Physical abuse of a boy aged under 1-years-old in 2016. Billy was born prematurely and placed in foster care subject to an interim care order at 2-weeks-old; pre-birth assessment had concluded that it was not safe for him to be cared for by his birth mother, who had had previous children removed from her care. Moved into the care of his father and partner, and her child in September 2016. Father had history of substance misuse, domestic abuse, having a child removed from his care; partner had history of a child being removed from her care because of poor parenting capacity. Concerns raised about couple's capacity to parent Billy, who had complex needs due to detoxification from mother's substance misuse during pregnancy. Following a home visit where it was reported that Billy had a swollen leg, medical assessment and x-rays revealed fractures and bruises sustained whilst placed with his father and partner. Ethnicity or nationality not stated. Learning includes: evidence of good practice with professionals working well together to do the best for Billy; some opportunities missed for professionals from different agencies and disciplines to formulate effective plans together; purposeful professional meetings may have promoted better clarity and more effective ways to have informed decision making. Uses the Welsh model methodology. Challenges to the Local Safeguarding Children Partnership includes: consider how all involved agencies can contribute effectively to the formulation of a child's plan; ensure the inclusion of hypothetical risks that may be predicted along with risks identified in a comprehensive assessment to better safeguard children.
      
 Title:  Serious case review concerning “Billy”: overview report. LSCB: Leeds Safeguarding Children Partnership Author: Sharda Parthasarathi Date of publication: 2019  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.                           Overview report Child E – September 2019 1 Leeds Safeguarding Children Partnership Serious Case Review concerning “Billy” Overview Report September 2019 Author: Sharda Parthasarathi Overview report Child E – September 2019 2 Chair’s PrefaceSome preface is necessary for this Serious Case Review as it utilises elements of the methodological approach developed by the Welsh Assembly Government, focusing on learning lessons, improving practice and above all on avoidance on unnecessary delay. A major historic criticism of Serious Case Reviews is that they often take so long to complete that any real opportunity to ‘feed-back’ lessons learnt into professional practice can be lost. Some delay, for example with respect to the need for judicial matters to be concluded before Serious Case Reviews can progress is inevitable, but nonetheless the unwieldy, often overblown and quasi-academic methodology frequently used in Serious Case Reviews in my opinion also adds to this. I also feel that the somewhat inquisitorial ‘tone’ and remote stance adopted in a number of Serious Case Reviews often engenders great anxiety on the part of all involved, as it can feel that the purpose of the exercise is more to apportion blame, than to better understand what went wrong. Hardly a circumstance likely to promote the type of open and frank discussion needed. In order to lead this process of change directly I have made the unusual (but not unprecedented) decision to Chair this first SCR that will use the “Welsh Model” methodology, so that at each point of the process I can clearly and directly explain and contextualise the focus of the review, and our concern to learn lessons and improve future practice. The fundamental question is did any professionals or agencies make fundamental errors? It is important to be clear from the outset, that following very careful reading of all the written evidence considered by this Review, direct consultations with key individuals and the views expressed at a well-attended Practitioner Event: it is our conclusion that whilst Billy received serious injuries this was not the result of any gross or fundamental error on the part of any professional or agency. As a result of our investigations we have made recommendations in a number of areas, but I would specifically mention here that in respect of better use of the existing LSCP Concerns Resolution Process; such that safeguarding professionals in Leeds become more aware of, and make more constructive use of this mechanism in future. This is especially pertinent given the forthcoming change to safeguarding arrangements from September 2019 with statutory responsibilities shared between Children and Families Services, Health and the Police. Indeed, what has impressed us greatly throughout our consideration of the issues we will go on to outline and consider below, is the enormous commitment and passion that all involved in this case held with respect to what would be (and what remains) in the best interests of the child concerned. The principal issue at odds being the wisdom or otherwise of ‘testing out’ family placement, given the range of complexities and concerns evident and expressed as to the likelihood of achieving a positive outcome.  Overview report Child E – September 2019 3 Contents 1. Introduction ....................................................................................................................... 4 1.1 Reason for the review .............................................................................................. 4 1.2 Reviewing expertise and Independence .................................................................. 4 1.3  Panel ...................................................................................................................... 5 1.4 Timeframe ............................................................................................................... 5 1.5 Methodology ............................................................................................................ 5 1.6 Key Lines of Enquiry ................................................................................................ 5 1.7 Participation of parents / family members ................................................................ 6 1.8 Parallel proceedings ................................................................................................ 6 1.9 Confidentiality .......................................................................................................... 7 1.10 Context and description of s 38 (6) .......................................................................... 7 2. Family Composition .......................................................................................................... 8 3. Involvement with Mother ................................................................................................... 8 4. Chronological sequence of significant events ................................................................... 9 5. Analysis addressing the key line of enquiry: ....................................................................14 6. Analysis addressing the key line of enquiry: ....................................................................22 7. Findings ...........................................................................................................................26 7.1 Evidence of good practice ..........................................................................................26 7.2 Learning Lessons .......................................................................................................27 8.Challenges to the Leeds Local Safeguarding Children Partnership ..............................28 Glossary ..............................................................................................................................29 Endnotes .............................................................................................................................30 References ..........................................................................................................................32 Note: the names within this review have been altered as follows: Child – Billy  Step Sibling – Child BFather – Robert Father’s Partner – Vivienne Overview report Child E – September 2019 4 1. Introduction1.1 Reason for the review 1.1.1 Billy was born at 35 weeks in October 2015.  He was discharged from hospital at 2 weeks and placed in foster care subject to an Interim Care Order. A Pre-birth assessment had concluded that it was not safe for him to be cared for by his birth mother, who had previous children removed from her care. 1.1.2 Early September 2016 the Family Court ordered the placement of Billy with his father and partner, under s38 (6) Children Act 1989 for a period of assessment. Billy subsequently moved to their care the following week. Early October Billy was observed to be pale, appeared to be in pain and had a swollen leg. A paediatric medical examination was undertaken, following full x-rays and other tests, it was identified that Billy had sustained fractured tibia right and left leg and healing fractured arm. The three fractures occurred at different times and there was bruising to the inside and the back of his left ear. It also concluded that they were non-accidental injuries and had happened in the previous 26 days whilst placed with his father and partner. 1.1.3 The Independent Chair of the Leeds Safeguarding Children Board1 (LSCB) agreed on the 18 May 2017 that the case had met the criteria for a Serious Case Review (SCR). An independent Lead Reviewer (Sharda Parthasarathi) was commissioned in August 2017 and a Chair appointed (Dr. Mark Peel, Independent Chair of the Leeds Safeguarding Children Partnership). A panel, comprising of senior representatives of involved agencies was convened and met on six occasions:  1.1.4 Individual interviews were held with: Foster carersConsultant clinical PsychologistConsultant PaediatricianSpecialist Health Visitor Neonatal Abstinence Service1.1.5 A workshop led by the lead reviewer was held for authors of single agency reports before their reports were submitted by 20th December 2017. 1.1.6 Practitioner Event was held on 10th January 2018. 1.2 Reviewing expertise and Independence 1.2.1 The Serious Case Review has been led by two people, both independent of the case that is being reviewed and of the organisations whose actions are being reviewed. Sharda Parthasarathi, Independent Safeguarding Consultant, has had lead responsibility for authoring this report and Dr Mark Peel, Independent Chair of the LSCP has chaired the Serious Case Review. 