalation policy.   7.6.11. Both LB and NX agreed to undergo a Parenting Assessment in December 2011 and this was completed in March 2012 by social worker 3. Having initially reported to the Core Group with LB in attendance, that the Assessment was ‘positive’, the final recommendation in the report concluded that Child C should continue to stay                                                  28 The Core Assessment, was used until April 2013, and was a more in-depth assessment than the Initial Assessment. The purpose of a Core Assessment was to gather detailed information about a child's developmental or welfare needs and circumstances and the parents' capacity to respond to those needs, including the parents' capacity to ensure that the child is safe from harm now and in the future.    76 with maternal grandparents and Care Proceedings were to be progressed.  This assessment is of extremely poor quality and offers little analysis or reflection on the parenting capacity of either adult. It simply reiterates much of the information contained in other files and offers no insights or comments for example, about NX not having any contact with five of his children.  Given that Child C was having regular contact with mother, this could have provided a rich stream of information about: the parents’ attachment to the child; the quality of LB’s parenting skills or her ability to develop these skills and the quality of her interactions with her own mother and children. If any of these issues were taken into account, it is not evident from the available information.  7.6.12. The IMR author for STNHSFT comments that in her opinion, the multi-agency assessment of risk for Baby A was clearly evident and was identified at ‘key’ multi-agency meetings. It is unclear whether this comment refers to an actual document not seen by this author or to an ‘understanding’ of risk by those present at multi-agency meetings.  The view is expressed by the IMR author that the analysis of risk did not always reflect the level of risk and she relates this particularly to the health risks posed to Baby A,  given LB’s addictive behaviours.  7.6.13. The Overview Author has had sight of minutes from the Core Group meeting on 5th December 2012, the ‘Care Team’ meeting on 5th February 2013 and the ‘Care Planning’ meeting on 6th March 2013, all of which are headed ‘Child C and Unborn Baby A’.  There is no reference in any of these minutes to the risks posed to unborn Baby A, despite the known risk indicators related to substance misuse and the impairment on parental capacity and consequently the dangers of co-sleeping, all of which increase the risk of Sudden Infant Death Syndrome.  Professionals should have been alert to these risks and those in relation to LB’s contact with Baby A if she was still using opiates. These should have formed the basis of the Child Protection Plan. There is no exploration in any of the IMR reports as to why these risks were not explicitly discussed but it seems possible that as Baby A was being discharged into the care of the maternal grandparents and not to LB and NX, the level of risk was minimised. It may also have been assumed that as LB had given birth without mishap to three children previously, the risks to LB having contact with Baby A were small.    7.6.14. What is clearly apparent however, is that there was no multi-agency discussion as to whether Baby A being placed with maternal grandparents was the right decision, there appears to be an almost palpable sense of relief which ignored the fact that until the day of the Child Protection Conference in March 2013 the maternal grandparents had not clearly indicated they would care for Baby A on a long-term basis.   7.6.15. The failure to undertake a Pre-Birth Assessment was a serious omission and one, which the Midwives and Health Visitor brought to the attention of the social worker on more than one occasion.  These concerns should have been escalated at an earlier stage to a more senior manager within CSC.  The failure to undertake this assessment impacted on the plans made for Baby A and consequently areas of high risk were left unexplored.      77 7.6.16. The IMR author for CSC notes that the Initial Assessment for Baby A was started on 26th September 2012 and ended on 4th February 2013. Although well outside of the seven-day timescale, this assessment is described as having a ‘significant amount of information’ within it, most of which was used for the Child Protection Conference held in early March. There were also two Pre-Birth Assessments entered onto the Children’s Case Management system but neither had any information and both were ‘ended’ on the system. The author does not explore this further to consider whether this relates to a systems failing and/or human error. These Assessments were not signed off by a manager.   7.6.17. It is difficult to understand why these assessments were never undertaken and how professionals were able to make plans and decisions without any assessment information to aid their thinking. These questions do not appear to have been considered by the IMR authors in any depth and are missed opportunities for the SCR Panel to gain any insight about how professionals viewed the case as it was unfolding.   7.6.18. The absence of/or poor quality assessments is also a significant issue in relation to the work of the Fostering Team. The Regulation 24 Connected Person Assessment should have started when Child C was placed with the maternal grandparents in March 2012 and been completed within 16 weeks.  This Assessment however was not concluded for 30 weeks. Although the required Police and CRB checks were undertaken, the Local Authority in [Place 2] were not contacted and some important information which related to this placement was not identified. The Fostering Officer did not read the Parenting Assessment report in respect of LB and NX and eventually submitted a weak and incomplete report, without a detailed risk assessment, to the Fostering Panel. Although the IMR author identifies this as poor practice, there is no exploration as to why this officer did not follow procedures or complete the necessary paperwork. The Fostering Panel should also have challenged the parts of the report that were not completed but this did not happen and again the IMR author does not seek to understand or explain this practice.   7.6.19. Once it became apparent at the Initial Child Protection Case Conference on the 15th March 2013 that the maternal grandparents were willing to care for Baby A in addition to Child C, a Viability Assessment should have been undertaken by the social worker and a Regulation 24 Assessment undertaken by the Fostering Team. The failure to embark on either course of action has been attributed by the IMR author (CSC) to the fact that a Regulation 24 Assessment had already been undertaken for Child C and had been presented to the Fostering Panel in November, only four months previously.  This is an error of judgement given that the Regulation 24 Assessment had been undertaken in relation to Child C’s placement and would not have taken into account the pressures on the grandparents caring for or supervising the care of a vulnerable baby. Neither could it have considered the impact on Child C and Child J.  A more up-to-date assessment would also have highlighted the emerging problems related to Child J and substance misuse, a factor which may well have influenced the decision to place Baby A with the maternal grandparents.   7.6.20. Even without these assessments however there were already known interacting risk factors in relation to Baby A which increased the risks of Sudden Infant Death   78 Syndrome and practitioners especially from health and social care would have been aware of these.  There is no evidence in either Midwifery or Health Visiting records to suggest that parents and grandparents were told of these risk factors or that any discussions were held or observations made, about where Baby A would sleep.   7.6.21. It is clear that in this case there were significant issues in relation to assessments within CSC, but given that it is a requirement that all Core Assessments, Risk Assessment and Pre-Birth Assessments are authorised by a manager, it must be questioned why the poor quality and incomplete assessments were not picked up through managerial oversight.  There is an inference that pressure of work impacted upon the performance of the Team Manager, but the poor quality of the IMR report for CSC leaves this as an open question to be addressed at later stage by senior managers within CSC.   7.6.22. Ofsted in their Inspection Report for Sunderland in 2012 concluded that in Sunderland ‘all assessments clearly identify risk and protective factors and include contributions from partner agencies who are involved with the family… [but] the overall quality requires improvements‘. These reflect some but not all of the findings in this Review so other explanations need to be sought which helps those involved with the family understand more clearly what happened and why.  Multi-Agency Recommendation 3  Planning 7.6.23. The approach to assessment inevitably has a consequent impact on all subsequent planning and interventions with a family. Child in Need and Child Protection Plans represent the framework in which improved outcomes for children can be secured.  Plans are developed and implemented through the functioning of the Core Groups and Child in Need meetings.  In the case of Child C and Baby A, however, there was no evidence of a purposeful framework underpinning the interventions that were put in place. Plans were not amended in the light of new information and they were largely ineffective.  7.6.24. Much of the planning in relation to Child C was of a short-term nature and reflected the immediate position rather than planning for the child’s safety in the long-term. The IMR author for CSC refers to both Child Protection and Child in Need Plans but states that these were not outcome-focused. The reason for this is not explored.   7.6.25. As has already been commented upon elsewhere in this report, plans were too general in content and not specific enough to know when tasks had been achieved and when progress was satisfactory. For example, some ‘tasks’ were written as follows: • LB and NX to fully engage with Children’s Services (CSC) (14th November 2011) • LB to commit to working and submitting tests with P1-SMTP on a weekly basis and to participate in random drug testing (4th February 2011) • Social worker will type something up for Conference re: past risk assessments • LB asked about detox. Social worker will follow up (7th November 2012)  7.6.26. A particular disadvantage was the lack of a full diagnostic assessment of the level and significance of LB’s drug taking and the impact this had on Child C.  This   79 prevented any clear planning taking place as to what interventions would be necessary to support LB and what opportunities would allow LB to demonstrate   how she could care for Child C and Baby A and contribute to their well-being and healthy development. What these plans did not address or make clear to LB and NX was what ‘safety and healthy development’ would look like and how ‘success’ could be measured in terms of building and sustaining future safety for the children.   7.6.27. The absence of robust plans or agreed birth arrangements for Baby A left health professionals having to chase up information and challenge decisions which they felt were inappropriate. Birth arrangements were discussed at the Core Group meeting on 18th March 2013 attended by the social worker, LB and the SSMM but clearly these arrangements were not discussed in detail. This left the SSMM having to later raise concerns about supervision of LB after delivery and try to ensure toxicology testing before LB’s admission and on discharge. This was particularly important as LB had been informed that if she tested positive for opiate use, all contact with Baby A would be supervised by CSC.   7.6.28. The lack of attention to these details left Baby A vulnerable.  Whilst the baby was kept in hospital for five days to monitor the impact of neonatal abstinence withdrawal, there is little to evidence that the time was used to discuss with LB, the impact on her baby if she continued to use opiates on top of her prescribed medication. Neither does it appear that any information was given to her about safe sleeping arrangements and the high risks for Baby A of SIDS.   These factors should not have been left to chance but should have been addressed in a carefully considered Child Protection Plan. The reasons why this did not happen is not explored by the IMR author despite the brief reference to staffing issues on the ward at the time.    7.6.29. The risk of neonatal abstinence withdrawal was clearly recognised. Risk indicators can present until day 10 and include difficulty in feeding and weight loss. Although the IMR author clearly highlights that procedures were not followed, Baby A should have been visited every day for 10 days, there is no information for the Overview Author and the SCR Panel to understand why the Community Midwife did not follow procedures and it is the ‘why’ of this practice that should have been explored by the author.   7.6.30. There was clearly a lack of planning and little foresight in terms of LB’s own health needs and these issues led to confusion for professionals about LB’s treatment plan and her need for prescriptions before leaving hospital.  There are no records, which evidence that any thought was given to discharge arrangements. Baby A was subject to a Child Protection Plan and it was not known at the time how the baby was transferred to the maternal grandparents. It is a matter of some concern that the social worker was not there on discharge and failed to visit the home of the maternal grandparents within 24 hours.   7.6.31. The specific interventions – Child in Need and Child Protection Plans - did not involve maternal grandparents or the aunt, or consider how these adults as a naturally occurring network around Child C, could commit to ensuring the child’s future safety. It is unclear why these important family members were not involved in exploring what safe care would look like for both Child C and Baby A and how it   80 could be achieved. There is no exploration about why they were not invited or whether they chose not to attend the many meetings concerning the care of Child C and later Baby A.  These issues are not examined in the CSC IMR or explored in any depth in the IMR reports despite these family members being identified as key protective factors in the lives of Child C and Baby A.   7.6.32. There are inferences in the CSC IMR that there were tensions between LB and her mother but these are not explored in any detail in the IMR nor in any multi-agency meetings. There are no references to LB’s relationship with her sister and it is unclear whether there is any contact at all between the siblings. Despite the apparent tensions the grandparents and the aunt are clearly committed to Child C and Baby A whatever difficulties they have with LB and her drug taking. This in itself presents a significant picture of the dynamics of the extended family, which merited further reflection and should have been a key feature of both Child in Need and Child Protection Planning.   7.6.33. Despite the lack of meaningful outcomes from the interventions agreed in multi-agency meetings in 2011, the same interventions and plans continued throughout 2012, indicating a lack of a review about the plans and how or if these were effecting change.  This is a serious omission, which led to Baby A being placed with the maternal grandparents, albeit on a Child Protection Plan but without any robust assessment being undertaken.  7.6.34. The author has not had sight of any actual plans but has seen minutes from Child in Need and Child Protection meetings where the ‘plans’ appear to be a list of actions, tasks and broad goals. Clearly specified outcomes were not recorded making it almost impossible to measure progress and review the effectiveness of interventions.   What is striking in this review is that what was known about LB’s parenting capacities and lifestyle in February 2013 is not significantly different to what was known in April 2008. This suggests that planning was not effective and assessments not robust enough to inform good quality decision–making throughout the period under review.  Had longer-term planning been considered, for example in February 2011, alongside a robust assessment of risk, the need for Child C to be placed for the second time on a Child Protection Plan in December 2011, may have been avoided.    7.6.35. When Child C was made subject to Child Protection Plan in February 2011, LB agreed to the child being placed with her parents but the status of this placement is not explored and there is no reference to a s20 agreement, a viability assessment or a Regulation 24 Assessment.  It would seem that because LB had given her consent for Child C to live with close family, the risks were thought to have been removed and the need for the Local Authority to consciously consider whether Child C’s case would meet the threshold for Care Proceedings was negated.  The subsequent discussion with the Legal Department should have triggered a greater degree of reflection and encouraged a more robust long-term planning process, with clearly defined and measurable outcomes, but this does not appear to have happened.     7.6.36. The decision to instigate PLO procedures was made following a legal briefing on 14th December 2011 just prior to the Initial Child Protection Case Conference for   81 Child C.  By March 2012, the Local Authority had decided to instigate Care Proceedings, but these were not progressed until May 2012.  The Team Manager attributed the delay to capacity issues in the Legal Team but the IMR author (CSC) appropriately notes that having the consent of the parent for a s20 meant there was less urgency, as the child was ‘probably considered effectively safeguarded’.  The author would question the validity of this assumption, as the risks related to where Child C was placed and with whom had not been properly assessed.   7.6.37. Child C was made subject to an Interim Supervision Order on 29th May 2012 and a decision taken the following day at the Looked after Child (LAC) Review meeting to end the Child Protection Plan.  There is no clear rationale offered for this decision but there is a question as to whether Child C’s status as a child needing protection became more obscure as a result of this decision. The fact that they were a Looked After Child seems to have contributed to the view that the child was safe and would continue to be so. However, the risks related to the regular contact with LB were minimised and not adequately assessed, factors which are also apparent when Baby A was placed with grandparents after the discharge from hospital.  7.6.38. Despite professional views to the contrary, some records suggest that LB and NX were co-operating with services. LB believed that providing she could demonstrate she was ‘clean’ for a period of time, her child would be returned to her care and there was a rationale for this view given her past history with professionals. For Baby A, it is fair to assume both parents also thought their baby would be returned to their care once they were able to ‘prove’ they could be responsible parents. However, given the lack of clearly defined plans and specified outcomes, it is easy to see how these parents might have understood that they were working towards shared and agreed goals, whilst the professionals thought differently. Good quality plans can minimise confusion and mistrust.   7.6.39. LB agreed to voluntary care for both Child C and Baby A but there do not appear to have been any contingency plans in place in case consent was at any time withdrawn. This was short sighted and could have led to a crisis situation if the maternal grandparents had at any time said they were unable or unwilling to look after either child or if LB or NX had decide to remove either child from the care of the maternal grandparents.   7.6.40. The action plans seen by the Overview Author for this and other reviews are extremely poor.  They tend to be formulated from more of a strategic perspective rather than from an operational one and this left the detail of what had to be done, and the measurement and evaluation of progress vague and unfocussed. There was also a widely-held assumption, clearly evident throughout the IMR reports, that the responsibility for the production and management of these plans lay with CSC, rather than with Core Groups or care teams. This view should be challenged as for Child in Need and Child Protection Plans to be effective, they need to be of good quality and ‘owned’ by all the parties involved, including the parents. This is a vitally important issue and one which should be carefully considered by LSCB and its partners.  Multi-Agency Recommendation 4    82  Assessment of Parenting Capacity 7.6.41. Key research findings relating to assessments of parental capacity include the importance of understanding the basic requirements of parenting and of considering the parent’s ability to change (Jones, 2009) 29.  In relation to LB, professionals did not do enough to ensure that LB and NX fully understood their concerns and what was expected of them in terms of their parenting. Both LB and NX were subject to a psychological assessment during Care Proceedings in October 2012. This report suggested that further psychological testing would be of benefit to determine the likelihood of LB   being able to address her addiction in a reasonable timescale for Child C and Baby A.  A three month timescale was proposed but there is little to evidence this information was acted upon.   7.6.42. Despite the views of professionals to the contrary, neither LB nor NX were given what might be called 'managed opportunities' to change. ‘Support’ was offered on the basis of drug testing and ‘Child Protection monitoring visits’ only. What both adults needed was to be informed and helped to understand what needed to change, how change would be assessed or measured and over what time scale. Equally important, was a need to understand what support they could expect and the consequences if no or insufficient changes were made. There are various models which can be used to assess motivation and readiness for change and to help individuals engage with professionals but these were never discussed or explored.  7.6.43. Research suggests that an outcomes-focussed approach may be particularly appropriate when working with families for whom parental substance misuse is an issue. One of the key challenges in thinking about outcomes in the context of parental substance misuse is the existence of many competing needs, including those of the parent, the child and the family/extended family as a whole. Meeting these needs is a challenge. While acknowledging this tension, evidence suggests that working in an appropriate way with the parent can lead to improvements in the outcomes for the child. However, research suggests that while remaining child-centred, work with families affected by substance misuse inevitably requires a large amount of direct work with parents and this was not evidenced in this SCR, despite a considerable amount of commitment from Health professionals and P1-SMTP.   7.6.44. It seems possible, that without clear and focussed plans, professionals made assumptions about what work was being undertaken and with whom, calling into question issues about multi-agency collaboration. 7.7. Multi-Agency Collaboration   Finding 3  A lack of robust multi-agency challenge and collaboration across agencies regarding decisions, plans and thresholds resulted in ineffective interventions. (Also identified in Learning Lesson Review 2013)                                                   29 Jones, D. (2010) Assessment of parenting. In: Horwath, J. (ed.) The child's world: the comprehensive guide to assessing children in need. London:   83  Finding 4 A lack of clarity about roles and responsibilities inhibited good communication information sharing and progress.  Partnership working 7.7.1. Research 30  suggests it is important that professionals from all agencies work collaboratively, sharing knowledge and expertise if children are be supported and protected.  Agencies have a collective responsibility to protect children and this demands effective communication and co-ordination of services at both strategic and operational levels. Professionals also have a shared responsibility to arrange appropriate packages of support for vulnerable families.   7.7.2. As a consequence of Child C being subject to Child in Need and Child Protection Plans, formal partnership working between agencies was in place throughout the entire period covered by this review.  Initially, four key agencies formed the basis of the multi-agency partnership, Children’s Social Care (CSC), Health Visiting Services (HV), the Children’s Centre (CC) and P1-SMTP (a substance misuse treatment provider).   7.7.3. As Child C grew older, a key worker from the Primary School replaced the Children’s Centre involvement and a School Nurse became involved. Once LB’s pregnancy was confirmed in September 2012, Midwifery Services were active in working with LB. The Probation Officer became involved only in the latter stages of the review.   7.7.4. The GP did not attend any meetings in relation to either Child C or Baby A but was kept informed by the Health Visitor 2.  The Practice also received regular updates from P1-SMTP so they were aware of LB’s substance misuse. However, this knowledge did not trigger a referral to CSC when it became known that LB was pregnant in 2012. The IMR author (GP) also notes the absence of any communication between the Midwives and the GP and points out that good practice would suggest that regular multi–disciplinary meetings in the Practice should take place so that information could be shared about vulnerable children. The IMR author identifies a number of weaknesses in systems and practice, which limited their contribution to this review but suggest a numbers of ways these could be addressed and these if implemented, would enhance communication and information sharing for the benefit of vulnerable children and their families in future.   