Accidental death of a 7-year-old boy in July 2015. Child R was found deceased in a pipe on a building site following a police search. He had been at a friend's house in the afternoon and had not returned home. He became subject to a child protection plan in March 2015 under the category of neglect. During Child R's early life there were instances of domestic abuse and substance misuse which impacted his mother's parenting capacity. In June 2015, Child R's behaviour was becoming more challenging; he was reported missing on several occasions from home; and care proceedings were being considered if required changes as set out in the child protection plan were not achieved. Ethnicity or nationality of Child R is not stated. Findings: unrealistic expectation by agencies for mother to address her substance misuse in a self-motivated manner; Child R not referred for specialist assessment or counselling as a result of the domestic abuse situation between his mother and father; at age six and a half, Child R was found to have considerable attachment and emotional issues but appears not to have benefited from psychological assessment or professional therapy. Recommendations: to review, with South Yorkshire Police, the current design of the child protection incident form to ensure it captures essential data to discharge appropriate safeguarding responsibilities to a child; to ensure that children's social care explores the need for specialist input into child protection conference proceedings, where the specialist is not currently engaged with the family and, therefore, not automatically invited.
      
 Title:  Child R: serious case review – summary report. LSCB: Barnsley Safeguarding Children Board Author: Barnsley Safeguarding Children Board Date of publication: 2018  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.                                          Child R  Serious case review – Summary report  February 2018 2   Contents Contents .................................................................................................................... 2 1 Introduction ....................................................................................................... 3 2 Terms of reference ............................................................................................ 4 3 An overview of the life of Child R .................................................................... 5 4 Constructive analysis of efforts made by agencies to safeguard Child R . 11 5 Summary of key learning points arising from this review ........................... 13 6 What improvement actions have agencies already taken? ......................... 14 6.1 Parental capacity and capability (Children’s Social Care) ......................................... 14 6.2 NHS Barnsley Clinical Commissioning Group ........................................................... 14 6.3 Public Protection Unit ............................................................................................... 15 6.4 Bank End Primary School ......................................................................................... 15 6.5 Barnsley Children’s Services .................................................................................... 16 6.6 Phoenix Futures ....................................................................................................... 17 7 Conclusions..................................................................................................... 18 8 Learning and improvement opportunities .................................................... 20 8.1 Learning and improvement opportunity 1 .................................................................. 20 8.2 The incident of 9 March 2015 – learning and improvement opportunity 2 ................. 20 8.3 Substance misuse – learning opportunity 3 .............................................................. 21 8.4 Substance misuse – learning opportunity 4 .............................................................. 21 8.5 Raising professional concerns – learning and improvement opportunity 5 ................ 22 8.6 Response to domestic abuse incidents rated medium to high – learning and improvement opportunity 6 ............................................................................................. 22 9 Appendix 1 ....................................................................................................... 24 9.1 The process of the serious case review .................................................................... 24 9.2 First Panel meeting ................................................................................................... 24 9.3 Second panel meeting .............................................................................................. 24 9.4 Third panel meeting .................................................................................................. 25 9.5 The frontline professionals’ day ................................................................................ 25  3  1 Introduction On the evening of 26 July 2015, a seven-year-old boy – Child R – was reported as missing to South Yorkshire Police by his mother, when he had not returned home, after the agreed time. It appears that, on this day, Child R had been to play at a friend’s house on the estate in which he lived. Both boys, it is believed, had returned to Child R’s home at some point in the afternoon to collect his Xbox. Child R left his friend later that afternoon and did not return home.  On 27 July 2015, following a police search, Child R was found deceased in a pipe, on a building site he is known to have frequented. It is not known how he came to be in the pipe; he may have fallen into it, or he may have hidden in it when people were looking for him. After the death of Child R, a parental support adviser was visiting Child R’s friend and his mother, and reported that Child R’s friend stated that Child R would have hidden if he had been aware that the police were looking for him. The friend felt that Child R would not have wanted the police to find him because he did not like them.  The precise sequencing of events during the night of 26 July, through to the time Child R was discovered on 27 July, is unknown. However, the circumstances of Child R’s death were tragic, and it is important that the antecedent period to it is understood as far as it is possible to achieve.  At the time this occurred, Child R was the subject of a child protection plan. Consequently, there was a requirement to look at the antecedent chronology leading up to his death, to determine whether the case management around the safety concerns for Child R was reasonable, and whether there was reasonable scope, at the time, for involved agencies to have acted to have prevented the accident that happened.   It was decided by the Independent Chair of the Barnsley Safeguarding Children Board, with unanimous agreement from the members of the Serious Case Review Panel meeting, that the case met the criteria for a Serious Case Review. The independent author of this report was commissioned to conduct that review.  This report sets out the considerations of the serious case review panel, and the independent author, in respect of the above. 4  2 Terms of reference The initial brief for the serious case review was to answer the following questions. • Were the agencies involved with the child and family fully meeting the needs of the family? • Were policies, procedures, and practice expectations of the agencies followed? • Were appropriate plans in place to safeguard the child, and were opportunities to safeguard the child missed? • How can services develop to ensure that similar incidents do not occur in the future?  However, following a detailed review of Child R’s entire chronology in relation to all involved agencies, except his initial primary school, it became clear that, although there were practice issues emerging from Child R’s pre-birth chronology and the chronology between his birth and 9 March 2015, practice across a number of the involved agencies has already changed significantly between 2008 and 2016; therefore, a detailed review of the historical contact with Child R, and his family, was unlikely to deliver new learning and improvement opportunities for the agencies involved.    