Injuries to a 3.5-year-old (A) sustained between February and August 2014. Child A and Child B were subject to child protection plans at the time, under the category of neglect. Charges of neglect and physical assault against mother and maternal grandmother were dropped. A and her 2.5-year-old sibling were placed in foster care. Children were living with their mother and grandmother, who was also known to authorities as she was caring for mother's sister's child. Mother was widowed and suffering from depression. Concerns around neglect included missed medical appointments and a dirty home environment. Issues discussed include a tendency to focus on the parent's perspective and not from the child's experience, leading to children at risk of neglect being seen as at less immediate risk than other forms of abuse; a pattern of telephone strategy discussions which excluded health professionals; confusion around reporting arrangements when an allocated social worker is unavailable; and confusion amongst partner agencies following a children's services reorganisation. Uses the Social Care Institute for Excellence (SCIE) Learning Together model to highlight issues for consideration by the safeguarding children board and partner agencies.
      
 Title:  Serious case review: regarding Children A and B: overview report. LSCB: Shropshire Safeguarding Children Board Author: Fiona Johnson, Claire Porter, Lisa Charles Date of publication: 2015  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                            1       Shropshire Safeguarding Children Board Report of the Serious Case Review Regarding Children A & B      Authors: Fiona Johnson, Claire Porter, Lisa Charles  2  Index  Title Page 1.1 Why this case was chosen to be reviewed 3 1.2 Succinct summary of case 3 1.3 Family composition 3 1.4 Time frame 3 1.5 Organisational learning  and improvement 3 2.1 Methodology 4 2.2 Reviewing expertise and independence 5 2.3 Acronyms and terminology 5 2.4 Methodological comment and limitations 5 2.4.2 Participation of professionals 5 2.4.3 Perspectives of the parents 5 2.5 Structure of report 5 3 Professional practice appraisal 7 4 The Findings 13 4.1 Introduction 13 4.2 What light has this case review shed on the reliability of our systems to keep children safe? 13 4.3 Summary of findings 14 4.4 Findings in detail 15 6 Conclusion 33  Appendix 1: The SCR Process in detail 34  Appendix 2: Glossary 40  Appendix 3: Bibliography 41        3  1 Introduction 1.1 Why this case was chosen to be reviewed  The Shropshire Local Safeguarding Children Board determined to conduct a Serious Case Review (SCR) because the circumstances of this case met the following criteria:  (a) abuse or neglect of a child is known or suspected; and (b) (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.  (Working Together to Safeguard Children, 2015:75)1  1.2 Summary of case  1.2.1 This review concerns the services provided by Shropshire agencies, over a period of six months, to two children who were cared for by their widowed mother who had recently returned to live in Shropshire. The children were the subject of ‘child protection plans’2 because of her neglectful parenting. During the review period the older child experienced two separate injuries. The investigations into these injuries were problematic and there were delays and insufficient follow-up on concerns. The second investigation resulted in the children becoming accommodated and care proceedings were instigated. The children are currently in foster-care and will not be returning to live with their mother. 1.3 Family composition  Family member  Age during review period  Child A 3½  years Child B 2½ years Mother 33 years Father deceased Maternal Grandmother 63 Maternal step Grandfather 64 Aunt 25 Cousin 10 1.4 Timeframe  The review period is from 18th February 2014, when the family first moved back to Shropshire until 5th August 2014 when the children were placed in foster-care. 1.5 Organisational learning and improvement  Statutory guidance on the conduct of learning and improvement activities to safeguard and protect children, including serious case reviews states that: ‘Professionals and organisations protecting children need to reflect on the quality of their services and learn from their own practice and that of others. Good practice should be shared so that there is a growing understanding of what works well. Conversely, when things go wrong there needs to be a rigorous, objective analysis of what happened and                                                            1 Working Together 2015 https://www.gov.uk/government/publications/working-together-to-safeguard-children--2  2 Where there are concerns about the well-being of a child an initial child protection conference brings together family members (and the child where appropriate), with the supporters, advocates and professionals most involved with the child and family, to make decisions about the child’s future safety, health and development it is the responsibility of all involved agencies   To plan how best to safeguard and promote the welfare of the child. https://www.gov.uk/government/publications/working-together-to-safeguard-children--2      4  why, so that important lessons can be learnt and services improved to reduce the risk of future harm to children.’ (Working Together 2015:72) and  ‘Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children.’ (Working Together 2015:73) Shropshire Local Safeguarding Children Board (LSCB) identified that a review of this case held the potential to shed light on particular areas of practice including addressing the following questions:   How effective is agency input and involvement in the child protection planning process?  How effective are professionals at recognising and responding to non-accidental injuries to children? Once the review was started and it became apparent that neglect was a key feature it was also agreed that the review would explore the extent to which the SSCB Neglect Strategy had impacted on frontline practice. 2.  Methodology  2.1 Statutory guidance requires reviews to be conducted in such in a way which:  recognises the complex circumstances in which professionals work together to safeguard children;   seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;   seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;   is transparent about the way data is collected and analysed; and   makes use of relevant research and case evidence to inform the findings. (Working Together 2015: 74)  It is also required that the following principles should be applied by LSCBs and their partner organisations to all reviews:   there should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice;   the approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined;   reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed;   professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith;   families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process (Working Together 2015: 72-73) In order to comply with these requirements the Shropshire LSCB has used a review methodology based on the SCIE Learning Together systems model (Fish, Munro &  5  Bairstow 2010). Detail of what this has entailed is contained in the Appendix 1 of this report.  2.2 Reviewing expertise and independence  The review has been led by Fiona Johnson, an independent social work consultant accredited to carry out SCIE reviews with extensive experience in writing SCRs/IMRs under the previous ‘Chapter 8’ framework; and, Claire Porter and Lisa Charles, who are employed by Shropshire Council and are also SCIE accredited. All reviewers have had no significant previous direct involvement with the case under review. 2.3 Acronyms used and terminology explained  Statutory guidance requires that SCR reports be written in plain English and in a way that can be easily understood by professionals and the public alike (Working Together 2015: 79) Writing for multiple audiences is always challenging. Throughout the report footnotes are provided to explain relevant aspects of professional practice. In the Appendix 2 we provide a section on terminology which aims to support readers who are not familiar with the processes and language of the safeguarding and child protection work. Shropshire LSCB is keen to improve the accessibility of SCR reports and welcomes feedback and suggestions for how this might be improved. 2.4 Methodological comment and limitations  2.4.1 This review was undertaken using the SCIE methodology but did not have supervision from SCIE and is therefore not a SCIE review. A key aspect of the methodology is the direct involvement of the frontline professionals who knew the family in the review process, assisting in developing the findings from the review. For more information regarding the methodology see appendix 1.   2.4.2 Participation of professionals  The lead reviewers and the review team have been impressed throughout by the professionalism, knowledge and experience that the case group (the professionals involved with the family, from all agencies) have contributed to the review; and their capacity to reflect on their own work so openly and thoughtfully in the review process. This has given the review team a deeper and richer understanding of what happened with this family and within the safeguarding network and why, and has allowed us to capture the learning that is presented in this report. There were two groups of professionals who were less involved in the review process. The hospital staff could not attend any of the case group meetings however review team members did meet with them at the hospital and gained their perspective. Similarly there was limited involvement by the GPs and practice staff. As their involvement in this case was greater than the hospital staff this was felt by the review team to be a significant limitation. The review team was very pleased that the Practice Nurse was able to attend the second case group meeting and found her input to the review process of assistance in developing the findings further. 2.4.3 Perspectives of the family The lead reviewers wished to involve the mother and grandmother in the review but this was not possible. The mother was invited to contribute on a number of occasions both by direct contact and via her solicitor. Most of these invitations were ignored and the only response was asking for a visit on the same day which was not possible as none of the reviewers were available. Since then the review team has received no response from the mother. This was regretted by the review team who wished to better understand what might have assisted the mother further in her care of the children.   6  2.5 Structure of the report  Section 1 of the report provides background information and Section 2 describes the methodology used to undertake the review. Section 3 is an overview of ‘what’ happened in this case and ‘why’ - providing an appraisal of professional practice and including the review team’s judgements about the timeliness and effectiveness of interventions. This leads on to Section 4 which is a presentation of the priority findings about what needs to happen in the multi-agency safeguarding system to reduce the risks of recurrence. Each finding concludes with some key questions for LSCB member agencies. It is the responsibility of the LSCB to decide how best to respond to the findings, with the aim or reducing the recurrence of poor practice. The questions are intended to support their considerations. Appendix 1 provides more detail about the methodology used in the review, Appendix 2 is a glossary of terms and abbreviations used in the report and Appendix 3 is a bibliography.     7  3. Professional practice appraisal 3.1. This section provides an overview of ‘what’ happened in this case and ‘why’. The purpose of this section is to provide an appraisal of the practice that is specific to the case and it therefore includes the review team’s judgements about the timeliness and effectiveness of practice including where practice was below expected standards. Such judgments are made in the light of what was known and was knowable at that point in time.   3.1.2 For some aspects of the case the explanation for ‘why’ will be further examined in the findings in section 4 and a cross reference will be provided that is highlighted in bold. There are also other issues that are underlined and italicised which the review team agreed were aspects of practice in which the LSCB might have an interest but were not prioritised to be findings.   