7.7.5. Northumbria Police did not attend any of the three Initial Child Protection Conferences but gave apologies and explained their informed decision not to attend was based on an examination of what, if anything, they could contribute. In response to more general concerns about the absence of Police attending Child Protection meetings, Northumbria Police reviewed their organisational structures to align the teams with a geographical area and attendance at these Conferences have now increased.                                                   30 Safeguarding in the 21st Century – Where to now Research in Practice 2010.    84 7.7.6. The Core Group comprising of social worker(s), Health Visitor(s) and P1-SMTP representatives remained relatively stable until the end period of this Review.  7.7.7. Despite significant efforts from some individual practitioners, a lack of multi-agency collaboration was clearly evident.  Over 35 multi-agency meetings took place between January 2011 and April 2013, yet it would be difficult to describe the work undertaken as being collaborative. Multi-agency working is about different services joining forces in order to work effectively with children and families. Upon reading the various IMR reports however, there is little evidence of joined-up working, or indeed joined-up thinking.  That is not to say there was no collaboration between agencies at times, the communication between P1-SMTP and the Midwifery practitioners in the period leading up to Baby A’s birth was an example of good information sharing and the liaison between Health Visitor 1 and the Children’s Centre helped to keep Child C in focus, but these examples are more about shared communication between individual practitioners rather than an outcome of effective multi-agency working.    7.7.8. From a procedural perspective, the actions undertaken by professional workers when concerns about Child C and unborn Baby A were raised were timely and responsive. The appropriate multi-agency meetings were established and initial meetings took place regularly within agreed timescales.  What is more important however, is the quality of partnership working and the extent to which partners were or were not involved in the subsequent planning and how this impacted on decision making.   7.7.9. Reading the IMR reports, there is a sense that a mechanistic approach predominated and it could be argued somewhat provocatively that professionals seemed to have attended the same meeting almost 30 times over. Whilst there was a clear commitment from practitioners to, in the main, attend these meetings and contribute to them, there were few imperatives to challenge or question their continued focus. A degree of ‘group think’ appears to have emerged in which members of the group failed to question whether planned interventions were working or if the group’s accepted wisdom about the best course of action should be reconsidered.  The ‘accepted wisdom’ in this case was that LB had to continue taking drug tests until she had stopped her substance misuse for an unspecified period of time.  However, the lack of challenge in this respect may also have centred around the professionals not reflecting for themselves about their own role and widely held assumptions, an issue further explored below.   7.7.10. There were some challenges made, across agencies and within individual supervision sessions but these related broadly to procedural and administrative issues and on the whole emanated from health colleagues.   Roles and responsibilities 7.7.11. The value and purpose of multi-agency meetings lies not simply in their taking place, but in the opportunities afforded to having active, reflective and robust discussions about how to best safeguard a child’s interests. What was missing in work with this family was any sense of cohesion between practitioners; there was no sense of team working and little evidence that practitioners were working together towards the same goal.  Roles and responsibilities were never clarified   85 and a lack of role demarcation led to fragmented and piecemeal interventions. Health Visitor 1, for example, appeared to be doing many of the tasks more commonly undertaken by the social worker, that of co-ordination and liaison and yet this does not appear to have been challenged or raised as an issue.  In contrast it is difficult to be specific about the social work input as there are few details about how the social workers were actually working with LB, what they were doing and what this achieved.    7.7.12. The involvement of Children’s Centre and nursery staff at the Primary School from both agencies appears peripheral and passive. Despite their skills and knowledge about Child C – they knew Child C better than any other professional – they do not appear to have been instrumental in helping other practitioners learn more about what life was like for this child or asked to undertake specific work which would keep the child in focus.  There is little evidence of their active involvement in multi-agency meetings but this is not explored in the Children’s Services Education IMR.  Both the Children’s Centre and the Primary School were key agencies yet the minutes of Core Groups and Child in Need meetings do not reflect this, further highlighting that LB was the focus of interventions and not Child C.  There is little in the IMR report for Education to suggest any specific concerns in relation to Child C, although the likelihood of significant harm is inferred through the many references to LB‘s drug taking and life-style.  References to LB from these professionals are broadly positive indicating she did engage with both the Children’s Centre and the Primary School.   7.7.13. Northumbria Police also remained on the periphery in this case despite the concerns around drug dealing and criminal activity.  There is no sense that as an agency the Police were working in partnership with others despite the reports provided and their involvement in strategy discussions.   7.7.14. Communication is identified within literature as the most common facilitator of multi-agency work and good communication is considered key to its success. Coupled with this, is the need for clarity of purpose through the establishment of clear and shared aims and objectives. These aspects were all missing in this case and continued to be so throughout the entire period under review.  Practitioners did not always have the right information about what was expected of them or what their colleagues had been told by LB and this led to professionals working in ‘silos’ as sole practitioners.    7.7.15. It is clear from reading reports from various agencies that interventions with this family could have been more effective if the professionals had been supported to actually work as a team and shared knowledge and understanding of some of the issues.  A key area of learning emerging from other SCRs, known to the Overview Author, is that professionals very often do not know or understand how other agencies work and very rarely do they ask. For this case, individual practitioners were in the main, very knowledgeable about their specialist area and yet this valuable expertise was not shared for the benefit of joint working.  The knowledge held by P1-SMTP practitioners about substance misuse should have had more of an impact on decision-making reminding others about addictive behaviours and how this could impact on compliance and timescales. Similarly, the Health Visitor and social worker might have shared more about neglect and its impact on the   86 developing child and the importance of P1-SMTP practitioners having the child’s needs at the forefront of any work they undertook with LB.  Significantly, what emerges throughout this Review is that the social workers were perhaps not as clear as they should have been about their role in co-ordinating work and keeping the child in focus.  There is much to learn about multi-agency working from this Review.   7.7.16. For partnership to work, and this includes parents, there must be clear communication channels and agreements of who does what and by when and most importantly, agreement about what ‘success’ will look like. All this needs to be co-ordinated and as the key partner agency, this was the role of CSC.  Given however, that Child Protection and Child in Need processes are not solely the responsibility of CSC and the importance of ensuring there is a genuine sense of joint responsibility, the Overview Report includes a supporting recommendation for multi-agency practice.  Multi-Agency Recommendation 5    Reflection and Building Hypotheses 7.7.17. It is apparent from the IMR reports that there has been limited reflection from practitioners about their role in multi-agency decision-making and why they did not recognise or challenge the lack of leadership in meetings or the lack of progress. These are issues, which should have been explored in more detail by the IMR authors, as they are fundamental to learning about whether things need to be done differently in future.   7.7.18. The multi-agency meetings focused on describing events or behaviour most often related to LB but there is no evidence to suggest these opportunities were used for reflection and analysis or to develop hypotheses. The evidence from this Review suggests that the information recorded at meetings or the assessments, to which they referred, were largely variations of the same information recycled and reiterated. There was certainly no sense that within single or multi-agency settings, narratives were emerging in which new insights were encouraged or developed.   7.7.19. In these conditions, it is perhaps less surprising that much of the practice reflected in this case was one dimensional and static and led to a preoccupation with LB and her substance misuse. As a direct result, other ways of working with family members including NX and extended family members, were never explored and significantly the notion of exploring what ‘safety’ would look like for Child C was never given prominence.  The view that ‘safety’ meant being removed from mother’s care was sadly found to be flawed given that Baby A died whilst with LB in the maternal grandparents home.   7.7.20. Munro (1999) highlighted that failing to revise risk assessments and judgement, is a common error amongst professionals in child protection work and one, which was not always recognised. The value of using hypotheses in work with families is widely reported but in the author’s experience is rarely used to its best advantage in multi-agency work and this approach would have been helpful in work with this family.  Multi-Agency Recommendation 6     87 Chairing of meetings 7.7.21. Chairs of meetings and especially those chairing Child Protection Conferences must push themselves to encourage dissent and be open to challenge, sometimes even adopting a ‘devil’s advocate’ position to facilitate this process.  There is not enough evidence of such practice in this review, although there are examples of the Independent Chairperson challenging a lack of information or non-attendance from a specific agency.   Nevertheless, the chairing of the Child Protection Conferences and reviews were not sufficiently robust and allowed a naive optimism to emerge as the risks to Child C were minimised and remained unassessed.  Minutes were not routinely circulated within acceptable timescales and tasks identified at previous meetings were not routinely followed up.   7.7.22. The IMR author fails to explore any of these factors in sufficient depth and does not offer any reference to the report prepared by an Independent Chairperson and colleague in November 2012, for LSCB. This report highlighted some of the barriers and difficulties facing Independent Chairperson(s) and in response the LSCB developed an action plan to address some of the issues identified.  However, the Overview Author has had sight of this action plan and notes that of 17 recommendations only three actions have been signed off to date.   7.7.23. The Independent Chairperson chaired a relatively small number of meetings; most were chaired by the social workers. The Overview Author would suggest there is an urgent need to improve and expand the skills and knowledge of practitioners tasked with responsibility of chairing multi-agency meetings.   Multi-Agency Recommendation 7   Records of meetings 7.7.24. Another key issue relates to not only the chairing of multi-agency meetings and the formulation of effective plans but also how those meetings and key actions are recorded. The minutes of the Initial Child Protection Conference meeting on 4th February 2011 for example record that all agencies present agree with the plan but the records, while providing background detail shows little in the way of any analytical thinking.  The minutes from the Core Group and Child in Need meetings, which have been seen by the Overview Author and the SCR Panel, are woefully inadequate, although the author is aware that new formats for these were introduced in 2012.  Even so, it is clear that records of meetings were, too often, seen as just an administrative task rather than an essential tool to support multi-agency work with families.   7.7.25. The Children’s IMR author states that ‘minutes [of conferences] do not reflect the discussion in any detail’. She goes on to say ‘individual comments, opinion and professional judgement within the conference are not documented as the minutes are not verbatim’.    7.7.26. Whilst it is clear that multi-agency meetings and Conferences cannot be recorded in detail, there must be a more effective way of recording how and why certain decisions are reached. This is absolutely crucial, especially if parents and others cannot attend, as they need to be able to understand the rationale behind certain actions. The responsibility for disseminating these records lies with CSC and it is   88 clear from IMR reports that this is an issue that is of some concern to partner agencies, leading to individuals maintaining their own records for their files.    7.7.27. It is worthy of note that if this Overview Report had to rely solely upon records from CSC and the related IMR report, many details would not have been available. If practitioners are not confident about the process for disseminating timely and quality records of meetings then they will take their own notes - and it is clear that they do - and use these as their own agency records. This makes it more likely that judgments, decisions and agreed actions will be open to interpretation by individual practitioners.  Having based much of this report on records from key meetings and the records in files, the author is struck by inconsistencies and dissonance between what was inferred, what was actually said and what professionals and LB understood what was agreed.   7.7.28. In the STNHSFT report, for example, there is a sense that Health Visitor 1 was deeply frustrated by what she seemed to think was unnecessary ‘drift and delay’ and her concerns are clearly evident from that agencies’ IMR report. Yet, there is no evidence of dissatisfaction or frustration evident from the notes of multi-agency meetings and no records to suggest these minutes were challenged.   7.7.29. These findings indicate a significant flaw in the way information is shared and recorded at multi-agency meetings. Enabling all the contributors to feel confident about their individual contributions and encouraging healthy debate and challenge is not an easy task, but it is made all the more difficult if there is poor or non-existent record keeping.  The extremely poor quality of the records of meetings accessed by the author and the absence of robust plans that are easily understood by all parties are significant failings which were not without impact on LB and consequently Child C and Baby A.  Multi-Agency Recommendation 8  7.8. Practice and Patterns in Professional Judgement  Finding 5 ‘Professionals did not fully understand or effectively assess, LB’s capacity to change her behaviour within Child C’s timeline and this left Child C and Baby A vulnerable.’    Finding 6 Professionals were falsely reassured about Baby A’s safety even though, or possibly because of, the baby was the subject of a Child Protection Plan.   7.8.1. Quality assessments and good planning are important, but they are not the only factors that affect outcomes for children. A number of other factors are involved including parental behaviours and importantly, their motivation to change. Recent research by Ward et al31 on infants at risk of significant harm found that most parents, if they are going to make positive changes in caring for their children, have done so within six months.                                                   31 Ward et al.     89 7.8.2. Concerns about LBs drug taking and the impact on Child C were addressed through Child in Need and Child Protection processes at various times over a six-year period. Professionals working with LB however, had unrealistically high expectations of what she could achieve and adopted a ‘natural love’ bias which mistakenly assumed that she would stop taking drugs, if to continue doing so, meant she would lose Child C and later Baby A.   7.8.3. LB had been using drugs since she was in her late teens and contrary to some reports, was often honest with professionals admitting that she used drugs, usually heroin, when she was stressed or worried.  It is highly likely that this was an over simplification and LB, like many individuals with addictions, significantly minimised her dependency on illegal substances.  Drug dependency is a chronic relapsing condition, typically marked by dramatic swings between relative stability and chaos. Despite the experiences of the professionals involved, it is clear from records that they believed LB could stop using drugs with support and by changing her behaviour and lifestyle.  Throughout the period under review, professional efforts focused on LB.  Whilst this is recognised in several IMR reports, the authors do not reflect on why the parent and not Child C remained central to their efforts.   7.8.4. Child C was described in reports as meeting developmental milestones, being small in weight and needing help with speech in development but in general was seen as a sociable and confident child. It is possible in perceiving Child C to be progressing ‘reasonably’ well, and without any crisis or incidents upon which to focus, professionals found it easier to turn their attention to LB and it was her need to have Child C returned to her care that dominated their work.   This perspective can be evidenced from minutes of multi-agency meetings and was reflected in the recordings from key agencies.   7.8.5. During the period under review, January 2011 to April 2013, thirty-five multi- agency meetings took place, the vast majority of which related to Child C, yet a significant number of the notes from the meetings centred around LB.  Whilst drug testing suggested that she could respond to treatment and refrain from substance misuse for several weeks, records also show she was unable to sustain this for any significant period of time and was unreliable at keeping random test appointments. This pattern, evident over several years and occurring through five pregnancies was not given due prominence and in relation to Child C, allowed the case to drift. The professional pre-occupation with LB’s substance misuse and testing overshadowed a more objective examination of her capacity, willingness and motivation to change. This led to professionals repeating the same interventions over and over again and yet expecting a different outcome.   7.8.6. Brandon et al32 consider the importance of analysing rather than simply identifying what is known about a family’s history and warns without such an analysis there is a risk of falling into the trap of what is referred to as the ‘start again syndrome’. Whilst the existence of previous evidence of poor and compromised parenting should not mitigate against the possibility of change, agencies should also be aware of repeat patterns of behaviour. There is no evidence of this issue being                                                   32 Understanding Serious Case Reviews and their Impact – A biennial Analysis of Serious Case Reviews 2005-2007.    90 explored in any depth either in multi-agency meetings or in individual supervision sessions.  7.8.7. The term single loop learning describes a process commonly used in social work interventions.  It means that professionals work with parents to help them understand why there are concerns, what they need to do and what needs to change to keep their child safe and well.  Whilst the author would question to what extent this occurred in work with LB and her family, the process is well understood in social work settings.  Whilst, this approach is valuable, Munro (2011) suggests that professionals should take the time to question and challenge the assumptions and beliefs that underpin the work they do with families - a form of ‘double loop’ learning.   7.8.8. If we extend this approach to work with LB, professionals assumed the issue was LB’s drug taking and therefore efforts were concentrated on and around that perceived problem.  Had they either collectively or individually been encouraged to challenge their thinking they may well have been reminded that the reason for their involvement was about how to keep Child C safe and well in both the short and long term.  As a result of the parent and not the child being at the centre of their work, professionals failed to consider how Child C could be kept safe in the future even if LB did not or could not stop her substance misuse. The focus on LB’s needs and vulnerabilities overshadowed other hypotheses as to what future safety might look like not only for Child C but also for Baby A.    7.8.9. The ‘neglect’ identified as the reason for both children being subject to Child Protection Plans, was not at the chronic end of the spectrum, and the willingness of the grandparents to care for their grandchildren appears to have led to a sense of complacency on the part of CSC. The long-term needs of the children were not considered in enough detail and neither were the emergent patterns of repeat behaviours and professional responses.  The emphasis on short-term solutions and the apparent unwillingness to think about the long-term needs of both children, suggests amongst other factors, the possibility of professional bias.   7.8.10. There is little information recorded in the IMR reports about why, in this particular case, there were concerns about the impact of LB’s substance misuse on her ability to parent Child C and Baby A. This is not to suggest the concerns were not justified, but highlights the lack of clear and concise recording, which explained the rationale for the involvement of services and the progress that was or was not being made.  Professionals need to be mindful of the dangers of making assumptions without assessments and using intuition as the only basis on which to make judgements.  Whilst intuition has a place in the reasoning processes that are needed, drawing as it does on professional life experience and practice knowledge, it is prone to bias and may lead to premature or inaccurate judgements.   7.8.11. There are many contradictions apparent in reviewing professional involvement with Child C and Baby A.  On the one hand there were health and social care professionals expressing concerns about LB’s drug taking resulting in Child C and later Baby A being made subject to Child in Need and Child Protection Plans. Conversely, there was also a willingness to consider that LB’s many missed appointments at P1-SMTP were inconsequential as long as the drug tests when   91 they were undertaken could show that she was ‘clean’.  This led to the absence of  ‘healthy sceptism’ and a naive optimism which resulted in Child C being subject to Child in Need and Child Protection Plans for almost four years since birth and little, if any change, being noted in mother’s substance misuse.   7.8.12. Whilst professionals need to develop ‘a dialectic mindset’ in which there is a constant balancing of opposing arguments, alternative hypotheses or conflicting versions of events, without structured opportunities to explore these issues further, certain biases emerged which impacted on the failure to make timely and appropriate decisions.  This is clearly evident in work with this family.  7.8.13. Research suggests that professionals need to take active steps to work against ‘our human tendency to seek only the information that we wish to find’, and confirms the dangers of a tendency to ‘stick to what we think we know’ and carry on with the plans without question or challenge.  Fish (2009) writes ‘one of the most common, problematic tendencies in human cognition ... is our failure to review judgements and plans – once we have formed a view on what is going on, we often fail to notice or to dismiss evidence that challenges that picture.’   7.8.14. Whilst there are descriptions in the IMR reports about LB failing to engage with services or professionals, there are virtually no records, which describe her personality or personal characteristics. What does emerge however is a picture of a mother clearly addicted to opiates, who did not want to relinquish care of her child/children and tried to convince professionals that Child C and later Baby A, should not be removed from her care.    7.8.15. Confirmation bias33 is the tendency to focus on evidence that is consistent with already held views or preconceptions and ignoring evidence, which contradicts this view. This bias may have prevented professionals from asking questions about what Child C meant to LB and importantly, what she meant to that child. The issues of Child C’s emotional care and security were not routinely explored despite information, which suggested there was an attachment and a bond between mother and child.  It is important to note here that the author is not suggesting that the eventual steps taken to safeguard and protect both Child C and Baby A were inappropriate but that a more questioning and reflective approach, would have identified the need for securing a stable and nurturing environment for Child C and possibly Baby A, at a much earlier stage.   7.8.16. There was a significant lack of interest in, or information about NX, although he was the father of Baby A.  