Summary of a review into the death of a 6 month old boy on 22 December 2011 following complications from a head injury. The mother's partner was charged with Section 18 Assault (Causing Grievous Bodily Harm) and subsequently charged with Child A's murder. Child A's mother had routine contact with health services during her pregnancy and after Child A's birth and at no point were there any safeguarding concerns. Mother of Child A met her partner in October 2011 on the social networking site, Facebook. An allegation of sexual assault had been made against mother's partner in June 2011, leading to his dismissal from his role with a voluntary sector provider of services to adults with learning disabilities; this information had not been passed to the Independent Safeguarding Authority. Mother's partner was babysitting on 17 December 2011 when Child A was taken to hospital after suffering a head injury and cardiac arrest; it is not known whether mother's partner had moved into the family home at this time. Review considers issues of information sharing between agencies; systems designed to identify individuals who could provide a serious risk of harm to others, including the Multi Agency Public Protection Arrangements (MAPPA); and, use of social networking sites. Key recommendations include: development of the educational aspect of the Local Safeguarding Children Board's e-safety policy; development of greater understanding and communication of ideas and improvements between Adult and Children's safeguarding systems.
      
Title: Executive summary of the serious case review in respect of Child A LSCB: North East Lincolnshire Local Safeguarding Children Board Author: Sian Griffiths Date of publication: 2012 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.  2 July 2012      Executive Summary of the Serious Case Review in Respect of Child A           This Executive Summary has been prepared on behalf of North East Lincolnshire Safeguarding Children Board.   Page 2 of 14   GLOSSARY    FAMILY:  Child A:    Subject MA     Mother of Child A MP     Partner of MA FA     Father of Child A   MPExP    MP’s ex-partner  CExP     Son of MP     Acronyms:  A & E Accident and Emergency ACPO Association of Chief Police Officers CPS Crown Prosecution Service CRB Criminal Records Bureau EMAS East Midlands Ambulance Service GP General Practitioner IMR Independent Management Review ISA Independent Safeguarding Authority LSCB Local Safeguarding Children’s Board NLaG Northern Lincolnshire and Goole Hospitals NHS Foundation Trust OFSTED Office for Standards in Education OOH Out of Hours service for Children’s Social Care PCT Primary Care Trust PPU Police Public Protection Unit SCR Serious Case Review SCRP Serious Case Review Panel TOR Terms of Reference NELSCB North East Lincolnshire Safeguarding Children Board   Page 3 of 14   1. Introduction  1.1 This report summarises the findings of a Serious Case Review that was undertaken during 2012 following the death of Child A.   1.2 Child A lived with his mother (MA) in North East Lincolnshire.  On the evening of 17th December 2011, his mother’s partner (MP) was babysitting for Child A, who was 6 months old at the time.  MP phoned MA, and then on her instruction, phoned the 999 service stating that Child A was not breathing.  A Fast Response Vehicle and an ambulance arrived within minutes and Child A was taken to the local hospital where it was identified he had suffered a head injury and cardiac arrest.  Child A was later transferred to a specialist paediatric unit at Sheffield Children’s Hospital, but died on 22nd December 2011 when the decision was taken to withdraw artificial life support.  1.3 On 18th December 2011, MP was charged with Section 18 Assault (Causing Grievous Bodily Harm) relating to Child A’s injuries and was subsequently charged with his murder.  1.4  A Serious Case Review Group met on 9 January 2012 to consider whether a Serious Case Review should be undertaken. In making its decision the meeting took into account the criteria outlined in Working Together 2010. In particular, the meeting identified the following criteria as having been met:  “a child sustains a potentially life-threatening injury or serious and permanent impairment of physical and/or mental health and development through abuse or neglect”.  1.5 The purpose of a Serious Case Review is to:     Establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children.   Identify clearly what those lessons are, how they will be acted upon, and what is expected to change as a result and   As a consequence, improve inter-agency working and better safeguard and promote the welfare of children’   1.6 A Serious Case Review Group met on 9th January 2012 and recommended to Martin Wright, Chair of the Safeguarding Children Board, that a Serious Case Review be undertaken.    The Chair endorsed this recommendation. During the course of this Review Mr Wright stepped down from the Chair’s role and the Review was then overseen to completion by the Vice Chair, Craig Ferris, with the agreement of the incoming Chair, Sue Woolmore who took up post on 15th June 2012.   Page 4 of 14  1.7 A Serious Case Review Panel was set up to manage the Review and an Independent Panel Chair, Colleen Murphy and Independent Author, Sian Griffiths were appointed.   Ms Murphy and Ms Griffiths both work as Independent Social Workers and are experienced in the undertaking of Serious Case Reviews.  Neither the Independent Chair nor the Independent Author has any relevant professional or personal connection with any of the agencies involved in this Review.  