1 Renamed Leeds Safeguarding partnership (LSCP) in April 2018. Overview report Child E – September 2019 5 1.3  Panel 1.3.1 The Panel comprised of: Head of Children’s Social Work, Children and FamiliesActing Head of Safeguarding Children and Adults, NHS Leeds CCG PartnershipService Manager, CafcassChief Inspector West Yorkshire Police, Safer LeedsConsultant paediatrician and Named Doctor for Child ProtectionHead of Service Safeguarding / Designated Nurse for Children Looked After andCare Leavers, Leeds Community Healthcare NHS Trust (LCH)Named Nurse, NHS Leeds CCG PartnershipAdvisor to the Panel, Assistant Manager to the Leeds Safeguarding ChildrenPartnership (Business Unit)1.4 Timeframe 1.4.1 The Panel agreed that the time period to be covered by the review should commence at the point of the mother’s and father’s partner’s pregnancies, as they were known to the agencies involved, and end with the date of the paediatric medical examination identifying that Billy had sustained three separate fractures.  The timeframe for the review was therefore March 2015 – October 2016. 1.5 Methodology 1.5.1 The general method of this Serious Case Review follows that developed for the Welsh Assembly Government (“Protecting Children in Wales: Guidance for Multi-agency Practice Reviews.” Welsh Assembly Government (2012)) for two main reasons; 1. This methodology has a clear focus on learning lessons and their direct applicationin practice.2. This methodology has been designed to minimise delay in bringing lessons learntto practice by ensuring the review process itself is as lean and efficient as possible.1.5.2 It is also important to note that the Welsh model methodology, especially with regard to the emphasis placed on directly bringing lessons learnt to practice, chimes well with the established Partnership approach to safeguarding in Leeds through early intervention and common commitment to restorative practice, as evidenced in the Leeds Children and Young People’s Plan 2015-2019. 1.6 Key Lines of Enquiry 1.6.1 The efficacy of testing out a placement with family, given the complexities and concerns of achieving a positive outcome, and the need to balance the risks associated with placing a child with family against the risks of severing all ties with family via adoption. Overview report Child E – September 2019 6   1.6.2 How professionals with particular expertise are involved, contribute and influence an effective multi-agency plan promoting high support and high challenge and making effective use of the concerns resolution process   1.7 Participation of parents / family members  1.7.1 Attempts have been made to contact biological mother to invite her to be informed and to make contributions, but all attempts have been unsuccessful.    1.7.2 Whilst it was initially agreed that engagement with biological parents was most important it was decided that attempts would also be made to father’s partner - these were also unsuccessful.  1.7.3 Over the time frame of this Serious Case Review, repeated attempts have been made to contact the biological mother and father’s partner by the Independent Author, but these have been unsuccessful. Despite some suggestion from social work staff that the parents were willing to contribute, they nonetheless did not respond to our many attempts to meet with them.  1.7.4 The lead reviewer eventually met with father who was supported by a professional working with him, in August 2019.     1.7.5 It was clear that father had a loving and warm attachment to his son and continued to be saddened by the outcomes in this case.  He genuinely hoped that his son was able to thrive and reach his potential.  He accepted that his son was a poorly little boy and these complex health needs presented challenges.  He wished that there had been more support for him and his partner but also accepted that significant support had been given.  He wished that the assessment process could have been much longer, delaying the period of time when his son was placed with him so that he could have been better prepared and that the care of the other children in his household was more established and settled, however he also understood the principles that delays in planning for a child of this age was detrimental, and that his son could not afford to wait the length of time father was suggesting.    1.8 Parallel proceedings    1.8.1 Billy is now the subject of a Care Order and is placed with prospective adopters.   1.8.2 In relation to the criminal proceedings; the matter was concluded by August 2019. The case relating to father’s partner was offered as no evidence was presented against her; as far as she was aware, medical attention for the injury to the leg had been sought by father at the GP clinic.   Father pleaded guilty to neglect:   He failed to bring the injuries to the attention to social care or professionals.   He did not seek medical attention for the injury.  Overview report Child E – September 2019 7   The Judge made no reference to any issues involving agencies; just that support had been in place with regular announced and unannounced visits.    1.9 Confidentiality  1.9.1 Names have been changed to protect the identity of Billy and his family.   1.10 Context and description of s 38 (6)  1.10.1 It would appear not all of the individual professionals, or indeed agencies, clearly understood the fact that the S38 (6) order in respect of Billy was an ‘interim /assessment order’. Rather thinking this was the final and permanent plan.  1.10.2 Section 38(6) of the Children Act 1989 is an increasingly utilised section of the Act applied as an interim or assessment direction, used to determine what is in the best interests of the child in especially complex or fraught circumstances by giving some limited scope to test out arrangements prior to permanent decisions being taken.  In respect of Billy it is evident that a S38 (6) order was made so that a complex and uncertain placement could be adequately supported, tested and evaluated before any final order was made i.e. a Care Order under The Care Planning, Placement & Case Review (England) Regulations 2010, or adoption.    Overview report Child E – September 2019 8 2. Family CompositionName used Relation DOB Info Billy   Subject child  October 2015 Placed with couple who have cared for him since he was 2 weeks old.  (Except for 3 weeks when he was placed with his birth father) Billy’sMother Biological Mother 1984 Mother to several children. Robert Biological Father 1985 Father to several Children Vivienne Father’s Partner  1982 Mother to three children Child A, Child B, and Child C Child B Child of Vivienne October 2015 Thought to be child of Robert until after the SCR timeframe. DNA testing confirmed that he was not the father. Child C Child of Robert & Vivienne   November 2016 Half-sister to Billy and to Child B. 3. Involvement with MotherThis section is included to give context to the narrative and is not part of the scope of thisSCR.3.1 There has been a lengthy history of social work involvement with Billy’s mother including several children having been removed from her care by the local authority.  In July 2015, a pre-birth assessment commenced in respect of the unborn child (Billy) and this concluded that the child would not be safe in her care.  Billy was born prematurely in October 2015; he was made the subject of an Interim Care Order and he was placed in foster care on discharge from hospital.   Overview report Child E – September 2019 9 4. Chronological sequence of significant eventsMarch 2015 July 2015 October 2015 October 2015 October 2015 October 2015 November 2015 December 2015 Late December 2015 January 2016 February 2016 February 2016 February 2016 Pre-birth assessment commenced in respect of Child B, born October 2015; she remained in the care of Robert and Vivienne, with a support plan in place.  This was firstly under the Public Law Outline (PLO) process, which subsequently de-escalated to a Child in Need plan due to positive progress made by parents. Pre-birth assessment in relation to Billy being cared for by his mother.  Mother and Father were no longer in a relationship; Father was denying paternity. Child B born. Decision and Review Panel gave permission to begin Public Law Outline in relation to Child B. Decision and Review Panel gave permission to begin Public Law Outline in relation to Billy. Billy Born. Care Proceedings issued – Interim Care Order made the following day, Billy placed with foster carers November 2015. DNA test concludes Robert is Billy’s father. He had previously denied paternity but agreed to be tested indicating that if he was found to be Billy’s father then he would wish to be assessed to care for Billy, along with his partner. Billy’s first contact session with his father. Father failed to attend a previously arranged one mid December. Foster carer expresses concern about Father’s ability to care for Billy’s complex needs and the competing demands of two babies.   Birth mother’s post-birth assessment confirmed as negative and contact to be withdrawn given her non-attendance at arranged contact sessions. The foster carer’s Supervising Social Worker (SSW) emails the IRO ahead of the review, with the concerns as expressed by the foster carer, about the plan to place Billy with his father.     IRO informs SSW that the assessment is ongoing and that the care plan is yet undecided. Statutory Child Care Review for Looked After child Father is having weekly contact with BillyOverview report Child E – September 2019 10 •Children Social Work Service (CSWS) to request the courts for an extension to the assessment period to explore placing Billy with his father and partner•No other viable family members have been identified•Adopters of Billy’s full sister have been approached and are not able to care for another child•Parallel planning for placement with Father and Partner along with the only alternative, adoption•PLO in respect of Child B is ongoing. Notes a positive shift since the initial application was made and couple are reported to be engaging well and making good progress•Couple have begun the Baby Parent education programme (Webster Stratton)•Father did not engage well with “Caring Dad’s (structured, multi-agency approach to addressing men's abusive behaviours within families) but agreed to one-to-one work•Father’s partner did not engage in the group work domestic abuse programme, but has agreed to one-to-one sessions•Father to engage with Drug and Alcohol Service for his cannabis use•Information about Birth Mother’s negative assessment is shared•Discussion about the complexities of caring for Billy including significant issues relation to feeding; regurgitation of his feeds; prolonged periods of being unsettled; suggestions that signs of stress could also be as a result of detoxification from substances exposed to in utero.