3.1.3 The time period for the review is from 18th February 2014, when the family first moved back to Shropshire until 5th August 2014 when the children were placed in foster-care. This review has been undertaken because of concerns about the agency response to the injuries experienced by Child A whilst she was the subject of a child protection plan. These concerns focussed both on the joint agency investigation of the injuries and the multi-agency work in support of the child protection plan.  3.2 Initial Contact 3.2.1 The first significant agency contact with the family was when there was a ‘transfer-in’ review child protection conference3 to consider whether the child protection plan needed to be continued following mother’s move from Wales to Shropshire. This meeting was challenging because mother was distressed and still grieving the death of her husband. It was however, chaired effectively and was attended by the relevant agencies. The decision reached was that the child protection plan should continue and the main focus of concern was seen as mother’s neglectful parenting in particular that the home she provided for the children had been dirty and that she had not taken the children to medical appointments. This behaviour was considered in the context of mother’s depression following the death of her husband and it was identified that she should be provided with additional support to help her care for the children more effectively. At the conference it was noted that mother would be staying with the maternal grandmother who was known to most agencies because she was caring for mother’s sister’s child. This information was not provided to professionals attending the conference prior to the meeting which meant they were not able to check their records for details of their contact with the wider family. This was relevant as although maternal grandmother was generally viewed by conference participants as a support for mother, all agencies had historic information that could have provided a fuller context about the wider family dynamic.  3.3 Fractured Clavicle 3.3.1 Within three weeks of the child protection conference mother took Child A to the GP concerned that she was in pain. The GP examined the child and could not identify any concern so told mother to give her some Calpol. The next day mother contacted the out of hours GP because she remained concerned and was advised to return to her own GP the next day. She did so but the GP remained unable to find a cause for the pain and so arranged for the child to be seen that day at the local hospital for an expert opinion. The GP did not check with mother whether she was able to take the child to the hospital                                                            3 When a child and family have moved permanently to another local authority area. In such cases, the receiving local authority should convene a child protection conference within 15 working days of being notified of the move. https://www.gov.uk/government/publications/working-together-to-safeguard-children--2    8  which was some distance from mother’s home address. Mother did not take the child to the hospital and later that evening hospital staff contacted the Emergency Duty Team (EDT) because they were concerned that a child with an injury who was the subject of a child protection plan had failed to attend an arranged appointment. This was an alert response by the hospital and is to be commended.  3.3.2 The Emergency Duty worker was unable to visit mother because there is only one worker covering Shropshire in the evening during the week and, although they have access to on-call cover workers, they chose not to use this resource. Instead they contacted the Police and asked if they could visit. There are known issues about the EDT which are being reviewed by the Local Authority, the LSCB may wish to consider the outcome of this review at some point. The police sent a uniformed officer to visit and he met with mother who explained that she had not been able to take the child to hospital because she had not been able to arrange a lift and could not afford public transport. The police officer saw the children, who were both asleep but seemed settled and well, and advised mother to await contact from her social worker the next day. The police officer then advised EDT of his actions. This was good practice by the police officer. The review panel was impressed by this co-operative work by the police service, although it is accepted that it would not be usual practice for the police to conduct the check. The EDT worker, in accordance with local practice, made a record on the case file and alerted the social worker by email that there had been activity overnight.   3.3.3 There is no record as to whether this email was received however the social worker (who no longer works for Shropshire Council) made no contact with mother the next day. Instead the day after a member of the family rang the GP and asked if the child should still be taken to the hospital and was told to take the child to casualty. It is noteworthy that there was no contact with the GP about the missed appointment and at the time of the review the GP was still unaware that mother had not taken the child immediately to hospital. Child A was seen in hospital and was found to have a fractured clavicle (broken collar-bone). The medical staff were surprised that mother could not provide an explanation for the injury which would have required significant force and were also concerned about her delay in bringing the child to hospital and so contacted the social work team asking for a section 47 assessment.4 This was in accordance with local procedures and professional practice. The social work manager decided to send a senior social worker to the hospital, with the allocated worker, because she was inexperienced in child protection investigations, this was good practice. The manager did not contact the police or formally initiate a child protection investigation via a ‘strategy discussion’5 and as this worker has left the council it was not possible to fully ascertain her reasons. The senior social worker understood that there had been a telephone ‘strategy discussion’ and that it had been agreed that the social work team would undertake single-agency inquiries.     The role of ‘strategy discussions’ in Shropshire and their effectiveness is discussed further in Finding 1.  3.3.4 The social workers attended the hospital and were present when Child A had a child protection medical. Maternal grandmother was also present (having brought Child B to mother at the hospital) and suggested that the injury could have been caused playing on the swing. Hospital staff were concerned that the explanations being given by the mother did not adequately explain the injury. They were not clear if the injury was accidental or non-accidental, but were concerned at the lack of proper explanation and                                                            4 A section 47 enquiry is initiated to decide whether and what type of action is required to safeguard and promote the welfare of a child who is suspected of, or likely to be, suffering significant harm. https://www.gov.uk/government/publications/working-together-to-safeguard-children--2  5 A ‘strategy discussion’ is a process to determine the child’s welfare and plan rapid future action whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm. As a minimum it should involve professionals from Children’s Social Care, Health and Police and may be a telephone conversation or a meeting. https://www.gov.uk/government/publications/working-together-to-safeguard-children--2   9  agreed that Child A should return home with mother. The senior social worker’s explanation for this decision is that they did not consider that the medical staff were clear in their view in terms of definitely saying that the injury was or likely to be non-accidental and considered it was probably a result of mother being neglectful and that this meant she would not harm Child A. They were also concerned that it was getting late and felt that the children needed to go to bed. The perception that neglectful parenting is less risky for children than other forms of abuse is examined further in finding 2. The medical staff considered that by advising the social workers of the injury they had fulfilled their responsibilities and that the social workers were therefore responsible for any further decision-making. There was no consultation with the manager about this decision as the decision-making responsibility was delegated to the senior social worker.    3.3.5 Early the next day the maternal grandmother contacted the social worker saying that the explanation for the injury was not right. She discussed this with her manager who telephoned the police and agreed that there should be a joint visit by police and social workers later that morning. The social work manager did not record this conversation as a ‘strategy discussion’ 6 or start a section 47 inquiry however the police officer did record it as a ‘strategy discussion’. The issue of recording of ‘strategy discussions’ is considered later in finding 3.   3.3.6 The social workers and a police officer attempted a visit to mother who was unavailable as she had taken Child A to a follow-up appointment at the hospital. They then visited maternal grandmother who suggested that the injury to Child A had been caused when a heavy curtain pole had fallen on the child the previous weekend. The social worker and the police then went to the local GP and discussed with them mother’s presentation at the surgery and confirmed that she had voluntarily taken Child A twice to the surgery because of she was concerned that she was in pain. When mother returned from the hospital they visited the family home. Mother explained that while she was on the lavatory Child A climbed up the curtain and pulled the pole away from the wall. She said that she did not see it happen but that she found Child A and the curtain pole on the floor. The social workers and the police officer considered that mother’s explanation was credible and jointly agreed that the paediatrician should be informed of the outcome of their visit and consulted about whether the injuries could have been caused in the manner described by mother. This joint visit by the police and social workers was thorough and comprehensive, in accordance with procedures and best practice.    3.3.7 Following this visit there was no further inter-agency discussion of this injury until the review child protection conference in May. Neither the social workers nor the police contacted the paediatricians and provided them with the alternate explanation for the injury. There was no follow-up strategy discussion meeting involving health professionals. The role and function of ‘strategy discussions’ within Shropshire is considered further in finding 1. The paediatrician’s report of the child protection medical was not received by the social worker until mid-May, despite it having been written in March, this is thought to be an administrative failure as a copy of the report was received by the named nurse within the hospital. This was a known problem at this time but the case group confirmed that following changes in the hospital administrative systems this has now improved.  It was not clear why the allocated social worker did not contact the paediatrician and discuss the outcome of the joint visit. The senior social worker advised her to do so but did not take any responsibility for ensuring that this had happened. This was because he had moved to another job as a result of the                                                            6 Whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm there should be a ‘strategy discussion’ involving local authority children’s social care https://www.gov.uk/government/publications/working-together-to-safeguard-children--2   10  reorganisation of Children’s Services and also he understood that this was a task for the social worker’s manager. It is clear that at this time there was a lack of clarity about the responsibilities of senior social workers and that this could have led to confusion. Since then the role has been reviewed and clearer guidance provided about relative roles and responsibilities. This role and function of senior social workers is an issue about which the LSCB may wish to receive a report from the Director of Children’s Services.  The fractured clavicle was reported to the child protection review conference in May but there was minimal discussion as it was reported as an accident and the only significant issue noted was the delay in taking Child A to hospital. The police investigation into the fractured clavicle was closed at the end of May 2014 when they received a copy of the child protection medical.  3.4 Routine Monitoring 3.4.1 Between April and July 2014 Child A remained the subject of a child protection plan. There was a review conference and three core group meetings but the allocated social worker was only present at one core group meeting. This lack of attendance led to a lack of continuity in case planning and placed pressure on other agencies to provide the continuity of care. The health visitor and family centre worker continued to work with mother around potty training and helping improve Child A’s speech and development. A new social worker became the key worker in early June but was told that it was a temporary allocation pending a permanent worker being identified. With hindsight it is clear that during this period there was drift in child protection planning with limited implementation and oversight of the child protection plan. One reason for this may be that the allocated key worker was temporary and therefore unlikely to be as focussed on the longer term goals. Core Group members were aware of the reorganisation and therefore accepted that this would result in some discontinuity of social workers. The review team were concerned that despite the evident absence of a consistent key worker there was no challenge from other members of the core group nor any attempt to escalate concerns about this situation. The issue of how effective core groups are in challenging and ensuring that there is a good enough service for children is considered further in finding 4.  