1.8 The members of the Serious Case Review Panel were: Colleen Murphy Independent Chair Head of Safeguarding and Youth Offending NE Lincolnshire Council Asst. Director of Assurance &  Adult Safeguarding NE Lincolnshire Care Trust Plus. Director Humberside Probation Trust Head of Integrated Family Services Integrated Family Services Designated Doctor, Child Protection/Consultant Paediatrician North Lincolnshire and Goole Hospitals NHS Foundation Trust Detective Chief Inspector Humberside Police Designated Nurse NE Lincolnshire Care Trust Plus. Consultant, Lincolnshire Children's Services.  Lincolnshire County Council  1.9 The Serious Case Review was prepared in line with the requirements of Chapter 8 of Working Together, including case specific terms of reference. The Terms of Reference identified that the time period for consideration by the SCR should begin with the approximate date of Child A’s conception and conclude a week after child A’s death ie:      1st September 2010 - 31st December 2011  1.10 The specific terms of reference in relation to Child A were established as:  TOR 1:  Did each agency have in place policies and procedures to safeguard the welfare of children and vulnerable adults, and were they applied appropriately in this case?  TOR 2:  Did agencies have the opportunity to work together to promote the welfare of Child A?    TOR 3:  To what extent did agencies communicate across sector and local authority boundaries in order to promote the welfare of children and  Page 5 of 14  vulnerable adults, and were there any barriers to achieving effective communication?  TOR 4:  What information was known to each agency regarding any aspect of safeguarding risk (relating to adults and children), and was this shared and managed responsibly?  TOR 5:  What was known about how well (or not) Child A’s family was supported or isolated?  TOR 6:  Did agencies respond to the known and presenting needs of Child A and the family?  TOR 7:  To what extent did services take account of issues such as: race & culture, language, age, disability, faith, gender, sexuality and economic status and how did this impact upon agencies assessment and service delivery in relation to their service user?  TOR 8:  How attuned are agencies to the risks that can be posed through use of social networking sites?  TOR 9:     To what extent did services have an understanding of the children and vulnerable adults that they were working with, their experiences and views, and how did this inform practice and progress?   TOR 10:  For IMR reports are there any common themes from previous SCR’s which your agency has acted on?   1.11 The Panel considered Individual Management Reports, including a full chronology of involvement with the family  and critical analysis of the services from the following agencies:   Humberside Police  Lincolnshire Police  Northern Lincolnshire and Goole Hospitals NHS Foundation Trust  East Midlands Ambulance Service   North East Lincolnshire Council Children’s Centres  North East Lincolnshire General Practitioner Services  North East Lincolnshire Council Children’s Health Provision  1.12 A Health Overview Report was prepared by North East Lincolnshire NHS Care Trust Plus, in order to provide an overview of all the health provision concerned.  1.13 It was identified that MP had previously lived in Lincolnshire and therefore enquiries were made with the Lincolnshire Safeguarding Children Board as to  Page 6 of 14  any current or historical involvement with agencies in that area and reports requested from 2 relevant agencies as a result.      1.14 The Panel also identified a number of agencies who had had some contact with either Child A, MA or MP but where that contact did not justify a full IMR.  These agencies therefore were asked to provide chronological and other relevant information within a brief report. The agencies concerned were:   The agencies who provided brief reports were:  NAVIGO (Provider of Mental Health Services in North East Lincolnshire)  North East Lincolnshire Children’s Services  Lincolnshire Children’s Services  Sheffield Children’s NHS Foundation Trust   The Armed Forces Welfare Service  Voluntary Sector Provider of services to adults in Lincolnshire  1.15 The Lincolnshire County Council Safeguarding Adults Team had had some limited involvement as a result of an allegation made against MP which led to a criminal investigation.  The Lincolnshire County Council Safeguarding Adults Team was therefore asked to provide a short chronology of their involvement.  1.16 Other parallel processes were taking place during the course of this Review.  MP was charged with murder following the death of Child A and was awaiting trial.  The trial took place at Hull Crown Court and on 27th June 2012 MP was convicted of the manslaughter of Child A.  He had separately been charged with two offences under the Sexual Offences Act 2003 for an unrelated incident for which criminal court proceedings were also ongoing.  An inquest into the death of Child A had been opened and adjourned pending the outcome of the criminal proceedings.  1.17 Careful consideration was given to seeking the involvement of Child A’s family in this Review in order to maximise learning. It was agreed that the mother of Child A, the father of Child A and MP should all be informed that the Serious Case Review was taking place. It was also agreed that the mother of CExP should be informed prior to the publication of the Review.  