The most significant period of Child R’s life, and the period when there may have been the opportunity for a different outcome for Child R, was between 2014 and 2015; the critical period being March 2015 to July 2015.  As a consequence, the independent author proposed focusing attention on the last 12 months of Child R’s life, in particular, on the period in March 2015 when Child R’s case became the subject of a child protection conference. The intent was to examine whether the agencies acted in the best interests of Child R, and made reasonable decisions to monitor and protect his safety.  This proposal was accepted by the chair of the serious case review panel and all panel members, as it delivered reasonable proportionality, and focused the review on maximising the learning and improvement benefit that could be achieved.  The methodology for conducting the Serious Case Review is attached at Appendix 1 5  3 An overview of the life of Child R This section of the report sets out a concise overview of Child R’s life, from the time of his birth, to his death in 2015, insofar as the panel and independent author have been able to compile it from a review of involved agency records.  During mum’s pregnancy and Child R’s early life, there were instances of domestic violence and substance misuse, which impacted at various times, and in varying degrees, with mum’s capacity to parent Child R.    2012 – 2015 Child R started school in 2012 and, during the next twelve to eighteen months, there are indications that there was an escalation in the number of domestic violence incidents (resulting in a letter from Children’s Social Care in November 2012 explaining the negative impact on children who witness domestic abuse) between Child R’s mother and father, which, whilst not recorded as having caused any resulting physical harm to Child R, must have impacted on Child R’s mother’s parenting capacity.  In 2014, it became clear that, whilst Child R presented as having a good attachment with his mum when they were both met by Children’s Social Care in February, generally, this period marked a significant deterioration in Child R’s behaviour, in his school attendance, and an escalation in concerns for his emotional, physical, and psychological safety.  During the spring of 2014, Child R’s second primary school was sufficiently concerned with his behaviour that they decided to conduct a Boxall Profile assessment, which seeks to identify likely causes for challenging behaviour. The results of the Boxall Profile assessment led the primary school to seek support from Education Psychology; in hindsight Child R’s psychological needs might have been more complex than could be resolved simply by Education Psychology interventions.  Through the summer of 2014, Child R’s behaviour continued to present as extremely challenging, with his mother finding it more difficult to manage, culminating, on one occasion, with his maternal grandmother presenting with Child R at the local police station, asking for help, insinuating that nobody else was doing anything.  2015 – Child R seven years old Although 2014 may have provided a small number of opportunities for a more robust, proactive response to signs that Child R was displaying ‘unmanageable’ behaviour at home and at school, 2015 represented the critical antecedent period leading to his tragic death; it is the year in which Child R became the subject of a child protection conference and a child protection plan. His case was one where professionals were on the cusp of needing to make the decision to remove him from his mother; he was termed as ‘on the edge of care’.  5 February 2015  Child R’s school highlighted a range of concerns relating to: • Child R’s attendance • financial issues 6  • suspected misuse of cannabis • Child R’s mother not engaging with them • Child R being fed by a family friend.  A child protection assessment was commenced the same day.  Between 5 February and 9 March 2015 Concerns about Child R’s mother continued, with the school experiencing her attending to collect her son under the influence of alcohol. On one occasion, this resulted in Child R making his own way home from school, contrary to the agreement the school had in place with Child R’s mother, which required her to collect her son. The school alerted children’s social care to the situation, and two social workers attended at Child R’s home to assess the situation; neither mother, nor son, were at home. They then contacted the local police force to request a same-day safe-and-well check. When this occurred, Child R was at home alone. His mother was unable to care for him that evening, owing to alcohol intoxication, so his grandmother cared for him. Child R was fit and well at this time.  10 March 2015 A strategy discussion and Section 47 investigation was progressed. Consequently, it was determined that the situation for Child R had moved beyond that which could be managed within the common assessment framework, and a decision was made to progress to case conference. Between this decision being made and the case conference, Child R returned to live with his mother, in line with a written agreement involving children’s social care; he had also expressed a wish to go home. This agreement included a range of commitments to behavioural changes in Child R’s mother; the purpose of this agreement was to emphasise, to Child R’s mother, the actions she needed to take to improve her parenting behaviours. However, the agreement had no enforceable status, and no consequence ensued, if it was not adhered to; compliance with the agreement would be assessed in subsequent case conference and core group meetings.  26 March 2015  In line with the procedures and timescales in place at the time, the child protection conference was convened, and Child R was made the subject of a child protection plan under the category of neglect. Present at the conference were Child R’s mother, his maternal grandmother, the education welfare service, his school, and a social worker.  27 March 2015 Child R’s case was transferred to Safeguarding Families West; this is the team that worked with the child protection plan, and thus Child R and his mother, until the time of Child R’s death.   Note: between this time, and the time of the tragic accident involving Child R, the social worker and advanced practitioner involved have reported undertaking a “balancing act”; bearing, in their minds, the potential impact of taking the decision to place Child R in care, versus working with Child R and his mother in line with the child protection plan that remained in place at the time of his death (and had been signed up to by all involved agencies).  7  It is important that all readers of this report remember that any decision to take a child away from its family requires careful consideration, and an exhaustion of all reasonable effort to have achieved successful maintenance of the family unit. The many considerations, checks, and balances required of agencies involved in such a decision-making process cannot be underestimated. Professionals do not tend to make the decision to leave a child with its family where they can see, and have acknowledged, that the safety threshold has been passed. Therefore, if it is perceived that the threshold for removal had been met prior to Child R’s death, it is possible that this perspective was reached with the benefit of hindsight; hindsight provides clarity of perspective that is rarely available to professionals managing complex situations ‘on the ground’, as they are progressing.  April to 13 July 2015 There was a combination of nine announced, and unannounced, visits to the home of Child R and his mother over this period; in seven of these visits Child R was seen, and direct work was undertaken with him and/or his mother.  