3.5 Burn to arm 3.5.1 In mid-July Child A came into school (after having had two days off) and was noted by teaching staff to have a mark on the arm that they thought was a burn. This was discussed with mother who was not communicative and could not provide an explanation for the injury. The teaching staff immediately had concerns as they felt that mother’s responses were different from usual (she was normally quite chatty) they also were concerned that Child A had nappy rash and was wearing a nappy that was too small for her. It was the last day of term and they decided that their concerns should be passed to the social worker. They contacted the social work team but the allocated social worker was unavailable so they sent her an email informing her of the mark and that they thought it was a burn and also advising her of the nappy rash and that she had missed two days of school. The school response in identifying the burn and discussing it with mother and then deciding to report the injury to the social worker was exemplary practice and showed a school that had a good understanding of its responsibilities with regards to safeguarding children. The decision to send the social worker an email was more problematic as although it ensured that the information was provided to the key worker there was no guarantee that this information would be accessed immediately. A more appropriate response in the absence of the allocated social worker may have been for them to have contacted the Initial Contact Team (ICT) who could have ensured that their concerns received a speedy response. The local procedure however is for professionals to attempt to contact the allocated worker and if that person is not available speak to their manager and in their absence they would be directed to a local duty worker separate from the ICT. The lack of clarity about actions to be taken  11  when there are concerns about a child and the allocated social worker is absent is discussed further in Finding 5.  3.5.2 The allocated social worker did not view the email until the next day and was unable to immediately respond to the concerns. At this time she was providing cover for her line manager, who was on leave, and was also in court. As a result she arranged for another social worker to visit the family; to see the burn in order to consider whether any further action was needed. There was no discussion with the police about the injury.  This social worker visited, by arrangement with the family, the maternal grandmother’s house, early evening on a Friday. When the Social worker saw the mark on Child A’s arm she believed the injury to be a cigarette burn due to its presentation. Mother told her that the injury had been caused by a toy but the social worker did not think that this was a coherent explanation. The social worker advised the mother to take the child to the GP on the Monday but did not arrange for the child to be seen by a medical practitioner that night, this was not good practice. That evening the Social Worker updated the allocated social worker (who was also her manager) of the course of action she had taken and she agreed that the social worker had taken the correct course of action and that she would follow this up on the Monday. The rationale for this decision was linked to a belief by both workers that the mother would not deliberately harm her child and associated with that a perception that because the mother was mainly seen as a neglectful parent she did not pose a risk of significant harm to the child. The influence on professionals of the belief that a neglectful parent does not pose harm to a child is discussed in finding 2. That neither worker considered at any point consulting with the police, via a strategy discussion, about the need for a joint investigation reflects the attitude towards strategy discussions described in Finding 1.   3.5.3 It appears that the social work team at this time was under significant pressure following the social work restructuring, with vacancies and temporary staff, which may have meant that good practice was undermined. There had been a period of significant change within the children’s social work service with all staff having experienced and adapting to changes in teams and roles. The effect of change on staff and the risks this may pose in safeguarding children are discussed further in finding 6.  It was also clear that a factor that was influencing the workers was that at this time it was usual practice to make all requests for medicals initially to the GP rather than asking for child protection medicals directly. This practice was partly a result of known difficulties in accessing child protection medicals, which were under-resourced. Social work practice has now changed and child protection medicals will now be directly requested however the service remains under pressure. It is reported that these difficulties are being addressed via a re-commissioning of the child protection medicals service. The LSCB should request a report as to the progress of the re-commissioning of child protection medicals and may wish to audit whether the service has improved.    3.5.4 On the Monday the Social Worker phoned mother to see if she has taken child A to the GP, mother had not, so the social worker again asked her to do so. The social worker phoned mother again on the Tuesday when she confirmed that she had been to the GP and gave a different explanation for the injury saying that Child A had brushed past a cigarette. The social worker tried to arrange a visit over the next two days but mother said she was unavailable. It was not good practice that the social worker did not visit the child at this time or confirm with the GP practice that the child had been seen. It is not known why this did not happen but it is known that at this time the worker was very busy and was covering for the line manager who was on leave. Child A was seen at the GPs surgery on two occasions: first on the Tuesday by the Practice Nurse who dressed the wound and was told by the mother that the injury was not a burn. The Practice Nurse told mother to bring Child A back in a week for the dressing to be changed. The next day Grandmother telephoned the surgery and said that the dressing had fallen off the burn.  12  She was told to bring Child A to the surgery. Child A was seen by the GP and was told by the mother that the burn was caused by Child A brushing against her grandmother’s cigarette when they were in the garden. The GP took a photograph of the injury. Both the GP and Practice Nurse were sceptical about mother’s explanation for the injury but did not feel that mother would deliberately harm her child and that therefore accepted her explanation that the injury was accidental. The reasons for professionals failing to challenge mother are discussed in finding 7    3.5.5 The following Tuesday the social worker rang the GP surgery to check if mother had taken Child A to the surgery, she spoke to the Practice Nurse who confirmed that the child had been seen and told the social worker about mother’s conflicting explanations for the burn. Two days later mother failed to bring Child A in to have the burn dressing changed and the Practice Nurse discussed with the health visitor for Child A’s cousin her concerns about the injury and that mother had failed to bring the child in for the dressing to be changed. The health visitor looked at the photograph of the burn and considered that it was a cigarette burn and that its shape suggested that it was unlikely to have been caused accidentally. The health visitor noted the Practice Nurse’s concerns on Child A’s records and agreed to raise them with the relevant health visitor on her return from leave after the weekend. Whilst it is good practice that the health visitor was available to the Practice Nurse to provide professional support and evidenced good multi-agency working, the review team was concerned that the Practice Nurse did not seem to be aware of the appropriate process for escalating concerns and felt that the health visitor should have advised her to raise the issues with the designated professional within the GP Practice. The difficulties in this service are being addressed with the GP Practice by the CCG and the LSCB may wish to ask for an update report regarding progress.  3.5.6 The following Monday the health visitor attended a meeting about the cousin of Child A and discussed with his social worker the concerns raised by the Practice Nurse the previous week. This social worker agreed to talk with Child A’s social worker when she returned to the office. As a result of this conversation Child A’s social worker phoned the police to request a strategy discussion to plan a joint investigation into the injury almost three weeks after the school had sent her the information about the burn. At this point the social worker spoke to the Development Officer in the Police Harm Assessment Unit (HAU) saying that she felt there was a need to hold a Strategy discussion to plan a Section 47 assessment and investigation. The HAU was newly established and the Development Officer had some difficulties in conducting checks with external forces however it was rapidly agreed that there needed to be a joint investigation. The HAU worker then attempted to contact the Detective Sergeant, who was not immediately available, as she was attending another strategy discussion. The information was however emailed to her, and she responded by agreeing that there should be a joint visit the next day, and passed the information onto a Detective Constable to arrange the visit. This officer was the same one who had been involved in the joint investigation of the fractured clavicle and based on his recollection of that investigation, he proposed that the visit and necessary medical assessment should not be postponed and the visit then took place the same day. It was good that this officer was alert and identified the need to prioritise the visit however the review team was concerned that all the relevant information was not considered as part of a strategy discussion involving the Detective Sergeant. There are deep-rooted issues associated with the understanding of police and social workers about the relative roles of the HAU and the police officers with regards to responsibilities for strategy discussions. These are explore more fully in Findings 1 and 3.  3.5.7 Later that day the social worker and the police visited the family and arranged for Child A to be medically examined. The paediatrician examined the burn and did not feel that it  13  was consistent with the explanation given by the mother that it was caused by brushing against a cigarette. As a result it was decided that the children should not return to mother’s care and they were accommodated on a voluntary basis and placed in foster-care. The next day the mother and maternal grandmother were arrested on suspicion of neglect and child assault. These charges were later dropped, however, care proceedings were initiated with regards to the children and they are now living permanently away from their mother.     14  4 The findings 4.1 Introduction Statutory guidance requires that serious case review reports provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence. Section 3 provides the analysis of what happened and why, whilst section 4 provides the findings about what needs to happen in the multi-agency safeguarding systems to reduce the risks of recurrence. The SCIE Learning Together systems approach uses the learning from an individual case to provide a ‘window on the system’7 into how well the local multi-agency safeguarding systems are operating.  4.2 What light has this case review shed on the reliability of our systems to keep children safe? 4.2.1 This case provided the LSCB with the opportunity to examine how effective professionals in Shropshire are at recognising and responding to non-accidental injuries to children and the strength of agency input and involvement in the child protection planning process. The review has highlighted some difficulties regarding strategy discussions and planning and concluding child protection investigations. It has also shown that professionals working with children who are perceived to be at risk of neglect do not identify the same level of immediate risk as with other forms of abuse. It is also thought that they may be too concerned with the parent’s perspective and therefore fail to focus on the child’s experience. The review has also identified a lack of clarity amongst professionals about referral routes on cases open to children’s social care and a possible lack of assertiveness by core group members. Finally it has also shown the negative effect that organisational change can have on safeguarding systems.  4.2.2 In order to help with identification and prioritisation, the systems model that SCIE has developed includes 6 broad categories of these underlying patterns.  The ordering of these in any analysis is not set in stone and will shift according to which is felt to be most fundamental for systemic change:-  Innate human biases (cognitive and emotional)  Family-professional interaction  Responses to incidents  Longer term work  Tools  Management systems  There is, of course, overlap between categories.  The precise nature of each Finding, expressed in its headline, forms a sub-category within each pattern.  