1.18 The panel particularly wished to seek the involvement of the mother of Child A as the key family member who may be able to contribute regarding the role played by the agencies concerned.  However, this was not possible prior to the completion of the review due to the risk of potentially compromising the proceedings.    It was therefore agreed that MA would be invited to meet with the Independent Chair and Author after the criminal proceedings were completed. It had been agreed that any further learning arising out of this meeting would be shared with the Serious Case Review Panel. Following the trial MA confirmed that she would like to take part in such a meeting and  Page 7 of 14  arrangements to do so were made with her, however MA did not attend.  Further attempts were made to contact MA and a second meeting offered, but MA did not respond.  The review was therefore unable to benefit from her involvement.    2. Summary of events and the involvement of services  The following information is a summary of the circumstances and events as they are known to the agencies involved with the family of Child A. 2.1. Child A was a white British boy who lived with his mother and her parents for the first couple of months of his life and then moved with his mother into their own home locally.  It is understood that his maternal grandmother supported Child A’s mother throughout.  Child A’s father is understood to have had no involvement with his son during his life.  There was at the time, and remains now, no information to suggest that Child A or his mother had any particular needs or vulnerabilities that would indicate a requirement for specialist or additional services.   2.2. Child A was known only to health services and the Children’s Centre, from where most of those services were provided.  Neither Children’s Social Care nor any other specialist service had any reason for involvement with Child A prior to the incident which resulted in his death. 2.3. MA had routine contact with health services during her pregnancy with Child A and after his birth, none of which resulted in any safeguarding concerns. The only potential issue of concern was that in November 2010 MA told her GP that she had been hit by her partner.  This information was not passed on, however shortly afterwards she identified herself as now being a single parent and there was no further information to suggest that she was at risk of further assault.  Child A was registered with the local Children’s Centre and was seen regularly by Health Visiting Services.  Child A was developing as would be expected and there was no information to suggest any reason to be concerned about his care. 2.4. It is understood that MA and MP met via the social networking site Facebook some time around October 2011.  It is not known when, or indeed if, MP moved into the family home, only that he was babysitting for Child A on 17th December 2011. 2.5. Little information is known regarding MP and none of the agencies in North East Lincolnshire were aware that he was in a relationship with MA.  What is now known to this Review however is that prior to moving to Grimsby, MP had been living in Lincolnshire.  MP served in the Armed Forces between 2009 and 2010, he was married at that time and the couple had a child CExP.  MP’s service with the Armed Forces was terminated in June 2010 after he had spent a period absent without leave and was consequently assessed as unsuitable for the army.  2.6. It is further known that MP was employed from April 2011 as a sessional worker by a voluntary sector provider of services to adults with learning  Page 8 of 14  disabilities1.  His role was to support adults in their own homes.  In June 2011 a female service user made an allegation of sexual assault against MP.  He was bailed by the police whilst they investigated the allegations and in February 2012 MP was charged with two offences under the Sexual Offences Act 2003.  At the time of writing the criminal court proceedings were still ongoing. The criminal charge was outstanding at the time the SCR took place.  However, MP was subsequently found not guilty following a trial. 2.7. The allegations were referred by the Voluntary Sector Provider, as expected, to the Lincolnshire County Council Safeguarding Adults Team who provided support to the service user throughout the investigation.  MP was suspended from his employment immediately following the allegations and dismissed in November 2011.  In August 2011 he separated from his wife and moved to Grimsby. 2.8. At just before 11pm on 17th December 2011 MP, who was babysitting for Child A, phoned MA and told her that Child A was not breathing.  She told him to call 999 which he did.  A Fast Response Vehicle arrived two minutes later and an ambulance within 8 minutes.  Child A was taken to hospital in Grimsby and from there transferred to Sheffield Children’s Hospital.  Child A had suffered a non-accidental head injury and cardiac arrest.   2.9. Shortly after Child A’s arrival in hospital a Staff Nurse in the Accident and Emergency department of the hospital approached a police officer who was attending another incident and informed the officer that there were concerns that the injury was non-accidental.  The Officer contacted the Police Command Centre and an investigation was immediately initiated by the Major Incident Team. In the early hours of 18th December 2011 MP was arrested on suspicion of causing Grievous Bodily harm, with which he was later charged.  At a subsequent court appearance MP was charged with murder.  