16 April 2015  The social worker records reported that Child R’s mother, and his grandmother, attended at the social work team office, and told the allocated social worker that neither of them could cope. The team reaffirmed their commitment to work with the family to achieve some change. The social worker involved reported that her rationale for persisting with the supportive work she was engaged with Child R’s mother in, and for not placing Child R in alternative care was:  “Child R had only recently gone onto a child protection plan and the focus was on supporting him to be safe in the care of his mum and wider family. A key focus of the plan was addressing the negative portrayal of grandma in this meeting that Child R was the ‘problem’, rather than helping mum to access support to address her own needs while recognising the impact her behaviour and that of her estranged partner would have on a child. Child R loved his mum and she loved him. Even a short period of accommodation risked damaging further their attachment to each other. Children often have poor outcomes from untimely or poorly planned separations from their caregivers. Hence, we continue to support and work with children in the community to promote family life. It was at a later stage of our involvement that the PLO process was appropriately considered.”    19 June 2015  The second child protection conference was held; Child R remained the subject of his child protection plan. There were small incremental improvements noted in his situation, although concern remained. Therefore, a decision was made to continue with the plan.  24 June 2015  The social worker allocated to Child R recalls that, following the child protection review case conference (where the level of concern had abated slightly), the level of concern for Child R then escalated. She is noted to have reported that she understood that Child R’s mother was known to be associating with two individuals who were known to social workers in relation to child care issues. The social worker also noted in her record, that Child R’s behaviour seemed to be more worrying at this 8  time, than previously. Reports about Child R, and the social worker’s own observations, began to indicate a level of aggressive, and confrontational, behaviour that the social worker had not observed before. Notwithstanding this, there were continued attempts to work with, and support, Child R’s mother. However, even though children’s social care continued to work with Child R’s mother, they also considered that they might be entering a situation where further consideration of Child R’s needs and best interests would be required. A key determinant would be evidence of ongoing deterioration in the engagement of Child R’s mother, and of no progress being made.  20 July 2015  A Gen 117 safeguarding concern was raised by the local police force. Child R had been reported missing on several occasions from his home, or when out with relatives; he would simply “run off”. The social worker involved with Child R was asked about her knowledge of Child R’s missing episodes, and recalled that the behaviour was occurring on a weekly to fortnightly basis during the time she was the allocated social worker (March 2015).   21 July 2015  Child R’s social worker referred him to the local children’s centre, to try to achieve intensive parenting and support, three times per week, throughout the school holidays. The children’s centre already knew the family and were considered to be the most appropriate source of regular support and advice during the school holiday period. The children’s centre agreed to give this support.   22 July 2015  A home visit was conducted at Child R’s home; it is not known if this was a planned or an unplanned visit. As with a previous visit, the general environment within the home raised no concern in the visiting professionals; Child R was well presented and there was no concern regarding his physical health. However, as on recent occasions, Child R was observed to be aggressive in his tone with his mother and constantly pushed the boundaries she put in place. Child R was also noted to be rude in his mannerisms and used bad language. His mother was observed to attempt to apply boundaries to his behaviour.  At this home visit, the professionals noted that Child R was using an age-inappropriate digital game; the possible negative impact of these for Child R was discussed with his mother, who then placed the games on top of the kitchen cupboards. Child R became aggressive when she did this, and started smashing up objects in the family home. The professionals present supported Child R’s mother in managing this situation, and in determining appropriate boundaries.  Child R’s mother was advised that the social care team would increase their visits to weekly, so that enhanced support could be provided. Child R’s mother, and the professionals, talked about how to keep Child R safe, especially around his ‘going missing’ episodes. The records indicate that Child R’s mother recounted some of the strategies she had used to prevent her son from slipping out unnoticed by her, one of which included locking the windows, although she had found her son unlocking them with a pair of scissors.  9  A plan for both Child R’s mother, and his maternal grandmother, to attend a parent course, so that they could achieve consistency in their strategies with Child R, was also discussed.  The records show that one of the children’s social care professionals had a discussion with Child R about house rules. This was noted to have progressed well when talking about rules and his maternal grandmother, but not his mother. When the conversation turned to home house rules, Child R was noted to have disengaged.  The overall impression formed by professionals, at the end of this home visit, was that Child R’s behaviour continued to escalate, and that the relationship between him and his mother continued to deteriorate. Also reported, was that Child R’s mother engaged well in the session, and was happy for an increased level of support.   Finally, there was a one-to-one conversation with Child R about the dangers in the community and the risk he was putting himself in. Child R was noted to respond that he was ok, could look after himself, and he didn’t care; they could put him in care.  The professionals noted that they advised him that they wanted to keep him safe in the home. Child R referred to himself as a “dickhead” at this meeting, and the professionals considered his self-esteem presented as low. This reflected the findings of the earlier Boxall assessment in 2014.  24 July 2015  The social worker for Child R was concerned that his behaviour was escalating, however, the experienced supervising manager considered the threshold for intervention would not be met if the local authority sought an emergency protection order. Police officers who had previous, and current, contact with Child R had not sought to exercise police powers during this period, despite being faced with the same risks to manage. The consideration of the children’s social care professionals was the agreed plan of support and development of positive parenting package in place for the summer holiday (which mum was committed to); this would undermine an abridged or emergency application. They, therefore, elected to seek approval to progress to PLO (Legal Gateway Meeting), and give notice to Child R’s mother that the local authority was considering care proceedings, should the required changes as set out in the child protection plan not show evidence of being achieved.   26 July 2015  Child R was reported to the police as missing from his home by his mother. He had been expected home by 8pm.   On this day, Child R was known to have been playing at a friend’s house. An individual providing parental support to Child R’s mother, and other women in the locality, reported to the independent author that Child R and his friend went to Child R’s home to collect a computer game that afternoon, and then returned to the friend’s house. Child R left his friend’s home later that afternoon. This did not cause undue concern at the time, as he was within his local neighbourhood and everyone knew him. It was only later, when he did not return home, that a concern materialised. 