4.2.3 The task in developing each finding is to present a clear example of how the issue manifests itself in the case, and then to:   identify in what way it is an underlying issue – not a quirk of the particular individuals involved this time and in the particular constellation of the case;  highlight any information gleaned about how general a problem this is perceived to be locally, or data about its prevalence more widely;  be clear about why it matters; and   state how the issue is usefully framed for the LSCB to consider relative to their aims and responsibilities, the risk and reliability of multi-agency systems.                                                               7 C A Vincent Analysis of clinical incidents: a window on the system not a search for root causes Downloaded from http://qualitysafety.bmj.com/ on July 3, 2015 - Published by group.bmj.com   15  4.3 Summary of findings 4.3.1 This section contains 7 priority findings that have emerged from the learning review. The findings explain how professional practice could be improved. It does this by considering patterns that are supportive of good quality work and patterns that introduce or increase risk to the reliability with which we can expect professionals to achieve good quality work.  4.3.2 Each finding also lays out the evidence identified by the review team that indicates that these are not one-off issues. Evidence is provided to show how each finding is indicative of potential risks to other children and families in future cases, because they undermine the reliability with which professionals can do their jobs. Findings for which there is only initial or emerging evidence of prevalence outside this case have been presented as questions.   4.3.3 The review team have prioritised 7 findings for the LSCB to consider listed below: -   Finding Category 1 Are strategy discussions in Shropshire seen as a one-off events for social care and police to plan short-term responses rather than an ongoing process involving all agencies for planning and concluding a child protection investigation? Responses to incidents 2 In Shropshire, where a child is seen to be at risk of neglect, professionals find it harder to assess the degree of risk, regardless of the impact on the child, because they do not consider that the harm would have been deliberately caused by the parent. Longer term work 3 In Shropshire the records of telephone strategy discussions are separately recorded by Police and Children’s Social Care meaning that there is no joint record of the decisions reached leading to the possibility of misunderstanding about their content.   Human–tool operation 4 Is there a pattern whereby members of core groups don’t understand their responsibilities for ensuring the effectiveness of the child protection plan and delegate responsibility to the social worker? Longer term work 5 In Shropshire agencies are unclear about who to contact when there are urgent concerns on open cases and the allocated social worker is unavailable. Longer term work 6 In Shropshire re-organisations of services by individual agencies are not planned in a multi-agency way, which means that there may be unintended consequences that can lead to confusion amongst partner agencies, resulting in poor accountability and decision making, which ultimately does not safeguard children. Management systems 7 In cases of neglect is there a tendency to assess risk from the parent’s perspective and not to focus on the child’s experience, meaning that neglectful parenting is tolerated? Longer term work     16  4.4 Findings in detail 4.4.1 Finding 1:  Are ‘strategy discussions’ in Shropshire seen as a one-off events for social care and police to plan short-term responses rather than an ongoing process involving all agencies for planning and concluding a child protection investigation? (communication and collaboration in response to incidents)  Working Together 2015 states that the local authority Children’s Social Care Services should convene a ‘strategy discussion’ to determine the child’s welfare and plan rapid future action whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm. This might take the form of a multi-agency meeting or a telephone call. Working Together 2015 recommends that a local authority social worker and their manager, health professionals and a police representative should, as a minimum, be involved in the ‘strategy discussion’. This case has suggested that the tendency to use brief, telephone ‘strategy discussions’ is precluding involvement of all relevant professionals, as recommended in the guidance.  4.4.2 How did the issue feature in this particular case? During the assessment of Child A when she had the fractured clavicle there was not a ‘strategy discussion’ meeting that involved a local authority social worker and their manager, health professionals and a police representative. There was one brief telephone conversation between the social work manager and the police that resulted in the joint visit to mother but this was only recorded by the police as a ‘strategy discussion’. It is clear that if there had been a follow-up ‘strategy discussion’ meeting following the visit to mother this could have involved the paediatrician and would have enabled a discussion about whether the curtain pole could have caused the injury or not. Such a discussion would also have alerted the other members of the core group to the outcome of this investigation.   4.4.3 How do we know it is an underlying issue and not something unique to this case?   Discussion with the review team and case group identified that the most recent Ofsted inspection of Shropshire, in 2012, had identified that there were too few ‘strategy discussion’ meetings and that the use of telephone ‘strategy discussions’ was excluding health professionals. As a result there had been an increase in the proportion of ‘strategy discussion’ meetings as opposed to telephone ‘strategy discussions’. It was acknowledged however that generally ‘strategy discussions’ were initiated at the beginning of assessments/investigations and that it was less usual for there to be review meetings/discussions to confirm the outcomes. Clearly many ‘strategy discussions’ result in child protection conferences however there are a significant number where this does not happen. Prior to April 2014 there was no separate method for recording telephone ‘strategy discussions’ as opposed to ‘strategy discussion’ meetings in Children’s Social Care (CSC). In April 2014 a new form was introduced requiring that they be recorded separately. Analysis of CSC statistics concerning all ‘strategy discussions’ showed that of 891 ‘strategy discussions’, only 67 were reviewed or followed up with a further ‘strategy discussion’. Police recording of ‘strategy discussions’ (telephone and meetings) would indicate that there are more ‘strategy discussions’ in Shropshire than Telford and Wrekin and that this is placing pressure on their resources. As a result the Police Harm Assessment Unit was established to attempt to rationalise and possibly reduce the number of ‘strategy discussions’ being held.  4.4.4 How common and widespread is the pattern?  CSC quarterly statistics about ‘strategy discussions’ in Shropshire indicates that there are approximately 200-220 per quarter and that in the first two quarters there were twice as many ‘strategy discussion’ meetings as telephone ‘strategy discussions’. The second  17  two quarters however show that these proportions were changing and by the fourth quarter there were equal numbers of telephone ‘strategy discussion’s as ‘strategy discussion’ meetings. In part this may reflect a decision by the police to try and reduce the time spent by CPU officers in ‘strategy discussion’ meetings and is associated with the change in roles as introduced by the establishment of the HAU. It is relevant to note that of 891 ‘strategy discussions’ held under a quarter 181 resulted in a joint investigation by Police and CSC, 490 resulted in a single agency assessment by CSC and 220, over a quarter, resulted in no action by either agency.  CSC records of Strategy Discussions by Type and Quarter (2014/2015) Type Quarter 1 Quarter 2 Quarter 3 Quarter 4 Total 2014/15 Telephone Strategy Discussion 64 80 87 102 333 Strategy Discussion  Meeting 137 191 125 105 558 Total 201 271 212 207 891   Police statistics about ‘strategy discussions’ (telephone or meeting) are not available for this period. Discussion with frontline practitioners has indicated that the police may not have recorded all telephone ‘strategy discussions’ with social work staff as ‘strategy discussions’. This is because of a confusion within the police service about who makes a decision about when and whether a ‘strategy discussion’ should be held.   4.4.5 What are the implications for the reliability of the multi-agency child protection system? The lack of involvement of agencies other than police or CSC in ‘strategy discussions’ and in assessments may lead to a gap in understanding of what is known about the needs of a particular child. This is particularly problematic with very young children where often the only agencies to have had significant contact will have been Health. To be effective such information sharing has to be a two-way process so that all professionals fully understand each other’s concerns.   Research has shown that effective communication requires an openness to detail, a willingness to engage with referrers and an avoidance of hasty categorisation. The facts are rarely out there simply to be passed on; rather, a case formulation emerges through discussion and interaction.8 The ‘strategy discussion’ meeting is a key opportunity for joint working enabling better planning of the investigation and subsequent work with families. However, brief and/or telephone-based ‘strategy discussions’ may not provide the best environment to effective information processing and decision-making.                                                              8 Ten pitfalls and how to avoid them What research tells us Dr Karen Broadhurst, Professor Sue White, Dr Sheila Fish, Professor Eileen Munro, Kay Fletcher and Helen Lincoln September 2010 www.nspcc.org.uk/inform  18   Finding 1: Are ‘strategy discussions’ in Shropshire seen as a one-off events for social care and police to plan short-term responses rather than an ongoing process involving all agencies for planning and concluding a child protection investigation?   This review has identified a pattern whereby the use of telephone ‘strategy discussions’ between CSC and police to plan short term responses rather than longer term planning leads to an absence of multi-agency involvement in investigation and assessment. It raised the question whether the right balance had been achieved focusing on timely investigations and assessments with ensuring the right professionals are contributing effectively to improve the outcomes for children.   Considerations for the Board and partner agencies   Is the Board confident that there is a common understanding about the purpose and function of ‘strategy discussions’ across all agencies?  Does the Board think that resources are a limiting factor for ‘strategy discussion’ meetings?  Since the revisions made in Working Together (2013), can the Board be assured that there is an appropriate balance between the focus on timeliness of investigations and assessments with ensuring involvement and engagement with other agencies?  Are there technological solutions that can facilitate greater involvement of agencies in telephone ‘strategy discussions’ separate from face to face ‘strategy discussion’ meetings? Does the Board think the MASH will make a difference?  Does the Board think there is a need for further clarity about the role of review ‘strategy discussions’?    19  4.5.1 Finding 2:  In Shropshire, where a child is seen to be at risk of neglect, professionals find it harder to assess the degree of risk, regardless of the impact on the child, because they do not consider that the harm would have been deliberately caused by the parent. (Communication and collaboration in long term working.)  Neglect is a multi-faceted issue, which can include dimensions such as emotional, supervisory and medical neglect, as well as neglect of physical care (Horwath, 2007)9. Neglect is notoriously difficult to define as there are no clear, cross-cultural standards for desirable or minimally adequate child-rearing practices. While neglect generally refers to the absence of parental care and the chronic failure to meet children’s basic needs, defining those needs is not straightforward. Working Together 2015 defines neglect as: ‘the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development.’ It includes in the description ‘a parent or carer failing to provide adequate food, clothing and shelter’ and a failure to ‘ensure access to appropriate medical care or treatment’.10   4.5.2 How did the issue feature in this particular case? Child A was on a child protection plan for neglect and all the professional involved with the family saw this as the major child protection risk. In March 2014 the hospital contacted the allocated social worker because they were concerned about Child A who had been seen at the hospital with a fractured clavicle. The paediatrician did not think that the nature of the injury matched the explanation given by the mother and furthermore was concerned that she had failed to bring Child A to the hospital for an appointment arranged by her GP. The Social Work Manager did not commence a section 47 inquiry but sent two social workers to the hospital to gain further information about the injury. At the hospital the social workers were unable to clarify whether the injury was accidental or non-accidental but considered it to be a neglect issue and so were content for the children to go home. They thought that the injury was possibly accidental and there was probably a lack of supervision as it was not clear who was looking after the children at the time. They did not consider that mother posed a risk to the children and so made the decision that they could go home with mother. The medical staff were not clear if the injury was accidental or non-accidental, but were concerned at the lack of proper explanation, however, as there was no medical need for the child to be admitted to hospital, they also agreed to the child going home with mother.   