•Health professionals and foster carer concerned with regard to the couple’s ability to care for Billy particularly given his additional needs whilst also caring for another child of the same age (4 months)February – March March 2016 Despite concerns expressed, it was agreed that the continued assessment was the most appropriate plan. Foster carer continues to voice her concerns with all professionals about the plan to place Billy with his father.  Health Visitor and Specialist Health Visitor, Neonatal Abstinence also expressing concerns given his complex needs and Billy’s adverse reactions following contact with father and partner. The addendum assessment of father and partner was completed. The assessment had entailed six further sessions with the couple which included contact with Billy in their home, in a contact centre and in the community. The couple also attended a consultation with Consultant Paediatrician to explore Billy’s current and future health needs. There were a number of concerns and risks that remained in relation to their ability to meet the needs of Billy and Child B, both young babies at that time.  The risks were identified as largely around potential emotional harm and neglect. However, on balance the recommendation of the assessment was that Billy was placed in their care under the auspices of a Care Order.    Overview report Child E – September 2019 11   March 2016 Consultant Clinical Psychologist facilitates and chairs a Consultation Meeting.  A meeting of professionals only so that all concerns that are currently being expressed in one to one dialogue can be fully explored and an effective plan considered.  Consultant Clinical Psychologist (CCP) advised of plan to place Billy with his father, and therefore increased contact to go ahead, then should be limited to 2 x 1 hour session per week, each session spread out for recovery time for Billy.    Follow up meeting arranged for early May.   April 2016 Social Workers visit foster carer to discuss the plan and listen to concerns.  Foster carer continues to have concerns but agrees to work with the plan for placement of Billy with father, including some contact sessions taking place at foster carers home to support the best interest of Billy.  April 2016 Plan to increase contact to 2 x per week each 1 ½ hrs. One to take place at foster carers home. Note this exceeds the advice given by consultant clinical psychologist.  April 2016 Permanency Panel: Some reservations about the placement held and explored, however on balance felt that placement with father was the best plan.  The only contingency to this plan was adoption.  April 2016 Communication between IRO and Cafcass Children’s Guardian; the assessment has identified areas to be addressed before a plan to place Billy can be made. Contact currently only 1 x pw given that Billy is so unsettled after contact and need to consider the advice of the CCP & IMHS and impact of stress on Billy.  April 2016 Consultant Child Psychologist (CCP) - Phone call to social worker (SW) to clarify that the meeting planned for May 2016 was going ahead and this would be a professionals meeting and no family would be present. SW confirmed.   April 2016 Court hearing.  CSW Team and Children’s Guardian joint instruction for an Independent CCP assessment.  Request for an extension to 26 weeks timescale applied to care proceedings.  April 2016 Health visitors escalate their concerns to the IRO and to the Named Nurse (NN) as per the concerns resolution process. NN also consults with consultant paediatrician.  Overview report Child E – September 2019 12 May 2016 May 2016 June 2016 June 2016 July 2016 July 2016 August 2016 Professionals’ meeting is arranged for early May 2016 to be chaired by the Named Nurse.   Professionals meeting called by LCH scheduled (concern resolution). However, Social Worker changed the purpose of the meeting to a general planning meeting to discuss the increased contact.  SW also invited Father, Partner and their solicitor.  Concerns Resolution meeting did not go ahead due changed purpose of the meeting. Deemed inappropriate for Named Nurse to attend. Professionals follow up meeting from the March meeting chaired by consultant Psychologist is scheduled – however this had been cancelled by the social worker as an Independent CCP has now been appointed by the courts. The CCP was not aware of the professionals meeting; The Named Nurse was not aware of this meeting having been scheduled.  Father’s partner informs Children’s Social Work Service that she is expecting a child in November. Independent psychologist’s report (See 5.24) recommended that, ‘Vivienne has her baby and that the family have time to establish routines with the new child and Child B for six months. This would give them the chance to show they can manage the demands placed on them by having two small children in the house.’   The Further Addendum Assessment Report completed by Children’s Social Workers, recommending: A further period of assessment with Billy living in the care of his Father and Partner. The assessment period will be completed under Section 38 (6) of the Children Act 1989.This was a change from the recommendation which had been for a Care Order, with placement with Father. The contingency plan should he not be placed with his father and partner remained adoption. Statutory Review for Child Looked After  Discussion took place to inform partner agencies of the plans for Billy including the recommendations to the Courts. The plan for Billy to be placed with father and partner as a “testing” placement, with a detailed plan of support. Children’s Guardian Report to court:  Recommendation: A further period of assessment under 38(6) Children Act 1989.   Overview report Child E – September 2019 13   The Children’s Guardian had identified that there were gaps in the CSWS assessment; with insufficient evidence to determine whether the couple could care for Billy and these needed to be tested before a final care plan could be made.  August 2016 Court Hearing  Judge raised concerns about the plan including; Father’s lack of compliance e.g. making enquiries about benefits; re-homing their dog.  Judge required a tighter contract of expectations including a more detailed support plan.  Increased contact to include supervised contact of Billy at Father’s and Partner’s home and care of Billy by father and partner at Foster Carers home.  August 2016  Directions made by the courts for all parties to agree a more detailed Contract of Expectations during the proposed period of the s38(6) assessment placement with parents.  Early September 2016 Statutory Child Looked After Review. The plan is discussed with all of those involved.  Early September 2016 Judge approves the plan for Billy to be placed with father and partner under the testing period of assessment s38(6).  Mid September 2016 Billy placed with his father and partner. With extensive 2 week support plan including professional nannies attending 5 hours a day; daily social work visits; and regular visits from health professionals.  This to be reviewed and if progress is made the support will be gradually withdrawn.  Mid September 2016 Placement review meeting.  Concluded that placement is going well. No agency reporting concerns.  Late September 2016  Concerns about the couple’s ability to cope become apparent during the week. Father’s partner appears to be undertaking more of Billy’s care and she reports being tired.   October 2016  A number of visits undertaken by health visitor and social worker. Health visitor advised Father to take Billy to GP.  GP examined Billy:  No temperature; vomited one feed been but OK with the rest. Nappies wet, teething, moist mouth, cheeks and conjunctiva pink and chest clear. Tummy soft and non-tender. Throat no abnormalities detected, right eardrum noted to be red. Prescribed antibiotics and infant paracetamol.  Overview report Child E – September 2019 14 October 2016 Home visit undertaken Billy reported to have a swollen leg. X-Ray and paediatric medical confirmed the leg was fractured.  Further examinations revealed. Fractured left tibia (shin bone) with swollen tissue around itFractured right tibia – signs of healingAbnormality to left ulna (forearm) suggesting a healing fracturePetechial bruising on the back of the left ear and purple red bruisingto the inner part of left ear.October 2016 Billy and Child B are made the subject of Police Protection powers and removed from the couple’s care. Billy and Child B's half siblings were also removed from the couple’s care following her birth. 5. Analysis addressing the key line of enquiry:The efficacy of testing out a placement with family, considering the complexities and concerns of achieving a positive outcome given the need to balance the risks associated with placing a child with family against the risks of severing all ties with family. 5.1. It is clear that Billy was born with additional needs and these became more apparent and more complex some months after he was placed with foster carers. Many of these additional needs came to light after Father had put himself forward to care for Billy. 5.2 These complexities and additional vulnerabilities were likely to be a result of trauma he experienced in utero as a result of his mother’s substance misuse during pregnancy as explained by the consultant paediatrician and the consultant clinical psychologist involved in his care. 5.3 When placed in foster care, Billy’s needs were felt to be so complex as to require highly skilled foster parents with considerable experience of caring for children with special needs. For Billy those needs were as follows: He was a premature baby born at 35 weeks following a difficult breech deliveryHe suffered from Neonatal Abstinence Syndrome (see definition in Glossary andEndnotes)  and was in visible constant distress due to his withdrawal (believed to be)from multiple substances including cocaine, opiates, amphetamines and alcohol asdescribed by the Infant Mental Health Team (IMHT) and specialist abstinence healthprofessionals.He was very difficult to feed initially, requiring use of a naso-gastric tube for manyweeks and suffered severe gastric reflux. He had a poor suck and unsafe swallow,raising the risk of aspiration that could potentially compromise his lung health.  