Apart from an antenatal visit by Health Visitor 3 in mid-January and his visits to his Probation Officer, there appears to have been no visits undertaken by the social worker or any other professional, with the primary purpose of getting to know more about him and to explore his position within the family. There is no information about why he has no contact with any of his children and although there are several references to his eldest daughter, there are no descriptions about the quality of that relationship. There are references in IMR reports to his being a good influence on LB, he was noted to have given up work so                                                  33 Gambrill, E.D. (2005) ‘Decision-making in child welfare: errors and their context’, Children and youth services review, vol 27, 4, 347–352.   92 he could better support LB and he wanted to act as a carer for both Child C and Baby A, yet there was little written about any face-to-face family meetings with NX being present.  7.8.17. The Overview Author is mindful of research, which suggests a tendency on the part of professionals to ignore the role of significant or transitory males in families and focus their efforts on mothers, despite the contact these men have with children in those families.  The term ‘hidden male’ is now common parlance and there is recognition that the role of the partner/father/husband in the family must be properly assessed to not only identify potential risks but also to explore their new and emerging role in relation to children within the family. 34   Given that LB and NX were married in December 2011, there are surprisingly few records which would indicate he was regarded as a significant individual in the lives of either Child C or his own child, Baby A and this is a serious omission which is not explored any of the IMR reports. The other male about who very little is mentioned is the maternal grandfather, despite his key role in offering care to three of his daughter’s children.    7.8.18. The issue of practice knowledge in relation to substance misuse, neglect and vulnerable babies is a key issue in this Review and one which has been identified in other reviews in Sunderland.   It would appear that there was an absence of underpinning knowledge and awareness in relation to these interrelated risks   despite the work of the LSCB in bringing the learning from previous reviews to the attention of frontline practitioners. It is significant that IMR authors did not refer to learning from these reviews or comment on the role for supervision in providing an opportunity to reflect on how local and national learning is used effectively in driving up the level of expertise of practitioners.  Multi- Agency Recommendation 9  7.8.19. Good assessment is a complex activity. It involves the systematic and purposeful gathering of information, more than simply gathering 'facts'. It requires a range of knowledge and skills including the capacity to think analytically, critically and reflectively.  What is significant in this Review is the absence of any of this type of work or any records of ‘social work practice’.   It is difficult to review what work was actually undertaken with any family member and although the IMR author for CSC comments on the social worker not having an appropriate level of understanding about key procedures, she does not explore in any detail the comment made by social worker 3 that her experience in USA was of a different kind of ‘social work’ and she was used to a more ‘hands on approach’ as opposed to undertaking assessment and analysing facts. It is possible that these details do exist and are not referred to in the IMR report, but that in itself is a concern and calls into question the IMR author’s understanding of what constitutes an IMR.   7.9. Management and Supervision   Finding 7  There was a concerning lack of managerial oversight in CSC which led to drift and delays and a failure to take protective action despite clear indications over a six                                                  34 Cheshire and Knowsley Child Development Programme:  The Hidden Male: A study of Merseyside Serious Case Reviews  2009.   93 year period that the parent was not capable of changing her behaviour to meet the needs of Child C and Baby A.   Finding 8 Robust managerial practice, which supports reflective supervision, is central to supporting critical thinking and good assessments in multi-agency work but in CSC, good supervision and case audit in this case, did not take place.   Managerial Oversight 7.9.1. Besides supporting frontline staff, managers have a duty to monitor the functioning of the organisation and to check that responsibilities are being met. There is evidence that managers within the Community Health Services and P1-SMTP had some managerial oversight in respect of the work undertaken by their frontline practitioners, but even so there was little challenge from the managers in Community Health Services about the drift in this case. Although the Health Visitors were advised by their managers at times to put their various concerns in writing, the managers themselves did not escalate concerns at any time to the respective managers in CSC. These actions should have been taken, especially when it became apparent that agreed assessments had not taken place or agencies had not been consulted about their contents.   7.9.2. Whilst some managerial oversight is evident from other IMR reports, there is far less to evidence robust managerial oversight in respect of the work undertaken by social worker 2 and social worker 3 and given the lack of experience of social worker 3 in working in the UK, and this is of some concern.   Research35 suggests that while managers in all agencies who work with and on behalf of vulnerable children cannot be expected to micro-manage or know the detail of every case in their area, they do need to ensure that quality assurance systems are in place so that team leaders and front-line staff can readily identify where things are going wrong at an early stage and can take early corrective action.  CSC were involved in the life of Child C for almost all of the child’s life and yet failed to seek measures over several years which would have offered the child stability and protection and would undoubtedly have highlighted risks to Baby A at a much earlier stage.    7.9.3. The advice from the Legal Section that suggested there was not enough evidence to seek Interim Care Orders should have alerted management to examine why that evidence was not available, given professionals concerns and their involvement over such a significant length of time.  There is no evidence to suggest that the drift, clearly evident in this case, was ever explored but neither does the IMR author seek explanations from practitioners or managers to understand what factors might have influenced professional judgements in this case.   7.9.4. As the lead agency, there should have been much greater scrutiny around the assessments and why they were not completed or undertaken. The messages from the IMR report is that the manager was not aware that the assessments had not been completed and were outstanding.  Equally there was no managerial oversight into how and why certain decisions were or were not made. This is extremely poor                                                  35 (House of Commons Health Committee 2003).     94 practice and left Child C and Baby A in a vulnerable position. Acknowledging the points made above about micro-management, there were however, enough indicators in this case to suggest that managerial oversight should have been a high priority - the substance misuse, neglect and the impact on children under five years old, vulnerable babies, these are all key risk indictors well evidenced in research. This, together with a social worker inexperienced in UK social work practice and being unfamiliar with child protection procedures and presumably national research, should have led to significantly more involvement from the Team Manager and greater oversight that is apparent from IMR report.   7.9.5. In this SCR, the Overview Author and the SCR Panel are concerned to note that this Review and others like it highlight the same issues, many of which relate to poor practice in CSC. If the reasons for these shortcomings are not explored and addressed by senior management, similar errors will keep occurring and this will leave children at risk and vulnerable.    7.9.6. The failure of the IMR author (CSC) to explore these important issues again brings into sharp focus the importance of agencies understanding what is required from them in the SCR process. It also highlights the importance of selecting the right person at a senior level in the organisation to undertake these reviews. This is not a direct reflection on the competence of the IMR authors who produced the reports for CSC, it is however a challenge to senior management to question and review their commitment to the SCR process.   7.9.7. Given the findings from previous SCRs in Sunderland and in the light of Edward Timpson’s letter36 to the Chair of Bradford LSCB, the Overview Author would urge an early meeting to include the LSCB Independent Chair, the Chief Executive and Director of Children Services to discuss and agree a way of addressing and progressing the issues related to CSC and outlined in this report.    Multi-Agency Recommendation 10  Supervision of practitioners  7.9.8. A key line of enquiry in this SCR is the extent to which practitioners had ‘sufficient and appropriate supervision’ and whether this ‘promoted critical reflection’.   7.9.9. ‘Supervision’ has different meanings and formats for the various agencies that make up the safeguarding partnership. Its components vary between settings, however the Children’s Workforce Council has provided a helpful definition, which identifies three key aspects, “Line management, which is about accountability for practice and quality of service. This includes managing team resources, delegation and workload management, performance appraisal, duty of care, support and other people-management processes. Professional supervision (sometimes described as case supervision) with workers or groups of workers to enable and support quality practice. A key aspect of this function is reviewing and reflecting on practice issues. This may include reviewing roles and relationships, evaluating the outcomes of the work and maximising opportunities for wider learning.  Continuing professional development of workers to ensure they have the relevant skills,                                                  36 https://www.gov.uk/government/publications/serious-case-review-for-hamzah-khan-government-response.   95 knowledge, understanding and attributes to do the job and progress their careers. Constructive feedback and observation of practice should be part of the learning process for workers and supervisors.”  7.9.10. In considering the role of ‘supervision’ in this section of the analysis, the term will be used to encompass more than just individual supervision within the line management context, but also any other models that incorporate the functions as outlined above.   7.9.11. Reflective supervision is the regular collaborative reflection between a practitioner and supervisor that builds on the supervisee’s use of thoughts, feelings and values within a service user.  Importantly reflective supervision provides the support needed by practitioners who are exposed to the intense emotional content and life experiences related to their work with families.   7.9.12. Evidence from the IMRs suggests that formal supervision took place regularly for the Health Visitors, the School Nurse and Midwifery staff, the practitioners in P1-SMTP and for some staff within the Children’s Centre. Staff within the Primary School had less structured opportunities but did have access to their Designated Officers and the Education Safeguarding Team when necessary.   It is not possible to say whether during these sessions there were opportunities for reflective supervision, as the authors of the relevant IMRs did not address this issue in sufficient detail. Whilst the author of the STNHSFT does describe supervision of Health Visitor 1 as being reflective, there is no detail given or exploration of what is understood by this and the author then moves on to refer to issues around accountability and processes.   7.9.13. The supervision of Health Visitor 1 at times appeared challenging and probing, but there is little to evidence that supervision offered Health Visitor 1 the opportunity to reflect on her work with LB and Child C despite evidence of frustration and waning energy. There are inferences that the relationship   between Health Visitor 1 and her line manager was not a strong one and this may have led to the decision of Health Visitor 1 in November 2012 to decline to continue to work with the family when LB’s pregnancy was confirmed. The IMR author does not explore this issue; nevertheless there is evidence that within health settings there is a strong commitment to supervision both in terms of clinical practice and managerial accountability, although the latter appears to be cited more frequently.   7.9.14. The group supervision sessions in P1-SMTP were regular and relevant and offered appropriate guidance and challenge to practitioners, which allowed them to usefully contribute to Core Groups and Child in Need meetings.  However, there were several occasions when information was not shared promptly and practitioners failed to ask about or comment about Child C. The IMR author does not comment on these issues and neither does she comment upon the shortcomings and limitations of group supervision in terms of reflective practice.  7.9.15. The effective supervision of practitioners within CSC is a crucial feature in safeguarding children.  The guidelines and procedures for the Department state ‘Supervision must allow time to address the monitoring of casework, management of time to complete organisational tasks arising from that casework, [and should]   96 include, supportive and challenging reflective practices to assist staff to consider their practice and professional development thinking’.  The IMR author states that she could find no evidence that this was being consistently followed for any of the workers involved but does not consider why this should be the case.   7.9.16. Social worker 2 had only two recorded supervision sessions between February and May 2011. Social worker 3 had supervision on 28th August 2012, 26th February 2013 and 12th April 2013. Some supervision notes were available to the IMR author and she states that only in the February 2013 session with social worker 3 was there any evidence of some reflective supervision, although she also notes that ‘neither Baby A or Child C were discussed at that session’.   7.9.17. The Team Manager made significant comments about workload pressures and how these were impacting on her own performance, presumably meaning she didn’t have time to offer supervision to social worker 3 or monitor her work on a regular basis. These issues however were not explored in sufficient depth and neither was there a detailed exploration of the quality of supervision that Team Manager received from her line manager. These are the pivotal issues, which should have been analysed by the IMR author in order for the SCR Panel to better understand why certain practices happened and the extent to which they may have reflected on wider practices across the Authority.   7.9.18. The Independent Chairperson was able to produce only one supervision record and informed the IMR author that whilst he was aware of the Department supervision policy, he could only recall receiving two supervision sessions in 2012 and two since April 2013.  He informed the IMR author that the consequences of his high caseload and his manager working part-time made it ‘very difficult to fit in regular meetings’.  The IMR author makes no comment on this issue despite the policy statement of the Department and evidence-based research, which clearly links quality supervision with positive outcomes for children.   7.9.19. The Fostering Officer was able to produce only one supervision record, which related to the time period under review. Whilst the IMR author explores the content of that session and the subsequent sessions which took place from November 2012, she does not comment on the quality of these or explore to what extent supervisory practices across the Fostering Team offered scope for reflective practice.   7.9.20. It is apparent that there was a lack of managerial oversight in CSC, the Independent Chairperson Service and the Fostering Team. There is no evidence that the supervision where it occurred led to reflection about the overall approach being taken: the effectiveness of the Child in Need and Child Protection Plans; the need to review assessments of family members or to provide challenge to the optimistic mindset that has been identified within this report. It is not apparent either that key points in the history of the case which might have triggered a more comprehensive analysis, for example, the plan to return Child C home in September 2011, and the decision to place Baby A with the maternal grandparents led to such critical reflection.  7.9.21. There is clear evidence that supervision did not provide adequately challenging and reflective opportunities for those working directly with LB, her children and other   97 family members. The absence of any real engagement with the maternal grandparents and the apparent reluctance on the part of professionals to consider that LB continued to use heroin and would be unable to stop the addiction within Child’s C timeframe, was not addressed and should have been a key challenge in supervision for all the practitioners.   7.9.22. It is important to consider the possibility that the relationship between a practitioner and a manager can lead to ‘common thinking’ and therefore reinforce the sense of certainty that a worker may have developed about a case over time. This is a persuasive view especially given the way in which the same interventions and the same decisions were made to little effect over a two-year period.  There is evidence here to suggest that supervision did not succeed in robustly testing out ideas or challenging hypotheses.  However, the IMR authors in general offer no reflection on these issues and offer no discussion about how their organisation can develop and improve the skills and knowledge of managers and practitioners especially in applying lessons from research and local reviews and national SCRs. The message from literature would suggest it is not compliance with procedures that leads to the best outcome for children, but the depth and quality of professional practice and this is an issue, which should be further explored by the LSCB, especially given the findings from other reviews in Sunderland.   7.9.23. Whilst supervision of frontline practitioners has been the predominant focus, the supervisory needs of their immediate line managers also requires comment.  The skills and training of managers in providing supervision has not been raised in any of the IMRs but it is an issue of some concern given the comments noted above.  Robust senior management is required to support line managers whose responsibility it is to ensure practitioner’s work is consistent with statutory guidance and in the best interests of children and young people. It is of extreme concern that this review has highlighted such poor practice, especially in the lead statutory agency and steps should be taken by senior management to address this issue.   7.9.24. This review has identified various aspects of practice, both for front line practitioners and in relation to management structures, which suggest that reflection and review is not considered as a priority. Fundamentally this raises the question of the effectiveness of supervision arrangements where safeguarding children is concerned.   7.9.25. Reflective thinking and supervision can be achieved within a wide variety of such models, including peer supervision, team approaches and self-directed learning. Notwithstanding the fact that the LSCB has developed and reviewed Supervision Standards as recently as 2012, it is the view of the author that before making significant changes to the details or models of supervisory practice, partners within the Safeguarding Board should ensure there is a shared agreement on the underlying principles for supervision and consider the development of a shared strategic approach to this process.  Multi-Agency Recommendation 11   7.9.26. Finally, irrespective of what approaches are adopted in theory, in order for practitioners to develop the sort of reflective practice being promoted in this review, they will only be able to achieve this with the explicit and continuing commitment of   98 the LSCB member organisations to create the time and space for them to practice in this way.    7.10. Contextual Issues   Finding 9 There was evidence in this case that frontline practitioners repeated errors previously highlighted in research and local reviews, suggesting that learning from these processes was not reaching professionals or impacting on their performance and decision making.    7.10.1. An OFSTED inspection of Safeguarding and Looked After Children services in February 2012 stated that the overall effectiveness of safeguarding services were ‘good’.  The inspection report commented on a number of issues pertinent to this review:  • need to ensure that all assessments take into full account the views of children and families  • need to ensure that all Child Protection Plans are specific and measurable including clear timescales for action and that all core group discussions are effectively minuted so that progress can be monitored more effectively  • review the chairing of Conferences to ensure that they are chaired by professionals who have the requisite experience and expertise to undertake this role   • inconsistent evidence of first line management oversight in case records  7.10.2. In October 2011, Ofsted published a national report37, which referred to 471 SCRs evaluated by Ofsted between 2007 and 2011 concerning 602 children, 210 (35%) children were babies under the age of one year. This had been a consistent pattern across the four-year period. These figures have implications for practitioners and the report highlights include some key messages, which not only have a bearing on this review but also are clearly linked to findings emerging from it. The Ofsted report states that: • there were shortcomings in the timeliness and quality of pre-birth assessments • the risks resulting from the parents’ own needs were underestimated, particularly given the vulnerability of babies • the role of the fathers had been marginalised • there was a need for improved assessment of, and support for, parenting capacity  • there were particular lessons for health agencies, whose practitioners are often the main, or the only, agencies involved with the family in the early months • practitioners underestimated the fragility of the baby • there is an increased risk of Sudden Infant Death Syndrome where babies are born to mothers who have substance misuse addiction                                                  37 Ages of Concern: Learning Lesson from Serious Case Reviews October 2011.   99  7.10.3. The issues raised in this SCR – poor quality assessments, lack of robust planning and review, ineffective multi-agency collaboration and lack of managerial oversight and a stark failure to place the children at the centre of their work are failures identified in a range of research literature. These are also issues, which have been identified previously as failings within this Local Authority and therefore leads to the question of why problematic practice does not appear to be changing.  This issue has not been robustly explored in any of the IMR reports and the failure of senior management to sign off and take responsibility for the contents of these reports highlights a significant challenge for the LSCB in executing its function to hold agencies to account for their safeguarding practices.   7.10.4. In the absence of any analysis or suggestions by the IMR authors, the Overview Author would suggest that understanding what needs to change is easier than knowing how to change and the LSCB would benefit from an overhaul of the way in which reviews are conducted and lessons are disseminated.  Since this SCR began another SCR has been commissioned and a different approach has been agreed.  This is to be welcomed and will create a more inclusive approach to learning than the model used for this SCR.  7.10.5. However, the challenge will still remain as to how learning about what works or what needs to be done differently, transfers to frontline practice in single agency and multi-agency work.  Having had sight of various action plans and had access to the extensive work undertaken by the LSCB over the last two years, it seems clear that a different approach is required to minimise the chance of the same errors in practice reoccurring in the future. From the author’s experience, the key factors which inhibit learning across organisations are, lack of effective communication, lack of clarity about what needs to change, the absence of review mechanisms and limited opportunities for practitioners to discuss what is changing and why, and importantly, what they now are required to do differently.    7.10.6. It would be of benefit for the LSCB to review the process through which case reviews are undertaken and examine more effective ways of disseminating information so practice outcomes improve.  Multi-Agency Recommendation 12   8. The Findings   8.1. The Findings  Assessment and Planning Finding 1:  The absence of any robust multi-agency assessments to inform the development of good quality plans and decision-making left Child C and subsequently Baby A vulnerable. (Also identified in Learning Lessons Review 2012)   100  Finding: 2 Without skilled and experienced chairs, the multi-agency meetings lacked focus and direction leading to unspecified outcomes and poor reviews of progress.  (Also identified in Learning Lessons Review 2012)   Multi-Agency Collaboration  Finding 3:  A lack of robust multi-agency challenge and collaboration across agencies regarding decisions, plans and thresholds resulted in ineffective interventions. (Also identified in Learning Lessons Review 2012)   Finding 4 A lack of clarity about roles and responsibilities inhibited good communication information sharing and progress.  Practice and Patterns in Professional Judgement Finding 5 Professionals did not fully understand or effectively assess, LB’s capacity to change her behaviour within Child C’s timeline and this left Child C and Baby A vulnerable.    