10   27 July 2015  Following a police search Child R was found stuck in a pipe on a building site. He had passed away before he could be located. 11  4 Constructive analysis of efforts made by agencies to safeguard Child R Traditionally, there is a detailed commentary about a child’s management from birth to the date of death, where a child has been known to safeguarding children’s services at the time of death. This has led to reports that are rich in narrative storytelling, but have, historically, been less robust in terms of analytical content.  In this analysis section, a decision was made to focus on aspects of the chronology in the last years of Child R’s life, which provide optimal opportunity for reflection, learning, and improvement in, and across, the agencies involved. This, after all, is the purpose of the serious case review process; to learn and to improve.   Part of ‘improving’ is to recognise aspects of single and multi-agency actions and interventions that went well; these are set out immediately below.  What went well for Child R? Although the behaviour of Child R’s mother, and the efforts made to support her, dominate all agency timelines, there are a number of points that represent activities that seem to have been specifically beneficial for Child R, or placed him as the focal point of attention. These were: • his first primary school provided him with regular and consistent support to help him engage in school and to try to support his behavioural issues; between September 2012 and 23 January 2014 there were 13 interventions or meetings for, or about Child R – these must have been reasonably successful, as, during the same period, the behaviour log identified no more than four incidents involving Child R • in February 2015, nurture provision was set up in Child R’s second primary school, and Child R was given the highest level of access to this throughout the school week; this was a provision that Child R was invited to access and was found to be positive towards • the Boxall profile was completed to ensure his individual needs were targeted and met through the nurture sessions; this gave a very clear picture of possible issues for him • in January 2014, Child R’s mother was referred to Parent Partnership, so that she could be supported with her son’s special needs assessment, as she did not understand the process • also in January 2014, there is evidence that shows that Child R’s learning mentor had engaged with him, and that Child R was coming up with excellent ideas for the agreement, including in relation to the statement ‘When we are together we …’. Child R was able to identify things he did well, and those issues he got into trouble for, such as running in school • Child R was referred to the behavioural support service by his school; this referral initiated the involvement of educational psychologist support for Child R • in March 2014, Child R’s first primary school completed a common assessment framework (CAF) for him; it was at this time that Child R was exhibiting bullying behaviour towards girls, and had had a recent ‘fixed-term 12  exclusion’ from school; the commencement of the CAF placed Child R’s school at the forefront of ‘working together’ to keep Child R safe • the interventions of the education welfare service were effective; the attendance of Child R at school increased from 76% to 81.2% in three months, and by 24 June 2014, it was at 92.65%, which was considered to be a good improvement – Child R’s case was closed by the education welfare service on 8 May 2014 • in May 2014, following a Team Around the Child meeting at Child R’s school, further efforts were made to try to secure a parenting course for Child R’s mother • the involvement of the educational psychologist for Child R; it was agreed that the aim of educational psychology involvement was to explore social and emotional needs, as well as self-regulation skills, and calming techniques • personal behaviour plans were utilised for Child R after he became subject to a child protection plan; these divided Child R’s day into small, manageable parts so that there was ample opportunity for praise and positive reinforcement for him, including rewards • in October 2014, Child R’s family was referred to the Troubled Families programme, and in November 2014 Child R’s family was escalated to a family intervention service key worker for more intensive support, the service was available seven days a week and provided both dispersed (support in alternative accommodation) and outreach (support within clients’ own homes) family support – the specialist housing provider delivered this service alongside its usual property management services. The types of interventions provided were: • individual support • parenting skills and support • anger management • communication skills • dealing with difficult situations • workshops to build motivation and self-esteem • social skills and life skills • budgeting and benefit advice • tenancy workshops • making sure people use their leisure time in a beneficial way.  All of the above were of the utmost relevance to the situation of Child R and his mother.  • In the summer of 2015, the social worker and the local children’s centre brokered a package of support for Child R to sustain him through the summer holiday period; this was to provide him with support, three days a week, and also to provide enhanced support for his mother. At this time, the children’s centre was under no obligation to agree to provide any support, as Child R was over the age of five, the upper limit for service provision. The brokerage of this package, therefore, represents excellence in partnership working between teams, and in the determination of the professionals to achieve a workable and robust support package for the family.13  5 Summary of key learning points arising from this review Whenever a retrospective review takes place, there is always the opportunity for learning and improvement; the case of Child R is no different. There are seven key learning and reflection points arising from this review, these are as follows.  1. Child R’s mother had substance misuse issues that neither she, nor her mother, could accept were unmanageable. Agency response to this was to require Child R’s mother to address her substance misuse issues in a ‘self-motivated’ manner, which was an unrealistic expectation.  2. It was recognised that Child R had been affected by the domestic abuse situation between his mother and father, however, he was not referred for specialist assessment or counselling as a consequence of this. It was documented that his mother had agreed to do this for him, but there is no evidence that this was followed up, on Child R’s behalf, by any agency.  3. There were approximately 21 domestic abuse related incidents towards Child R’s mother between 2009 and 2014, of which 10 appear to have met the threshold for a medium risk categorisation. Apart from writing to Child R’s mother advising her to contact domestic abuse support services, there does not appear to have been a proactive outreach approach to try to secure her engagement in a suitable recovery programme that would have benefitted her, and her son. There was, and is, a free, 10-week Freedom programme that she could have been encouraged to attend. Pathways Family Support Centre also offer a home visiting service, as well as a town centre drop-in service. More positive support should have been provided to her.   4. The Pathways Family Support Centre has an informative website that is not the easiest to navigate or read. This may act as a barrier to engagement with some individuals experiencing abuse. 