MP was convicted of the manslaughter of Child A on the 27th of June 2012 following a trial at Hull Crown Court 2.10. On 17th December and in the following days, information was established as to whether he was known to other agencies, including the police. Formal safeguarding procedures were instigated leading to this Review. 2.11. On 22nd December 2011 Child A died following the withdrawal of the artificial life support on which he was reliant.  3 Key Issues Arising from the case  3.1. The information provided to this review has been subject to analysis, both within the Individual Management Reviews and by the Serious Case Review Panel, leading to this Overview Report.                                                     1 The Voluntary Service Provider is not identified in this Review in order to protect the identity of the service user concerned.  Page 9 of 14  3.2. Unlike the majority of children who are the subject of Serious Case Reviews, it is evident from the history of Child A’s brief life, that he was a child who at no point gave cause for concern to the agencies.  There was neither at the time, nor with hindsight any information to suggest any concerns about his wellbeing prior to the catastrophic injury that resulted in his death.  3.3. The IMRs have identified that their agencies had suitable policies and procedures for safeguarding the welfare of children.  There was, however, no basis for implementing any safeguarding procedures. Practice by the professionals concerned was largely of a good standard, in line with the service standards and expectations.  Medical care provided to Child A following his injury was of a high standard and the police response to concerns raised by the hospital was swift and appropriate.  3.4. One issue that required attention has been identified in relation to the service provided by the GP, in that when MA disclosed possible domestic violence, the GP did not forward this information to other health professionals who were involved with MA. It is not clear if appropriate support or advice was given to MA, potentially representing a missed opportunity to support her and safeguard her unborn child.  However, given that MA  shortly afterwards was no longer in the relationship and there were no further known occurrences, it is quite clear that  even had the midwife been given this information she would not have had reason to intervene further and this issue had no ultimate effect on the events that led to Child A’s death.  Nevertheless this has been identified as something for future learning within the Health Overview report and is subject to a recommendation as a result.  3.5. Having considered the information that was available to agencies at the time and also with hindsight, the Review has reached the conclusion that there was no information to suggest that Child A could be at risk from MA, his primary carer.  3.6. The Review gave significant consideration as to whether any information regarding MP could, or should have raised safeguarding concerns or triggered action by any agencies.  In doing so, the Review was mindful that MP was still awaiting trial for the murder of Child A and therefore was not making any assumptions as to whether he had in fact committed the offences for which he was charged.  The focus was to consider whether in light of the information known to the Review it would have been reasonable, prior to 17th December to consider him a potential risk.  3.7. None of the agencies within North East Lincolnshire were aware of MP’s relationship with MA prior to 17th December.  There was no basis on which they would have been required to seek information about any new relationship in which MA was involved.  It is for a child’s parent to make decisions regarding who should care for their child.  Safeguarding agencies would have no basis to intervene without specific information that a parent was recklessly putting their child at risk.    Page 10 of 14  3.8. MP became known to a limited number of services in Lincolnshire arising out of the allegation of sexual assault in June 2011.  The voluntary service provider who employed MP informed Lincolnshire Police and the Lincolnshire Adult Safeguarding Team immediately they were aware of the allegation and suspended MP.  MP was dismissed from his employment in November 2011. The Voluntary Sector Provider had undertaken full reference and Criminal Records checks before employing MP and nothing of concern had been discovered.    3.9. The only process which was not followed correctly at the time was in relation to the Voluntary Service Provider who omitted to tell the Independent Safeguarding Authority, the body which makes decisions about barring people from working with children or vulnerable adults.  The Voluntary Service Provider has accepted this was a mistake and taken remedial action.  However, even had this referral been undertaken at the correct time, it would not have impacted in any way on the outcome for Child A, as MP was in a personal relationship with his mother, not an employment relationship.  Had MP applied for further employment with children or vulnerable adults, the enhanced CRB check would have identified that he was currently under investigation for a serious sexual offence.  3.10.  Whilst there was an 8 month gap between the allegation of sexual assault and MP being charged with a criminal offence, this was a result of the need to obtain specialist forensic reports and advice and the Review was satisfied that no criticism could be made of the police as a result.  