Finding 6 Professionals were falsely reassured about Baby A’s safety even though, or possibly because of, the baby was the subject of a Child Protection Plan.   Management and Supervision  Finding 7  There was a concerning lack of managerial oversight in Children’s Social Care which led to drift and delays and a failure to take protective action, despite clear indications over a six year period that the parent was not capable of changing her behaviour to meet the needs of Child C and Baby A.   Finding 8 Robust managerial practice, which supports reflective supervision, is central to supporting critical thinking and good assessments in multi-agency work but in Children’s Social Care, good supervision and case audit did not take place.  (Also identified in Learning Lessons Review 2012).   Contextual Issues Finding 9  There was evidence in this case that frontline practitioners repeated errors previously highlighted in research and local serious case reviews, suggesting that learning from these reviews was not reaching professionals or impacting on their performance and decision making.    8.2. Good Practice (this is practice where individual practitioners do more than is required as part of their role or service standards)   8.2.1. Health Visitor 3 undertook liaison role with agencies when information need to be shared.   101  8.2.2. The efforts made by the midwifery team to share information and to alert LB to concerns about the DVT were commendable, as were the attempts and the tenacity of the SSMM to put in place safety arrangements for Baby A in the hospital and on discharge where these had not been considered in the Pre-Birth Assessment.   8.2.3. There were also good examples of challenging practice from some practitioners in P1-SMTP although this was not consistent across the service.    9. Conclusion  9.1.1. It is important to be aware as Munro (2011) states just how much hindsight distorts our judgement about the predictability of an adverse outcome.  Once it is known there is a tragic outcome, we can look back and believe we can see where practice, actions or assessments were critical in leading to that outcome. Munro writes that hindsight bias ‘oversimplifies or trivialises the situation confronting the practitioner and masks the processes affecting practitioner behaviour before the fact. Hindsight bias blocks our ability to see the deeper story of systematic factors that predictably shape human performance’.   9.1.2. It is reasonable to conclude that had the various assessment processes been conducted more thoroughly, the complex mix of risks and vulnerabilities surrounding Child C and Baby A would have been more readily identified. This in turn would have led to more realistic evaluations and subsequently better planning about how to safeguard the children if the risks were not managed in a timely way, or they increased.  What is clear from this Review is that work with all vulnerable children and their families must be focussed and this requires leadership and direction.  In this case, the leadership that should have been provided by CSC was absent. Equally, although professionals in other agencies may have recognised drift and risks, their managers did not escalate these and a sense of complacency developed which left Child C and Baby A vulnerable.  The importance of frontline practitioners having access to good quality supervision cannot be underestimated and there is evidence in this Review that the benefits of reflective supervision are not well understood.    9.1.3. Consideration has been given as to whether the death of Baby A was predictable. Predicting the likelihood of such an outcome for a vulnerable baby is difficult to achieve with any meaningful degree of accuracy. The risks to Baby A were considered significant enough to make the child subject to a Child Protection Plan and arrange a placement on discharge with the maternal grandparents. It is understandable that these arrangements gave professionals a sense of security, especially knowing that maternal grandparents were caring for two other of LB’s children.  It is unclear from records or reports to what extent the parents and the maternal grandparents were alerted to the increased risks to Baby A, compared to other babies. Neither are there records which suggest they were reminded about the complex effects of chaotic or polydrug misuse which can induce drowsiness/deep sleeping and might have impaired the parenting capacity of LB, but it is not possible to conclude that had they been so informed this would have led   102 to a different outcome for Baby A.  The Coroner’s verdict indicates that Baby A died as a result of natural causes and not as a result of neglect or abuse.   9.1.4. The impact of not having outcome focussed plans derived from good assessments and the fact that the absence of these was not noticed or challenged, both within agencies and collectively, led to a distinct lack of clarity about the purpose of intervention. This, together with the fact there were no ‘incidents’ relating to the children, blunted the practitioners’ awareness of the risks involved allowing the case to drift and the specific risks to Baby A remaining unassessed.     9.1.5. The poor quality of the IMR reports in terms of offering critical and reflective insights into frontline practice highlights a significant challenge for the LSCB, which needs to be urgently addressed if future reviews are to lead to better outcomes for children and young people.    9.1.6. The SCR Panel informed the Overview Author that the failure of CSC to meaningfully engage in this Review has been evident in other reviews, despite efforts by the LSCB to seek responses, which demonstrate an awareness of failing and poor performance and a commitment to improve practice at both operational and managerial levels.  The poor quality in general of the submitted IMR reports has been noted, but the Overview Author would stress that in relation to the CSC report, the identification of some significant systems and practice issues should be of pressing concern to senior managers within that service.   9.1.7. Given the findings from this review process and the fact that some of these are also to be found in other reviews, which have, taken place over previous years, the Overview Author, supported by the SCR Panel would urge that the work outlined and the recommendations listed below are addressed as a matter of some urgency.  The resulting Action Plan should be robust and actively supported by senior managers from all partner agencies.    10. Recommendations  10.1. Multi-Agency Recommendations  Multi-Agency Recommendation 1  a) The LSCB should be confident that partner agencies understand their role in contributing to SCRs and have skilled personnel able to undertake critical analysis of practice and produce high quality reports when required.  b) Senior Managers in all partner agencies should be reminded about their responsibilities to sign off these reports thereby confirming acceptance of quality and contents.   Multi-Agency Recommendation 2  The LSCB should as a matter of some urgency require CSC to respond to the questions raised in 5.2.8 within a specified timescale and then consider how partners can work collaboratively to address the emerging issues.     103 Multi-Agency Recommendation 3 The LSCB should examine the processes it has in place so the Board can be assured that statutory assessments and those agreed at multi-agency meetings take place within agreed timelines, are robust and of good quality. LSCB should also ensure that effective escalation policies are in place and well understood by all partner agencies.   Multi-Agency Recommendation 4  a) The LSCB should re-evaluate how multi-agency plans relating to children in need and child protection are formulated and recorded, using where possible an agreed template which places the child first and foremost at the front of the deliberations and allows for realistic and meaningful monitoring and review.  b) The LSCB should ensure there is a robust process for regular scrutiny and challenge of these plans, including those that are developed and utilised by the Board.   Multi-Agency Recommendation 5   The LSCB should ensure that frontline practitioners have a clear and detailed understanding about the safeguarding responsibilities and expertise of colleagues attending multi-agency meetings and this information is used to justify attendance, rationalise allocated tasks and confirm areas of joint responsibility.   Multi- Agency Recommendation 6 The LSCB should explore the advantages of requiring multi-agency meetings to state the hypothesis38 or hypotheses that form the basis of their Child in Need or Child Protection Plan.    Multi-Agency Recommendation 7  The LSCB should consider ways in which the Board can be satisfied that practitioners who chair multi-agency meetings relating to the safeguarding of children and young people, have the requisite skills, knowledge and confidence to do so assertively.   Multi-Agency Recommendation 8 The LSCB should redesign the systems in place for recording and disseminating information from any multi-agency meetings to ensure these are robust and effective.   Multi-Agency Recommendation 9 The LSCB should seek agreement from partners that all vulnerable babies under the age of one are discussed as a matter of routine in supervision, and assessment of risk discussed and recorded.  Multi-Agency Recommendation 10 The LSCB should as a matter of some urgency and in line with its statutory functions39 establish a meeting to include the Chief Executive and the Director of                                                  38 “a proposition made as a basis for reasoning,..a starting-point for further investigation from known facts”.  39 Regulation 5 of the Local Safeguarding Children Boards Regulations 2006.   104 Children’s Services to agree a way of addressing and progressing the issues outlined in this report, especially in relation to 9.1.7 of this report.    Multi-Agency Recommendation 11 The LSCB should develop learning opportunities for managers across all agencies to improve their skills and knowledge about reflective supervision and the links this has with better outcomes for children.   Multi-Agency Recommendation 12  The LSCB should design more effective ways to ensure lessons from reviews and research are disseminated to frontline practitioners so improved practice and better outcomes for children and young people can be assured.   10.2. Single Agency Recommendations (these are copied directly from the IMR reports)  Children’s Services: Children’s Social Care (CSC) 1. The fostering service must ensure that all foster carers have the Out of Hours telephone number and understand its use. All foster carers and professionals must be made aware of Out of Hours service and how to access it. The number should be included in social workers’ voicemail messages on both landline and mobile telephones.  2. The process for sending notification letters when children are placed or foster carers are approved outside Sunderland must be strengthened. Appropriate notifications must be sent to all relevant parties for all foster carers approved and children placed outside the boundary of the Local Authority. Business support need to save copies of the letter to ESCR, copied to the social worker and make a case note to the effect that it has taken place to ensure that information sharing is clearly evidenced. 3. The Council’s Fostering Service needs to improve the quality of Connected Persons’ assessments. The Fostering Service should develop a Quality Assurance process to ensure that all Connected Person’s assessments meet statutory requirements, including adherence to timescales. The Fostering Panel must ensure that reports are of an acceptable standard. The standard of Connected Persons assessments must be improved. All reports should provide comprehensive details about family history and the relationships and dynamics of those involved. Fostering officers must talk to the child(ren(s)) social workers and check  CCM, to ensure that any assessments already undertaken inform the assessment. Home local authority checks must be undertaken without exception and prospective Connected Person’s assessments must not be taken to Fostering Panel for approval without this information being included. 4. Ensure that the Placement and Resources Panel (PARP) risk assessment includes any risks to child from previous caregivers, including during contact. The PARP Risk Assessment must be amended to reflect risks to the child by their previous care givers and any risks surrounding contact arrangements. 5. There must be a clear procedure for Operational Managers to take responsibility for information sharing if social workers change teams. A formal transfer process for workers transferring between teams needs to be developed and implemented. Consideration needs to be given to any particular issues   105 pertaining to their caseload, their professional skills and abilities and any developmental or personal issues that will impact on their abilities. 6. A written Contact Plan must be in place for all looked after children to ensure that all parties are fully aware of the contact arrangements. Written contact plans must be completed for all contact arrangements at the start of a placement, with consideration being given to location, time, venue and frequency of contact as well as appropriate supervisors and the risks for the child depending on who is supervising. The contact plan must be shared and signed by all parties at the point of placement.  7. All reports for Family and Friends placements must be supported by clear evidence of need for placement and how the placement will meet the child’s needs. There needs to be a more explicit explanation within the SLAC 199 paperwork as to why a child is becoming looked after and information regarding the family and risks posed. Without this information the placement must not be signed off by the senior manager. There must also be clarity re the process for placing a second or subsequent child within a connected foster carer’s household. 8. There must be a discharge meeting attended by a social worker for all babies who are not being discharged home to parents. A review of the discharge from hospital process is required. Procedures need to address safe sleeping, visiting arrangements, contact expectations and procedures for discharge.   9. Child Protection Conference Chairs need to ensure that a Birth Arrangements Form is always completed and signed at Initial Child Protection Conferences for unborn babies. If for any reason a birth arrangements form cannot be completed at an Initial Child Protection Conference it needs to be completed immediately afterwards. 10. Procedures for children becoming looked after need to be clear. A review of procedures for children becoming looked after needs to be undertaken, with particular consideration to the process surrounding children being accommodated with s20 consent of their birth parents and the attendance of workers at PARP. 11. The system for storing documents on children’s case files should be standardised. A review needs to be carried out of current recording systems, including ESCR, CCM, SWIFT and the ongoing use of paper case files in the fostering service. All word documentation currently used to complete assessments, investigations, reviews and plans must be re-integrated into the database system of CCM to ensure that reports are linked to the child they are being created for and saved appropriately.  12. Notifications for children placed out of City, children with Child Protection Plans living outside Sunderland and out of City foster carers must be evidenced on case files and foster carers’ files. All social workers and managers must be reminded of the need to follow LSCB procedures in relation to notifying the relevant people about children with Child Protection Plans living outside the Local Authority boundary, children placed outside Sunderland and foster care living outside the city. 13. The vulnerability of unborn babies and very young babies must be highlighted. Operational managers must discuss all unborn babies and vulnerable babies at every supervision. They need to be sure that all vulnerable baby cases are following the correct procedures and that all risks and factors pertaining to the specific case have been considered. These discussions need to be taking place   106 between the social worker managing the case and their own supervisor so there is a clear understanding of any issues throughout. This has already been implemented in relation to unborn babies but needs to be extended to include all vulnerable babies up to the age of one.  14. Supervision files must evidence that staff receive regular supervision in line with supervision policy. All staff must have regular, recorded supervision in line with the supervision policy. All case discussion must be saved onto the relevant child’s file and all information pertinent to the worker must be saved into their personal file.  15. The Case File audit system to be reviewed to ensure that social workers receive timely feedback on audits completed. Currently the audits focus on a selection of cases rather than the caseload of one worker. The audit system needs to enable managers to identify and address any areas of practice which are not meeting required standards or where a worker requires further training or support. 16. The process for booking Initial Child Protection Conferences needs to be strengthened. The Independent Reviewing Team must have sight of a completed s47 document before an Initial Child Protection Conference is able to be arranged. 17. A review of the format of conference minutes needs to be carried out to see whether it is possible to highlight discussions so workers are able to see patterns and repetitions in the events.  18. There should be a review of the level of support for Operational Managers. A review must be undertaken of managerial responsibilities and ways in which support can be provided to ensure that all cases are understood and managed appropriately. The caseloads of the newly appointed senior social workers, created to take on the responsibility of Deputy Managers in all teams, need to be adjusted accordingly to ensure that they are able to fulfil their new role.  19. The interim management arrangements for the Children’s Independent Review Team need to be resolved. Urgent resolution must be found to the current interim arrangements surrounding the temporary management of the Independent Reviewing Unit.  20. Measures should be put in place to ensure that staff who are put at personal risk through their work are fully supported. Senior managers must put in place mechanisms to ensure that there is sufficient emotional as well as practical support in place for staff who are put at personal risk through their work. 21. There should be a review of the risk assessment template to ensure it covers all risks to a child.  Currently there are a number different templates in place.  These should be standardised to ensure that all risks are properly evaluated. 22. There should be a review of all training that incorporates information regarding substance misuse. Currently training courses either focus on the presentation of young people who may be abusing substances or the hidden harm caused by those misusing substances. Training needs to ensure that all elements are considered at all training so as many workers as possible are alerted to the risks both to and from an individual so that the additional risks posed to vulnerable babies, including the dangers of co-sleeping, are highlighted. 23. The views of social workers need to be taken into consideration when planning the training programme. A social work representative should be appointed to the Training Development Group. A social worker will be able to support any development of training to assist and promote the best ways in which to   107 safeguard children. The needs and issues for frontline workers will be able to be voiced. Training courses need to be reviewed to consider if they are as effective and efficient as possible to make attendance and accessibility as straightforward as possible for workers which will also impact the number of workers able to enhance their skills and knowledge, which in turn will improve outcomes for children.  Additional actions recommended by Overview Author Further consideration should be given to consider: • Why were managerial oversight and supervision arrangements so inadequate, given the LSCB had undertaken an exercise relating to supervision in the recent past? • Given that effective records contribute to better outcomes for children, why were   records, minutes and plans of key meetings not available and why, when some were submitted were they so poor? • Why are arrangements for chairing and note taking at various meetings so inadequate?  • Why are the   training opportunities provided to frontline practitioners and the learning from research and reviews not leading to improved practice? • Are high caseloads accepted by senior management if this leads to poor practice and leaves children vulnerable?  • What factors mitigated against expected practice in this case?  • The inadequacy of IRO resources has been raised by the Board on a number of occasions, why has there been no effective action to date?  Northumbria Police 1. The need to ensure that where possible and appropriate an Officer attends the ICPC in order to provide details of family member’s involvement with the Police and to ensure that the Police participate in the decision-making process and subsequent recommendations. This action has already been addressed following the alignment of two PVP teams to Sunderland Local Authority and will be monitored on a monthly basis to ensure compliance.       Northumbria Probation Trust 1. With regard to Probation Officer 1, the recorded information relates to a personal issue not a Trust wide issue. This is currently being addressed through an action plan under Capability procedures.  2. With regard to practitioners accessing LSCB training, the Organisational Development Manager is working across all six LSCBs in the Trust area to develop a consistent and effective system to ensure that Probation staff attend appropriate courses.  3. However, there are issues that need to be picked up and reinforced in the forthcoming revision of the Safeguarding Children Policy, currently being undertaken by the Safeguarding Communities Manager. The first concern is how Probation staff deals with the lack of minutes from Core Group Meetings.  A proforma will be introduced to ensure that decisions made and actions allocated are recorded. Reinforcement of the importance of home visits, the need to register on the Child Protection Register and ensuring that all relevant information with regard to children is on file. These have been raised with the   108 Safeguarding Communities Manager, and will form part of the revised policy due to be launched in the autumn following Board approval. As a result of the latter, a firm date cannot be given.  Additional actions recommended by Overview Author  • Improve the Action Plan so it is ‘SMART’ thus allowing for robust monitor and review. Place 1 Substance Misuse Treatment Provider 1. Arrangements to be developed within the Information Technology system of P1-SMTP to allow the easy copying of e-mails into case recording. 2. To be included within safeguarding training for P1-SMTP staff, a session explaining the differing meetings and the purposes of these meetings within the Child Protection arena.  If this is already part of the training then refresher events should take place within the agency. 3. Discussions to be undertaken by senior management of P1-SMTP to establish a system of receiving information from MARAC meetings especially where a service user may be at risk of harm. 4. Arrangements to be formulated within the safeguarding procedures to allow for staff from P1-SMTP to be included when Birth Plans are agreed.   Where P1-SMTP staff are involved with a mother then they should be part of the Birth Plan unless there is good reason for them not being so.  Additional actions recommended by Overview Author • A fifth recommendation should include the need for P1-SMTP to examine how it can ensure that staff remain child focussed in their work with substance users who are parents.  Place 2 Children’s’ Services 1. Place 2 Children’s Care to ensure that all team managers and social workers are reminded about their responsibilities under the cross boundary procedures. 2. Real Service to Review Circle of Support to include genogram. 3. Place 2 EDT to advise substantive and sessional staff of the need to personally ensure that there are no outstanding safeguarding issues in relation to children and young people rather than rely on information from partner agencies.  Children’s Services, Education 1. All Designated People and Nominated Deputies for safeguarding and SENCOs to have a secure understanding of the thresholds for neglect and the impact within education. 2. All Designated and Nominated Deputies/SENCOs to have a secure understanding of the impact of drug taking during pregnancy on children and its impact within education. 3. Children subject to Plan when transferring to a new setting must be formally handed over to the new receiving school or settings, Designated People and Nominated Deputies to ensure they are safeguarded. 4. Within all meetings of children subject to Plan appropriate educational progress information for pupils must be identified and discussed.       109 5. Quality assure random education files for children subject to Plan during Education Safeguarding Team and Early Years Quality Improvement Support Programme audits. 6. Enhancing Early Years practitioners’ understanding of the need to and methods of accessing pupil voice.  Additional actions recommended by the Overview Author  • The Overview Author would advise strengthening the recommendation, which relates to Child Protection files and records.   City Hospitals 1. Any baby who requires continuous supervision for safeguarding purposes should be transferred to the neonatal unit following delivery. 2. Any baby born to a substance misuse mother to be transferred to the neonatal unit for assessment of withdrawal. 3. Review and update ‘Substance Misuse’ Guideline. 4. Review and update of the ‘Prevention and Management of Excessive Weight loss in the Breast Fed Newborn’ guideline. 5. Pre-discharge planning meetings to be arranged for all discharges were a relative is providing supervision. 