4.5.3 How do we know it is an underlying issue and not something unique to this case?  During individual conversations with case group members a number of them reported that their immediate thinking was that any injury sustained was likely to be due to neglect or lack of supervision, as this was a family where a need for parenting support had been identified.  There was a firmly held belief amongst practitioners that mother would not harm her child.  Professionals did not seem to recognise at the time that the impact on the child was the same regardless of how the injury had occurred.  The child’s lived experience did not seem to be considered and the risk to the child from physical harm and neglect was minimised and downgraded. There were a number of occasions where the threshold for a Section 47 investigation was met but the response from Children’s Social Care was to gather more information before deciding if a strategy meeting/discussion was needed.  When social workers were sent to gather more information they were pre-disposed by the ‘label of neglect’ to                                                            9 Horwath, J (2007) Child Neglect: Identification and Assessment, Basingstoke, Hampshire: Palgrave Macmillan 10 Working Together 2013, DfE   20  assume that the injuries were accidental and this affected the outcome of the investigations. As this was the mind-set of a number of practitioners and not something that they recognised as being unique to this case it would suggest that it is an underlying pattern There was no evidence from any members of the case group that they had used the SSCB Neglect Strategy in this case.  There was a misunderstanding of the application of the strategy with a number of case group members thinking that it was only to be used to identify neglect in the first instance and that as neglect had already been identified in this case the practitioner toolkit was not viewed as something which could be applied to monitor concerns over time.  This would imply that practitioners are not making use of any specific tools to neglect assessment tools or recording their concerns over time in order to consider the history of the family and inform sound decision-making.  Therefore this pattern could well apply to all children who are already on a child protection plan for neglect. SSCB undertook a practitioner survey in early 2014 to understand how well the SSCB Neglect Strategy was being used, if it was fit for purpose and if it was helping professionals and families in achieving better outcomes for children and young people.  The showed the following:   57% of the 132 practitioners from a range of agencies that completed the survey reported that they had never used the strategy, with 34% of the respondents having only used it 1 to 5 times in the last 12 months.   20% of respondents identified barriers to using the strategy.  One of these being not having the confidence to challenge parents - however the majority of practitioners who had used the strategy felt that it had helped to increase their confidence generally in dealing with issues of neglect.   Only 22 of the 55 practitioners that had used the strategy made use of the Home & Circumstances Checklist tool.   Discussions with the case group also identified that at the time there was limited awareness of the SSCB Neglect Strategy and little understanding of its intended application to assist practitioners in working with neglectful parents over time  4.5.4 How common and widespread is the pattern? Neglect is the most common reason for someone to contact the NSPCC (NSPCC, 2012). Neglect has been described as the "most serious type of child maltreatment and the least understood" (Dubowitz, 1999 p.67). It is the most common reason for a child having a child protection plan in the UK. In the year ending 31 March 2011(or 31 July 2011 in Scotland), 44 per cent of child protection registrations in the UK related to children considered to be at risk of neglect. 11 In March 2014 the rate of children in Shropshire that were on a child protection plan under the category of neglect was 20.9 per 10,000 of the children and young people population, rising to 21.3 by the end of March 2015, (the latter figure equates to 128 children).National research has also highlighted the difficulties professionals face in ascertaining whether certain behaviours constitute neglect (Gardner, 200812; Rees et al. 201113). It is noteworthy that although neglect is a factor in determining many children to be either ‘vulnerable’ or ‘in need’ there is currently limited data collection about this matter. Recent summary research commissioned by the Department for Education identified seven mind-sets that could                                                            11 Neglect NSPCC research briefing August 2012  12 Gardner, R. (2008) Developing an effective response to neglect and emotional harm to children. London: NSPCC 13 Rees, G. et al. (2011) Adolescent neglect: research, policy and practice. London: Jessica Kingsley   21  hamper professional confidence and limit their actions, many of which the review team thought were evident in this case:     Fears about being considered judgemental,   A focus on the parent rather than the child,   Failure to consider the child’s lived experience or understand the child’s world,   A fixed view of the family,   Parents’ superficial or false compliance,  Not my area of expertise,   Reluctance to refer. 14  4.5.5 What are the implications for the reliability of the multi-agency child protection system?   For children to be effectively protected professionals need to be confident in their understanding of all aspects of neglectful parenting. Over-emphasis on one aspect of neglect will result in a failure to identify children at risk and could result in other risk factors not being fully understood.  In Shropshire, where a child is seen to be at risk of neglect, professionals find it harder to assess the degree of risk, regardless of the impact on the child, because they do not consider that the injury would have been deliberately caused by the parent.  This review has identified that professionals working with children where neglect has been identified as a risk factor are less likely to identify physical injuries as non-accidental because they explain the injuries as accidents resulting from poor oversight by the parent.    Considerations for the Board and partner agencies   Does the Board consider that the multi-agency neglect training and strategy has been effective?  Does the Board think the current Neglect Toolkit and Strategy are fit for purpose?  Does the Board think that training initiatives are an effective way of addressing professional mind-set?  Does the Board think that supervision arrangements are sufficiently robust in enabling the child’s experience to be understood?                                                                14 Missed opportunities: indicators of neglect – what is ignored, why, and what can be done? Research report https://www.gov.uk/government/publications/indicators-of-neglect-missed-opportunities   22   4.6.1 Finding 3:   In Shropshire the records of telephone strategy discussions are separately recorded by Police and Children’s Social Care meaning that there is no joint record of the decisions reached leading to the possibility of misunderstanding about their content. (Patterns in human–tool operation)   Working Together 2015 states that the local authority Children’s Social Care Services should convene a strategy discussion to determine the child’s welfare and plan rapid future action whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm. This might take the form of a multi-agency meeting or a telephone call. Where the strategy discussion is a meeting, Children’s Social Care Services minute the meeting and circulate the record to all attendees however where it is a telephone conversation each professional makes their own record which are not shared and which are not available to professionals not involved in the telephone conversation.  4.6.2 How did the issue feature in this particular case? In March when Child A suffered a fractured clavicle and maternal grandmother contacted Children’s Social Care (CSC) saying that mother’s explanation of the injury was inaccurate the Team Manager contacted the police to arrange a joint visit. This was not recorded on the CSC system as a strategy discussion but was recorded as such by the police. There was no record sent to any other agency so the health visitor, who was aware that Child A was in hospital, did not know that a joint police investigation had started.  4.6.3 How do we know it is an underlying issue and not something unique to this case?  Discussions with the case group identified a lack of consistency & clarity around who was responsible both within and across agencies for making key decisions, and how those decisions are recorded internally & between agencies.  The case group identified that following the Police restructure there was a lack of clarity felt around who decision makers in the Police were, and who was responsible for conducting Strategy discussions, once CSC made contact with the Police HAU.  Further investigation by the Review Team has shown that there has continued to be confusion in this respect with Police HAU staff believing they were responsible for conducting the telephone ‘strategy discussions’, rather than information sharing for the Detective Sergeants to then conduct the ‘strategy discussion’.  CSC have been under the impression that they were holding a ‘strategy discussion’ with HAU and have recorded these discussions as such. The fact that the record of the content of telephone ‘strategy discussions’ is not shared across agencies has allowed this misconception to continue until recent weeks.  4.6.4 How common and widespread is the pattern? According to CSC records, of the 891 ‘strategy discussions’ held in Shropshire in 2014/15 333, over a third, were telephone ‘strategy discussions’ where the recording was not shared. It is not known what proportion of these records would not tally or how significant the discrepancies are.  4.6.5 What are the implications for the reliability of the multi-agency child protection system?  Joint understanding of agreed actions are a fundamental tenet of joint investigations as outlined in Working Together 2015. If there is the potential for miscommunication of agreed actions this could place children at risk.   23   Finding 3: In Shropshire the records of telephone ‘strategy discussions’ are separately recorded by Police and Children’s Social Care meaning that there is no joint record of the decisions reached leading to the possibility of misunderstanding about their content.   This review has identified that the recording systems for telephone ‘strategy discussions’ do not allow for all agencies to know and understand the actions taken to protect children as part of section 47 investigations.  Considerations for the Board and partner agencies  Does the Board think the current recording arrangements for ‘strategy discussions’ are adequate?  Will the introduction of a MASH make a difference?  Do current procedures need changing/amending?     24  4.7.1 FINDING 4:  Is there a pattern whereby members of core groups don’t understand their responsibilities for ensuring the effectiveness of the child protection plan and delegate responsibility to the social worker? (Communication and collaboration in longer-term work)  Working Together to Safeguard Children 2015 states that a responsibility of core groups is to “implement the child protection plan and take joint responsibility for carrying out the agreed tasks, monitoring progress and outcomes, and refining the plan as needed.”  4.7.2 How did the issue manifest in this case? In May 2014 there was a review child protection conference with a different chair for the conference because the allocated chair was off sick. The police did not attend the meeting having not been invited; the GP did not attend or send a report.  The allocated social worker was absent so her manager and a duty social worker attended instead.  There was little mention in the conference about the investigation into the clavicle injury and there was no consideration whether the category for the child protection plan should change from neglect to physical harm.  In June 2014 an advanced practitioner social worker became the child’s social worker with a brief to hold the case temporarily until it was allocated elsewhere. During the three month period (April to June) there were three core groups and a review child protection conference and the allocated social worker was only present at one core group meeting. This lack of attendance lead to a lack of continuity in case planning. Despite the lack of clear direction from the key worker none of the other agencies involved challenged CSC about the inconsistencies or escalated concerns through other routes.  