5. The ranking system utilised in the child protection conferences, in March and June 2015, highlighted stark differences in the professional and family perceptions of risk for Child R; these appear not to have been considered as robustly as they might at the time of Child R’s case conference. Furthermore, professionals currently expressing concern did not utilise the escalation of concern avenues open to them, to express professional concern at the time. 6. Child R’s Boxall assessment, conducted in January 2014, highlighted that Child R had considerable attachment and emotional issues at the age of six and a half, however, structured interventions for him only materialised within the education system; he appears not to have benefitted from a psychological assessment from anyone experienced in childhood trauma, or from any professional therapy, at an early enough stage to assist him in exploring and addressing these issues in an age-appropriate way.  7. Although well managed by Child R’s social worker, and the children’s centre, in the summer of 2015, this case has highlighted the dearth of provision of structured summer activities for children such as Child R, who are over the age of five and whose parents cannot afford to enrol them in summer clubs and camps.  14  6 What improvement actions have agencies already taken? 6.1 Parental capacity and capability (Children’s Social Care) The models now utilised in Barnsley include Signs of Safety, supported by Harnett’s procedure for assessing capacity to change (placing greater emphasis on measuring what change has actually occurred rather than what the parent’s stated intent is).   The DiClemente (1991) model of change (the change cycle) forms the basis of the understanding of motivation to change, and is the model cited within the current Barnsley Assessment Framework.   Since July 2015, there has been a comprehensive audit of all children subject to child protection plans within Barnsley; the action plan that has derived from that is focused on ensuring that high-quality SMAART (specific, measurable, agreed, achievable, relevant, and timely) plans are produced, that support the assessment of parental capacity for change.   Development of the procedures for child protection conferences now result in consideration being given to the capacity to change within conferences, and a new conference reporting template asks all professionals to consider what harm and safety look like, and what both the strengths and the complicating factors are. This is being supported with training, the promotion of web-based resources (for example https://www.rip.org.uk/events-and-online-learning/change-projects/change-projects-resources/smg-change-project/) and regular auditing against these defined criteria; allowing the measurement of organisational change.  6.2 NHS Barnsley Clinical Commissioning Group The workforce management and development subgroup of Barnsley Safeguarding Children Board plans to focus on the toxic trio of mental health disorder (and/or depression), drug and alcohol abuse, and domestic abuse at its October 2016 conference, in order to enhance awareness and understanding among safeguarding professionals of the complexity of these issues, and their impact on the wellbeing of a child.  The chief nurse for the clinical commissioning group is leading a work stream entitled ‘Future in Mind’ in Barnsley. This work aims to promote, protect, and improve the mental health and wellbeing of children and young people. One impact of this project has been to reduce the waiting times experienced by young people referred to, and accepted for, a child and adolescent mental health team assessment to five weeks.  The child and adolescent mental health service has a new service manager, and she has made alterations to the existing referral service, so that education professionals can now refer a child directly to the child and adolescent service, rather than being required to progress this via a general practitioner (GP).  The child and adolescent service has initiated training for GPs, so that they know what information to include in a referral letter for a child or young person. The information provided directly contributes to any decision by the child and adolescent 15  service to accept a referral or not; it is therefore important that the content of any referral letter is as good as it can be.  In 2015, the clinical commissioning group implemented a practice delivery agreement to encourage GPs to send reports to child protection conferences. This means that there are financial penalties for GP practices that do not send child protection conference reports. The clinical commissioning group is monitoring the impact of this incentive.  6.3 Public Protection Unit There are a number of changes already enacted, as follows. • The multi-agency risk assessment conference (MARAC) confidentiality statement has been amended. • The MARAC meetings are now fully recorded, and the recordings are kept, and can be accessed if required. • There has recently been a further campaign on the South Yorkshire Police intranet, enforcing the fact that the children involved in any domestic abuse incidents are spoken to, and checked upon, by the officers attending, and the forms are submitted to social care. Posters have been printed and distributed in prominent positions around the buildings for officer information. • The College of Policing have run, a trial of a reduced frontline DASH form. After a second-level review it will be evaluated, and depending on the result, may be rolled out nationally. • Missing-from-home procedures now include guidelines, which state that three missing-from-home incidents within a 28-day period require the escalation of the concerns. Actions are then taken to identify the reasons for the child being away from home, and an action plan is implemented to minimise the risk of any further occurrences. Furthermore, a strategy meeting should be convened when a child or young person has been missing for a period of 72 hours, or when a child or young person has gone missing three times in any 28-day period, where it has been deemed that the child is at risk of significant harm, following a risk assessment.  6.4 Bank End Primary School  The school told the independent author:   “As a school we are always concerned at the start of a long holiday that we will not be in touch with our children and families for a significant time. We know that Bank End Primary School is at the heart of the community in which we are and every day we are providing support not just for our children whilst they are in school but support for families at home too. Since summer 2015, as a Senior Leadership Team we have discussed ways to provide some form of activity during the longer holidays that will provide two things.  • Purposeful and safe activities for our children • An opportunity for our staff in school who know our families well to be in more regular contact with the community during the holidays.  As a staff team we have been able to generate a team of Middle and Senior Leaders, including our Parent Support Advisor, who are willing to work and be 16  available in school during some weeks of the holidays. We initially trailed [sic] this during March 2016 during the Easter Holidays. This initiative was self-funded by the school. From this initiative the school saw positive engagement from families and found a manageable system for staff to cover. (Note the staff volunteer to make themselves available during the holiday period).  For the summer of 2016 the school has a clear plan in place for this provision to continue, providing holiday clubs and sports camps during four separate weeks. These are at a significantly discounted rate and are run by staff in the school. The school already has uptake from families who have signed up for these clubs.   