6. GP patient records and archived information to be accessed by team midwives. 7. Postnatal handheld records to be reconfigured to clearly display safe sleeping arrangements for babies. 8. Mandatory one-to-one Clinical Supervision for safeguarding at induction for newly qualified midwives.  Additional actions recommended by Overview Author • There should also be a recommendation, which relates to the timely use of the LSCB’s escalation policy.    General Practitioner 1. Practices to share information with professionals where there are vulnerable patients. 2. GP’s to be aware of the need to enquire about domestic violence and that this is an ongoing issue, not a one off event. 3. Primary care team within the practice must be compliant with LSCB procedures. 4. All practices to hold regular multi-disciplinary meetings. 5. Health professionals to give consideration to the THINK family approach to patient care. 6. Practices to open communication with midwives, either through MDT meetings or improving access to records for EMIS. Midwives to improve the quality of the antenatal vulnerability assessment score and ensure this information is shared with GP’s. 7. Records for all family members where there are issues such as drug misuse, or domestic abuse to be flagged in a manner that any health professional reading the records is aware of the problem.   110 8. GP’s to review record keeping and ensure that the records are kept in a manner that all clinicians are clearly able to ascertain a patients circumstances and that information can be effectively shared.   NHS Trust 1. Practitioners be clear about the aim and expected outcomes from safeguarding supervision. 2. Supervisors will be clear about their role and accountability when delivering supervision. 3. Practitioners should clearly demonstrate their specific health roles when a member of a Multi-Agency Meeting. 4. Health Visitors will take opportunities to actively interact with children.  5. Workshops will be made available for STNHSFT practitioners on the effects of Substance Misuse on Families and Children.  Additional actions recommended by Overview Author • These five recommendations are too vague and do not state specific outcomes – these need to be ‘SMART’ recommendations • There should also be a recommendation, which relates to the timely use of the LSCB’s escalation policy.    Clinical Commissioning Group (CCG) 1. STNHSFT to develop a system of peer review for safeguarding supervision arrangements to ensure the service delivered is consistently of a high standard.    2. STNHSFT to ensure there is effective communication between Safe Care Leads/Modern Matrons and the Safeguarding Team to ensure staff who are not able to meet the needs within their caseloads are identified and appropriate support and supervision can be made available. 3. CHS to review the drug testing arrangements available in community and hospital maternity settings. 4. CHS to ensure that accountability arrangements for Named Professionals are clear when advising on babies within the NNU. 5. In reviewing their substance misuse guidance CHS will ensure appropriate          information is included on risk/harm minimisation for breast-feeding mothers who continue to misuse substances. 6. CHS to undertake an audit to ensure that all babies subject to a Child Protection Plan are seen daily for 10 days post-natally within the community.  7. CHS to review how safe sleep messages are delivered to all parents/carers 8. Drug Treatment Services will ensure that details of children of substance misusing parents/carers who accompany them to appointments are documented in records and this information is passed to the social worker. 9. Drug Treatment Services will share information regarding potential criminal activity of their service users who have care of children with the local Police and with the allocated social worker. 10. LSCB to develop multi-agency risk/parenting assessments incorporating the     knowledge and skills of all core group/care team members. 11. LSCB to ensure the birth arrangements plan covers discharge arrangements specific to how the baby will be transported, and by whom on discharge.    111 Additional actions recommended by Overview Author • The Overview Author would suggest a recommendation that supervising personnel are reminded about the LSCB’s escalation policy.     112 Appendix 1  Terms of Reference: Baby A and Child C  Practice and Patterns in Professional Judgement  a) Were practitioners aware of and sensitive to the needs of Baby A and Child C and where appropriate, were Child C’s wishes and feelings ascertained and taken into account when making decisions about the provision of services?  b) Was practice sensitive to racial, cultural, linguistic and religious beliefs?  c) Were practitioners knowledgeable about the potential indicators of abuse and what to do in response to concerns?  Specific attention should be paid to professional understanding and training around neglect.   d) What role did human factors such as confirmation bias and situation awareness play, if any, to the achievement of robust and effective safeguarding practice in this case?      Assessment and Intervention  e) How effectively did planned and responsive services recognise and manage issues of need and risk; including the ability to recognise the impact of parenting issues, such as parental mental health issues, parental substance misuse and criminality.   f) When considering the circumstances of the children, did the agencies’ assessments include an appropriate assessment of risk?    Specifically: • Were the child protection investigations, which led to Child C being made the subject of a Child Protection Plan for the first and second time, thorough and robust? • Was the child protection investigation, which led to Baby A being made the subject of a Child Protection Plan in 2013 robust and thorough? • Did all relevant agencies make appropriate contributions to the child protection investigations? • Was a robust antenatal assessment undertaken in respect of Baby A and did it result in appropriate planning and decision making for the baby? • Did all of the agency’s assessments give appropriate consideration to the potential impact of a new baby on the extended family, particularly in light of the following: - The long standing concerns about parenting capacity - The pre-existing concern for the children’s safety - The fact that grandparents decided to care for Baby A at a late stage - The evidence with regard to the vulnerability of babies   113 • Was there an analysis of risk in the context of neglect for Child C and Baby A? • Did assessments pay appropriate attention to the role of both of the fathers for the children? • How effective were the drug screening/drug monitoring processes in assisting professionals to have a clear assessment of mum’s substance misuse?   Decision-Making   g) Were decisions reached appropriate and justifiable at the time? • Did the risk assessment result in robust birth planning arrangements? • Did all agencies involved with the family attend and contribute appropriately to the Initial Child Protection Conference in December 2012 and March 2013? • Was the decision to discontinue the Child Protection Plan for Child C in 2011 based on a robust assessment of risk? • What impact, if any, did the four day Easter weekend have on the safety of Baby A? • With regard to the Letter before Proceedings (both in terms of issuing it and not progressing it), were the decisions made appropriate and justifiable at the time?  • How were these decisions reached? • Was the assessment process with regard to this robust and based upon sound evidence of change?  h) How effectively did the MARAC arrangements safeguard mum in 2010?   i) Were agency procedures for safeguarding children followed appropriately in relation to the decisions made in this case and was practice compliant with Working Together 2010 and relevant multi-agency safeguarding children procedures?   Multi-Agency Collaboration  j) Core Group Meetings/Cross Boundary Working  •••• Were Core Group meetings held within timescales? •••• Was there appropriate membership of and attendance at the Core Group meetings? •••• Is there evidence of outcome focussed planning to implement the co-ordinated Child Protection Plans for Baby A and Child C? •••• How did Core Group members feel about their contribution to the group, and did they feel able to challenge the views of other members? •••• What capacity did professionals have to challenge decisions and actions in relation to safeguarding Baby A and Child C and the professional understanding of their responsibilities with regard to this in the LSCB procedures?    114 k) Were decisions made and actions taken concerning failure to engage, appropriate and justifiable at the time?  Management and Supervision  l) Was supervision undertaken with staff in line with the agencies’ supervision policy and is there evidence of reflective supervision where appropriate?   m) Were senior managers or other organisations and professionals involved at points in this case where they should have been?   Contextual Issues  n) Were there any issues within the individual agency e.g., high level of staff vacancies, which may have impacted on the ability of the service to effectively meet the needs of Baby A, Child C and the family.   October 2013  115Appendix 2 GENOGRAM      MGF BX    NX    m. Dec 2011   d. April 2013 MGM ST Aunt  Child J Child P Child C Baby A LB Child Child     116 Addendum to Overview Report in respect of Baby A and Child C  1. Background  1.1. The Overview Report for Baby A and Child C was completed early 2014 and signed off by Sunderland Safeguarding Children Board (SSCB) in February 2014.   1.2. The Serious Case Review (SCR) process was concluded well outside the 6-month time frame due to delayed Individual Management Review (IMR) reports and in particular to the SCR Panel’s dissatisfaction with subsequent rewrites of the Children’s Services Social Care report.  The SCR Panel had reluctantly accepted the last report submitted by the IMR author when it was advised by the manager representing Children’s Services, on the Panel, that the report had been agreed with her senior manager and additional work could not be undertaken without a further and significant delay of the SCR40.  1.3. The SCR Panel deliberated this issue and concluded that the timescale for the SCR should not be extended again.  Further feedback was given to the Children’s Services representative and the Overview Author agreed to consider and include any amendments to the IMR report should these be received before December 2013.  There were however no further amendments made to the IMR report although the related action plan was later forwarded to the author.  1.4. The Overview Report highlighted the shortcomings of the Children’s Services IMR and advised an urgent and immediate consideration of several unanswered ‘why’ questions in respect of practice and systems.  The Director of Children’s Services41 having advised SSCB that an independent body, ‘core assets’ 42 , had been commissioned to undertake a ‘Safeguarding Review’ of systems and practice in Children’s Social Care, subsequently informed the Board that as part of that process, ‘core assets’ would also seek to address the ‘why’ questions contained in the final SCR report.  1.5. A decision was taken a short time later by the [then] Chair of the LSCB, the Executive Director of People’s Services and agency leads, to delay publication of the SCR Overview Report until ‘core assets’ had completed their analysis.  1.6. The SSCB Chair and SSCB Business Manager later approached the Independent Author to discuss how best any findings could be incorporated into the SCR report.  Whilst unable to agree to a request that the original report signed off in February 2014, be amended to include ‘new’ information, the author did agree to write an addendum to the Overview Report in response to any subsequent findings.                                                    40In effect, this delay occurred anyway following a decision by the LSCB Chair and Director of Children’s Social Care not to publish until Children’s Services had undertaken further work. 41Now known as the Executive Director of People Services. 42http://www.coreassets.com.    1171.7. The findings from the ‘core assets’ review were accepted by Children’s Services and formed the basis of what shall be referred to in this document, as the Children’s Services’ Review report (CS Review report).  This was forwarded to the [new] SSCB Chair and the Independent Author on the 18 July 2014.  The report did not clearly identify what changes had been implemented and did not include an action plan.  A further delay was incurred whilst these documents were prepared.   1.8. The Independent Author subsequently received a report from Fiona Brown, Chief Operating Officer, and People’s Directorate in mid-August and this offered a chronology of actions implemented to date (FB1) and an action plan (FB2).  1.9. The SCR Panel was reconvened on 23 September 2014 to sign off the Addendum Report written by the Independent Author, although it should be noted that not all those present at the meeting had been forwarded copies of the Chief Operating Officer’s report or action plan, i.e. FB1 or FB2.  It was agreed however that these documents would be appended to this report without any additional changes and circulated to the SCR Panel.  2. General Comments   2.1. The documents forwarded by the Chief Operating Officer would suggest that the decision to undertake an independent review of safeguarding practice in Children’s Social Care has led to a number of improvements specifically around service delivery and quality assurance arrangements.  These changes, whilst long overdue given the findings of previous case and SCRs and previous challenges from LSCB43, are to be welcomed.    2.2. Having met with family members in relation the SCR for Baby A and Child C, at the end of 2013 and discussed with them the SCR process and issues around publication, the Independent Author remains concerned about the length of time it has taken to complete this SCR and publish its findings.  Recommendation 1: There would be merit in an open and honest discussion between LSCB partners about the circumstances, which led to the significant delay in the publication of this SCR to ensure similar patterns, and practices are not repeated in subsequent reviews.   2.3. The CS Review report very helpfully provided a critical analysis of practice and systems and goes a considerable distance in answering the ‘why’ questions originally presented to SSCB.  That this report has been produced now and not as part of the SCR process highlights that this information was indeed available when the SCR was being undertaken, but the IMR author44, through lack of experience, appropriate guidance or seniority was unable to access it and senior managers crucially failed to see the relevance and importance of this information being required as part of the IMR report.                                                  43According to documents seen by the author. 44The IMR author who wrote the report on behalf of Children’s Services was a Principal Social Worker, not a senior manager in Children’s Services.    118 Recommendation 2: It is noted that a new Management Development programme has been commissioned which includes a module on SCRs.  This programme needs to ensure that managers understand the significance of SCRs and their role as key contributors to the SCR process.   Recommendation 3: Senior Managers in Children’s Social Care should consider how they can be kept better informed about the process, progress, and outcomes of SCRs.  They should identify what immediate steps should be taken if issues affecting progress, and which relate to their representatives, are brought to their attention.   2.4. The CS Review report appropriately highlight that the recommendations contained in the  [original] IMR for Children’s Social Care lacked the necessary focus and rigour needed to bring about effective change in social care practice.  The amended action plan (FB2) forwarded by the Chief Operations Officer is more robust and together with the Improvement Plan 45  should help Children Services move forward in improving practice.   Recommendation 4:  Senior managers in Children Services need to assure themselves that the actions arising from this and other SCRs are realistic and achievable and there are stringent and on-gong monitoring systems in place to ensure changes in practice are sustained.   3. Findings from Children Services Review Report  The information contained in the CS Review report offers details in response to the ‘why’ questions posed in the Overview Report.  Additional analysis is provided in the main body of the text.  It is not the intention of the author to reiterate the findings in this addendum but the same headings are used to capture what appear to be the significant findings, which require further consideration, by SSCB.  The headings used are as follows:  • Quality Assuring practice • Management oversight and supervision • ICT and case management systems • The role and function of the IRO/CP Unit • Social care caseloads • Impact of training on practice  3.1. Quality Assuring Practice:  Finding 1:  The absence of a coherent and robust quality assessment framework led to practice and service failings going unrecognised.                                                  45This is a Strategic document emerging from a review of Children Services.   119Why this is significant: In order to measure performance and deliver quality services, Children’s Social Care need objective or more effective ways to assess how well they are doing and monitor changes over time.  Measuring the impact of service delivery is central to achieving improved outcomes for children.  This requires a strong quality assurance system to be in place that evidences that services are being delivered effectively and to standards that enable children’s welfare to be safeguarded and promoted.  The CS Review report offers a number of organisational and external factors which explain why such a framework was either not working or was not in place in Children’s Social Care.  These issues are noted to have been addressed and are being addressed through the following actions: • The Quality Assurance role of the Children’s Independent Review Team has been strengthened (FB1: implemented May- June 2014) • All completed assessments for Looked After Children and Child Protection are monitored by Independent Reviewing Officers and Child Protection Conference Chairs (FB1: implemented July – August 2014) • A Quality Assurance Sub-group is to be formed to analyse and report on data to Senior Managers  (FB2: Action 7) • A caseload management system will be implemented across social care and this will be monitored through the QA framework.  (FB2: Action 6) Issues for consideration by SSCB:   • Is the Board confident that the Quality Assurance framework proposed or amended by Children’s Social Care is robust? • Was the Board aware of the shortcomings in Children’s Social Care quality assurance framework?  If so, how was this addressed and if not, why was this not picked up through the Board’s own audit processes? • In what way can the Board evidence that its own arrangements for auditing and review are now robust and effective?  3.2. Management Oversight and Supervision:  Finding  1: As above Finding 2:  Regular high quality and organised supervision was compromised by the ever-increasing demands in the Local Authority and strong leadership to champion the supervisory process was missing.   Why this is significant: The absence of managerial oversight and reflective supervision was a key factor in this SCR and a range of internal and external constraints were identified as being contributory factors.  Managers and social work staff work will continue to work within a climate of increasing uncertainty and organisational challenge and unless senior leaders regard the supervision of staff as a key priority, some managers will elect to prioritise other aspects of their managerial role.  Despite evidence of good quality practice in some teams, an audit   120in Children’s Social Care undertaken in May 2014 highlighted that good supervisory practice is not consistent across the Authority.  These issues are noted to have been addressed and are being addressed through the following actions:  • All teams now have senior social workers and senior practitioners increasing the team manager’s capacity for effective managerial oversight.  (FB1: Implemented May - June 2014) • Introduction of a new mandatory Management Development Programme for Team Leaders.  (FB1: Implemented May - June 2014) • Confirmation that Team Managers and Senior Social Workers are expected to sign off all assessments.  (FB1: Implemented July – August 2014) • The supervision model and policy document are to be reviewed and protocols developed as required by December 2014.   (FB2: Action 2) • All babies under 2 year old are to be discussed in Supervision.  (FB1: Implemented May – June 2014) • Arrangements for transition and case handover will be reviewed by December 2014.  (FB2: Action 5) • Senior Managers now seek evidence that Social Workers receive regular supervision.  (FB1: July- August 2014) • Weekly briefings for teams are to take place so staff can be informed of policy changes.  (FB2: Action 7)  • In terms of risk management, Monday morning meetings will take place to support the allocation of cases to ensure that there are no unallocated CP cases.  (FB1: Implemented July – August 2014)  Issues for consideration by SSCB:  • The LSCB has set standards for supervision practice across all partner agencies, how does assure itself to what extent is it possible to monitor these arrangements? • Does the Board commend other supervision models? • Do Senior Managers receive supervision and training in relation to their safeguarding responsibilities? • How does the Board ensure it is kept informed about the number of unallocated CP cases and the rationale for this practice?  3.3. IT and Case Management Systems:    Finding 1: As above  Finding 3:  Difficulties in recording, storing, and retrieving key data compromises the ability of Social Workers to quickly and purposefully locate important information about a child’s journey and therefore impacts on the quality of social work practice.  This was clearly an issue in this SCR.   Why this is significant: The Integrated Children’s System, commonly known as ICS, has been a point of controversy in children’s social care across the UK since its   121creation. Although, the Government initially was very prescriptive with ICS requirements, Councils were eventually given the ability to adapt their own services to meet their own local needs. The confusing and complex information management system(s) in Sunderland, (although by no means the only Local Authority to have this problem) was a contributory factor in respect of the poor quality of information accessed by the IMR author for social care.   The CS Review report states this as ‘being an information management system, which does not support a safe systematic and orderly storage of a child’s file and weakens quality assurance’.  These issues are noted to have been addressed and are being addressed through the following actions:  • Social workers have been instructed to store all completed documents in ESCR to facilitate retrieval.  (FB1: Implemented May- June 2014) • Version 28.2 of CCM is planned for implementation in the autumn of 2014 and this will make storage and retrieval more straightforward.  (FB1: Implemented/confirmed July – August 2014) • A data cleansing exercise will be undertaken and file structures revised.  (FB2:Action 8)   Issues for consideration by SSCB:   • How will the Board monitor the impact of this new system in terms of multi-agency working? • Is there any way the Board can support Children’s Social Care in terms of information management? • Has the Board a robust and comprehensive management information system of its own?  3.4. The Role and Function of the IRO and Child Protection Conferencing Unit  Finding 1: As above  Finding 4: The high caseload of Independent Reviewing Officers (IROs) combined with inadequate arrangements for administration, and the case recording system being applied compromises the ability of this unit to fulfil its core quality assurance and scrutiny functions.    Why this is significant: The CS Review report indicated that on average IROs in Sunderland hold the equivalent of 102 children46 this undoubtedly impacts upon their capacity to undertake their role effectively and continues to be an issue despite the recent increase in staffing.  This issue requires further review.  The IMR for Children’s Social Care highlighted significant issues around the supervision of experienced IROs and it appears that this will remain an issue as yet another interim manager is appointed to the unit.  This will be the third interim manager in two years.                                                   46The national average is around 50 – 70 cases for each Independent Reviewing Officer.   122 Finding 5: The failure of Children’s Services to provide sufficient administrative support to facilitate the delivery of an efficient and effective review service impacts on effective planning and is not cost or service effective.    Why this is significant: The IRO service does not have a dedicated administrative resource.  The CS Review report highlights that there is some admin support from a limited number of staff within a pooled admin team but this is subject to availability.  This means IROs and Conference Chairs retain overall responsibility for most administrative tasks relating to the management of reviews and conferences, and this again can impact on their ability to perform their role effectively.   These issues are noted to have been addressed and are being addressed through the following actions:  • Increase in the establishment of the IRO service.  (FB1: Implemented/confirmed March- April 2014) •  A revised quality assurance framework and quality standards for the administration of the IRO service will be developed and implemented by December 2014.  (FB2: Action 4)   Issues for consideration by SSCB:   • How does the Board monitor the effectiveness of multi-agency meetings? • Is the quality of these regularly reviewed and monitored? • Is the Board working with Children’s Social Care to improve templates, agendas and format for multi-agency meetings? • Do partner agencies contribute administrative support for multi-agency meetings, if not why not?  3.5. Impact of Training on Practice  Finding 1: As above.  