4.7.3 How do we know it is an underlying issue and not something unique to this case?  Discussion amongst the Case Group highlighted that core group members felt that the child protection plan provided a safety net as there was an allocated social worker, and that this reduced their levels of concern. Similarly both hospital staff and health staff at the GP practice assumed that because there was an allocated key worker and there was a child protection plan that the child would be safe. This assumption continued even when those workers agreed actions, such as allowing the child to return home with mother that contradicted their understanding of the risks to the child.  An SSCB Multi-agency Case Audit in September 2014 focussed on children subject to a second child protection plan within two years, which included cases of neglect, identified that:  Core groups could be strengthened as there was evidence that the meetings need to be more effective in monitoring the child protection plan.   Professionals should provide appropriate challenge in core groups and child protection conference to ensure that they are clear about next steps.  An SSCB SCIE pilot Learning Review that concluded in May 2014 identified that professionals with the Case Group had different understandings of the purpose of meetings and therefore the role that they should play in the meeting.  This resulted in a lack of effective multi-agency working to safeguard the young person. Evaluations of SSCB multi-agency training on Case Conferences and Core Groups demonstrate that the learning is effective.  Practitioners leave the course understanding their role in the process and feeling more confident to make contributions in the meetings.  When evaluating the transfer of learning in to practice one example given by a delegate suggests that this training is crucial for those professionals attending case  25  conference and core groups in order to understand the role that they play and to be able to actively contribute to the monitoring of the child protection plan. “I am currently supporting two clients through case conference and core group meetings. The training has provided me with the skills to be able to prepare and support my clients with what to expect at conference and core meetings. It has given me more knowledge and confidence when attending these meetings”  4.7.4 How common and widespread is this pattern?  The quality assurance of child protection conferences process identified that there has been a steady percentage of agencies that attended and contributed meaningfully to the core groups.  Year % All agencies attended and contributed meaningfully to the core groups 2012-2013 92% 2013-2014 93% 2014-2015 91%  The figures above give a general indication of how prevalent this issue may be, but only really inform us of a lack of contribution when agencies are not represented at core groups.  This performance indicator does not measure the quality of the contributions made in multi-agency working nor does it measure the impact of those contributions on monitoring the effectiveness of the child protection plan. The SSCB Multi-agency Case Audit in September 2014 that identified the need for core groups to be strengthened and for professionals to provide challenge was undertaken on five cases of children subject to a second child protection plan in two years.  These findings featured across all five of those cases. SSCB multi-agency training figures show that there has been a decrease in the number of professionals attending the Case Conference and Core Groups training, (52 delegates in 2013-2014 and only 19 delegates in 2014-2015).  This is due to courses being cancelled as they have not been promoted by agencies A national report which analysed over 800 serious case reviews from 2003-201115 where neglect was a feature found the following: ‘Undue professional optimism can mean the impact of medical neglect and the danger for the child is missed and thus no referral is ever made to children’s social care.  Health professionals sometimes appear to shield parents from children’s social care.’ and ‘There was drift and a lack of a sense of urgency among professionals, even when the risk of harm through poor supervision had been highlighted by a CP Plan in the category of neglect.’                                                             15 Neglect and serious case reviews: a report from the University of East Anglia commissioned by NSPCC, January 2013, Marian Brandon et al. http://www.nspcc.org.uk/globalassets/documents/research-reports/neglect-serious-case-reviews-summary.pdf   26  4.7.5 What are the implications for the reliability of the multi-agency child protection system?  A robust effective safeguarding system requires all professionals to take responsibility for child protection which means that they need to have the confidence to provide challenge to professional colleagues where there are concerns that children’s well-being are not being best met.  Finding 4: Is there a pattern whereby members of core groups don’t understand their responsibilities for ensuring the effectiveness of the child protection plan and delegate responsibility to the social worker? This review has highlighted that when there was sub-optimal leadership from the allocated key worker professionals within the core group did not question this practice or raise concerns within their own service system. Throughout the case history there were assumptions made by professionals that the child protection plan would safeguard the child even when the actions of the involved social workers did not support that premise. QUESTIONS FOR THE BOARD TO CONSIDER  Does the Board recognise this issue?  Does the Board think that the current data collection about core groups is effective?  Does the Board know whether the right professionals have received core group training?  Are there are other barriers to effective multi-agency working within core groups?       27  4.8.1 Finding 5:  In Shropshire agencies are unclear about who to contact when there are urgent concerns on open cases and the allocated social worker is unavailable. (Communication and collaboration in long term working.) When professionals have concerns about a child their responsibility is to raise those concerns with Children’s Social Care by making a referral. If those concerns are about a child who has a known allocated social worker they would pass the concerns directly to that worker. If the worker and their manager are unavailable these concerns can be raised with a duty worker either from the team or from the team responsible for receiving referrals, which in Shropshire is ICT.  4.8.2 How did the issue feature in this particular case? When the school identified the burn injury on Child A and were unhappy with mother’s response they immediately tried to contact the allocated social worker but she was unavailable and her line manager was on leave. They did not consider that they should pass the information on to the Initial Contact Team (ICT) as they felt this was for new referrals’ They decided instead to pass the information to the allocated social worker via email. This meant that there was no guarantee that the allocated social worker would access the information in a timely way and it is thought that the email was not read until late in the following day.  4.8.3 How do we know it is an underlying issue and not something unique to this case?  The West Mercia Consortium Child Protection procedures16 direct agencies to report concerns to the relevant social worker or their manager and in their absence to the duty worker from that team. Discussion with the review team and case group showed that there was a lack of knowledge of the procedures and some concern that administrative staff may be protective of duty workers and not advise other agencies where to address their concerns when the allocated social worker was unavailable. The case group also confirmed that the guidance and flow-chart provided to agencies regarding the use of the ICT service did not include any detail about how agencies should act where there were concerns about children who had an allocated social worker who was unavailable.   4.8.4 How common and widespread is the pattern? Potentially this is a relevant issue for all children who are open to Children’s Social Care and have a social worker. In May 2015 there were 313 Looked After Children and 250 children with child protection plans about whom there could be concerns raised by professionals that need an urgent response. A Review Team member involved in a recent internal file audit (not related to this review) identified one case file where child protection concerns has been e-mailed to a case manager and recorded on the file under observations. It is not clear whether there was any delay in the key worker receiving and acting on those concerns in that case.   4.8.5 What are the implications for the reliability of the multi-agency child protection system?  In order to safeguard children it is necessary that there are clear communication systems in place that accommodate the absence of key workers. These arrangements need to be trusted and accessible to all agencies otherwise it is possible that information will not be shared and children will not be protected effectively.                                                              16 www.westmerciaconsortium.proceduresonline.com/   28    Finding 5: In Shropshire agencies are unclear about who to contact when there are urgent concerns on open cases and the allocated social worker is unavailable.  This case has highlighted confusion about reporting arrangements for agencies when there are concerns about children with an allocated social worker who is unavailable particularly when their manager is also absent.   Considerations for the Board and partner agencies  Does the Board have a view about how this issue should be resolved?  Are the current arrangements with duty workers in individual teams the most effective way of covering this work?  Does the Board have a view as to why agencies are unaware of the local procedure?  Is the current procedure easily understood by professionals from external agencies?  Would it be more appropriate for the ICT to cover this work?  Does the Board know if the ICT is sufficiently resourced to undertake this work?      29  4.9.1 Finding 6:  In Shropshire re-organisations of services by individual agencies are not planned in a multi-agency way, which means that there may be unintended consequences that can lead to confusion amongst partner agencies, resulting in poor accountability and decision making, which ultimately does not safeguard children. (Patterns in human-management systems operation) Within Shropshire between April and July 2014 there were two major re-organisations of services intended to improve outcomes for children and to ensure best use of limited resources. Children’s Services were restructured into a different configuration in order to reduce the number of social workers a child would have through their journey within the service. The Police created Harm Assessment Units (HAUs) with the intention of streamlining services by providing a single 'gateway' into policing services. There was also a re-organisation of Women’s and Children’s Hospital Services that led to a reduction of in-patient beds and overall resources.  4.9.2 How did the issue feature in this particular case? In April 2014 there was a major restructure within Children’s Social Care which meant that many social workers and managers were moved into different teams. When the temporary social worker, who had case responsibility for Child A, left in May 2014 it was not possible to permanently re-allocate case responsibility and so the case was allocated temporarily to a social worker who already had a high case load. This meant she was unable to prioritise attending meetings associated with this child and although there was always social work representation at the meetings there was a lack of continuity and some drift. During the six month period of the review Child A had three allocated key workers which did not provide good continuity of care. It is noteworthy that in the six months following the end of the review period there has been one allocated worker who has been able to provide focussed care planning and has achieved good permanence outcomes for Child A and the sibling.   4.9.3 How do we know it is an underlying issue and not something unique to this case?  The case group members reported that the major restructure within Children’s Social Care meant that many social workers and managers were moved into different teams and all staff involved in this case were anxious about their personal position. Following these changes there was a period when individual workers were holding high caseloads and there was increasing turnover of staff. This resulted in some cases being held temporarily by workers whilst the problems were resolved.  At the same time as the CSC restructure the Police restructure their service and created the HAU intending to streamline the way that police received referrals and optimising the use of their professionally qualified police officers. The case group identified that following the Police restructure there was a lack of clarity felt around who decision makers were, and which staff were responsible for conducting Strategy discussions, once CSC made contact with the Police HAU. Further investigation by the Review Team has shown that there has continued to be confusion in this respect.  