Another development for the primary school is how they escalate their concerns about children of concern. For example, if a concern is raised to social care and the school considers further action is needed, their concerns are now escalated via the appropriate pathway with that service. In order to ensure this consistently happens we have adapted the cause for concern system used in the school. The school has added an additional section to the reporting system for follow up. Weekly the Safeguarding Team meet to review Cause for Concerns received that week and chase up any that we have not had feedback from a service from or feel have not been addressed in the way we would like or expect.    With regards to domestic abuse the school has developed links with the Pathways Service and now have a ‘Helping Hands’ therapy session running constantly in school. This is a course of 4 weeks therapy, for groups of up to 6 children at a time, delivered by a trained Pathways worker alongside our Nurture Staff in school. This programme helps children develop self-esteem, manage their own feelings and recognise and value their own safety. The programme has been positive and valuable for a number of children and as a consequence the school will continue to run it for as long as Pathways as a service are able to provide it.   The three themes reinforced for children throughout the course are: • We all have the right to feel safe all the time • Others have the right to feel safe with us • There is nothing so small or so awful we can’t talk about it with someone.”   6.5 Barnsley Children’s Services  Children’s services in Barnsley have been improving since their Ofsted inspection in 2012. That inspection identified sub-optimal practice in relation to core child protection practices, and judged Barnsley’s children’s services overall to be inadequate. The Department for Education issued an improvement notice, setting out the improvements Barnsley was expected to make, and specifying that Barnsley should establish an improvement board with an independent chairperson. After being inspected again under the single inspection framework two years later, in June 2014, the inspection again noted improvements required in Barnsley’s children’s services.  “The Department for Education lifted the Improvement Notice in November 2014 following a further Ofsted inspection under the single inspection framework in June 2014. The outcome of this inspection was more positive and consequently 17  there was an overriding message that Barnsley Children’s Services were improving and continuing to build on their achievements. The service has been able to maintain the momentum for improvement. As Barnsley Children’s Service continue to be judged as requiring improvement, the governance for service improvement was transferred from the Improvement Board to Barnsley Safeguarding Children Board and Children and Young People’s Trust Board.”      A continuous service improvement framework remains in place, that is shared right across the partnership, to collectively deliver services that are judged to be ‘good’ or better, so that the best possible outcomes for children and young people in Barnsley are achieved.  The framework is designed to secure continuous improvement for Barnsley children and young people’s services, and is supported by Barnsley’s continuous service improvement plan; this provides the means by which progress and impact on services and outcomes for children and young people will be measured.  The plan is mapped against the Ofsted requirements (following the child’s journey) and enables both Barnsley Safeguarding Children Board, (BSCB) and the Children and Young People’s Trust, to determine whether sufficient progress is being made, in the right direction, and at the right pace.  A strong performance management culture is now firmly embedded in children’s social care, to ensure that the service is delivering improved outcomes for vulnerable children. The improvement plan has progressed beyond the actions and requirements arising from the 2014 Ofsted inspection, all of which have been met.  Key activities that enable the continuing momentum for improvement include learning from a programme of case file audits, serious case reviews, frontline visits, and observations of practice; these activities all shape and drive further improvements in getting it right for children.   6.6 Phoenix Futures Since August 2015 Phoenix Futures has recruited and trained peer mentors, specifically because of the experiences they can bring and share with people, such as Child R’s mother, who may be ambivalent about change in relation to their behaviours or addictions. Peer mentors are people who have lived through the experience of substance misuse and treatment services, and want to support others in some way. The aim is to engage individuals in the early stages of their recovery journey. The peer mentor can share their personal experiences of treatment and recovery, while encouraging individuals to embrace a variety of treatment options.  18  7 Conclusions This is a tragic case of the sudden death of a young boy aged seven.   By all accounts, although there were serious concerns about Child R’s mother’s ability to parent him to a satisfactory level, and about his behaviours of pushing and not respecting boundaries, wandering off, and being aggressive towards other children, the incident leading to Child R’s death was an accident.  A key question for the serious case review was the predictability of a tragic accident for Child R. Although it is clearly recorded that there was concern that Child R might have an accident and that his behaviours presented a clear risk of this (hanging out of bedroom windows, climbing onto flat roofs, not returning home at the agreed scheduled time, wandering off in the dark), there was nothing in his behaviours that would have reasonably prompted his family, or professionals, to consider him at risk of a life-threatening event; it was more likely that Child R would fall and suffer a broken bone, or have a fight with local boys. There was scope for Child R to be involved in a road traffic accident, but this was less likely.  The second key question is the potential of avoiding Child R’s death; this is a much more challenging question and requires an objective, non-emotional consideration of his life course and the interactions he, and his mother, had with the range of agencies involved. These mainly constituted: • the police • Children’s Social Care • education services (school, and education welfare) • Family Intervention Services (housing provider).  These agencies were aware of the challenges facing Child R and his mother, and a range of interventions and strategies were employed to support and improve the parenting of Child R. There were also interventions that were aimed at supporting Child R to moderate his behaviours, especially in school. Having read all the information provided, the independent author considers that the only way the death of Child R could have been avoided was if he had: • stayed at his friends, rather than deciding to leave • not been able to access the building site he was found on; this issue is outside of the authority of the serious case review process  • already been removed from his mother into care.  This report has already made clear that removing Child R from his mother, prior to his death, was not something that was reasonably achievable in the situation pre-dating it. The decision to try and achieve this via a non-emergency route was a reasonable one; there was nothing that required an immediate and urgent removal of Child R from his mother, and this was not a child who had dropped off the radar of agencies – far from it.  ‘When is the right time’ to remove a child from their home? The answer is not easily arrived at, and is a decision that cannot be seen in black-and-white terms. It also cannot be considered with the benefit of hindsight, when information is available that was not available to the agencies when they were managing the complex situation.  19   The independent author has not seen, or heard, any information that robustly shows the decision to continue to work with Child R’s mother to achieve a satisfactory outcome, was wrong.  