Hisfluids needed to be thickened before they could be given to him.Billy additionally demonstrated an over sensitised stress response, as evidenced byhis tense, watchful and vigilant presentation which, consequently, left him less able toOverview report Child E – September 2019 15  make use of comfort and reassurances.  In consequence Billy’s demeanour rapidly and frequently alternated from calm to stressed, with resulting prolonged episodes of stress.  Such frequent experiences of high stress also increased Billy’s production of cortisol; high and prolonged levels of cortisol can be toxic to a developing brain which, in Billy’s case, inhibited his production of oxytocin, which is linked with feeling safe, secure, calm and supportive of healthy social and emotional development. The consultant clinical psychologist confirmed that Billy’s presentation corresponded to this.  In combination this would result in Billy:   Being difficult to sooth and reassure   Crying frequently with a sustained cry and high-pitched scream  Have loose stools/ unusual smell/ sore bottom   Demonstrating a poor sleep pattern   Potentially suffering significant global developmental delay  These symptoms were described by the foster carer, the IMHT, the Consultant Clinical Psychologist (CCP) and Consultant Paediatrician based on their observations and their respective clinical expertise and the opinion was supported by the Consultant Paediatrician/Named doctor member of the SCR panel.  5.4 Taken together it is clear that Billy’s needs were considerable, such that even the most experienced and motivated of parents would have found challenging.  5.5 There were also factors affecting father’s ability to care for Billy and keep him safe. The Children’s Social Work Team (CSWT) had raised concerns that needed to be addressed in assessing his ability to care for his son in the likelihood that a placement was to be made. Notably his:  history of substance misuse  history of domestic abuse with issues of his anger   history of motivation and commitment to his two older children and initially to Billy  history of not having care of, and only sporadic contact for his older child  history of a child being removed from his care  questionable motivation and commitment (initial denial of paternity for Billy; did not engage with birth mother during the pregnancy; did not see Billy for the first 8 weeks of his life, did not attend his first arranged contact and was late for his second)  5.6 Although it was the father who was putting himself forward to care for his child, CSW team had a duty to consider his partner as co-carer and as such factors affecting her ability to adequately care for Billy also had to be tested.  Regarding the partner the CSW identified:  history of being parented poorly  history of domestic abuse  history of a child being removed from her care following assessment of poor parenting capacity, inability to keep her child safe from those who may pose a risk and poor engagement with support services   history of mild to moderate anxiety/low mood  Overview report Child E – September 2019 16  5.7 The reality of successfully looking after any child with complex needs requires skill; organisation; time and energy and, above all, an ability to put the needs of the child first. For the couple other issues and concerns needed to be addressed in assessing their ability to keep Billy safe if any such placement were to be made. Specifically  The couple were already caring for a child of the same age as Billy with some evidence of poor caring of that child who had been the subject of a Public Law Outline (PLO) later de-escalated to Child in Need.  There was evidence that father’s partner had not always followed professional advice and guidance in caring for the older child e.g. weaning her much earlier than current health advice suggests.   Evidence early on that they did not understand or follow the advice about feeding Billy (continued failure to follow this advice could have led to significant harm given his unsafe swallow).  5.8 The CSW Team were aware of all of these issues and as such set a number of requirements for the couple to enrol and engage in and to complete so that concerns highlighted above could be addressed.  These included sessions with; domestic abuse and drug services; counselling; regular attendance and appointments with health professionals; a parenting programme for parents of babies (0-12 months), a paediatric first aid course and observed family contact sessions.   5.9 In general terms, this range of required assessment elements was certainly seen as a mechanism to test out the degree of real and mutual commitment each of them had with respect to their expressed wish to care for Billy. Whilst the CSW Team demonstrated their own creativity, persistence and tenacity in supporting the couple in this part of the assessment, it was suitably challenging for the couple and they did demonstrate an acceptable and progressive level of co-operation and engagement with these requirements and their capacity to care for Billy increased.  5.10 The additional needs and complexities for Billy were becoming more apparent after father and his partner had begun to engage in the assessment process and these were discussed extensively with all of the professionals involved with Billy, with effective information sharing.    However, given Billy’s complexities (5.3) and the couple’s factors impacting on their ability to care for Billy (5.5 - 5.7) concerns were beginning to be expressed about a plan to place Billy with his father and partner. These concerns were initially expressed by the Foster Carer and subsequently by Consultant Clinical Psychologist; Consultant Paediatrician; Health Visitors including Specialist Health Visitors, the Children’s Guardian and IRO.  5.11 In February 2016, there was good information sharing at the statutory Looked After Child Review and this was well within timescale as set out in guidance.  Whilst concerns were expressed, it was felt by those present that the assessment of father and partner as carers for Billy was the most appropriate plan, particularly given that the only viable alternative for him was to be placed for adoption.  5.12 The concerns expressed by the health professionals and others began to be shared following this review, they were that, the couple did not have the capacity to care for Billy to a level that was safe and that would promote his welfare given his additional Overview report Child E – September 2019 17  needs. In addition the couple’s history of poor parenting and inability to keep a child safe from other adults was also of concern. The consultant paediatrician and the consultant clinical psychologist were both of the opinion that Billy required better than good enough standard of care.  5.13 Over the months these concerns did not change. There were additional complexities, for example the signs and symptoms of Billy’s withdrawal from drugs were lasting longer than had initially been anticipated, suggesting his withdrawal was from multiple substances.  He also had some additional needs in relation to his feeding, such as his unsafe swallow, which became more apparent. He was displaying more signs of being stressed and distressed, particularly after spending time with his father and partner who were still unfamiliar to him.  5.14 There is much research about the impact of stress and distress on infants particularly in the crucial 1001 days (from conception to two years).  The Leeds Infant Mental Health Service did provide information to the professionals involved.  They also provided training (Babies Brains and Bonding) to agencies within the Leeds Safeguarding Children Partnership (LSCP). The CSWs involved in the case had undertaken the training.    5.15 It is noted that when babies are exposed to high (and prolonged) levels of the stress hormone, cortisol, they are more likely to develop behaviour problems and stress-related diseases later in life (Asok et al 2013; Luby et al 2013). In the worst-case scenario, toxic stress can alter brain growth and shorten the lifespan.    5.16 With this in mind the CCP made positive contributions to slow down the assessment process particularly the frequency and duration of contact between Billy and his father (and partner and her daughter) to minimise the stress to Billy and to allow for him to recover from additional stress. The Children’s Social Work Team did take this information into account and made efforts to curb the family time plan but were also mindful of their duty and the pressure to comply with the Court’s 26-week target within which care proceedings are currently expected to conclude.    5.17 There is, of course, a need for proceedings to conclude swiftly to ensure the needs and best interests of the child are met and that further harm is not caused to already vulnerable children. The correct balance must be found between the need for proceedings to conclude and the harm that would be caused should the time limit be strictly adhered to.    5.18 In the case of Devon County Council v EB & Ors [2013] EWHC 968 (Fam) Baker J commented “That, with regard to concluding cases within 26 weeks, whilst this may be possible for the vast majority, there will still be a minority of exceptional cases where investigation takes longer. Judges should be vigilant to identify these as soon as possible at the outset of proceedings and that any delay is kept to a minimum.”  5.19 In April 2016, a request supported by the Children’s Guardian and agreed by all parties was made to seek an extension to the proceedings outside the 26-week timescale, in order for a further period of assessment and further work to be undertaken with father and his partner. In this case, the Judge was mindful of the need to take some time to Overview report Child E – September 2019 18  be clear that a thorough assessment was undertaken with a robust plan. Even after the proposal for a s38(6) was heard by the Judge early August and mid August, it was not granted until early September when she was satisfied that the plan was sufficiently robust.  It is unclear if professionals involved from Health or Fostering were aware of this, but they may have been reassured by the efforts being made to safeguard Billy.  