Finding 6:  Children’s Social Care need to develop better and more systematic means of providing opportunities for their staff to reflect, develop curiosity, and enhance their clarity of thinking and practice.   Why this is significant: Developing professional wisdom around safeguarding is nurtured through supervision and various learning opportunities. The dynamics involved in safeguarding; the ease with which the focus on the child can be lost and unhelpful mindsets unknowingly developed e.g. rule of optimism, start again syndrome, desensitization poor standards, are realities that affect all practitioners.  Training courses are only one way that adults learn, peer supervision, action-learning sets, coaching and mentoring can also be of value. These issues are noted to have been addressed and are being addressed through the following actions:    123• A service-wide training need analysis is to be undertaken across Children’s Social Care which will lead to improved training opportunities and improved practice.    (FB2: Action 3) • Action Learning Sets and Road shows will be rolled out across teams.   (FB2: Action 7)  Issues for consideration by SSCB:  • How are multi-agency training programmes devised and how does the audit and quality assurance framework impact on these? • How does the Board ensure that learning from SCRs is shared across the whole authority and is embedded and sustained in frontline practice? • To what degree do audits test out whether learning from case and SCRs are discussed in supervision? • To what extent is the Board confident that senior managers in partner agencies understand and acknowledge the significant SCRs? • Senior managers who make decisions about budget and resource can be divorced from the practice implications that those decisions create, how does the Board deal with this challenge?  3.6. Partnership working: how well professionals and organisations work together  Finding 7 Author’s Comment: There is an observable tension between Children’s Services and partnership agencies, which is not helpful and which undoubtedly makes working in this complex and challenging area of work even more challenging.   Why this is significant: Children and families need professionals and organisations that work well together to promote their wellbeing and safety. Failing to work collaboratively continues to be a key message from SCRs and this can take various forms including not only practical working arrangements, but also the mindset in which organisations and professionals approach what they do. Silo thinking and practice, blaming other agencies, poor information sharing, lack of professional confidence and leadership, and unclear or unresolved safeguarding thresholds were all reported in this SCR.   Issues for consideration by SSCB: • In what way might SSCB facilitate improvements in working relationships between partner agencies? • How might Board structures, systems and sub-groups be developed to encourage more integrated practice across different disciplines as well as agencies? • Do key parties understand the challenge and scrutiny function of LSCB, is there any way that this understanding could be strengthened to foster and improve collaborative relationships? • Is the Board confident that the developing Resolutions Policy will be effective in ensuring that agencies comply with, and are committed to, SSCB policies and procedures?   124 4. Conclusion  4.1. The CS Review report asks why the SCR process was concluded without key questions being answered.  This is a pertinent question but one, which should be discussed in SSCB, taking into account the first recommendation highlighted in 2.2 above.  Having read the reports from previous case and SCRs, it is clear that many of the issues in relation to Children’s Social Care and outlined in the Overview Report for Baby A and Child C, had been raised previously and had not been addressed.  It was also evident from having attended the SCR Panel meetings for this SCR, that partner agencies were in general, dissatisfied with the perceived failure of Children’s Social Care to continually address identified failings in practice and systems.  These issues again, should form the basis of further discussions also taking into account the comments in 3.6  above.  4.2. The actions taken by the Executive Director and his team during the last 6 months demonstrate a strong commitment to address many of the issues highlighted in this SCR and in the previous reviews, which have been undertaken in Sunderland.  The changes and proposed changes are noted.  The SSCB should ensure however, that these developments remain under scrutiny, to ensure that good practice is sustained and can be identified in future SCRs.  4.3. The CS Review report and the chronology of actions taken to date together with the action plan for Children Services are welcomed.  It would however be useful if all three documents could be merged into one report so partner agencies and others can more easily recognise what was required, the achievements made to date and the work yet to be accomplished.   Linda Richardson, Independent Overview Author 25 September 2014     1                         May 2014           Prepared by: Rosie Rae & Richard Burrows             Report for Sunderland City Council: Executive Director People Services Re Children’s Safeguarding response to “why” questions raised in the SCR Overview Report re Baby A & Child C       2 Introduction 1.1 Baby A died in April 2013 and in February 2014 Sunderland LSCB subsequently completed a Serious Case Review (SCR) into the circumstances surrounding the death (and the involvement of services with sibling Child C) This was in accordance with Regulation 5 of the LSCB Regulations (2006). 1.2 There is a requirement for the LSCB to undertake a serious case review in cases where a child has died or been seriously harmed in circumstances of abuse or neglect and there may be cause for concern about the way agencies have worked together to safeguard the child or children. 1.3 The serious case review for baby A was commissioned and undertaken in accordance with statutory guidance, assuring independence through the appointment of an independent SCR panel chair and independent author. 1.4 The purpose of SCR’s is not to establish who is responsible for any death or injury, nor intended to attribute blame. They are conducted in order to enable a critical analysis of local multi agency practice and to ensure that lessons learned are identified and shared in order to improve practice. 1.5 The decision to hold a SCR was determined only two weeks after the launch of revised statutory guidance (Working Together 2013), the SCR panel decided to adhere to the previous SCR guidance in Working Together (2010). That is to say the requirement for Individual Management Reports (IMR’s) from agencies involved and an independent Overview Report. The LSCB were also mindful of the revised guidance that advocates a more systems based review. There is an acceptance by the LSCB in hindsight that a sharper methodology would have produced a more succinct and complete report overall. 1.6 The overview report was completed in February 2014 but somewhat unusually, given that the purpose of a SCR is to draw out all key learning points, the final version of the report contained a number of unanswered challenge questions directed toward Sunderland Children’s Social care (SCSC).   1.7 The ‘why’ or challenge questions posed by the LSCB are both pertinent and relevant and a detailed response to the individual questions provided by Children’s Social Care is attached as Appendix 1. However, the underlying issues identified are inter-related and cross cutting hence the main body of this report has been compiled in order to respond to the challenge questions posed by the LSCB under the following key headings; • Quality assuring practice • Management oversight and supervision • ICT and case management systems • The role of the IRO/CP Unit • Administration arrangements for the IRO CP service • IRO capacity and adequacy • Social care caseloads • Impact of training on practice    3  Exploring the LSCB challenge or the “why questions” 2.1 The Children's Social Care IMR and the LSCB Overview report both accurately identify shortcomings in local practice with regard to this case. It is also accepted that the Social Care IMR is incomplete in as much as key questions are left unanswered.  2.2 It may never be possible to wholly answer all of the questions pertaining to the case of Baby A and Child C, as some of the key personnel involved have moved on, and the information recorded about some elements of decision-making is weak and lacks supporting rationale. The issue of the quality of recording is addressed in some detail within the SCR overview report and in the Children’s Social Care response to the challenge questions.   2.3 Many of the local case review findings replicate themes identified in national serious case reviews. This is not offered as mitigation it simply provides context and highlights the challenge for local partnerships and systems in quality assuring safeguarding practice. This is particularly relevant with regard to the following themes;   • Management instability and lack of oversight and supervision arrangements  • Quality and timeliness of assessment • Absence of  practice challenge and quality assurance scrutiny • Over optimism and family history not being taken into account (start again syndrome) • Drift in care planning /lack of focus and clarity in plans • Inexperienced staff lacking the confidence and competence to deal with complex cases • Disguised compliance  • The invisible child and an absence of child centred practice.    2.4 Fundamentally, the factor that allowed practice issues to go unrecognised and therefore unchallenged within the case of Baby A and Child C overall was the absence of a robust quality assurance system within Children’s Social Care and therefore to some extent in joint working arrangements.  Quality Assuring Practice 2.5 A robust performance management and quality assurance framework enables early identification of deviations from accepted standards and tolerance levels. This is an essential element of good safeguarding practice. The capacity for human error means that even the most effective practitioner cannot be considered infallible and given the complexity and demands placed upon safeguarding and child protection services, mistakes and oversights are always possible and in some respects may be    4 considered inevitable. This is particularly relevant where additional factors in the work environment or organisation influence practice capacity and delivery.   2.6 This case review and the subsequent external review by Coreassets identified that the quality assurance framework within children’s social care had become fragmented and is recognised as requiring urgent review. This fragmentation has occurred due to a number of contributory organisational and external factors; • The loss of an experienced and competent data analyst through restructuring • The internal case file audit programme being compromised, both through the way information were recorded on ICS, but also the loss of the key analyst post above. Audits were undertaken to some extent but seemingly without rigour or consistency, and once uploaded to the system, in the absence of a suitably qualified person (above), key findings were unable to be retrieved in order to understand the relevance to local practice.  • The absence through ill health of the quality assurance lead officer • The way that the ICS system was used locally by practitioners and management. This approach compromised the ICS system gate-keeping measures and therefore the ability to track the child’s journey as part of audit and broader quality assurance measures. This approach entailed word documents being used to maintain case management records, as opposed to the formatted ICS fields. This approach was undertaken in an attempt to manage the limitations of the existing version of ICS (due for upgrading in summer 2014). • The quality assurance, scrutiny and challenge functions of the IRO/CP service being compromised through limited capacity and high caseloads. This was exacerbated by a lack of adequate administrative support. • High case loads and issues with recruitment, sickness and absence placed pressures on the service overall. • Management restructures disrupted the continuity of management oversight at some levels and temporarily reduced management capacity overall as new structures ‘bedded in’. • Regular supervision in line with accepted LSCB standards was not being routinely applied; there was no consistent supervision model in place across the services. This despite some previous significant investment in supervision training. • Reductions in the levels of administrative support across the service significantly increased the time social workers needed to spend on administrative functions.  Management Oversight and Supervision 2.7 Evidence of management oversight and supervision was largely absent in the case of Baby A and Child C. Supervision where it was recorded was scant and of variable quality across all officers involved in the case. This is attributed predominantly (but not wholly) to reduced management capacity during that time frame, with some posts being lost in restructuring, a level of disruption as new restructuring arrangements were bedding in, and long term sickness absence of a senior manager.     5 2.8 The Social Worker initially involved in this case had qualified in the USA and recently joined Sunderland children’s social care. The IMR author identified that while this was an experienced qualified social worker, there were some cultural differences with regard to practice and the application of thresholds, (in neglect for example) which had not been considered in induction. 2.9 There were no concerns with regard to high case load in the case of baby A, with only 17 cases allocated to this member of staff. However managers were unaware of factors and pressures within the social workers personal life that could have had an impact on her practice and decision making.  It is recognised that adequate supervision arrangements would have provided not only an opportunity for reflection and challenge on case decisions, but also identification of both cultural practice differences and additional training or support required. It is accepted that this was not the case. 2.10  Supervision enables social workers to develop good practice and exercise professional judgement and discretion in decision-making. The absence of sound supervision in the case of Baby A and Child C meant that opportunities to reflect on or challenge practice were overlooked.  2.11  The Coreassets case file audits undertaken in May 2014 showed that the quality and regularity of supervision remains variable, with some evidence of good clear directive supervision and management oversight but this was not consistent over all cases audited. 2.12  It is important that supervision is consistent and takes place regularly, that both the manager and the practitioner have time to prepare for the supervision session, and that this is then recorded appropriately.  2.13  Children’s social care have signed up to and remain committed to compliance with the LSCB standards for supervision, they have previously invested in supervision training to support that standard. In the light of the audit findings, and the changes in management staff, further training may be required to support the implementation of a standardised supervision model.  Information technology and case management 2.14 The information management and case recording system applied by children’s social care is the Northgate Swift/ICS system, which is also referred to locally as CCM. The current version of ICS was heavily criticised as being unwieldy and cumbersome, with system pre-determined forms/formats that were not considered to be user friendly,(feedback from service users,professionals and Ofsted (2010/11). 2.15 This criticism led to children’s social care senior management team advocating the use of an ‘alternative recording system’ from early 2012, which circumnavigated the set parameters of ICS. This involved transferring the format for children’s plans and assessments into word documents. As these documents cannot then be uploaded to ICS they must be stored separately in the Electronic Social Care Records drive (ESCR) which is a cumbersome and time consuming measure. This was proposed by senior management as a short term solution to overcome the ICS shortcomings pending further investment and the implementation of ICS    6 upgrades to a more user friendly version (28.2) due in summer 2014, (not yet implemented).    2.16 Northgate ICS and other comparative systems, set service parameters as part of a broader quality assurance process, and in essence play a role in “gate keeping practice”. System parameters effectively reduce opportunity for deviation from procedures and accepted practice. For example, a request to convene a child protection conference cannot be progressed without confirmation on the system that a Section 47 strategy meeting has taken place, similarly the completion of assessments cannot progress without management sign off, ensuring a level of quality assurance. Also, significantly and most importantly the system enables a file structure that follows the child’s journey through service involvement. 2.17 In addition to the information stored in ESCR, and ICS, some case information pre-dating 2012 is held in E- Files. The indexing and file structure within this system is not reliable and data retrieval problematic. Workers also routinely stored (and at the point of this review and subsequent audit continued to store) ‘live’ reports in another word folder called current files. Once any documents, including assessments and plans are complete they should be uploaded to ESCR, which creates a PDF document. However, there is no standard file structure within current files and therefore no cohesive approach to how information is filed, and in practice finalised documents are not always uploaded to ESCR. Case summaries and chronologies are not consistently applied and the capacity to follow the child’s journey across disjointed systems is compromised as a result. 2.18 In summary, four individual non-standardised information and case recording systems are applied. This creates opportunity for both key information to be ‘lost’ across the systems, and for case recording and assessments to be overlooked or simply not completed. Information retrieval is laborious and unreliable, and can significantly limit social workers ability to locate and consider case history in order to inform their practice.  2.19 The removal of systemic gate-keeping parameters that promote compliance with procedures creates an opportunity for noncompliance and undoubtedly compromises efforts to quality assure practice through case file audit and management oversight. 2.20 The system of uploading to ESCR is highly time consuming, and as the document are PDF’s, they cannot be amended or edited and this contributes to staff opting to hold completed documents in current files folders as opposed to ESCR in accordance with policy guidance. 2.21 This system places extra and unnecessary demand on social workers, IROs and managers, (already under considerable time restraints due to high caseloads and the complexity of many cases).  It is a contributory factor to the quality of information being recorded and the reliability or accuracy of information that is able to be retrieved from the system. This was identified as a factor in the challenges    7 faced by the children’s social care IMR author in trying to gather adequate information for her report.     2.22 The Core Assets auditor identifies this as “being an information management system, which does not support a safe systematic and orderly storage of a child’s file and weakens quality assurance”. 2.23 This may have been a contributory factor in the family history not being taken into account in the case of Baby A and Child C. It would have certainly compromised management oversight and ability to routinely monitor the quality of assessments or identify and challenge delays or drift in the case plans.  This, combined with limited capacity in administration support, and relatively high social worker caseloads would also have had an impact of the standard of minutes and record keeping. The Role of the Independent Reviewing Officers (IRO) and Child Protection Conferencing Unit. 2.24 The IRO is a statutory post whose primary function is to quality assure the care planning and review process for children in care, ensuring that the wishes of each individual child are given full consideration. 2.25 When a child first becomes looked after a named individual must be appointed as the IRO for that child (S25a (1) CYP Act 1989). They have a responsibility to review and monitor the performance of the local authority in respect of each child’s case. They should also; • Promote the voice of the child • Ensure plans are based on detailed and informed assessments and provide a real response to the child’s needs • Offer a safeguard to prevent drift in care planning and service delivery to children looked after • Monitor the activity of the local authority as corporate parents.  2.26 The role of the IRO is a specialist function which may require them to challenge senior local authority managers. There is a specific requirement for them to be authoritative professionals with at least the equivalent status as an experienced social care manager.  2.27 The IRO is responsible for the effective chairing of each looked after child’s review meeting.  In order for these meetings to be productive and sensitive to the needs of the child, time and careful preparation is required (IRO Handbook).  IRO must have the capacity to be able to;    8 • Speak with the child before the review (and good practice is to also speak to them between reviews) • Speak to the social worker 15 days before the reviews. • Scrutinise any relevant reports, plans and assessments, including personal education plans, health plans and medical assessments    2.28 The IRO manager has additional line management and supervision duties and is also required to produce an annual service report. That annual report should include outcomes of quality assurance audits undertaken by the unit, service performance data and identify whether resource issues are putting the quality of service delivery at risk. 2.29 The IRO Handbook (7.15) estimates that a caseload of 50-70 looked after children for a full time IRO would represent good practice in the delivery of a quality service, enabling them to meet the full range of functions required of them.  2.30 Child Protection Conferences are convened where concerns have been substantiated and it is judged that a child is suffering or likely to suffer significant harm.  The Role of the Child Protection Conference Chair is; • To review all relevant documentation in preparation for the Conference and Review, including the social workers report and any assessments and plans. • To meet with the family prior to the conference and their role in it. • To agree issues of attendance and participation of family members • Ensure the child’s voice is heard  • Ensure consideration to any individual or cultural needs, including any requirements for disabled participants • Chair the meeting, setting out its purpose for all participants and ensure that families are involved in the planning • Make a final decision about child protection plans. •  In many areas, in addition to the above responsibilities the CP Chair quality assures conference and review minutes.   2.31 In Sunderland (and many other authority areas) the roles of the IRO & Child Protection Chair have been merged into one unit with shared responsibility for CP and IRO functions. Administration of the looked after child reviews and child protection conference process  2.32 While Sunderland CP/ IRO unit are able to draw admin support from a limited number of staff within a pooled admin team this is subject to availability, they do not have dedicated administrative resources. There are a number of issues with this approach, not least that IRO/CP officers in addition to their core role are spending valuable time on administrative functions such as managing the bookings of rooms for meetings, sending out meeting invitations and typing up    9 minutes. There is as a result a sense that the administrative functions and standards may not be wholly coordinated or consistent across the service. 2.33 The role of the minute taking of a child protection conference carries a significant responsibility in ensuring key confidential and sensitive information is recorded, and requires a high level of competency to produce reports to an accepted standard. The information content of conferences can be distressing and this should be considered in relation to the resilience of the record takers. There are inherent benefits with regard to coordination and maintaining quality standards in having some consistency and continuity in the minute takers.  2.34 The IRO/CP Manager also identifies the impact of limited administration resources elsewhere within children’s social care as having a negative impact with regard to the quality of reports, records, minutes and key documents overall. 2.35 The IRO handbook (7.3) states that the local authority has a responsibility to provide sufficient administrative support to facilitate the delivery of an efficient and effective review process and sets out key standards for the administrative process. The handbook also directs the IRO manager to inform the local authority of any shortfalls in this provision and I am advised that this action was undertaken but remained unresolved at the time of the Coreassets review. IRO/CP Chairs Capacity and Adequacy of the Service 2.36 All of the staff in post meet the standards required for their role as IRO/CP Chairs. No performance issues have been reported as part of this review. The arrangements, in respect of chairing these meetings are therefore considered adequate, (subject to capacity and adequate support being provided).  