However, had any of the following been true, it may have provided a different chronology for Child R and his mother, with regards to the case conference and case conference outcomes; had: • there been a structured approach to assessing parental capability and the capacity of Child R’s mother to change at strategic points between 2008 and 2015 • Child R’s mother been proactively referred to substance misuse and domestic abuse services as part of the child protection plan, if not before • Child R received trauma counselling and interventional therapy as part of the child protection plan, if not before.  One cannot say how it would have impacted on the tragedy that occurred  20  8 Learning and improvement opportunities The agencies in this case have demonstrated a proactive commitment to improving aspects of their services where their own internal management reviews demonstrated that this was required. Many of those actions are listed above.   The issues set out below, have been identified by the independent author of this review, to represent the additional actions or considerations that are required within and across agencies, in the borough of Barnsley.  8.1 Learning and improvement opportunity 1 It is recognised that the multi-agency risk assessment conference (MARAC) coordinator has already acted on aspects of the process highlighted during this serious case review process as requiring attention.   However, because, on 23 February 2016, some agencies reported that they were not empowered to share important information emerging at MARAC with relevant frontline professionals, and the quality of notes captured during the 2014 MARAC minutes did not demonstrate delivery of the MARAC aims, or relevant consideration of child safety issues, the Safeguarding Children Board, alongside its adult equivalent, must satisfy itself that: • due consideration of child safety issues (physical and psychological) is consistently taking place at MARAC meetings • an appropriate assessment of risk is conducted and documented • frontline case workers, care coordinators, the education welfare service, head of school, etc, are properly debriefed about the key issues and plans emerging from a MARAC meeting • MARAC representatives from all agencies are surveyed to determine how many of them are consistently taking information from the MARAC meeting and sharing this with the frontline case workers • frontline staff from all agencies are surveyed to obtain their perspective on the reliability with which information from a MARAC meeting is communicated with them, so that they can case-manage effectively; a series of straightforward audits could achieve this, a one-off audit would not be sufficient.   Furthermore, the Safeguarding Children Board needs to be assured that, where a child becomes subject to child protection conference proceedings, the process of preparing for the meeting includes a standardised enquiry to the MARAC coordinator about any MARAC meetings held, that relate to the child’s family, and the key risk factors associated. It is essential that a child protection conference chair is as situationally aware as possible, so that informed decisions, in the best interests of the child, can be made.  8.2 The incident of 9 March 2015 – learning and improvement opportunity 2 One of the difficulties in maintaining a grounded perspective in the assessment of this incident was the lack of attention to detail in the information recorded by frontline professionals.   21  The design of the child protection incident report, utilised within the local constabulary at the time, did not require a police constable to set out: • his or her assessment of safety for the child • how decisions were made regarding the safe placement of the child, if removal from the family home was required • to whom in children’s social care the case had been communicated • what the position statement was, 72 hours after the child had been placed with ‘another’ person, other than his/her parents.  The form design did not place a police officer in a position of being able to demonstrate retrospectively that the responsibilities conveyed by the Children Act 1989 were known, understood, and delivered.  Furthermore, although, objectively in this case, the threshold for a supervision order appears not to have been reached, there was nothing to prompt any record of why the case was not considered to meet the threshold for a care or supervision order. Given the scrutiny that agencies receive following unexpected child deaths, it seems sensible that documentation tools are designed to support professionals in recording core data, that retrospectively helps them demonstrate that they did their jobs well, and that the best interests of the child were preserved.  The Safeguarding Children Board is recommended to review, with South Yorkshire Police, the current design of the child protection incident form, to ensure that it captures the essential data set necessary to demonstrate legislative compliance and appropriate discharge of safeguarding responsibilities to a child.   8.3 Substance misuse – learning opportunity 3 The child protection conference plan, in relation to achieving a change in behaviour around the substance misuse by Child R’s mother, was insufficiently robust. Substance misuse services were not invited to be active participants in the child protection conference process, and there was, therefore, no expert input to the child protection plan in respect of the substance misuse concern.   The service director for children’s social care and safeguarding is recommended to ensure that the service explores how it can enable its conference chairs to recognise the need for ‘specialist’ input into the child protection conference proceedings, where the specialist is not currently engaged with the family, and, therefore, not automatically invited.  8.4 Substance misuse – learning opportunity 4 Throughout the engagement of services with Child R’s mother, there were missed opportunities for professionals to optimise the opportunities for her to recognise the destructive nature of her alcohol and cannabis use.   All agencies are asked to consider the extent to which frontline professionals are encouraged, or required, as part of their professional development, to attend ‘open’ addiction recovery meetings; those hosted by statutory, non-statutory, and self-help groups in the area of Barnsley, including groups focusing on the support of families living with people with addictions. The issue of substance misuse is such a dominant 22  feature in domestic abuse and child neglect, that attendance at such meetings could be considered essential, as well as an effective way to enhance professionals’ insight into these complex issues.  8.5 Raising professional concerns – learning and improvement opportunity 5 8.5.1 Part A  Although the flow chart set out in Barnsley Metropolitan Borough Council’s ‘Protocol for Resolving Professional Disagreements When Safeguarding Children and Young People’ (June 2011) is straightforward, it would benefit from the inclusion of relevant contact email addresses and telephone numbers for ease of use and reference. Consideration could also be given to moving the placement of this flow diagram to the beginning of the protocol document, with a cross-reference to additional guidance notes contained within the document; it may make the protocol document easier for partner agencies to use.   Furthermore, all agencies working within the borough council need to have easy and immediate access to this, and any, updated version of this protocol. Therefore, consideration could be given to including a link to it on the safeguarding page of the borough’s safeguarding children and safeguarding adult’s website.  8.5.2 Part B:  With regard to disagreements arising directly from a case conference, in particular where professionals are not in agreement with the overall risk score arrived at for the child, the protocol is insufficiently directive.  