5.20 The CSW Team, as directed in policy and procedure, presented the case to the permanency panel for a decision about how to proceed. The panel recommended to the Agency Decision Maker (ADM) that the threshold for adoption had not been reached and therefore the proposed care plan for Billy was to be placed with his father.  The ADM ratified this decision in July 2016.  At this stage, the plan was to apply for a Care Order and place Billy with his father utilising The Care Planning, Placement and Case Review Regulations (England) 2010.  This plan was soon amended to the s38(6) placement for further assessment whilst Billy would remain subject of an Interim Care Order.  The Children’s Guardian (CG) and Independent Reviewing Officer had discussions about their concerns about the plan, the CG particularly identified insufficient evidence to determine whether couple could care for Billy and these needed to be tested before a final care plan could be made.   The CSWT filed the assessment report and care plan in July 2016.  This was so that the CSWT could further test the couple’s capacity to care for Billy safely, initially with a comprehensive package of support in place.  5.21 It is not clear from the case files whether the Children’s Social Workers helped other agencies fully understand the requirements to comply with the Court’s timetable and the necessity to conclude proceedings swiftly in the best interest of the child.  In Billy’s case, the only viable alternative to placing him with his father was adoption. Before this could be considered, all other options had to be fully tested.  In case law Re B-S (2013) EWCA Civ 1146 – it states that: “adoption without parental consent is an extremely draconian step and one that requires the highest level of evidence” “family ties may only be severed in very exceptional circumstances and everything must be done to preserve personal relationships and, where appropriate, to ‘rebuild’ the family.  It is not enough to show that a child could be placed in a more beneficial environment for his upbringing.” [paragraph 18] Orders contemplating non-consensual adoption are “a very extreme thing, a last resort, only to be made where nothing else will do” [paragraph 22] 5.22 The CSW Team was hopeful for the placement with his father to succeed, they were creative in their use of support and resources to assist the success of the placement. They also anticipated some failures and that the placement may break down due to Overview report Child E – September 2019 19 neglect and therefore parallel planning was also in place. They did not anticipate physical injury. 5.23 On that basis, the CSW Team had to ensure a timely conclusion of the assessment, so that if the placement were to fail they would still have opportunity to find a successful match for adoption for Billy. They were mindful that Billy did have additional and complex health needs and that caring for him would be challenging and this would make it more difficult to find suitable adopters. They understood and were very mindful of the research and the Principles of the Children Act 1989 and of the detrimental impact on a child if delayed. They placed him with his father and partner before his first birthday in the knowledge that as a child becomes older it becomes increasingly difficult to find suitable adopters.  5.24 The Judge had the recommendation from the Independent Consultant Clinical Psychologist (CCP) to wait until father’s partner had had her baby (born November 2016). This would have given father and his partner an opportunity to establish routines for the baby for a six-month period before placing Billy with them.   However, this would have added a further 8 or 9 months to what might still have been a testing placement for Billy. The CSW Team and the Children’s Guardian did consider the recommendations from the Independent CCP to ensure that a full package of support was in place and this package was also very carefully considered by the Judge.  5.25 It would have been helpful for CSW Team to have discussed their rationale for disregarding the advice from the Independent CCP about delaying the placement until after the birth of the couple’s child due in November with all of the professionals involved. They had explained this rationale with the courts in their assessment report.  Explaining this with the professionals involved in Billy’s care, particularly those expressing concern, may have reassured them that Billy and his best interest was remaining the focus of their work. 5.26 It is noted that the proposal to place Billy with his father for a period of further assessment under 38(6) was made after the Independent CCP had written her report, the contents will have had some bearing on the proposal to further test the placement.  Given the depth of the report it may have been helpful for Billy’s social workers to have discussed their proposal, i.e. not to wait, but to place Billy for a further period of assessment, with the Independent CCP so that she could have given an informed opinion on this. The CSWs in their report to the courts (July) did consider the Independent CCP comment, on the progress that the couple had made in caring for Child B was like a, “House of Cards and looks solid” however, “it would not take much disturbance to bring the ‘house’ down”.  On that basis the CSWs were mindful of the risks of neglect on all three children; (Billy, Child B and the unborn baby) and planned a comprehensive package of support for the first two weeks, including professional nannies supporting from 6pm to 11pm. 5.27 It is evident that in assessing the potential risks to Billy being placed with his father and partner that the risk of neglect was carefully considered. The Social workers assessment report did address other risks but did not appear to identify a specific risk of physical harm.  During the Serious Case Review, all professionals, when asked if they had anticipated the likelihood of the injuries that Billy sustained, said they had not expected it. Their risk assessment was based on the presenting behaviours, issues and Overview report Child E – September 2019 20 concerns balanced with protective factors and it was felt that the greatest risk was of neglect and emotional abuse.  The assessment report did not address any concerns predicated by the research about persistent crying, (stressed / distressed babies) noting how complex and stressful caring for Billy could be.  5.28 It has been reported that infant crying is the most common reason why parents seek help when they have a small baby, as many as 1 in 6 new parents approach a medical professional for advice (Kaley, Reid and Flynn, 2011), and in extreme cases persistent crying is known to cause problems in parenting and serve as a trigger for abuse (Lester et al, 1990). 5.29 We know that Billy had additional complex needs, was a stressed baby and often unsettled with prolonged and frequent periods of crying.  There were also continued stress factors in the family household including the couple’s care of Child B alongside the care of Billy, both under 1 year of age, and Vivienne was approximately 31 weeks pregnant at the time of the placement.  These factors should have alerted professionals to the possibility or a trigger of potential physical abuse or harm.  The Children’s social work assessment did consider physical abuse; the assessed risk was in relation to managing Billy’s unsafe swallow and the ability of the couple to keep him safe from other adults who may pose a risk to him.   Whilst there was no evidence to indicate that either father or his partner would physically harm him, this predictive risk of physical harm following the triggers from the daily lived stress factors was something that should have been considered. It is unlikely to have changed the decision to place Billy with his father and partner, but may have alerted all of the professionals involved in supporting the plan and the placement to the possibility of physical harm and this may have identified some additional work or support for the couple in relation to the impact of Billy’s crying and distress on them.  This may have increased the couple’s help seeking behaviours and enabled them to ask for help when things became difficult for them.  5.30 In regard to why Billy was not removed from the couple’s care after he sustained the first injury, it is noted that Billy’s normal state was stressed.  He was a child who experienced severe distress and discomfort from his Neonatal Abstinence Syndrome, and as such it may have been difficult for any professional to have noticed any change in his behaviour following the first injury he sustained after he was placed with his father. 5.31 The question of whether Billy should have been placed with his father in September 2016 has largely been answered with almost full agreement, but this continues to be contentious and was an issue that required careful judgement on the balance of all presenting information to the Court. 5.32 There were reasons that did not support a placement, notably the skill required to manage his complex needs particularly in relation to feeding and his unsafe swallow; his stressed state and the impact of ‘toxic stress’ which disrupts brain development and can have long term implications for a child; and the limitations of his father and partner given each of their histories of parenting.  However, the CSW Team and the Children’s Guardian were clear that the couple’s skills had not been fully tested in the assessment period to recommend that all ties are severed from his family and that he should be placed for adoption. Overview report Child E – September 2019 21   5.33 The mitigating factors supporting the placement were:  The couple attended health appointments and sessions with the consultant paediatrician, health visitors including specialist health visitors and speech and language therapist to learn about Billy’s specific needs and how to manage them. There was evidence that the couple could manage during extended contact sessions, but it was accepted these were not real daily lived experiences and therefore required further testing.    5.34 In relation to Billy’s stressed state, this was normal for Billy, he was a stressed baby and the Infant Mental Health Service including the Consultant Clinical Psychologist were supporting the couple and the foster carers in reducing his stress.  There was evidence that Billy knew his father and partner and he would look for him and would smile when he saw them, and there were observations made of Billy being settled in their care.  