2.37 Following the Sunderland Ofsted inspection in 2012, there was the first of two subsequent reviews of the IRO/CP service that led to the staffing establishment being increased by one full time equivalent post.  2.38 During 2013 there was a significant increase in the numbers of children entering the care system; this prompted the LSCB to raise a formal challenge as to whether the IRO/CP service had capacity to respond to the rise in numbers and still deliver against their core quality assurance function. A second service review was undertaken and this resulted in a further increase in the staffing establishment, taking the total staffing establishment to 8 FTE. 2.39 The service has had three different managers since 2012 with the substantive manager retiring in September 2012, two interim managers have held the post between then and May 2014. At the time of this report a third interim is about to be appointed until a substantive manager is appointed. This level of change will have undoubtedly impacted on the stability of the unit. 2.40 The IRO/CP access the ICS/ESCR systems to record and check information pertaining to the child’s journey as part of their core function, the time requirements and limitations of this have been previously explored. 2.41 The staffing establishment of the IRO/CP services currently stands at 8FTE, yet there are 318 children (May 2014) subject to children protection plan and 499    10 children with looked after status (May 2014). Given the combined role of the unit this is equivalent to each officer holding a caseload of 102 children compared to the advised caseload of 50-70 children.  2.42 The high caseload, combined with the inadequate arrangements for administration, and the case recording system being applied undoubtedly compromises the ability of this unit to fulfil its core quality assurance and scrutiny functions.   2.43 The time span between 2012 and 2014 also spans the scope of the serious case review. The issues outlined above must be considered as contributory factors in both the absence of quality assurance and challenge of practice and also the quality of some of the records of formal meetings. These form part of the LSCB challenge questions regarding case records and arrangements for minute taking. Social Care Caseload levels 2.44 Social workers caseloads in Sunderland over the last two years have ranged on average between 20 and 35 per social worker, the increase in numbers of looked after children have placed additional pressures on capacity. Social care managers have endeavoured to manage the demands of this through a form of caseload management that considers case allocations balanced against the experience of the social worker and the complexity and level of risk of the case, however the rigour of this approach is untested in this review.  2.45 While this number of cases being held is comparable with many other authority areas it is acknowledged both nationally and locally as being too high. Social workers with caseloads exceeding 25 have very limited capacity to bring about change in families at the level and intensity needed to tackle complex high-risk needs. The administrative and associated business support issues notwithstanding, this pressure is exacerbated where there are high sickness levels, challenges with recruitment and high turnover of social workers as appears to be the case in Sunderland.  2.46 The case load of the Social Worker primarily involved in the case of Baby A and Child C was not considered to be high, as she was only case holding 17 cases. 2.47 We are given to understand that as part of the revised Recruitment and Workforce Development Strategies further research is planned to explore the issues impacting upon recruitment and retention, alongside a review of existing induction arrangements, training and development and career pathways within Social Care. The Impact of Training on Practice 2.48 It is concerning in the light of the recurrent themes in national SCR’s that practice does not appear to change in the light of the lessons learned. However, this appears to be a challenge nationally and is not unique to Sunderland Social Care.  2.49  There are number of ways of measuring the impact of training;    11 • Through built in evaluation measure at the point of training delivery that are then revisited at later date and this may need to be considered by both the LSCB and single agencies. • Reflection during supervision in relation to specific case discussions • Case file audit findings testing the impact of training and then reflected on with the worker or workers concerned.  The latter two areas are identified as requiring strengthening in children’s social care. 2.50 The LSCB has a responsibility to ensure training is in place but this does not remove the employing agencies responsibility to ensure adequate training is provided to ensure a confident, capable and competent workforce. Within the findings of the Baby A case review there were some identified concerns with regard to social workers knowledge in respect of the impact of substance misuse, disguised compliance, and the vulnerability of babies under 12 months old alongside further quality issues with regard to assessments and the identification and management of risk.  2.51 Noting the pending review of the Workforce Development Strategy the Council may also wish to consider the value of conducting a training needs analysis of all staff, to accurately identify training requirements, and also exploring opportunities for action learning sets in relation to the above topics. Commitment needs to be given to enabling workers to prioritise training and this will present significant challenge given current caseloads and service demands. 2.52 The implementation of the LSCB Learning and Improvement Framework will be of added value locally in ensuring lessons learned are translated into improved practice. Conclusion 2.53 In exploring the underlying factors which compromised practice in this case it is apparent that the recommendations for children’s social care currently included in the overview report may lack the necessary focus and rigour needed to bring about effective change in social care practice.  2.54 The SCR process in this case has been compromised in that key questions remained unanswered at the point of the completion of the current version of the overview report. There are further implications to be carefully considered by the Local Authority and the LSCB if this report is to be published in its current form. Further consideration is also needed as to how the responses to the ‘why’ questions’ are to be shaped into robust and cross cutting recommendations forming part of the overview report and associated action plan, and it may be that there is a need to re-enter the SCR process to conclude this satisfactorily.  2.55 The wider safeguarding system and partnership relies as much on confidence and trust as they do on robust systems, processes and quality of professional practice. It is important that the further response by children’s social care results in a shared and clear view from all concerned that the recommendations from the SCR result    12 in improvement that promotes confidence in single agency and joint working arrangements. 2.56 Identified practice issues will be shared with social care staff without further delay and looked at within the context of the recurrent themes found in previous reviews undertaken in Sunderland and also in national serious case reviews.  .    Appendix 1 Sunderland Council Children’s Safeguarding Service response to the “why” questions asked in the Baby A and Child C Serious Case Review Overview Report. Meg Boustead.  1.  Why was managerial oversight and supervision arrangements so inadequate, given the LSCB had undertaken an exercise relating to supervision in the recent past? 1.1  This section considers the reasons why management oversight was not good enough in this case. It also explains why supervision standards were not adhered to, and considers current arrangements for supervision across the service. 1.2  It is fully accepted that the level of management oversight in this case was not at the level that is expected by the service. None of the assessments, including the parenting assessment completed in early 2012 and the subsequent pre-birth initial assessment were signed off by the team manager, as they should have been. Also delays in completing the pre-birth assessment and arranging the pre-birth conference were not challenged. The individual team managers and senior management have accepted responsibility for these oversights. The wider systemic reasons why team managers are not always able to provide the level of management oversight that is expected are being addressed through external review. There is recognition nationally that the role of the team manager in a Child Protection Team is a particularly demanding one. In Sunderland each of the 5 child protection team managers has responsibility for between 200 and 300 children and young people. The demands made upon Child Protection team managers have increased over the past 2 years, as there has been an increase in the number of care proceedings being initiated and overall the number of children in care has increased by 25%. There is acknowledgement that team managers need additional support to enable them to discharge their responsibilities as consistently and effectively as they would want to. Consequently since September    13 2013 all of the teams now have at least one Senior Social Worker in post to provide additional management capacity. There is also a plan in place to increase the amount of administrative support available to Team Managers that will increase their capacity to provide effective managerial oversight to the teams. 1.3  Since the events described in this Serious Case Review all team managers and senior social workers have been directed to ensure that they quality assure and sign off all assessments. Developmental work has been undertaken with social workers and managers to increase their understanding of issues of risk to vulnerable babies. Since July 2013 there has been a requirement that all Child Protection Team Managers discuss all unborn babies in each social worker’s supervision. This was extended to babies under 2 in December 2013. Managers have been reminded to scrutinise the detail of plans for vulnerable babies living in Regulation 24 / Connected carer settings and to ensure that all plans for children in these circumstances detail contact supervision arrangements and evidence that carers are aware of their responsibilities and are capable of carrying these out. Team Managers are required to sign off these plans, and any pre-birth arrangements forms, prior to the discharge of a baby from hospital to family placements. The senior managers are also checking in their 1 to1s with Team Managers that the vulnerable babies’ protocol is being followed.  1.4  In addition Child Protection Conference chairs and Independent Reviewing Officers (IROs) now ensure that they have sight of all completed assessments, for child protection and looked after children respectively (previously if assessments were completed between reviews meeting the chairperson did not always see them). This will ensure that the quality of assessments is also monitored by the Independent Reviewing team for children who are either subject to child protection or are looked after. Further consideration is being given as to how similar arrangements can be developed for children who are subject to a Child in Need plan and Early intervention services. 1.5  As a result of this Serious Case Review we have put in place a new mandatory Management Development programme specifically for Team Managers in Children’s Social Care. The programme includes modules on learning from Serious Case Reviews, assessment, supervision and quality assurance.  1.6  The requirements for professional supervision of social workers, fostering officers and Independent Reviewing Officers are clearly laid out in our Supervision Policy that stipulates that supervision should be held at least 10 times per year. Although the policy complies with the LSCB’s supervision standards, it is recognised that supervision does not always take place at the frequency stipulated due to the workload pressures on team managers. The frequency of supervision is discussed by Senior Managers in formal 1;1s with Team Managers. Team Managers now have to provide evidence to Senior Managers that supervision of social workers is taking place. There is evidence of good supervision taking place across the    14 service, but this cannot be consistently evidenced at present, as other aspects of the system require development. Compliance with the supervision policy will be monitored through a supervision monitoring spreadsheet where planned and delivered supervision will be recorded. The quality will be monitored through a dip sample of supervision files. All managers will receive externally commissioned training on supervision on 19th June 2014.  1.7  There was a particular problem with the supervision of the IROs/Child Protection Chairs as there had been a part time manager in post between October 2012 and December 2013, which meant that this team were not receiving supervision as regularly as they should have been.  Since January 2014 there has been an experienced interim full time Independent Review Team manager in post and regular supervision now takes place. During the same time period there had been a change in manager in the fostering team and management arrangements are now stabilised .We are therefore reviewing and strengthening our practice on supervision audits as an integral part of our new quality assurance framework.  2.   Given that effective records contribute to better outcomes for children, why were records, minutes and plans of key meetings not available and why when some were submitted were they so poor? 2.1  This section explains why the records and plans for some key meetings were not available, and considers the process of recording the outcomes of such meetings and what has been done to improve this since the events described in the serious Case Review.  2.2 There are 3 related reasons why it was not possible to locate the minutes of all core group meetings, and some other meetings, in this case. These are, firstly, the way in which these documents were stored, secondly the number of different places where these records are held, and thirdly, in the case of core group minutes, the ability of social workers to make an accurate record of such meetings. The first reason is that the records are currently quite difficult to store in the electronic case file management system. Until February 2012 the assessments and plans were linked to what was the Integrated Children’s system, (ICS) now known as the Children’s Case Management system (CCM). However CCM (due to the difficulties with the nationally designed “exemplars”) did not create user-friendly documents and the service was criticised by Ofsted in 2010 and 2011 for this. Therefore the assessment formats, and individual children’s plans were removed from the CCM system between March and May 2012. The documents were instead replicated as Word documents, making them easier to complete and to read. The revised documents were welcomed by families, social workers and    15 other professionals. However the new challenge that this created is that these documents are not now linked into CCM so have to be stored separately in the Electronic Social Care Record (ESCR) which is a cumbersome and time consuming process.  2.3 The second, linked, reason is the number of systems where documents are stored, which can make locating documents difficult. The Individual Management Review Author of the Social Care report explained in her report that part of the difficulty in locating records of meetings is that there are 4 separate places where these are stored on the current electronic case files. As well as CCM itself, and the linked ESCR, there are also e-case files (a separate system that has not been used since 2012 although it is still holds some historical information). One of the problems with the e-case files, was that in the past information was not always indexed properly, sometimes making retrieval problematic. The other place where documents are stored are the social workers’ “Current work” files, which are working files where unfinished documents not yet ready to store in ESCR are held. This is a temporary situation until the new version 28.2 of CCM is implemented in August 2014. Version 28.2 will reconnect key documents to the CCM system and make storage and retrieval more straightforward. In the meantime all social workers have been instructed to make sure that they store all completed documents in ESCR to facilitate retrieval. Additional administrative support has been deployed to assist with moving finished documents from social workers personal work files to ESCR.  2.4 The third reason particularly relates to Core Group meetings, in that the social worker has to chair and take the record of the meeting at the same time. Consequently the record is not always of the quality that is required. At the time of the Serious Case Review it also had to be typed, correctly stored and then circulated to the other Core Group members by the social worker. (In some core groups other core group members from other agencies offered to take the notes of the meeting, which freed the social worker to chair, but this was not routine practice). Inevitably the competence of social workers in completing, typing, storing and circulating these records varied, particularly in the face of competing priorities on their time. A Core Group Meeting template has now been introduced to encourage consistency in the format. This is designed to assist social workers with the task of making a record of the outcome of core group meetings and improves the quality of the content. Business Support staff now type the minutes of the core group, save them into ESCR and distribute then to the core group members. 2.5 There are 4 different types of meetings; the first two are Child Protection Conferences and Looked after Reviews, which are both chaired by a team of Independent Review Officers (IROs) and Child Protection Chairs. In relation to the records of Child Protection meetings, these meetings are minuted by a team of    16 minute takers, most of whom are experienced and competent. There is still some variation in the quality of the minutes of Child Protection conferences and this is being addressed through the Children’s Independent Review Team Quality Assurance framework. As a result of this Serious Case Review the Child Protection Conference agendas, report formats and the template for the minutes have all been reviewed and strengthened in order to improve the outputs of Initial and Review Child Protection Conferences, in particular by making child protection plans more outcome focused. The minute takers now save the minutes of all Child Protection Conferences into the Electronic Social Care Record (ESCR) this is part of the electronic file for the child or young person.  2.6 Minute takers do not attend Looked After reviews, which are often less formal meetings and the child or young person is encouraged to attend. Consequently the record of these meetings is made by the Independent Reviewing Officer (IRO) and then typed afterwards. These records are then filed within the Electronic Social Care Record (ESCR) this is part of the electronic file for the child or young person. The difficulty locating some of the records of LAC reviews in this Serious Case Review has led to Business Support staff in the Children’s Independent Reviewing Unit being instructed to store all LAC Review minutes in ESCR, and this is now in place. 2.7 The 3rd type of meeting referred to in the SCR is the Strategy meeting. These meetings are normally chaired by Team Managers or Senior Social Workers and are recorded by minute takers. The minutes of Strategy meetings are recorded on a template agreed in December 2012. The format for recording the minutes of Strategy meetings and the process for circulating and storing them has been reviewed and strengthened, additional administrative support is being put in place to help ensure that strategy meeting minutes are returned to the minute taking service to enable speedy circulation and electronic filing. Business support resources have been identified to assist with this. 2.8 The 4th meeting type is the Child Protection Core Group. In common with many other areas, there is an on-going problem with social workers needing to chair the core group and keep a record of core group meetings. Until recently there was an additional burden on social workers, as they had to also type and distribute the notes of these meetings to attendees. However business support has now been put in place to type, circulate and electronically file core group minutes. There has also been further discussion with some SSCB partner agencies about other core group members taking notes at Core Group meetings in order to reduce the burden on the social worker.  2.9 Compliance with all of the above will be tested through the case file audit process, which is currently being strengthened. Case file audits are being carried out by managers and the findings are communicated to social workers so that and gaps or issues can be addressed.    17      3.  Why are arrangements for chairing and note taking at various meetings so inadequate? 3.1 This section considers arrangements for chairing and minuting the 4 types of meetings detailed in 2.1 above. Generally the arrangements for chairing and recording Child Protection Conferences and Looked after Reviews in Sunderland works very well. All of the Child Protection Conference Chairs and IROs meet the requirements of Working together 2013 and the IRO Handbook. They are all very experienced at chairing meetings and complaints from service users or professionals about the conduct of the meetings are very rare. However following the criticism of the practice of the Child Protection chairs / Independent Review Officers within the Serious Case Review, the quality assurance role of the Children’s Independent Review Team has been reviewed and strengthened as it was recognised that they were not always providing sufficient challenge within the system. As Child Protection Chairs they are now more regularly raising Quality Performance Reports in relation to Child Protection Conferences and as Independent Review Officers (IROs), they are invoking the IRO Dispute Resolution protocol if there is any delay in plans for looked after children. The challenges they make are recorded in the Children’s Independent Review Team Challenge log as well as being recorded on the individual case files of children and young people. As described, in 2.4.and 2.5 above, arrangements have now been put in place for the Child Protection Conference minute takers to save the Conference minutes in ESCR, and for business support staff to save the Review record for LAC Reviews in ESCR, ensuing that there is a clear record and facilitating retrieval. 3.2 In addition, as part of the implementation of the recommendations from the Serious Case Review, the LSCB is reviewing the agenda, report format and the template for the minutes of Child Protection Conference are all being reviewed in order to strengthen and improve the outputs of Initial and Review Child Protection Conferences, in particular by making child protection plans more outcome focused. 3.3 As explained at 2.6 above, Strategy meetings are normally chaired by Team Managers or Senior Social Workers and recorded by minute takers. The minutes of Strategy meetings are recorded on a template agreed in December 2012. As a    18 result of this Serious Case Review the format for recording these minutes and process for circulating and storing them has been reviewed and strengthened. 3.4 As outlined in 2.7, core group meetings are chaired by social workers.  The competency of individual social workers in chairing core groups will vary. Consequently training for social workers in chairing core groups is being provided as part of the Children’s Safeguarding Workforce Development plan 2014/15. This will include re-enforcing the requirement for social workers to be open to professional challenge from other core group members and the need to avoid being defensive when challenged. Until recently the social worker not only had to make the record of the meeting but also had to distribute and file this record. The minutes are now recorded on a template which ensures consistency in the format and promotes quality in the content they are given to business support staff to type, distribute and file.    4.  Why are the training opportunities provided to frontline practitioners and the learning from research and reviews not leading to improved practice? 4.1  Until 2012 the training programme in place for social workers had a broad focus which reflected the wider models of professional practice and standards in place at the time. However during 2013, the early responses to the Munro Report (2011) begun to impact on provision and the training provided placed more emphasis on social workers being responsible for their own professional development. Social workers were provided with access to research and learning through Community Care Inform, an online leaning resource, and a range of e-training was provided, which has benefits in terms of accessibility. However this did leave a current gap in training opportunities for more experienced social workers and managers which we are addressing via the Management Development Programme and the 2014/2015 training programme, which includes externally commissioned training on assessment, which is being delivered in June 2014.  It is recognised that more single agency training is required alongside the SSCB training programme. Consequently the Workforce Development strategy has been revised and updated, reflecting the changes in practice development nationally and the new social work career pathway that will be put into place over the next year. This will include the requirement for all social workers to maintain appropriate levels of child protection knowledge, including attendance at relevant SSCB training events, and personal reflection on their professional development. This will be identified through the Annual Appraisal and regularly monitored through supervision. The revised supervision audit process will check that this is in place for all social work qualified staff. 