It is also noteworthy that the CSC restructure of teams was driven by the need to reduce the number of social workers a child would have through their journey with the service. Despite this the case group reported that high workloads, absence of line managers & seasonal increases in reporting continued to cause issues in this case and in general over the July 2014 period, thereby preventing the key social worker to have the degree of involvement required.  30  The SSCB Annual report 2013/14 summarises in point 8.7 ‘At an organisational level, there have again been considerable changes and developments, driven by a combination of national requirements (in the case of the NHS and Probation, for example) and local responses to financial constraints (e.g., Shropshire Council, West Mercia Police), which brings risk in relation to service quality and consistency and also has an impact on the LSCB itself. Partners have worked hard to maintain continuity despite all this, and have usually ensured that the LSCB has been kept well informed of developments.’  4.9.4 How common and widespread is the pattern? National research on neglect has identified that a factor that can lead to poor outcomes for children when there is ‘ … a systemic problem when drift and confusion is prompted by overwhelming workloads, high staff turnover and high vacancy rates alongside numerous unallocated cases’17. During Autumn 2013 five serious case reviews (SCRs) were published which attracted considerable media attention, Daniel Pelka (Coventry), Keanu Williams (Birmingham), Child T (Haringey), Child D (Portsmouth) and Maisie Harrison (Northamptonshire)’. While each case has unique features the accounts given by the SCRs have much in common with each other and with the conclusions of research by Marion Brandon et al who says that ‘In nearly all cases there was evidence of resource and organisational, capacity and capability problems in key social care, police and NHS agencies’. In her conclusions Marion Brandon states:  ‘It was notable that resource issues were rarely mentioned in any of these reviews. This seems surprising in a time of austerity and widespread cuts in welfare budgets. It is possible that both the professionals involved and those conducting the serious case review are blind to the impact of resource, staffing and finance on working practices, that they accept this as the status quo and an issue that cannot be changed, or that, in the absence of a direct link with the outcomes, they do not make a connection between the two’.18  4.9.5 What are the implications for the reliability of the multi-agency child protection system?  It is generally accepted that at times of restructures of services children and young people are at greatest risk because professionals may be distracted by the change process and the changes themselves may have unknown consequences that affect service delivery to children. An effective safeguarding system will ensure that there is the opportunity for the fullest discussions between agencies about the proposed changes in order to minimise the risks posed by the changes.                                                              17 Neglect and serious case reviews: a report from the University of East Anglia commissioned by NSPCC, January 2013, Marian Brandon et al. http://www.nspcc.org.uk/globalassets/documents/research-reports/neglect-serious-case-reviews-summary.pdf 18 New learning from serious case reviews: a two year report for 2009-2011. Brandon et al Research Report DFE-RR226.  31   Finding 6:  In Shropshire re-organisations of services by individual agencies are not planned in a multi-agency way, which means that there may be unintended consequences that can lead to confusion amongst partner agencies, resulting in poor accountability and decision making, which ultimately does not safeguard children.  Considerations for the Board and partner agencies  Is the Board aware of this issue?  Is the Board assured that there is sufficient focus on safeguarding children when planning re-organisations  Does the Board think there should be more multi-agency consultation prior to re-organisations?  Is the Board fulfilling its functions ‘to coordinate local safeguarding work and ensure the effectiveness of local activity to keep children safe’ with regards to re-organisations of services?    32  4.10.1 Finding 7:   In cases of neglect is there a tendency to assess risk from the parent’s perspective and not to focus on the child’s experience, meaning that neglectful parenting is tolerated? (Communication and collaboration in long term working.)  Working Together 2015 emphasises the importance of child-centred safeguarding systems, and the risks posed to practice when professionals lose sight of the needs and views of children, or place the interests of adults ahead of the needs of the children.19 This case highlighted a tendency for professionals to assess the seriousness of the situation in terms of the intentions and motivations of the parent, rather than the impact on the child.  4.10.2 How did the issue feature in this particular case? Repeatedly throughout the brief history of agency involvement professionals considered that the injuries experienced by Child A could not have been done deliberately by the mother who was seen as a loving parents who was experiencing difficulties because of her recent bereavement and difficult childhood.   As Child A had very poor speech it was difficult for professionals to get the child’s views and few professionals spent enough time with Child A to develop the trust and engagement that was required to understand her world. This was compounded by the tendency by professionals to focus on mother’s motivation, which meant that insufficient attention was paid to the child’s experience.   Professionals were asked about this during the review, and their replies suggested that they saw the mother as loving and caring. In other words, it seemed that practitioners based their judgement of ‘safeguarding’ from the perspective of the parent. Because practitioners felt that the mother’s inability to care for her child was unintentional, and based on her poor mental health, this did not constitute a safeguarding concern. This led to a view that the mother was doing her best in the face of adversity and should be supported and encouraged, not penalised.  4.10.3 How do we know it is an underlying issue and not something unique to this case?   Discussions with the Review Team and Case Group identified that mother’s situation did lead to professionals over-empathising with her resulting in a lack of focus on the risk to Child A. They also confirmed that this was not uncommon when working with parents with personal problems who are also neglectful parents. Such adults often have their own difficulties and genuinely want to be good parents which makes it hard for professionals to be critical when this is not achieved because of the parent’s personal problems.    Research into neglect would support this approach with the emphasis being placed on the responsibility for the act of omission and the intention behind it. Some researchers argue for the importance of distinguishing deliberate harm, which is defined as abuse, from instances of harm that occur as a result of carer ignorance or competing carer priorities, which they define as neglect. Others consider carer or parental acts to be neglectful irrespective of the reason why they occurred and warn against a pre-occupation with determining carer intention as it may over-shadow concern about the impact on the child and also hinder working with parents.  4.10.4 How common and widespread is the pattern? The ‘rule of optimism’ that can affect assessment and decision-making in child protection work was first identified by Dingwall Ekeelaar and Murray (1983) who identified that the key concern was that child protection professionals would wish to ‘see                                                            19 Working Together 2015 p9  33  the best’ in people, and have hope and optimism that their interventions can help the safety and well-being of the child. They identified however that these attitudes could, however, also leave children at risk of being abused and neglected. (Laming, 2009; Marshall, 2011).20 Similarly research by Marion Brandon et al identified that empathy and established relationship skills were necessary when working with resistant families but that they need to be balanced with an eyes-wide-open, boundaried, authoritative approach aimed at containing anxiety and ensuring that the child’s needs stayed in sharp focus. They identified that the complexities of the adults’ problems often eclipsed children’s immediate needs. All practitioners need to be ever vigilant to children’s needs for protection in the short and long term.21  4.10.5 What are the implications for the reliability of the multi-agency child protection system? A safe multi-agency child protection system is one where professionals are able to assess and evaluate risk from the perspective of the child and are not unduly influenced by sympathy for adults’ experiences. The focus of professional intervention needs to be on the child’s experience regardless of the causal factors Finding 7:  A tendency to assess risk from the parent’s perspective, and not to focus on the child’s experience, means that neglectful parenting is not viewed seriously. (Communication and collaboration in long term working.) This review has shown that professionals may fail to acknowledge the effect of neglectful parenting on children because they judge risk from the perspective of the intention and motivations of the parent, rather than the experience of the child.  Considerations for the Board and partner agencies  What does the Board know about what enables professionals to be able to assess risk from the point of view of the child?  How can the Board ensure that multi-agency risk assessment of neglect is sufficiently robust?  What does the Board know about multi-agency consideration of neglect factors and how professionals work together with neglectful families?                                                                20 https://swscmedia.wordpress.com/2012/05/23/%E2%80%A8avoiding-avoidance-recognising-and-responding-to-the-risks-of-resistant-and-uncooperative-parents-in-child-protection-swscmedia-debate/  21 http://www.ncb.org.uk/media/60156/safeguarding_knowledge_review.pdf   34  6 Conclusion 6.1 At the start of the review it was agreed that the focus would be on understanding how well agencies worked together when children were the subject of a child protection plan. There was also a desire to understand how effective professionals were at working together to investigate injuries to children. Finally the LSCB was interested to know if the SSCB Neglect Strategy was embedded in professional practice and was being used by frontline practitioners. 6.2 The review has shown that there were a number of areas of individual good practice at the front line: the health visitor input was exemplary, and there was evidence of good joint investigative working in the joint visit by police and social worker to investigate the clavicle injury: and effective partnership working, as witnessed by the response by the hospital and police when mother failed to take Child A to hospital after the clavicle injury. 6.3 The review has also identified some significant issues regarding the functioning of ‘strategy discussions’. In particular the creation of the HAU has led to confusion within the Police Service as to who is responsible for convening and recording these processes which impacts on other agencies. This matter has been able to continue because of the absence of a joint record between agencies where the ‘strategy discussions’ are by telephone. This poses a risk that there is a lack of joint understanding of agreed actions. There are also concerns about whether all agencies are appropriately involved in strategy discussions and whether the discussions focus too heavily on immediate issues and fail to consider longer term goals and outcomes. 6.4 Conversations with Case group members confirmed that the SSCB Neglect Strategy is generally viewed as an assessment tool and front line practitioners are not sufficiently aware that it can be used to work with families where neglect is an identified problem. The difficulties that professionals have in maintaining focus on the child’s experience when working with a neglectful parent was also evident. 6.5 There is a lack of clarity amongst agencies about who to contact when allocated social workers are unavailable and a concern that whilst core groups are meeting their effectiveness is less obviously visible. Finally the review highlighted the risks associated with significant changes in structure and organisation of services and queried whether there was sufficient inter-agency planning and scrutiny of these changes prior to their introduction.        35  Appendix 1 – Methodology 1.  This SCR has used an approach based on the SCIE Learning Together model for case reviews. This is a ‘systems’ approach which provides a theory and method for understanding why good and poor practice occur, in order to identify effective supports and solutions that go beyond a single case. Initially used as a method for conducting accident investigations in other high risk areas of work, such as aviation, it was taken up in Health agencies, and from 2006, was developed for use in case reviews of multi-agency safeguarding and CP work (Munro, 2005; Fish et al, 2009).  