MP was subject to police bail, with proportionate conditions, during the investigation period and there were no other restrictions that could be placed on him in this regard.  3.11. The Review has considered in detail the current systems designed to identify individuals who could provide a serious risk of harm to others, for example the Multi Agency Public Protection Arrangements (MAPPA), or the 2 systems for disclosing information to the relevant members of the public:  the Child Sex Offender Disclosure scheme and the Domestic Violence Disclosure scheme. None of these systems would have been applicable to MP as he had no history of offending.  The Review is fully satisfied that there was no further action that the Voluntary Service Provider, Lincolnshire Police or Lincolnshire County Council Safeguarding Adults team could, or should have taken, which would have identified MP as a future risk to children or impacted on the ultimate outcome.   3.12. It is widely accepted that the prediction of the risk of harm by individuals is a complex and imprecise activity with the most accurate results arising out of the use of detailed assessment tools combining statistical calculations in depth clinical assessment.  MP had, and at this time, still has no convictions of any nature. Whilst the allegations of sexual assault inevitably raise questions for his capacity for harm, this alone could not lead to a presumption that MP was a greater risk of physical harm to a child.  3.13. Finally the Review has reflected on whether the adults’ use of social networking sites played any significant role in these events given an emerging  Page 11 of 14  recognition nationally of the particular risks this form of communication can pose.  There is no information available to the Review that MA or Child A were targeted deliberately by MP via social networking.    3.14. The use of social networking sites as a means to meet a partner may carry different risks than other means.  There may, for example be an illusory sense of transparency created by the process in which individuals can post their own version of themselves which may differ greatly from reality.  There may also be a lack of information about family, work or friends which would provide a fuller context.   However, no route to meeting a partner can be presumed to guarantee safety for the individual or their children.  The degree to which an individual parent is alert to the potential risks of introducing another adult into their household is not something which agencies can control.  This Review has concluded that there is potential for some limited educative work with parents as a result so has made a relevant recommendation.  However, it is important that the likely impact of this should not be overstated.  3.15.  In the absence of any known risk in relation to any of the adults concerned there was neither the reason nor the practical means to assess the potential for such a catastrophic injury to Child A.   Child A’s death can be better understood as an unanticipated crime rather than as an unidentified safeguarding failure.  4. Priorities for learning  4.1 On the basis of the information available to it, this Review has concluded that the events that led to Child A’s death could not have been predicted either at the time, or with the benefit of hindsight.  Direct lessons for the agencies are therefore limited.  Two specific areas of vulnerability have been identified in relation to the GP service and the Voluntary Service Provider and recommendations made as a result. The remaining single agency recommendations relate to consequential learning about a range of practice such as will always arise from a Review of this nature.  4.2 Recommendation 4 from the Health Overview has been particularly commended to the Safeguarding Board given the significant role of GPs in contribution to safeguarding and the risks to any service during times of transition.  4.3 Two multi agency recommendations have been made, the first being a quite practical recommendation to develop the educational aspect of North East Lincolnshire Safeguarding  Children Board’s e-safety policy.  4.4 The second recommendation, whilst on the face of it perhaps appearing a purely procedural one, has the potential to provide the basis of the most significant future learning.  The Serious Case Review Panel considered that one of the most valuable aspects from an agency perspective arising out of this Review was the development of greater understanding and cross fertilisation of ideas and improvements between the Adult and Children’s safeguarding systems.   North East Lincolnshire Adults and Children’s  Page 12 of 14  Services felt that this was something that could have wider long term benefits for the way in which they worked together and for this reason identified the value of sharing this report with the Adult Safeguarding Boards in both authorities as well as the Children’s Safeguarding Board in Lincolnshire. 6.   Recommendations for individual agencies  The following recommendations were made arising out of this Review and endorsed by the Serious Case Review panel. A detailed Action Plan including timescales has been prepared in relation to each of the recommendations.  Recommendation for the Voluntary Service Provider (made by the Overview Report):  The Voluntary Service Provider to review its procedures for referring to the Independent Safeguarding Authority, and its successor, in order to satisfy itself that the procedures are adequately robust.  