Again, these were not in daily lived experiences, but there were positive reasons why this needed to be tested.  At that time, the alternative to placing Billy with his father was adoption where he would need to form a completely new relationship with complete strangers.   The threshold for adoption would not have been met and would have been open to legal challenge.  5.35 The couple’s history was of concern particularly as both the consultant paediatrician and the consultant clinical psychologist said that Billy required better than good enough parenting. The couple attended sessions in relation to domestic abuse and substance misuse and counselling, they attended parenting programmes, and health courses.  Father spoke of his previous parenting experiences and the impact this had had on him and how this had motivated him into doing all that was asked of him so that he could care for Billy.  He remained keen throughout for his son to be placed with him and as such his positioning and behaviour changed markedly from his initial denial of paternity and lack of contact, to consistent commitment, significant effort and motivation for Billy to be in his care.  5.36 It is not as clear from the information considered by this Review if father’s partner was similarly as keen for Billy to be placed with them, but setting aside this caveat, she certainly never expressed direct dissent, and fully engaged in all that was asked of the family prior to placement being made.  She also spoke of previous parenting experiences; she did reflect on that experience and her feelings did motivate her in fully engaging with all that was asked of her. She expressed to the Independent Consultant Clinical Psychologist that such a separation would not be good for her, her partner and most of all not for Billy.   5.37 For Billy to be placed with his father and partner careful consideration needed to be given to the benefit for Billy of being cared for within his own family, which is well established in research and reflected in precedent within the judicial system, against the potential problems the couple would need to overcome in order to care for him successfully, and the support they would need to do so.  5.38 The assessment of the couple remained incomplete and the only way to fill the gaps was to test their care of Billy in a daily lived situation. The Courts were presented with all of the relevant information including the concerns expressed by the professionals Overview report Child E – September 2019 22  involved. The CSW Team, supported by the multi-agency partnership, put in place an extensive package of support to test the placement. The Judge adjourned the proceedings in August for the care plan to be made more specific and more robust in order to satisfy the safeguarding concerns.  5.39 Conclusion: The Review concludes that the couple’s ability to effectively care for Billy could only have been appropriately tested by a placing him with them.  6. Analysis addressing the key line of enquiry:  How professionals with particular expertise are involved, contribute and influence an effective multi-agency plan prompting high support and high challenge and making effective use of the concerns resolution process.  6.1 From the start of this Review, professionals involved have reported that involvement in this case has been more emotional and poignant than in many others, this may be indicative of the level of risk* the multi-agency team (professionals involved with Billy) was carrying in this case.   The language used has been expressive, emotive, and has demonstrated sensitivity and empathy.  It has shown some excellent child centred practice, professional persistence, tenacity, and creative problem solving; and has highlighted that Billy’s best interest was always paramount in all of the professionals’ minds even when the consensus on the best approach could not be reached.    * That is, there was a shared understanding of the risk but this was not expressively communicated by all the professionals within the multi-agency group.  6.2  However, the emotions may also have got in the way of clarity and understanding that good evidence-based analysis was not complete, relying more on professional intuition and professional judgement supported by underpinning theory and research but in this case had not been tested. It may also have made professionals defensive about their decision making and impeded conversations about the shared risk they were all carrying. If this conversation or discussion had been more open and expressive of feelings, it may have reassured the multiagency group of professionals working with Billy and his family and supported better working together.  6.3 There continued to be a need for all those involved to remain professionally curious, inquisitive and problem solving. However, it appears that people were becoming rigid and fixed in their view and unable to reach or maintain agreement. Some of the health professionals involved felt that their concerns were not fully listened to, considered or valued.   Information that has been made available to the Review indicates that concerns were expressed and considered but it may have been they were not appropriately responded to, leaving those concerned professionals to perceive that their views had not been taken into account.  6.4 The review has had access to notes of multi-agency meetings and these reflect that concerns and challenge about the plan to place Billy with his father were expressed, but the notes also concluded that at the meetings there was generally agreement with the Overview report Child E – September 2019 23  plan. However, the communication amongst professionals after these meetings suggest that there was on-going dissent.   6.5 The contrast between discussions that took place during meetings, to those which took place afterwards, became frustrating and added to the perceptions of not being listened to or valued and ignored, and impeded what had been good communication and excellent information sharing.    6.6 Those expressing concern did so based on their professional judgement and years of experience supported by theory and research and contributed to the formulation of hypotheses. However, these judgements still required robust testing in order to satisfy any criteria to break all ties with family and place Billy for adoption.  As stated in case law Re: BS 2013, the highest level of evidence was required, so, testing the couple’s capacity to parent Billy in a daily lived setting rather than rely on what might be predicted, based on the couple’s history; given the only alternative for Billy was adoption.  The CSW Team did not fully explain the level of evidence that was required and it is clear that people’s thresholds and understanding of the required evidence varied considerably.   6.7 Findings from the SCR Practitioner Event and the consensus from the SCR panel members noted that whilst there was not full agreement for the placement, there was no real evidence to conclude that the couple categorically could not offer a viable placement. On that basis, an alternative placement of adoption needed to be put to one side until their ability could be assessed, supported and tested.  It is additionally noted however that all the professionals had some personal misgivings, apprehensions or doubts about how potentially successful the prospective placement would be. The professionals experienced the dichotomy of analysis and direct evidence versus professional judgement and what could be predicted.    6.8 Whilst studies suggest that analytical problem solving is more powerful and less vulnerable to biases, holistic intuitive processes can outperform analysis. It is clear that when dealing with human lives and emotions and effective risk assessments both of these processes have a part to play in problem solving and risk management.    6.9 This dissention also demonstrates that managing risk when safeguarding children is complex and that there is rarely a clear right or wrong solution but a best fit, with professional risk management forming a fundamental part of good health and social care practice.    If all of the risk was removed rather than managed, then more children would be separated from their families. In Billy’s case the professionals involved worked collaboratively in sharing the risk. Even though they did not always agree with the plan they continued to share the professional risk management during the delivery of the care plan, visiting and supporting Billy, his father and partner while he was placed with them. This shared risk management and working together was commendable and positive lessons have been and should be learned from it.   6.10 Had the professionals been given the opportunity to effectively share their apprehensions, the shared risk management at the planning stage is likely to have been strengthened. Overview report Child E – September 2019 24   6.11 There were lots of multi-agency meetings taking place, but it seems that the purpose of the meetings was not always clear to all of those attending; some professionals could not attend or were not invited to all of the meetings.   It is also apparent that some professionals requested and arranged professional only meetings.  These were to properly consider the differing viewpoints and how consensus or compromise could be negotiated, but again the purpose was not clearly communicated to all of those concerned.  6.12 The Review has given much thought to the use of meetings attended by professionals only. Whilst this may be seen by some as being at odds with the restorative and transparent orientation of safeguarding in Leeds, in this case a meeting without parents/partner would have been helpful. It could have afforded greater multi-agency reflection, analysis and review of this complex and contentious case. It would also have enabled a wider spectrum of professional expertise to have contributed to the formulation of plans from a much more informed position and for recommendations and decisions to be multi-agency, rather than just the children’s social work team.  It would also have given professionals a chance to express their reservations without undermining the couple’s confidence so that all the partners could work together to strengthen the plans.  6.13 In some complex cases such as this, it is necessary for professionals from different agencies to have the opportunity to discuss the pertinent issues without parents present, in the same way that professionals will discuss a case with their line manager or supervisor in supervision.  