National guidance in the 2013 revision of Working Together to Safeguard Children (2013) now requires all SCRs to adopt a systems methodology.  2 The model is distinctive in its approach to understanding professional practice in context; it does this by identifying the factors in the system that influence the nature and quality of work with families. Solutions then focus on redesigning the system to minimise adverse contributory factors, and to make it easier for professionals to practice safely and effectively.  3 Learning Together is a multi-agency model, which enables the safeguarding work of all agencies to be reviewed and analysed in a partnership context. Thus, many of the findings relate to multi-agency working. However, some systems findings can and do emerge which relate to an individual agency. Where this is the case, the finding makes that explicit.  4 The basic principles – the ‘methodological heart’ – of the Learning Together model are described in summary form below: a. Avoid hindsight bias – understand what it was like for workers and managers who were working with the family at the time (the ‘view from the tunnel’). What was influencing and guiding their work? b. Provide adequate explanations – appraise and explain decisions, actions, in-actions in professional handling of the case. See performance as the result of interactions between the context and what the individual brings to it c. Move from individual instance to the general significance – provide a ‘window on the system’ that illuminates what bolsters and what hinders the reliability of the multi-agency Child Protection system. d. Produce findings and questions for the Board to consider. Pre-set recommendations may be suitable for problems for which the solutions are known, but are less helpful for puzzles that present more difficult conundrums. e. Analytical rigour: use of qualitative research techniques to underpin rigour and reliability. 5  Typology of underlying patterns 5.1  To identify the findings, the Review Team has used the SCIE typology of underlying patterns of interaction in the way that local child protection systems are functioning.  Do they support good quality work or make it less likely that individual professionals and their agencies can work together effectively?  They are presented in six broad categories of underlying issues: 1. Multi-agency working in response to incidents and crises 2. Multi-agency working in longer term work 3. Human reasoning: cognitive and emotional biases 4. Family – Professional interaction 5. Tools 6. Management systems   36   Each finding is listed under the appropriate category, although some could potentially fit under more than one category.  6 Anatomy of a finding For each finding, the report is structured to present a clear account of: -   How the issue manifests itself in the particular case  In what way it is an underlying issue – not a quirk of the particular individuals involved this time and in the particular constellation of the case?  What information is there about how widespread a problem this is perceived to be locally, or data about its prevalence nationally?  How the issue is usefully framed for the LSCB to consider relative to their aims and responsibilities, the risk and reliability of multi-agency systems. This is illustrated in the Anatomy of a Learning Together Finding (below).    7   Review Team and Case Group 7.1 The review team comprises senior managers from the agencies involved in the case, who have had no direct part in the conduct of the case. Led by two independent lead reviewers, they act as a panel working together throughout the review, gathering and analysing data, and reaching conclusions about general patterns and findings.  They are also a source of data about the services they represent: their strategic policies, procedures, standards, and the organisational context relating to particular issues or circumstances such as resource constraints and changes in structure. The review team members also have responsibility for supporting and enabling members of their agency to take part in the case review.  37    Review Team Members Fiona Johnson, Independent Lead reviewer Claire Porter, Shropshire Council Lisa Charles, Shropshire LSCB Steve Ladd, Local Authority Social Care,   Helen Kinrade, West Mercia Police, Dr Ganesh, Designated Doctor, Julie Harris, Named Nurse Safeguarding Children, SCHT Sarah Wilkins, Children Centre’s, Local Authority Social Care 7.2  The Case Group are the professionals who were directly involved with the family. The Learning Together model offers a high level of inclusion and collaboration with these workers/managers, who are asked to describe their ‘view from the tunnel’ – about their work with the family at the time and what was affecting this. In this case review, the Review Team carried out individual conversations with 19 case group professionals, and up to 25 professionals were invited to attend the case group meetings which discussed the practice in this case and agreed the findings.  7.3  Structure of the review process   A Learning Together case review reflects the fact that this is an iterative process of information-gathering, analysis, checking and re-checking, to ensure that the accumulating evidence and interpretation of data are correct and reasonable.   The review team form the ‘engine’ of the process, working in collaboration with case group members who are involved singly in conversations, and then in multi-agency ‘Follow-on’ meetings. The sequence of events in this review is shown below:   Date Event 6th February 2015 Introductory meeting for the Review Team 6th February 2015 Introductory meeting for the Case Group – to explain the Learning Together model/method, and the case review process which they will be part of.     9th to 10th February   2015 30th & 31st March  Four days’ conversations with members of the Case Group – these were all initially set up for February but some had to be delayed till the end of March because of possible criminal charges. (individual sessions of about 1.5 hours with each member of the Case Group; normally conducted by two members of the Review Team) 8th April 2015   First Review Team analysis meeting 24th April 2015   Second Review Team analysis meeting  38  12th May 2015 First Follow-on meeting (Review Team and Case Group)  In this meeting, the group works together on  identifying Key Practice Episodes (KPEs) in the case which affected how the case was handled and/or the outcome of the case  appraising the practice in these KPEs  considering what was affecting the work/workers at the time (the ‘view from the tunnel’) 13th May 2015 Third Review Team analysis meeting 1st June 2015 Fourth Review Team analysis meeting 2nd June 2015 Second Follow-on meeting (Review Team and Case Group) At this meeting, the group were provided with a draft report which sets out the emerging underlying patterns and findings, and were asked to consider whether these are specific to this individual case or pertain more widely and form a pattern. 29th June 2015 Fifth Review Team meeting  – to consider the draft final report 10th July 2015 Learning & Improvement Sub-Group meeting – to consider the draft final report 14th July 2015 LSCB Executive meeting – to consider the draft final report 17th September 2015 LSCB Meeting to endorse the final report and action  plan 12th November  2015 Final report, fit for publication, to be submitted to Department for Education (DfE)  7.4  Scope and terms of reference  Taking a systems approach encourages reviewers to begin with an open enquiry rather  than a pre-determined set of questions from terms of reference, such as in a traditional  SCR. This enables the data to lead to the key issues to be explored. 7.5  Sources of data 7.5.1  Data from practitioners  Conversations, as described above, with members of the Case Group; these were recorded and discussed by the whole Review Team.  Members of the Case Group have also helpfully responded to follow-up queries and requests from the Lead Reviewers and the Review Team for clarification or further information, where this has been needed.  7.5.2  View from the Tunnel and Contributory Factors The data from the conversations with the Case Group translates into their ‘view from the tunnel’ which enabled us as reviewers to capture the optimum learning from the case. Case Group members are also an invaluable source of information about the why questions – an exploration of the Contributory Factors which were affecting their practice and decisions at the time.  7.5.3   Participation The Lead Reviewers and the Review Team are grateful for the willingness of the professionals to reflect on their own work, and to engage so openly and thoughtfully in  39  this SCR.  Everyone has contributed very fully in the process. Individual practitioners all have participated responsively in conversations, which have recalled their role in this story, and in group discussions which have at times been very difficult and challenging. All this has given the Review Team a deeper and richer understanding of what happened with this family and within the safeguarding network, and has allowed us to capture the learning which is presented in this report. 7.5.4  Data from documentation The Lead Reviewers and members of the Review Team reviewed the following documentation: CSC records, Police records, Hospital records, GP records, Health Visiting records, Child Protection conference Minutes, Core group records, Strategy Discussion records.  7.5.5  Data from family, friends and community   As in traditional SCRs, the Learning Together model aims to include the views and perspectives of family members as a valuable element in understanding the case and the work of agencies.       40  Appendix 2 GLOSSARY OF TERMS AND ABBREVIATIONS  CAIU Child Abuse Investigation Unit (Police)  CSC Children’s Social Care  EDT Emergency Duty Team providing emergency out of hours social work service to Shropshire  HAU Police Harm Assessment Unit the staff who respond to all initial contacts regarding child protection within the police  ICT Initial Contact Team the team who respond to all initial contacts with Children’s Social Care  GP General Practitioner   LSCB Local Safeguarding Children Board MASH Multi-Agency Safeguarding Hub S.47 enquiry / Section 47 enquiry /child protection enquiry S.47 enquiry refers to section 47 of the Children Act 1989 which gives local authorities the duty to ‘make, or cause to be made, such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare’ when they have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm Strategy Discussion Whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm there should be a strategy discussion involving local authority children’s social care (including the fostering service, if the child is looked after), the police, health and other bodies such as the referring agency. This might take the form of a multi-agency meeting or phone calls and more than one discussion may be necessary. A strategy discussion can take place following a referral or at any other time, including during the assessment process SCR Serious case review SSCB Shropshire Safeguarding Children Board TM Team manager          41  Appendix 3 Bibliography Marian Brandon et al. Neglect and serious case reviews: a report from the University of East Anglia commissioned by NSPCC, January 2013 http://www.nspcc.org.uk/globalassets/documents/research-reports/neglect-serious-case-reviews-summary.pdf  Brandon, M. Glaser, D. Maguire, S. McCrory, E. Lushey, C. & Ward, H. – Childhood Wellbeing Research Centre. (2014) Missed opportunities: indicators of neglect – what is ignored, why, and what can be done? Research report Department for Education: London https://www.gov.uk/government/publications/indicators-of-neglect-missed-opportunities   Marion Brandon et al. New learning from serious case reviews: a two year report for 2009-2011. Brandon et al Research Report DFE-RR226  Dr Karen Broadhurst, Professor Sue White, Dr Sheila Fish, Professor Eileen Munro, Kay Fletcher and Helen Lincoln, Ten pitfalls and how to avoid them - What research tells us, September 2010. www.nspcc.org.uk/inform   Fish, S., Munro, E., Bairstow, S., SCIE Guide 24: Learning together to safeguard children: developing a multi-agency systems approach for case reviews, Social Care Institute for Excellence (SCIE), 2009  Gardner, R. (2008) Developing an effective response to neglect and emotional harm to children. London: NSPCC  HM Government, Children Act 1989,  HM Government, Working Together (2015) https://www.gov.uk/government/publications/working-together-to-safeguard-children--2   Horwath, J (2007) Child Neglect: Identification and Assessment, Basingstoke, Hampshire: Palgrave Macmillan  Munro, Prof. E., ‘A systems approach to investigation child abuse deaths’, British Journal of Social Work, 35 (4), pp. 531-546, 2005 (also LSE Research Online)  Neglect, NSPCC research briefing August 2012  Rees, G. et al. (2011) Adolescent neglect: research, policy and practice. London: Jessica Kingsley  Vincent, C, A, (2004) Analysis of clinical incidents: a window on the system not a search for root causes Downloaded from http://qualitysafety.bmj.com/  on July 3, 2015 - Published by group.bmj.com   