4.2 All Children’s Social Care staff are encouraged to attend SSCB training and attendance is monitored through the SSCB. The Children’s Social Care Individual    19 Management Review identified that the social worker and the two team managers had attended relevant SSCB training and departmental training. The social worker and her manager were also both booked onto the SSCB Vulnerable Babies workshops that were being held at the time of Baby A’s death but unfortunately were not scheduled to attend until after the events that led to the Serious Case Review.  The SSCB is in the process of putting in place an audit to evaluate the effectiveness of training which will at first be used to evaluate SSCB training but can then be used to measure the effectiveness of single agency staff development, and this will compliment planned revisions to internal arrangements outlined above. 4.3 The learning from this Serious Case Review had already begun to be disseminated to the teams prior to the Learning and Improvement workshops hosted by the SSCB, in September and October 2013. The Head of Children’s Safeguarding and the Assistant Head of Children’s Safeguarding   met with each of the CP teams about the initial learning from the SCR, including the requirement to follow the Vulnerable Babies Protocol, and the involvement of other agencies, especially midwifery, in pre-birth assessments. The learning from the SCR, and the Single Agency Action plan arising from the SCR has been shared with all Children’s Social Care Team Managers  5. Are high caseloads accepted by senior management if this leads to poor practice and leaves children vulnerable? 5.1 In relation to this Serious Case Review, the Children’s Social Care single agency management review author specifically asked the social worker about her workload at the time of the events described in the Serious Case Review, and she reported that she felt that her caseload at the time (17 cases) was manageable. However caseload sizes are an issue in Sunderland as elsewhere. 5.2 Overall most social workers’ caseloads are more manageable than they were 3 or 4 years ago. Caseload sizes were shared with the SSCB Vulnerable Babies Group in November 2013; at this time average caseloads in the child protection teams were approximately 25. There was a regional exercise on caseload size undertaken at this time and caseload sizes in Sunderland were in line with those across the Region. Although social work caseloads do fluctuate in size and complexity, and at times there is variation between teams, there is recognition that for some social workers they are still too large. Caseloads fluctuate in relation to demands on the service and the recent increase in number of Looked After children has inevitably had an impact on caseloads. Current caseload sizes in the Child Protection teams range between 22 and 29, but are over 30 in some instances.    20 5.3 Caseload sizes are actively managed by moving cases between staff, on occasion moving staff between teams to address a workload imbalance, and when necessary employing additional agency staff. Agency social workers are also used to cover for long-term absences and fill any gaps; there are currently 8 agency social workers in the service. The safe management of higher caseloads is dependent upon the experience of the individual social worker and the quality of the manager overseeing the work. More experienced managers are more able to support staff with higher caseloads than less experienced managers. The current structure is designed to have the Senior Social workers having reduced caseloads and taking on a quality assurance function alongside the Team Manager.  Where the senior social workers are able to fully realise their role the team managers are able to operate more effectively. 5.4 Individual poor practice is not tolerated and disciplinary measures are put in place if practice falls below the acceptable standard and cannot be addressed by the worker and manager together. Although the skill mix across the social work teams has improved, the imperative to continue to recruit and retain experienced social workers remains as much a priority as ever. Children’s Social Care currently has 14 vacancies, 9 posts were recruited to in March 2014 and these staff are beginning to come into post. Of these new staff, 7 are newly qualified and 2 are experienced social workers. There is a further round of recruitment currently underway targeted at attracting experienced social workers.   6.  What factors mitigated against expected practice in this case? 6.1 Although the practice identified in this Serious Case Review is not standard practice across the service, it does demonstrate weaknesses in the quality assurance mechanisms in place to ensure consistency of practice.  There has previously been recognition that there is a significant challenge in relation to improving the consistency of quality of social work across the service. This was recognised by the Ofsted Inspection of Safeguarding and Looked after Services in February 2012, and continues to be evident through case file case file audits and management reviews. Some progress has been made, but due to the combination of staff turnover, volume of work/caseload sizes, problems with the Children’s Case Management (CCM) case system and sometimes-stretched management capacity, progress against these objectives has been slower than planned.  6.2 It is very difficult to say exactly why the failings that characterise this case occurred. The Individual Management Review Author did try to outline some of the reasons underlying what went wrong with the management of this case. One of the problems was that there was no handover between the two-team managers when the social worker moved team in October 2012. This was because the first team manager was on sickness absence at the time the social worker transferred    21 team. Both the team managers acknowledge that had this handover taken place the support needs of the social worker would have been more fully explored and the second team manager would have made fewer assumptions about the competence of the social worker to complete the tasks she had been assigned. The 2nd team manager fully acknowledges that she should have identified the lack of robust assessment at a much earlier stage. The capacity of team managers to provide sufficient critical challenge and the lack of challenge from other parts of the system, notably the CP Chair/IRO has been described above. These constitute missed opportunities and the response to this learning is being embedded across management and social workers. 6.3 A broader understanding of the reasons why practice in this case fell short of what is expected from staff and managers can be seen in the wider context of the other changes taking place across the service at the time. The immediate impact of 3 key managers leaving the service at the same time in September 2012 needs to be seen in the wider context of overall reduced management capacity due to implementing the new structure, at the same time as a reduction in the availability of key support services such as business support, training, and performance management. These factors were cumulatively significant in there effect on our capacity to maintain consistent levels of oversight in this case. 6.4 The lack of a robust quality assurance process throughout the child protection system at the time meant that the failings in this case were not identified until after the sad events that precipitated the review. This has led to the need for a full review of the QA framework in place across Children’s Social Care, including the fostering service and the Children’s Independent Review Unit.  7.   The inadequacy of IRO resources has been raised by the Board on a number of occasions, why has there been no effective action to date? 7.1 As outlined in 3.1 above the current Child Protection Conference Chairs and IROs are all experienced at chairing meetings and meet the requirements of Working together 2013 and the IRO Handbook. The team is very experienced and knowledgeable, however there has been an issue about their capacity to provide effective challenge in relation to Child Protection and looked after planning. The service has benefited from additional resourcing and has implemented a range of measures to improve effectiveness. Regular reports from the IRO service to the SSCB will seek to provide further evidence and assurance of these improvements. 7.2 Since the Ofsted inspection of Safeguarding and Looked After services in February 2012 the capacity of the Children’s Independent Review Team has been reviewed twice, both times leading to an increase in the establishment. An additional permanent full time IRO post was created in 2012, bringing the capacity    22 to 7 full time equivalent. However with the increase in number of looked after children over the course of 2013 the capacity of the Children’s Independent Review Team again became stretched. Therefore an additional member of staff was seconded into the service on a temporary basis in January 2014.This post has now been established on a permanent basis, increasing the permanent establishment to 8 full time equivalent IRO/CP Chairs.    7.3 During 2013 the LSCB raised concerns about the capacity of Child Protection Chairs to carry out their quality assurance functions. Since the full time manager has been in post the quality assurance role of the Child Protection Chairs/IROs has been reviewed. The size of the establishment will be kept under review to ensure that there continues to be sufficient capacity in the service to provide effective challenge to both the Child Protection and looked after systems. 7.4 Between late 2012 and the end of 2013 there was also an issue in relation to the management capacity of the team, which was reduced following the early retirement of the Independent Review Team Manager in September 2012. A temporary part time interim management arrangement had been put in place while an alternative service delivery model was explored. This was reviewed in late 2013; an experienced full time interim manager has been in post since January 2014 and the permanent manager post is now being advertised.           1  Chronology of actions taken by Executive Director of People Services in response to the serious case review of Baby A and Child C as at 30th July 2014  In seeking to achieve the best possible outcomes for all people in the city, the People Directorate was formed in the autumn of 2013, with a remit which would see it embracing an open culture, be outward looking, and welcome the views and opinions of all stakeholders. Therefore in response to concerns expressed, the Executive Director informed a Sunderland Safeguarding Children’s Board of his intention to undertake a review of the service and subsequently wrote to partners and stakeholders inviting views and contributions in order to inform the terms of reference. Partners responded positively to inform the terms of reference and the Chair of the Safeguarding Board also submitted a report to the SSCB in December on ‘Concerns re: multi-agency working’ which further informed the terms of reference. The Executive Director drew up draft terms of reference by the end of December 2013 and during January 2014 sought advice on how best to deliver the review.  Advice was sought via ADCS, LGA and SOLACE as well as taking soundings from colleague DCS’s. The outcome of the discussions led to the conclusion that a 2 stage approach would best deliver what is needed.  The first stage would focus on the Council’s Safeguarding Service, its effectiveness and how it interacts with partners, including the response to a set of why questions posed by the Chair of the SSCB.  The second stage would be a Peer Review to look at the Safeguarding system in its wider since and is scheduled for the autumn. Progress over the last six months The pace of change in Children’s Safeguarding Services can be illustrated below:- 1 March – April 2014  • In order to assess and address issues raised in relation to the Local Authority’s Safeguarding Services response to a serious case review, an independent organisation was commissioned to undertake a review. The review commenced in March, it concentrated on a number of “why” questions that had arisen from the services IMR report into the Baby A and Child C serious case review. • Since the Ofsted inspection of Safeguarding and Looked After services in February 2012 the capacity of the Children’s Independent Review Team has been reviewed twice, both times leading to an increase in the establishment. In particular in relation to the increase in number of looked after children over the course of 2013 an additional member of staff was seconded into the service on a temporary basis in January 2014.This post has now been established on a permanent basis, increasing the permanent establishment to eight  full time equivalent IRO/CP Chairs.  2  2 May - June 2014 • Draft Action Plan from the review received mid-July.  • All teams have a senior social worker and senior practitioners increasing the team manager’s capacity to provide effective and managerial oversight to the teams.  • All team managers and senior social workers quality assure and sign off all assessments. Work has been undertaken with social workers and managers to increase their understanding of issues of risk to vulnerable babies. There is a requirement that all Child Protection Team Managers discuss all unborn babies in each social worker’s supervision and this has been  extended to babies under two.  • The quality assurance role of the Children’s Independent Review Team has been reviewed and strengthened.   • Introduction of a new mandatory Management Development programme specifically for Team Managers in Children’s Social Care. The programme includes modules on learning from Serious Case Reviews, externally commissioned assessment training, supervision and quality assurance delivered from June 2014.  • All social workers were instructed in June 2014 to store all completed documents in ESCR to facilitate retrieval.  3 July – August 2014 • Child Protection Conference chairs and Independent Reviewing Officers (IROs) now ensure that they have sight of all completed assessments, for child protection and looked after children respectively.  • Team Managers now have to provide evidence to Senior Managers that supervision of social workers is taking place.  • The Child Protection Conference agendas, report formats and the template for the minutes have all been reviewed and strengthened to make them more outcome focused to improve the outputs of Initial and Review Child Protection Conferences.   • A full time manager is in post and the quality assurance role of the Child Protection Chairs/IROs has been reviewed and the permanent manager post is now being advertised.  • Regular meetings with early intervention services to step down cases safely. 3   • Risk management approach each Monday to support the allocation of cases no unallocated child protection cases.  • A range of improvements on templates has been made; A Core Group Meeting template to assist social workers with the task of making a record of the outcome of core group meetings and improves the quality of the content. Business Support staff now type the minutes of the core group, save them into ESCR and distribute then to the core group members.  • All team managers and senior social workers quality assure and sign off all assessments.   • Version 28.2 of CCM is planned for implementation in the autumn of 2014; this will reconnect key documents to the CCM system and make storage and retrieval more straightforward.     Fiona Brown Chief Operating Officer People’s Directorate  4  APPENDIX 4   Action Plan re: Safeguarding Children service, Sunderland City Council   Recommendations  Actions required Outcome required  Responsible Person Timescale  Evidence of Action taken Aug 1014  Monitoring of implementation  1Information packs provided to foster carers and children in care, and professionals will be updated to ensure they are fully aware of the role of the Out of Hours service and how to access it.   Landline and Mobile phones for workers all to have a message that carries the out of hours number.  Induction packs provided to foster carers and looked after children include OOH number  OOH Contact number is listed on website  All foster carers looked after children and professionals to have out of hour’s information. Service Manager Lynne Goldsmith September 2014 Landline / Mobile phones now have appropriate messages.   Audit / spot check of phones to ensure all workers undertake change 2. The supervision model and policy will be reviewed and implemented consistently across service areas in accordance with LSCB standards. Cases of babies under 1 year of age will routinely be discussed in supervisions Review and re-publish the supervision policy to ensure all members of staff receive quality supervision that is commensurate with their role and responsibility to safeguard children.  Review the training The quality of social work is improved as a result of quality supervision which includes personal and professional development issues as well as casework discussion. In supervision staff are supported and challenged to ensure that the HOS safeguarding  December 2014 The supervision policy has been recirculated.  Supervision training was delivered in June 2014.  Managers are required to discuss all cases of babies under 12 months in supervision from July 2013, and this was extended to all babies under 24 months in December 2013 Case file audits 5  programme on supervision for social care staff to support improved supervision in the following; reflective practice, impact challenge, risk analysis, developing SMART actions and appropriate recording.   Ensure the quality of supervision is included in the case file audit programme. needs of the child remain at the centre of their social care practice.  Compliance with supervision policy is monitored through 1;1 meetings with senior managers.  3. A service wide training needs analysis is to be undertaken across children’s social care and early interventions services; staff training pathways and mechanisms to measure impact on practice will be developed and training provided. TNA undertaken.  Training requirements for staff identified.  Training budget reviewed.  Rolling programme developed and in place  The quality of social work is improved through learning. Stephen Mason Service Manager August 2014  September 2014     October 2014    TNA  tool has been developed and will be circulated and analysed by September 2014  . Followed up through annual appraisals 4. The IRO/CP service will be reviewed; this will ensure adequate capacity is available to perform core functions and will include Service review undertaken.  Staffing capacity agreed  IRO/CP unit able to fulfil core functions to a high standard as part of the broader quality assurance of HOS Service Safeguarding December 2014 Arrangements for the administration and case information of CP conferences and LAC review have been strengthened.  Monitored through case file audit 6  administrative support. A revised quality assurance framework and quality standards for the administration of the service will be developed and implemented. Standards for administration function agreed and in place.  IRO/CP quality assurance process established. children’s services. The permanent IRO manager post is currently out to advertisement, and the unit is currently being managed by an Interim Manager.  Report templates have been revised to improve recording standards.   Arrangements for note taking at core groups are being shared across partners reducing the burden on social workers, these are typed up by admin and uploaded to the case files and circulated appropriately   A revised QA framework and dispute resolution procedures in the IRO units QA role is strengthened and a challenge log is now maintained with details of practice challenge also entered    on the child’s care file.  The signs of safety model of child protection conferencing is being considered as part of the broader improvement plan, and this decision will influence the revision of plan templates.   7  5. Arrangementsfor transition and case handover will bereviewed and protocols developed as required. Develop robust protocols for managing case transfers between teams and individual workers, ensuring this also allows for absence through annual leave or sickness, and aligned to the Step Up/Step Down protocols..   Children and families experience seamless transition through services. Opportunities for children to ‘fall between services’ are minimised. Head of Service Safeguarding  December 2014 Regular meetings with early intervention help enable more robust step down and this is impacting on case- loads.   Childs experience monitored through case file audit and quality assurance processes 6. A Case load management system will be implemented across social care and monitoring and reporting caseload levels will form part of the quality assurance framework.  Develop an accepted model of case load management in consultation with staff and unions.  Case loads are effectively managed according to capacity, competency, and experience of social workers Head of Service Safeguarding  December 2014 Pending the development of a formal case load management system case loads are more closely monitored and currently stand at between 22 & 29 in child protection cases on average.  Regular meetings with early intervention help enable more robust step down and this is impacting on case- loads Case load levels reporting forms part of quality assurance framework. 7. A robust quality assurance framework will be developed across children’s social care and early intervention services. This will identify measure and risk owners   Review and revise the council’s quality assurance framework so that it meets statutory requirements and ensure it is implemented across children’s services.  The council is able to quality assure the child’s journey through services Head of Safeguarding December 2014 A quality Assurance sub group is formed and tasked with developing a framework. Operational procedures are in the process of being finalised Weekly performance data is provided to senior managers and discussed at the weekly Regular reporting is visible, including reporting to the LSCB 8  SMT Risk management approach to Child protection allocation of cases introduced and information reported to the Head of service weekly. 7.Operational guidelines will be provided to all staff to ensure they are aware of requirements and expectations in LAC care planning, including formalising contact arrangements, placements out of area, assessments (including PARP) emergency placements, and requirements under section 20 and Reg. 24.  Develop operational guidance for all staff On good practice and clear understanding and expectations of LAC Care Planning.  Action Learning Sets and Road Shows are rolled out across teams..  Finalise review of Permanency Strategy.  Children and young people’s needs are better understood and effectively addressed through robust assessment and care planning.  The views and wishes of children are fully explored in assessment and care planning.  Children and families/carers understand care plans and are involved in achieving good outcomes. Service Managers Lynne Goldsmith & Sheila Lough December 2014 Operational procedures are in the process of being finalised  Weekly briefings planned to provide staff with clarity of changes to policy. Case file audits  8.  The ICS case recording system will be reviewed to determine its suitability for purpose. A data cleansing exercise will be undertaken and appropriate file structures agreed.   Operational guidance will be provided to ICS review undertaken & decision made regarding suitability or alternative commissioning.  Data cleansing exercise undertaken to ensure all records are held appropriately. Case information management systems will support improved management oversight throughout the child’s journey through services.        All safeguarding Service Managers December 2014.       August 2014 (70% complete) 8 additional admin staff have enabled a data cleansing exercise to be undertaken between April 2014 & August 2014 which has also established an appropriate structure for case file management on ICS pending a system upgrade due later this Autumn.  Social workers have been Case file audits & staff feedback. 9  ensure all staff are aware of the requirements and expectations  of using the system effectively  Staff are advised of interim recording requirements.   July 2014 (complete)  given operational guidance on case information management.   9. All assessments, plans (including court plans) statements and review reports are to be signed off by service managers. System gatekeeping mechanisms will enforce this post 2016.  Interim guidance issued to managers and social workers Assessments are undertaken appropriately and quality is improved and consistent across service area.  Head of Service Safeguarding  December 2014 Every team now has allocated Principle SW’s &a Senior  Practitioners – management capacity improved as a result.  All assessments and plans are signed off by managers & Senior Practitioners- improving QA processes.  Briefings have been delivered to all managers regarding the understanding of risk of vulnerable babies and compliance with pre- birth assessments and discharge arrangements. Case file audits  10.All social workers and managers to be reminded of need to follow child protection procedures especially in relation to notifying appropriate people about children subject to CP planning living outside the local authority area.  Reminder made to all staff through team meetings.  Check of all children currently placed outside area to ensure host authority is aware.   Ensure that procedures are accurate with regard to post birth hospital discharge Host Local Authorities are aware of all children with child protection plans in their area.  Compliance with child protection procedures.   Vulnerable children are safeguarded effectively.   HOS Safeguarding February 2014 Checks have been made to ensure all host authorities have been made aware of children subject to CP residing outside the Sunderland area.  Lessons learned from the SCR have been shared with staff who are also encouraged to attend the LSCB briefings.  Staff have been reminded of the need to comply with CP Regular case file audits as part of QA systems  10  arrangements  procedures.  Notifications and compliance with policy, in regard to CYP subject to CP plans moving to another LA          