Supervision supports positive reflection, analysis and plans and actions and is essential to good practice.  There is good evidence in this case that the social workers sought supervision and that the case had good management oversight, as did the health professionals within their respective agencies and departments. The opportunity to have this in a multiagency setting supports collaboration and working together enabling the professionals involved to focus on the best interest of the child.  6.14 Leeds Children’s Services has developed the use of a formulation approach2 to case analysis, to produce more effective plans for children.    This should allow practitioners to objectively review complex or high risk cases, maximising opportunities to explore and discuss hypotheses, value differing perspectives and either establish consensus or step into escalation processes culminating into the effective use of the LSCP Concerns Resolution Process.  6.15 Leeds LSCP procedures with regard to how agencies with safeguarding responsibilities respond to the needs of children and families in the City; “Right Conversation, Right People, Right Time” is the most important guidance with regard to how partners should work together cooperatively and effectively, in the best interests of children. Whilst the professionals working together in this case did follow the general principles of this procedure, it is our finding that some of the many meetings held did not to bring together the ‘right’ professionals to fulfil that purpose fully, and specifically to take account of the level of concern felt by some.                                                 2 https://www.leeds.gov.uk/docs/Rethink%20Formulation.pdf Overview report Child E – September 2019 25  There are lessons to be learned about how such meetings are best managed in order to be effective; specifically that whichever agency ‘calls’ the meeting should clearly state the purpose of the meeting and thereafter take lead responsibility for practical arrangements such as arranging venue, inviting the ‘right’ people to attend and ensuring circulation of agreements and minutes subsequently. In this case, a meeting of this sort might have served to reduce the overall number of meetings held and enabled the professionals involved to better appreciate the benefit of escalating the concerns expressed here to a manager of sufficient seniority. (e.g. a Named Nurse or Service Manager) The Re-Think Formulation approach now being used in Leeds certainly would have been helpful.    6.16 The Review of this case has centred on how concerns about Billy were expressed, considered and responded to and examines the effectiveness of practitioners’ knowledge and understanding of the concerns resolution process.  The community health professionals (LCH) initiated the Leeds LSCB Concerns Resolution Process and worked through stages one and two of four.  As part of this process the Named Nurse called a professionals meeting that he was to chair in early May 2016 in an attempt to discuss and resolve the matter in a multi-agency setting. He had informed the social work team manager, the IRO and health staff in accordance with the procedures however; the social worker also invited Billy’s father, father’s partner and their solicitor.  This changed the purpose of the meeting to discuss the plan for increased contact.  The Named Nurse was then advised just before the meeting started that his attendance was not appropriate given the family’s presence.  This meeting was not re-scheduled.   6.17 There was also a professionals’ follow up meeting (from March) scheduled in early May to be chaired by the CCP, but the social worker cancelled this given that a professionals meeting had also been scheduled for early May 2016.  The CCP had not been informed of, or invited to, the professionals meeting.  6.18 The communication and information sharing during the SCR timeframe was generally very good however, with regard to these two meetings over two days, it was limited, lacked clarity and relied on a general “word of mouth” way of informing professionals about the meeting, rather than a more formal invitation process. The Named Nurse arranging the professionals meeting and the Consultant Clinical Psychologist arranging the follow up meeting both believed that concerns and dissent needed to be discussed without parents present and had made it clear that they should be professionals only invitations and yet the social workers invited the parents.    6.19 In the absence of a purposeful* Concerns Resolution meeting, professionals communicated their concerns via phone, email, letter and at meetings arranged for other purposes.  This led to the same concerns being expressed and repeated without the opportunity for all to share them effectively and to understand the rationale for certain decisions to be made.  * Purposeful meetings [“right conversations, right people, right time” with thought being given to a chair of sufficient seniority and perhaps some independence; ensuring all of the right people are being invited and enabled to express their concerns; and to understand the views of all those involved; with opportunity for appropriate reflection and analysis; leading to professionals who are then informed at the stage of formulating the plans and actions]  Overview report Child E – September 2019 26   6.20 There was challenge; relationships were strained with opposing views as to whether the placement for Billy was viable, nonetheless the professional relationships did not breakdown.  A conclusion of the Practice Learning Event (PLE) and consensus of the SCR Panel, noted those involved remained committed to Billy, working towards better outcomes for him, even though there was dissent on how to achieve this.  One of the concluding findings from the PLE was: “the relationships became fractured but did not breakdown, they kept talking”.  6.21 The evidence of their continued dialogue and commitment to Billy’s welfare was demonstrated in how they formulated the comprehensive plan of support and how it was implemented at the point of the placement in September 2016.   6.22 This review notes that whilst the outcome of this case led to Billy sustaining serious injury, this was not as a result of gross or fundamental error on the part of any professional or agency.    6.23 Throughout this case there are excellent examples of good communication and information sharing and of how professionals made use of the expertise available.  6.24 The Concerns Resolution Process was appropriately initiated but it appears to have lacked effective co-ordination, particularly in relation to inviting attendees and the process was not monitored or tracked, leaving timescales to drift and some professionals feeling frustrated and overlooked. However, despite this ineffective co-ordination, it is noted that all the professionals involved with Billy remained committed to ongoing dialogue and his welfare.   6.25 Conclusion: The Review concludes that professionals with particular expertise contributed and influenced the plan for Billy comprehensively.  The plan was effective and there was considerable challenge but also support for the plan.  The Concerns Resolution Process was considered appropriately and initiated but not progressed. However this did not interfere with continued working together to support the plan for Billy.  7. Findings  7.1 Evidence of good practice  7.1.1 There is evidence of good practice throughout the case with professionals working well together and trying to do the best for Billy who had additional social needs and complex health concerns.  7.1.2 The social workers comprehensively considered all aspects of the three adults’ history (birth parents and father’s partner) in their assessment and worked with father and partner to address the concerns and potential risks, improving their capacity to care for Billy.  Overview report Child E – September 2019 27  7.1.3 There is evidence of good multi-agency practice and information sharing with timely statutory reviews as set out in national guidance.  7.1.4 Professionals felt well able to express concerns and challenge the plan whilst remaining child centred, with Billy’s welfare remaining paramount throughout.  7.1.5 The professionals working with Billy had access to expertise from the Infant Mental Health Service and made good use of their advice and support.  7.1.6 The Social Workers and Children’s Guardian used information available to them to balance the duty to comply with the court’s 26 week target to complete care proceedings; understanding the principle that delay is detrimental, with the need to progress at a slower pace for Billy,  given his increased anxiety when adapting to change.  7.1.7 There is a strong body of evidence which supports children being placed with their families. The Leeds Children and Young People’s Plan 2015-2019 also supports this with one of its priorities being, “Help children to live in safe and supportive families”. The professionals worked together to ensure that the opportunity for Billy to remain with his family was fully tested before a decision to sever all ties and place him for adoption was made.   7.2 Learning Lessons   7.2.1 It is clear that the professionals involved with Billy maintained an open dialogue and shared information about the plans for him well.  However, there were some opportunities missed for professionals from different agencies and disciplines to formulate effective plans together.   7.2.2 As described in 6.15 and 6.19, purposeful professional meetings may have promoted better clarity and more effective ways to have informed decision making.  In the way that single agency case management supervision would not include family members, a multi-agency formulation planning meeting without family members would be a mechanism by which professionals are able to have an opportunity to reflect, clarify and analyse all of the presenting information before drawing up a coherent plan with clear actions.    7.2.3 This coherent plan could then have been discussed with the family. It is noted that meetings without parents’ attendance should not become a standard, but arranged to assist in effective formulation planning and it should be the role of the agency calling this meeting to effectively explain this to all of those involved,  including parents if appropriate.  