Currently the policy says:  “3.10. In cases where professionals dissent from the decision made at a Child Protection Conference they may formalise their reasons for dissent in writing to the Chair of the Policy, Procedures and Practice Developments Sub-Committee who will arrange for the disagreement to be considered by an independent Panel.”  The protocol does not set out clear timescales for the receipt of concerns raised, or the response to the concerns raised. It needs to set these out.   The protocol also needs to address the steps required, in advance of writing to the chair of the Policy, Procedures and Practice Developments Sub-Committee. The nature of a child protection conference (an open meeting at which the family are present) can present an obstacle to one or more agencies voicing dissent at the time of the meeting. It makes logical sense for there to be a defined process whereby any individual/agency present can raise issues directly with the chair of the conference in the 24–48 hours immediately after the case conference. The safeguarding board manager is asked to ensure that this learning opportunity is presented to the person tasked with the responsibility of updating the 2011 protocol.  8.6 Response to domestic abuse incidents rated medium to high – learning and improvement opportunity 6 23  The domestic abuse steering committee is recommended to initiate a partnership piece of work to determine how responses to domestic abuse incidents rated medium to high can be more proactively managed. In this case the standard response to the domestic abuse incidents experienced by Child R’s mother was to send her a letter advising her of the local support networks available. This was not proactive and the domestic abuse steering committee needs to consider a wider range of options for more successfully engaging those experiencing domestic abuse.  24  9 Appendix 1 9.1 The process of the serious case review  The process for this serious case review followed a blend of the traditional ‘panel’ model and the principles of the Learning Together model; once the panel itself had achieved clarity that the level of understanding necessary to form fair and reasonable judgements about the decisions made regarding ‘safeguarding Child R’ could not be made without involving frontline practitioners as active participants in the case review process.  9.2 First Panel meeting There were four panel meetings and one frontline professionals meeting (attended by staff engaged with Child R or his family and their managers).  The first panel meeting was an opportunity for all agencies to be introduced, and for the initial chronology across the agencies to be presented. The format of this was challenging to work with, and a variety of coded references were used to depict Child R and his parents. It was agreed by all present that the document in its then format was not useable for the review.  Furthermore, the chronology, as compiled, gave no indication as to each agency’s consideration of: • the case management • where internal standards had been met, or exceeded • where standards had not been met, and the seriousness of any such instance.  The independent author asked the agencies if, instead of producing a traditional IMR (Initial Management Review report), they would be willing to work with an alternative model of chronological timeline that required commentary throughout, about where standards were met and not met, and the magnitude of any lapse.  The independent author agreed that she and her team would import all the data already supplied by agencies into this alternative template, and separate the data into individual chronologies for Child R, his mother, and his father.  The agencies present agreed to work in this way.  Each agency was subsequently presented with the alternative timeline format, which included a number of questions the independent author wished to pose to the agency about its involvement with Child R or his parents. These questions emerged from the independent author’s reading of all of the initial data submitted by the agencies to Barnsley Metropolitan Borough Council.  9.3 Second panel meeting This meeting enabled agencies to provide feedback on how they had found using the alternative chronology model, compared to the more familiar IMR report they would have written.  25  The feedback was mixed: • most agencies reported finding it helpful to be able to see the entire chronology for Child R, his father, and his mother, as this was not something they usually had access to at such an early juncture in the process • a number of agencies reported that it was helpful to have questions posed by the independent author at this early stage, as it supported a constructive and reflective process  • some agencies considered that the process reflected the approach they took in their IMRs, but in a different format  • a high percentage of agencies reported a lack of the necessary IT knowledge to work with the Excel-based tool as easily as they would have liked • some agencies had such a volume of data that it could not be contained in the maximum number of characters a single Excel cell could accommodate; this resulted in their truncating of the information provided.  9.4 Third panel meeting The focus of this meeting was to agree the key areas requiring exploration and commentary in the serious case review report. The challenge for all present was to achieve, and maintain, a focus on the most important issues; to not get distracted by historical information and/or gaps in historical information that were not going to be filled owing to either changes in staff or memory loss over time.  This meeting was pivotal for the serious case review process, as all agencies present recognised and agreed that to achieve a grounded understanding of how decisions were made about the case management of Child R, frontline professionals who remained in the employ of an agency, and who also had care contact/case management contact with Child R, his mother, or father, needed to be invited to a frontline professionals day so that they could contribute their ‘first-hand’ experience of working with Child R and his parents.  9.5 The frontline professionals’ day In preparation for this event, the independent author produced three separate chronologies • Child R’s pre-birth chronology • Child R’s chronology from birth to 9 March 2015 (i.e. just before he was made subject to child protection proceedings via case conference) • Child R’s chronology from 10 March to 26 July 2015.  Attendees at the meeting were asked to focus their attention on the last five to six months of Child R’s life, to ensure that the optimal opportunity for meaningful learning and safety improvement was achieved. As previously stated in this report, the dominant reason for this was the criticality of the last five months of Child R’s life.  It is indisputable that there are reflective learning opportunities for several agencies in the time period predating March 2015. However, the purpose of a serious case review is to establish what lessons can be learnt to improve child safety for the future.   26  In this case, the possible opportunity for lessons learnt predating March 2015 will, for much of Child R’s chronology, have been superseded by contemporary developments in practice within single agencies, and across agencies. Furthermore, the most important questions about the reasonableness of Child R’s management, in terms of his safety, arise in the five to six months preceding his death.  At the start of the day, because a significant number of panel members attended the frontline professionals meeting, each work group was facilitated in working privately, utilising the private post box method; this is where post boxes are provided to each working group so that they can contribute experiences and observations without having to articulate these in a large group, which can be daunting.   Professionals present were also asked to reflect on, and respond to, a series of 18 core questions, of relevance to the last five months of Child R’s life.   This was well received by the professionals most closely involved with Child R and his mother, in the last five months of his life.  