Recommendations for North East Lincolnshire Children’s Centres:    1. Training needs assessment for front line children’s centre staff to be part of their annual appraisal, to include consideration of LSCB domestic violence and the impact on the child levels 1 and 2.  2. Continue to develop a multi-agency pre natal parent craft programme for all first time parents to be commencing September 2012  3. Include within home safety sessions advice on the use of social networking sites and keeping personal information safe.  Recommendations for East Midlands Ambulance Service:  1. Ensure a safeguarding referral is completed after child death or prognosis, where this is unexpected.  2. Emergency call taker to have refresher training regarding the importance of initiating bystander CPR as soon as possible within the cardiac arrest situation by using “repetitive persistence”.  3. Re-enforce the importance of managers to be present at Police interviews.       Recommendation for North East Lincolnshire General Practitioner Services:  The lead GP will work with Designated Professionals and other safeguarding children leads to ensure all GPs and primary care understand and act on the need to share information with relevant professionals where there are safeguarding concerns and in particular where there are concerns in respect to Domestic Violence.  Recommendations for North East Lincolnshire Children’s Health provision:  Page 13 of 14   1. Children’s Health Provision will review and develop new guidance for staff in respect of both clinical practice and safeguarding in order to improve and sustain the quality of services.  Safeguarding practice and supervision will be a focus for audit annually during the 2012/13 calendar year  2. Children’s Health Provision will work with midwifery leads to ensure that information sharing and the transition process between midwifery and health visiting is reviewed and recommendations made for a clear and robust process of transition and information sharing.  3. Children’s Health Provision will work with the CTP and Primary Care to strive towards all children having electronic SystmOne “shares” in place and where a practice uses EMIS, evidence of information sharing in line with the agreed process.  4. The community Children’s Safeguarding Team will raise awareness with staff through training about potential risks of social networking sites.  Recommendations for North East Lincolnshire NHS Care Trust Plus (produced by the Health Overview Report):  1. North East Lincolnshire Care Trust Plus will through the Lead (Named) GP and Designated Professionals, and in collaboration with safeguarding children leads, ensure all GPs and primary care staff understand and act on the need to share information with relevant professionals where there are safeguarding concerns, and in particular where there are concerns in respect to Domestic Violence. This will be addressed through a review of accessibility of GP and primary care training which will be completed by September 2012 with a roll out of training by March 2013.  2. North East Lincolnshire Care Trust Plus will ensure that robust processes are in place by September 2012 for a written report completed by midwifery service identifying issues of concern, in respect to the health and/or welfare of mother, baby and family, in all circumstances, on transfer from midwifery to health visiting care. This will include the completion of a “nil” report where there are no identified concerns  3. North East Lincolnshire Care Trust Plus will work with provider organisations/services using SystmOne, to ensure that by March 2013, all barriers are removed, to the creation of a single, accessible record which reflects all the patient’s needs, including the impact of parental and environmental issues on children, and provides a full account of all activity to promote the health, and welfare, of children  4. North East Lincolnshire Care Trust Plus, through the Designated Nurse and the Lead (Named) GP, will work to develop, by October 2012, a localised template for a practice specific safeguarding children policy, and encourage adoption by all general medical practices.   Page 14 of 14  5. North East Lincolnshire Care Trust Plus, through the Lead (Named) GP, working in collaboration with other relevant practitioners will by October 2012, develop a template for practice based protocol for the robust assessment and follow up of positive test results, and patient failure to attend appointments.  The Overview Report made two further multi-agency recommendations designed to support future learning within the agencies working across children and adult’s safeguarding in both North East Lincolnshire and Lincolnshire.  Recommendations for the Voluntary Service Provider  1. The Voluntary Service Provider to review its procedures for referring to the Independent Safeguarding Authority, and its successor, in order to satisfy itself that the procedures are adequately robust  Recommendations for North East Lincolnshire Safeguarding Children Board:  1. The North East Lincolnshire SCB to review its ‘e-Safety strategy’ to develop and include opportunities for awareness raising of the potential risks to adults and their children when initiating relationships as a result of  contact via social networking  sites.   2. The North East Lincolnshire SCB to share the Serious Case Review Overview report with the Lincolnshire and North East Lincolnshire Adult Safeguarding Boards and the Lincolnshire Safeguarding Children Board immediately, in order to share the learning  