The Leeds partnership has already learned lessons from this and has put a process in place for a formulaic approach to case analysis leading to more effective plans.  7.2.4 The Children’s Social Work teams have also developed safe parenting assessments adapted from the Reunification Framework (An Evidence informed Framework for Return Home Practice) which supports greater structure and involvement of partner agencies to the assessments of parents when placing or returning a child to their care.  This along with the formulation approach should strengthen the process significantly. Overview report Child E – September 2019 28   7.2.5 Whilst there was no part of the assessment that identified either father or his partner would physically harm Billy (other than exposure to other adults who may pose a risk or feeding him properly given Billy’s unsafe swallow) the professionals did not appropriately consider the links between persistent crying with increased parental stress that can serve as a trigger for abuse.  7.2.6 The Leeds Concern Resolution Procedure is clear and was initiated appropriately but there does need to be increased dialogue and shared understanding that the procedures can be used to promote and support resolution in a case and not initiated just when things have gone wrong or where there are disputes between agencies. They should be seen as a positive way through and encouraged in the way that healthy challenge is encouraged.  In this case the procedures were initiated but not effectively concluded.  When these meetings are called they should remain the responsibility of the agency who calls the meeting to also take the lead on inviting appropriate professionals, administrate the meeting and ensure that if family members are not invited then restorative practice is maintained.   8. Challenges to the Leeds Local Safeguarding Children Partnership  8.1 Disseminate the good practice across the partnership. Not only to celebrate success but also to replicate, develop and improve it.  8.2 Consider how best that all involved agencies contribute effectively to the formulation of a child’s plan, (child protection plan or care plan to a child looked after).  8.3 Once the Concerns Resolution Procedure is initiated, consider how best to effectively track the process to resolution and to clarify that professional only “consultation” style meetings, so long as clearly justified and exceptional, are not contrary to the restorative approach to work with families championed in Leeds.  8.4 The LSCP to raise professional awareness of the Concerns Resolution Process in place in Leeds.  8.5 Ensure the inclusion of hypothetical risks that may be predicted along with risks identified in a comprehensive assessment to better safeguard children.  8.6 Consider how best to disseminate relevant knowledge about care proceedings to all professionals involved in care planning.  8.7 The LSCP to commission the production of a One Minute Guide around the types of court proceedings and outcomes found in this case.    Overview report Child E – September 2019 29  Glossary   ADM   Agency Decision Maker   CAFCASS  Children and Family Court Advisory and Support Service    CCP Consultant Clinical Psychologist   CIN   Child in Need; Section 17 (10) of the Children Act 1989   CSWS  Children’s Social Work Service  CSWT   Children’s Social Work Team  IMHS   Infant Mental Health Service  LCH   Leeds Community Healthcare NHS Trust  LSCB   Leeds / Local Safeguarding Children Board (2006-2018)  LSCP   Leeds Safeguarding Children Partnership (from April 2018)  NAS   Neonatal abstinence syndrome    PLO   Public Law Outline  S38(6)  Section 38 (6) Section 38(6) of the Children Act 1989   SCR   Serious Case Review    Overview report Child E – September 2019 30  Endnotes  Children and Family Court Advisory and Support Service (CAFCASS) is the Government agency responsible for Children’s Guardians and other Court officers appointed by the Court in Court Proceedings involving children.  Consultant Clinical Psychologist (CCP): In this case there are two, an Independent CCP and one who leads the Infant Mental Health Service (IMHS)  Child in Need; Section 17 (10) of the Children Act 1989: A child is a Child in Need if:  He/she is unlikely to achieve or maintain, or have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision for him/her of services by a local authority;  His/her health or development is likely to be significantly impaired, or further impaired, without the provision for him/her of such services; or  He/she is disabled.   Infant Mental Health Service (IMHS): The field of Infant Mental Health has grown dramatically over the past few decades and its increasing importance is now widely accepted.  Leeds Infant Mental Health Service came second in the annual Journal of Health Visiting Awards 2018 in the category of Innovation in Health Visiting Practice Award.  Looked After Review: Looked After Reviews (also called a Statutory Reviews) are held at specified intervals in relation to all Looked After Children. Looked After Reviews are normally chaired by an Independent Reviewing Officer and are designed to ensure that adequate plans are in place to safeguard and promote the overall welfare of children; and to make recommendations, as necessary, for changes to those plans.  Looked After Reviews are convened at the following intervals:  Within twenty working days of the child becoming Looked After;  Then within three months of an initial looked after review;  Then subsequent looked after reviews should be conducted not more than six months after any previous review.  Neonatal abstinence syndrome (NAS) is a result of the sudden discontinuation of foetal exposure to substances that were used or misused by the mother during pregnancy.  Parallel Planning: A Parallel Plan, also referred to as a Twin Track Plan, is a term used when a Contingency Plan for a Looked After Child is being explored at the same time as the primary plan for the child. As part of Permanence Planning for Looked After Children, Parallel Plans must be drawn up to ensure that alternative plans have been explored and are available without delay if the preferred permanent outcome proves unachievable.  Permanence Planning: Permanence for a Looked After child means achieving, within a timescale which meets the child's needs, a permanent outcome which provides security and stability to the child throughout his or her childhood. It is therefore the best preparation for adulthood.   Wherever possible, permanence will be achieved through a return to the parents' care or a placement within the wider family but where this cannot be achieved within a time-scale Overview report Child E – September 2019 31  appropriate to the child's needs, plans may be made for a permanent alternative family placement, which may include Adoption   Leeds City Council Permanence Policy Statement: Permanency planning is based on the philosophy that every child has the right to a permanent and stable home, preferably with his or her own family. The primary focus of permanency planning is to prevent children drifting in care.  Leeds City Council, as corporate parent for Children Looked After will work diligently to find permanent, safe homes for children in care, in a timely manner. The best possible care involves giving children security, stability and love through their childhood and beyond.  Public Law Outline (PLO): The Public Law Outline: Guide to Case Management in Public Law Proceedings came into force on the 6th April 2010.  An updated Public Law Outline came into effect on 22nd April 2014, alongside the statutory 26-week time-limit for completion of care and supervision proceedings under the Children and Families Act 2014.  The Public Law Outline sets out streamlined case management procedures for dealing with public law children's cases. The aim is to identify and focus on the key issues for the child, with the aim of making the best decisions for the child within the timetable set by the Court and avoiding the need for unnecessary evidence or hearings.  Practice Learning Event    Right Conversation, Right People, Right Time Guidance  http://www.leedsscp.org.uk/LSCB/media/Images/pdfs/Right-conversations,-Right-people,-Right-time-Guidance.pdf  Concerns Resolution Process: When having conversations (and working) with practitioners from other agencies there will at times be differences of opinion. Disagreements can be a sign of developing thinking, and the value of exchanging ideas from different perspectives should not be under-estimated. However, disagreements may disadvantage the child or family involved if they are not resolved constructively and in a timely manner.  When such disagreements occur, practitioners should refer to and follow the dispute resolution process, ensuring that quality conversations with line managers are key to supporting the process.   Section 38(6) of the Children Act 1989 is an increasingly utilised section of the Act applied as an interim or assessment direction, used to determine what is in the best interests of the child in especially complex or fraught circumstances by giving some limited scope to test out arrangements prior to permanent decisions being taken.       Overview report Child E – September 2019 32  References  Asok A, Bernard K, Roth TL, Rosen JB, and Dozier M. 2013. Parental responsiveness moderates the association between early-life stress and reduced telomere length. Dev Psychopatholgy. 25(3):577-85.  Devon County Council v EB & Ors (Minors) [2013] EWHC 968 (Fam)  Kaley, F, Reid, V & Flynn, E (2011) The psychology of infant colic: a review of current research. Infant Mental Health Journal 32(5): 526-541 [Freely view abstract or access full text by subscription: Infant Mental Health Journal 32(5): 526-541]  Leeds Children and Young People’s Plan 2015-19  Lester, B. M., Boukydis, C. F., Garcia‐Coll, C. T., & Hole, W. T. (1990). Colic for developmentalists. Infant Mental Health Journal 11(4): 321-333 [Freely view abstract or access full text by subscription: Infant Mental Health Journal 11(4): 321-333]  Luby J, Belden A, Botteron K, Marrus N, Harms MP, Babb C, Nishino T, and Barch D. 2013. The Effects of Poverty on Childhood Brain Development: The Mediating Effect of Caregiving and Stressful Life Events. JAMA Pediatr. 2013 Oct 28. doi: 10.1001/jamapediatrics.2013.3139. [Epub ahead of print]  Re B-S (2013) EWCA Civ 1146 http://www.familylawweek.co.uk/site.aspx?i=ed117048  Reunification Framework  http://leedschildcare.proceduresonline.com/chapters/p_reunification.html    